Junkfood Science: July 2007

July 29, 2007

Pediatric Grand Rounds - Deathly Hallows Edition

Harry Potter fans will enjoy the latest edition of Pediatric Grand Rounds just up at Highlight Health - Health from a Scientific Perspective. To commemorate the release of the final edition of the Harry Potter Series, each article on children’s health and healthcare is magically tied to the book. Have fun!

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Measures designed for prejudice

A fascinating study released this month received absolutely no media notice, perhaps because its myth-shattering findings might be too uncomfortable to acknowledge. It demonstrated one reason why more poor women in developed countries are labeled “obese” than women of privilege.

Israeli researchers, led by Dorit Nitzan Kaluski, M.D., MPH, R.D., at the Ministry of Health and Tel Aviv University, demonstrated that body mass index (BMI) is a discriminatory measure, biased against women who are poor....

In developed countries, obesity is more common among those of lower social and economic status. The researchers wrote that it is popular to blame an “obesogenic” environment with its “unhealthy lifestyles” and to condemn poorer people as eating more cheap, fattening foods and doing less leisure-time exercise. But, as they reported in a study just published in the journal Obesity, a more accurate explanation could partly account for higher rates of obesity among the poor.

Currently, obesity is determined using an arbitrary mathematical formula of weight in kilograms over height (in meters) squared — the body mass index (BMI). For years this measure has been criticized by researchers for lots of reasons, but one is that it is skewed by height, meaning shorter people disproportionately find themselves labeled “obese.”

To investigate the differences in height, weight, socioeconomic status (SES) and the effect on BMI, the researchers examined data from the Israeli National Health and Nutrition Survey, named MABAT. They used the random sample of 2,781 ethnically-diverse Israeli adults who had been visited in their homes by trained public health workers. Similar to the U.S. National Health and Nutrition Examinations Surveys (NHANES), health and diet information had been obtained, and actual measurements had been taken twice by the examiners.

Among women, the prevalence of obesity was about twice as high among those of lower socioeconomic status compared with those of higher status. But, the researchers found:

For any given weight, the socially deprived will have a higher BMI, some of whom will be misclassified as more obese.

In other words, in two women of the same weight the poor one will be more likely to have a higher BMI and fall into the category of being labeled as too fat. Why? The researchers found that adults “of lower SES were significantly shorter than men and women of higher SES.” The differences in height between the higher and the lower SES was 2.3 cm in women, while their weight difference was 4.6 kg. They concluded that the higher prevalence of obesity among poorer women in developed countries is partly due to them being misclassified as obese because of the use of BMI. A 1% change increase in weight leads to a 1% percentage increase in BMI, while a 1% lower height leads to a double percentage increase in BMI, they explained “So, the combined effects are additive.”

After adjusting for age, population group, and ethnic origin, height was significantly inversely associated with obesity among women, with a 7% increase in risk of obesity for each 2.5-cm decrease in height.

This has significance especially when looking at population-wide statistics and making conclusions about obesity or “bad” behaviors, when the real issue is the social and economic situation. Height is a complex trait controlled by both genetic and environmental factors, they explained. The body of research, they said, points to decreased height as reflecting “suboptimal nutrition during fetal, child, and adolescent life, notwithstanding the influence of heredity.” Thus, they wrote, the higher rates of obesity seen among poor people could be due to inadequate prenatal and childhood nutrition, “rather than to various degrees of ‘sloth or gluttony.’”

According to Dr. Kaluski’s research, food insecurity and not having enough to eat, as found amongst poorer populations, leads to higher weights:

[I]t was previously shown that women exposed to starvation conditions at childhood presented with increased plasma levels of insulin-like growth factor and weakly decreased levels of its plasma carriers at adulthood. These results are opposite to the immediate responses seen under starvation and suggest a compensating hormonal overshoot after improvement of famine condition. Possibly, inadequate childhood nutrition may also result in an overshoot of certain hormones and, subsequently, compensatory higher weight at adulthood.

This speaks to the need to address poverty and ensure women and children have enough calories and higher-density and nutritious foods to eat. It also points out that promoting dieting is illogical and will only raise weights long term. Which, in fact, every study on dieting has shown this to be the case, tripling the development of obesity among children who’ve restricted their eating and tried to diet for weight control.

They noted that obesity, in turn, affects SES, with discrimination against obese people well-documented as "impeding attempts to attain higher status."

These researchers went on to demonstrate how simply making minor changes to the mathematical formula for BMI could dramatically change who is labeled “overweight” and “obese,” even virtually eliminating the SES disparities. When they recalculated the BMIs among the 1,410 women in their study using weight/height1/2 they reduced the prevalence of obesity among women of lower SES and significantly reduced the association between poor women and “obesity:”

In short women of lower SES, the prevalence of obesity was reduced by 7-fold when calculated by weight/height1/2 index rather than by BMI. However, for short women of middle and high SES, the prevalence of obesity was reduced by only 4.5-fold when calculated by weight/height1/2 index compared with BMI.

Why does a discriminatory arbitrary measure with such obvious problems — that leads to the greater condemnation of those of certain ethnic and genetic backgrounds, those who are aging and those who are poor — continue to be favored? The answer lies in the fact that the war on obesity isn’t an issue of health, any more than dieting is about health — how can it be when fat people have a survival advantage, while chronic diseases of aging are shared by people of all sizes, and there is no evidence that losing weight prolongs life?

No, the war on obesity is about aesthetics and classism and ageism. It is a war against people some don’t want to see.

© 2007 Sandy Szwarc

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July 28, 2007

How she spent her holiday

This isn’t what most of us might think of as summer tourism, but for this woman in the UK, it changed her life.

The East Anglian Daily Times in Suffolk reports:

Health tourist claims back cash from NHS

A PENSIONER who borrowed more than £7,000 to pay for a hip operation abroad after being told she was too overweight to be treated on the NHS is trying to claim the money back from health chiefs. Former Bartlet Hospital canteen worker Moira Ryan, 69, from Felixstowe, flew to Malta with her son for the successful hip replacement....

The PCT had refused her treatment because of its policy of not providing surgery to most people with a body mass index of more than 35 unless they go through a weight-loss plan....Mrs Ryan said: “I had gone to Ipswich Hospital for an appointment and was told I needed a new hip but ...NHS kept putting me off, telling me to lose weight. I am obese, but I paid my taxes all my life and feel let down badly. I am very, very disappointed - I had to turn to the banks to get a loan...

Mrs. Ryan, who has three children, flew from Stansted with Operations Abroad, which arranged for her to be picked up at her home, taken to the airport, and met off the plane in Malta. She was taken to the hospital, underwent tests, and was operated on the following day.

She said: “I feel brilliant, and I am back on my feet and doing very well. I am out of pain for the first time in five years....

Mrs. Ryan is thankfully doing well now after taking matters into her own hand. She found that being on the waiting list for her hip replacement meant being perpetually put off. No doubt, Ms. Anjelica Allen, the woman denied her hip operation in May for being six pounds overweight, is hoping that won’t be the case for her. In an update on her story, the Gainsborough Standard recently reported that due to the media attention to her treatment, the Lincolnshire Primary Care Trust has agreed to put her back on a waiting list.

But don’t rejoice yet. Besides an undefined wait ahead for her, it appears they’ve loosened their ruling restrictions only for lesser fat women. Women with BMIs above 35 are still being denied routine surgeries, including hysterectomies, until they take part in weight loss programs:

Hip, hip, hurray!

A TOWN woman who made national headlines after being refused a hip operation for being just six pounds overweight has been left overjoyed after hospital chiefs performed a dramatic climb-down. Anjelica Allan, after appearing on The Standard's front page in May, made national news in The Sun, The Sunday Times and GMTV as she voiced her discontent after being refused the op.

Health bosses admitted to The Standard that people with a Body Mass Index (BMI) of greater than 30 - as in Miss Allan's case - were refused hip and knee operations to save the primary care trusts money. But health officials have now overturned the policy - and Miss Allan is back on the waiting list....

Lincolnshire Primary Care Trust (LPCT) made the ruling on funding for knee and hip replacements as part of a savings drive in May 2006 - cutting costs by £500,000 per year.

Patients with a BMI of more than 30, were denied routine surgery - including hysterectomies - under a ruling made when Lincolnshire had three separate PCTs. However, the limit has only been raised to those with a BMI of higher than 35. Patients with a higher BMI will need to take part in a weight loss programmes....

How many people will continue to be denied treatment that can return them to quality, functional living, and will be left to suffer excruciating pain, simply because they are fat? As has been well documented in the medical literature, there is no credible evidence to support claims that fat people don’t benefit just as much as anyone else from joint replacements. There is only one reason for rationing and denying them care.

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July 26, 2007

Oh what a tangled web we weave — Sir Walter Scott (1771-1832)

I wasn’t even going to write on this “study” because it has elicited a plethora of thinly veiled hate speech in the blogosphere and media, and was such junk science, I was certain no one would take it seriously.

I was wrong.

Within hours of the press releases, a massive, well-orchestrated marketing campaign was off and running. By dinnertime yesterday, Google noted 300 nearly identical articles had been published about it and there were 500 by this morning. Television and radio reporters have been gushing over it, with MSNBC reporting that having a fat friend can make you fat and be downright dangerous for your health. It isn’t genes, environmental influences or hanging around together, either, they reported, but the obesity epidemic could be spreading via email and instant messaging. [The power of the internet as a new energy modality?] ABC news told viewers this morning that having fat friends was bad for you and that fat friends could be spreading the attitude that being fat was okay and making it acceptable to have unhealthy behaviors. The groupthink instantly made it acceptable to publicly make fat people out to be pariahs and no one noticed the hurt it was causing.

Let’s not beat around the bush. This study was used to justify and promote the social shunning and discrimination of fat people.

Not one health or medical writer, even at the most prestigious consumer or medical publications, has critically reported on this study. Not one has pointed out its unorthodox methods, its findings that conflict with known science and known biological mechanisms, or the flawed and contradictory findings within the study itself.

Gina Kolata at the New York Times wrote one of the earliest reports:

Obesity Can Spread, Study Says

Obesity can spread from person to person, much like a virus, researchers are reporting today. When one person gained weight, their close friends tended to gain weight, too. Their study, published in the New England Journal of Medicine, involved a detailed analysis of a large social network of 12,067 people who had been closely followed for 32 years, from 1971 until 2003... people were most likely to become obese when a friend became obese. That increased a person’s chances of becoming obese by 57 percent.

There was no effect when a neighbor gained or lost weight, however, and family members had less influence than friends. Proximity did not seem to matter: the influence of the friend remained even if the friend was hundreds of miles away. And the greatest influence of all was between mutual close friends. There, if one became obese, the odds of the other becoming obese were nearly tripled. The same effect seemed to occur for weight loss, the investigators say. But since most people were gaining, not losing, over the 32 years of the study, the result was an obesity epidemic.

Dr. Nicholas Christakis, a physician and professor of medical sociology at Harvard Medical School and a principal investigator in the new study, says one explanation is that friends affect each others’ perception of fatness. [The co-author is James H. Fowler, a political science professor at the University of California, San Deigo.] When a close friend becomes obese, obesity may not look so bad. “You change your idea of what is an acceptable body type by looking at the people around you,” Dr. Christakis said.... The investigators say their findings can help explain why Americans have become fatter in recent years — each person who became obese was likely to drag some friends with them.

She went on to report that their analysis was unique and could explain why people have gotten fatter. Genetics can determine ranges of weights around 30 pounds, she claimed, but “that leaves a large role for the environment.”

We are to believe, it seems, the media images that we’ve all gained gargantuan amounts of weight, rather than the average 7 - 10 pounds actually evidenced over recent decades among our increasingly diverse population, as reported by Dr. Jeffrey Friedman, head of the Laboratory of Molecular Genetics at Rockefeller University in New York.

We are also to overlook the genetics of obesity that has been recognized by scientists for more than half a century. “The heritability of obesity is equivalent to that of height and greater than that of almost every other condition that has been studied,” said Dr. Friedman in a 2004 review of the genetic science in Nature Medicine. The simplistic notion that weight can be controlled by diet and exercise and proper behavior “is at odds with substantial scientific evidence illuminating a precise and powerful biologic system that maintains body weight within a relatively narrow range,” he wrote. Already, many of the genes which regulate body weight have been identified, and these “genes balance calorie intake and energy expenditure with considerable precision,” with us having little long-term control over things.

Instead, Ms Kolata went on to interpret the study, opining:

If the new research is correct, it may mean that something in the environment seeded what many call an obesity epidemic, leading a few people to gain weight. Then social networks let the obesity spread rapidly.

It also may mean that the way to avoid becoming fat is to avoid having fat friends.

That is not the message they meant to convey, say the study investigators... Friends are good for your overall health, [Christakis] explains. So why not make friends with a thin person, he suggests, and let the thin person’s behavior influence you and your obese friend?

Ms Kolata lent the study additional credibility in readers’ minds by reporting glowing expert opinions.

Their research has taken obesity specialists and social scientists aback. But many say the finding is pathbreaking, and can shed new light on how and why people have gotten so fat so fast. “It is an extraordinarily subtle and sophisticated way of getting a handle on aspects of the environment that are not normally considered,” said Dr. Rudolph Leibel, an obesity researcher at Columbia University.

Dr. Richard Suzman, who directs the office of behavioral and social research programs at the National Institute on Aging, called it “one of the most exciting studies to come out of medical sociology in decades.” The institute financed the study.

Medical writers at publications such as MedPageToday were equally credulous, giving physicians the action point: “Explain to patients who ask that this observational study found that the likelihood of a person becoming obese is heavily influenced by obesity in their friends, siblings, and spouse.” Medical professional readers were told: “Surprisingly, the researchers found, the greatest effect was not among those sharing the same genes or the same household, but among friends, even those living apart.”

No need to go on, as you’ve heard all of this, too. But what you haven’t heard was that this paper wasn’t actually a study, researching people using recognized, proven sound medical research methodology.

It was computer animation and, in essence, created a virtual reality.

The fact it was published in the New England Journal of Medicine, a “peer-reviewed” medical journal, as scientific research is proof only that fancy degrees, prestigious reputations and affiliations have become meaningless.

How’d they do that?

The cohort these authors used was the 5,124 children of the original Framingham Heart Study participants. And in actuality, only 45% of them proved to be connected. The researchers dredged through “handwritten administrative tracking sheets that had been used since 1971” in the Framingham Heart Study. The information they used from the tracking sheets was the contact information that had been gathered on the participants at each of the seven interviews between 1971 and 2003 to facilitate future follow-up, asking them to name a close friend or person who might know where they are in a few years should they move, get married, etc. [Someone you know who keeps a good address book doesn't mean they're your best friend. This information was never meant to be used to research social relationships.] The tracking sheets also noted their relatives.

Using this contact information, the authors then created three levels of friendships based on if the cohort had listed someone or the person had listed them, and if they had mutually listed each other. They put the 38,611 different people connections — friendships, family and neighbors — into a computer and created a computer model the likes medical research has never seen. It’s one for Dr. John Brignell’s computer modeling record book.:)

As they described:

We graphed the network with the use of the Kamada–Kawai algorithm in Pajek software. We generated videos of the network by means of the Social Network Image Animator (known as SoNIA). We examined whether our data conformed to theoretical network models such as the small-world, scale-free, and hierarchical types.

In other words, they made up a computer animation. SoNIA is a Java-based package for visualizing dynamic or longitudinal data, currently under development by two young developers at Stanford, Dan McFarland and Skye Bender-deMoll. Pajek is a free, non-commercial use software program for drawing large networks of relationships.

These authors chose to use the Kamada-Kawai drawing algorithm, but as Kim Holmberg, MSc, PhD, of the Department of Information Studies at Åbo Akademi University in Oslo, Norway, illustrated at Webometrics, different drawing algorithms will give completely different results using the same data. For instance, compare the network of municipal websites in the region of Varsinais-Suomi as drawn using Normal interlinking, using Fruchterman Reingold 2D, and using BibExcel, with frequencies, to Kamada-Kawai.

Here is the social network map [courtesy of James Fowler, UC San Diego] these authors drew “of 2,200 people, the largest group of connected individuals in the Framingham Heart Study, in the year 2000. Each circle represents one person, and the size of each circle is proportional to that person's body-mass index. Yellow circles indicate people who are considered medically obese and green circles indicate people who are not obese. Lines indicate family and friendship ties:”

This “new science of networking” appears to be the up and coming computer research technique and some actually believe it should be a new medical specialty. An editorial in the New England Journal of Medicine, written by Albert-László Barabási, Ph.D., a computer scientist at the University of Notre Dame, Notre Dame, Indiana, said:

The role of links and connections does not stop here. In the past few years, we learned that network effects increasingly affect all aspects of biologic and medical research, from disease mechanisms to drug discovery. It is only a matter of time until these advances will start to affect medical practice as well, marking the emergence of a new field that may be aptly called network medicine.

But there’s more to this study. For their statistical analysis to come up with links, these authors created models and ran countless simulations, with so many assumptions and complex selections and elimination of variables, that no one could hope to unravel it:

The use of a time-lagged dependent variable (lagged to the previous examination) eliminated serial correlation in the errors (evaluated with a Lagrange multiplier test) and also substantially controlled for the ego’s genetic endowment and any intrinsic, stable predisposition to obesity. The use of a lagged independent variable for an alter’s weight status controlled for homophily....A significant coefficient for this variable would suggest either that an alter’s weight affected an ego’s weight or that an ego and an alter experienced contemporaneous events affecting both their weights. We estimated these models in varied ego–alter pair types....

We calculated 95% confidence intervals by simulating the first difference in the alter’s contemporaneous obesity (changing from 0 to 1), using 1000 randomly drawn sets of estimates from the coefficient covariance matrix and assuming mean values for all other variables. All tests were two-tailed. The sensitivity of the results was assessed with multiple additional analyses.

In other words, any pretense that these statistical machinations in any way resemble reality is a myth.

What did they find? None of the odds ratios their computer model came up with were tenable. But they didn't simply admit the null findings. Instead, they reported that obesity was associated less with genetic, familial ties; less with geographical proximity, as in immediate neighbors or even friends hanging out together socially; less with even being married and living, eating and sleeping together; than in simply being friends with a fat person. [But among the fine print: the weight gain of a fat friend wasn’t “contagious” if the friends were the opposite sex or among two females; the finding was only statistically significant among men.]

They made no efforts to give any physiological explanations for these implausible findings or how long-distance relationships might be more associated with obesity than genetics. Nor, did they have any data on the closeness of the friendships or how often people were in contact with their supposedly fattening friends.

Forgetting that their study was a data dredge looking for correlations, which is unable to ever demonstrate causation, Christalkis said it showed the social effect was “a direct, causal relationship.” In their University of California, San Diego, press release, he said: “What appears to be happening is that a person becoming obese most likely causes a change of norms about what counts as an appropriate body size. People come to think that it is okay to be bigger since those around them are bigger, and this sensibility spreads.”

Embellishing its significance

In the study conclusions, the authors said that their findings and “the observation that geographic distance does not modify the effect,” ruled out environmental factors or behavioral imitation effects, as well as genetics or childhood experiences, to explain the obesity epidemic. They attributed the rise in obesity to a change in the “general perception of the social norms regarding the acceptability of obesity.”

Then, in the very next paragraph, they contradicted that, proposing:

Yet the relevance of social influence also suggests that it may be possible to harness this same force to slow the spread of obesity. Network phenomena might be exploited to spread positive health behaviors, in part because people’s perceptions of their own risk of illness may depend on the people around them... The observation that people are embedded in social networks suggests that both bad and good behaviors might spread over a range of social ties. This highlights the necessity of approaching obesity not only as a clinical problem but also as a public health problem.

The press release went on to advance the “profound policy implications of the study,” far beyond any evidence the paper could support. Community-wide weight loss programs that “harness the force of networks” to compel social changes are already being hailed as the solution to the obesity epidemic.

“The findings lend support to treating people in groups or even whole communities,” reported the Washington Post. “If these close social environments can promote a disease, they can also promote solutions to disease,” said William H. Dietz of the Centers for Disease Control and Prevention. “These same social networks might be used to turn a disease like obesity around.” According to the Post, the results of this study support forming relationships with people who have healthful lifestyles.

This is not the first time Christakis has proposed far-reaching public policy implications for social networks and advocated societal-wide interventions for the collective good. In an editorial in a 2004 issue of the British Medical Journal, he said the effects of social networks require a “rethinking of the relative value of healthcare interventions or of the conduct of clinical trials... Doctors, trialists, patients, or policy makers might see reason to take them into account when choosing treatment or evaluating benefit.” He suggested:

When the cost-benefit assessment is made by policy makers with a collective viewpoint, all the downstream costs and benefits of health care accruing to a group might be relevant, and the argument in favour of accounting for collateral effects might be even more compelling than that perceived by individual doctors or patients. From a societal perspective the assessment of the cost effectiveness of medical interventions might change substantially if the benefits of an intervention are seen as including the collateral positive effects and the costs as including the collateral negative effects... For example, preventing a death from heart attack, which is clearly desirable from the individual's perspective, may mean that we have to forego the motivation that would otherwise have accrued to others to whom the patient is connected to improve their own health habits. Another provocative implication is that policy makers might value socially connected individuals — such as married people — more when it comes to health care since benefits might be multiplicative in such people...

Even if someone isn’t fat and won’t derive direct benefit from weight loss in their neighbor, he said, the greater good it will have on influencing others gives it socially important value. “Exercise or smoking cessation in one person may prompt numerous others to behave similarly. Conversely, there may be epidemics of disorders such as obesity, alcoholism, suicide, or depression that might spread in a peer to peer fashion.”

Whenever we come across a study with questionable science, that receives massive marketing and media attention far beyond its merit, and is being used to support sweeping public policy change, it’s worthwhile to ask why. But, in this case, Dr. Christakis declared “no potential conflicts of interest relevant to this paper.”

He is, however, on the Executive Committee of the Robert Wood Johnson Scholars in Health Policy program at Harvard and was elected to the Institute of Medicine last year. The Scholars website says it is “the most sought-after interdisciplinary post-doctoral fellowship program in the social sciences. Its purpose is to foster the development of a new generation of creative thinkers in health policy research.” Each year, it enables twelve Ph.D.s up to five years “to undertake two-year fellowships without any of the usual obligations of teaching and university administration” and is a program of the Robert Wood Johnson Foundation. The fact that RWJF is the largest foundation in the world funding societal policies against obesity, smoking and alcohol, we are to believe, does not constitute a potential conflict of interest.

This study illustrates the difference between politics and good science. The reporting and responses from media and medical professionals have illustrated the difference between stereotype versus knowledge, understanding and compassion. There is absolutely no credible science to support stigma against any group. You cannot “catch” fat from associating with a fat person anymore than you can catch “black” from a black person.

What the science knows about obesity “should be sufficient to end the opprobrium of the obese,” said Dr. Friedman. “To end the stigma of obesity, the scientific community must communicate more effectively a growing body of compelling evidence indicating that morbid obesity is the result of differences in biology and not a personal choice.”

The public trusts medical and journalism professionals to give them reliable information to help them. Over the past 24 hours, that trust has proven to be undeserved.

© 2007 Sandy Szwarc

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July 25, 2007

Healthcare Privacy Update: Critical news today

Did you know that federal agencies are in the midst of deciding who will own and control our personal health information? Under a new proposal, a federal agency would be empowered to establish health privacy rights and how our private healthcare information is disclosed and used. Their proposed new national data collection entity would “nationalize ownership and control of private patient data,” said Twila Brase, RN, PHN, president of Citizens’ Council on Health Care.

The just-released issue of Health Freedom Watch from the Institute For Health Freedom reports:

The federal Agency for Healthcare Research and Quality (AHRQ) is proposing to establish a national “entity” to set rules and standards for collecting, sharing, using, and reporting health-care data. The AHRQ, a division of the Department of Health and Human Services, is requesting public comments on its proposal to create a National Health Data Stewardship Entity (NHDSE)....[T]he entity's responsibilities would primarily focus on specific issues relating to data collection, aggregation, analysis, and sharing.

Regarding data collection, the agency wants to “set policies, rules and standards for collecting public and private sector data from relevant stakeholders, including providers, employers, health insurance plans and others…” It notes that based on current law, allowable data uses may include quality and efficiency improvement, consumer reporting, accountability, and pay-for-performance programs.

The agency also proposes setting policies, rules, and standards for data access and sharing. For example, the new entity would determine “who should have access to data and applicable limitations, such as confidentiality and privacy rules; should consider policies which allow contributors, including both public and private sector entities, to have access to their own data as well as information which allows them to compare their data against benchmarks.” It would also develop “guiding principles” for public reporting.

[Junkfood Science readers will remember the significant goals and interests behind the AHRQ.]

In a letter to AHRQ, the Citizens’ Council on Health Care wrote that the proposed entity (NHDSE) would “open wide the vaults of private medical data, authorizing the exposure of more than 300 million Americans to unwanted disclosures and research, potential embarrassment, fear in and outside the doctor’s office, privacy violations, genetic discrimination, breaches in the confidential patient-doctor relationship, profiling and surveillance, outside controls on the practice of medicine, and health care rationing.”

Examining the proposed NHDSE, they found that it would eliminate individual privacy, consent and data ownership rights; and abolish the current state medical privacy laws that protect patient privacy, while eliminating the ability of state legislators to enact future medical privacy laws. Worrisomely, it authorizes secondary uses of patient data unrelated to the direct care of patients and expands government access to private medical information. The CCHC review concluded this entity would:

Place control over access to and use of confidential patient medical records data in the hands of unelected and unaccountable bureaucrats, corporate executives, and political appointees in a centralized bureaucracy far from the people whose privacy is violated— and whose access to medical care would be threatened by statistics-based health care rationing decisions.

According to the proposed mission statement of the NHDSE, it would facilitate or enable:

• Surveillance and outside monitoring of all patients and doctors

• Patient and doctor profiling

• Health care rationing – use of patient data to build so-called “evidence-based” and statistics-based rationale for the purpose of denying medical services and controlling the practice of medicine.

• Expanded government access to private patient data

• Subjection of patients to medical, genetic, and other research projects without consent

The CCHC itemized seven major concerns, the first of which was that the public has not been informed about any of this and the AHRQ has kept their efforts virtually secret from the public, while claiming to be gathering public opinions on this initiative. A search of their website, (as of last night) finds nothing that even mentions this proposal or request for public comment.

The CCHC finally found it mentioned on the Federal Register, which asks for RFPs (requests for proposals) from interested stakeholders in the formation of this public-private organization. RFPs should be emailed to steward@ahrq.hhs.gov or mailed to P. Jon White, MD, Health IT Director, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850. The deadline is this Friday, July 27th!

Through this we learn that it is part of the government’s AHRQ’s health IT initiative to create a “health information infrastructure” and foster “many conversations among organizations interested in collaboration to exchange clinical data.” The foundation and private partners partnering with the AHRQ and funding this Health IT initiative include an assortment of IT interests, managed healthcare interests (such as Kaiser Family Foundation and the National Institute for Health Care Management), RAND Corporation and, of course, Robert Wood Johnson Foundation. The AHRQ health IT initiative included $166 million in grants to begin development of electronic health databases in 100 healthcare provider settings and hospitals across the country.

Given the enormous impact this issue will have for 300 million Americans, isn’t it interesting that the media has virtually ignored it? Healthcare IT News, an exception, wrote of a workshop held on July 11th among members of the government’s Office of IT Adoption. The director, Karen Bell, M.D., said: “There’s no question that the secondary use of data is a big one....We have a unique opportunity to work on the issue before it becomes front and center in consumers' minds.” Senior Editor, Diana Manos reported:

[Charles Safran, MD, Harvard Medical School] said the secondary use of data is widespread – “more than we thought.”... According to Safran, policy has so far “ignored the 800 pound gorilla in the room,” which is the selling of healthcare data as part of commercial gain. “The public is woefully unaware to what is happening to their data,” Safran said....

Nancy Davenport-Ennis [co-chair of the workgroup] said the group should explore how to regulate a violation of stewardship over the data, how to protect consumers and how to provide incentives to consumers who make lifestyle changes to improve their health based on information gained from the data.

Before this issue becomes front and center in consumers’ minds.... It appears it will be up to caring healthcare professionals and private citizens to expose this back room dealing. Remaining quiet and complacent will come at enormous costs. When the government, in the pockets of mammoth special interests, has control over our most private health and lifestyle information, our healthcare access, and the care doctors will be obligated to provide under ‘pay for performance,’ what choices will we have but to do what they say?

© 2007 Sandy Szwarc

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Learning the hard way

Massachusetts is seeing another problem that can happen when public healthcare policies are based on feel good politics, rather than careful examinations of the facts and correctly defining the problems they profess to hope to solve. We could have predicted this...and, in fact, did less than two months ago.

‘Free universal health care for all’ sounds great only if you don’t look around, dig deep or think too much. Massachusetts’ statewide universal healthcare coverage mandate went into effect three weeks ago and already the State has realized it hadn’t accurately identified the uninsured, that their financial projections and how they would pay for their program weren’t even close, and now, that they really goofed in identifying the problem to begin with!

Health insurance is not the same as access to care. The state mandate doesn't address access. In fact, as seen in other single-payer systems, healthcare monopolies worsen the problem of who will provide the care. State regulations and cost-containing efforts drive away healthcare providers and leave shortages of providers, rationing of available resources, and growing waits for care. As the Wall Street Journal reports today:

Doctor Shortage Hurts A Coverage-for-All Plan

...Earlier this month, [Tamar Lewis] signed up for state-subsidized insurance under a new Massachusetts law that aspires to universal coverage. The plan costs her $80 a month. But it takes a lot more than an insurance card to see a doctor in this state. On the day Ms. Lewis signed up, she said she called more than two dozen primary-care doctors approved by her insurer looking for a checkup. All of them turned her away.

Her experience stands to be common among the 550,000 people whom Massachusetts hopes to rescue from the ranks of the uninsured. They will be seeking care in a state with a "critical shortage" of primary-care physicians, according to a study by the Massachusetts Medical Society released yesterday, which found that 49% of internists aren't accepting new patients. Boston's top three teaching hospitals say that 95% of their 270 doctors in general practice have halted enrollment.

For those residents who can get an appointment with their primary-care doctor, the average wait is more than seven weeks, according to the medical society, a 57% leap from last year's survey.... “Health reform won't mean anything for the state's poor if they can't get a doctor's appointment," says Elmer Freeman, director of the Center for Community Health, Education, Research and Service in Boston.... State officials have acknowledged the problem. “Health-care coverage without access is meaningless," Gov. Deval Patrick said in March.

As it happens, primary-care doctors, including internists, family physicians, and pediatricians, are in short supply across the country.... A principal reason: too little money for too much work.... The advent of managed care in the mid-1990s added to the burden as insurance companies called on primary-care doctors to serve as gatekeepers for their patients' referrals to specialty medicine.

Ms. Lewis, a 24-year old high school drop out, told the WSJ: “I thought insurance was supposed to be some kind of great thing, but it hasn't changed” a thing.

An article in the Washington Post today reported on the growing shortage of physicians on a national scale with medical school enrollments declining nearly 20 percent in the past decade, as physicians have seen their incomes drop 7 percent just between 1995 and 2003 due largely to reduced insurance and Medicare/Medicaid reimbursements. They also say government regulations and insurer managed care mandates mean they can no longer practice medicine. Medicare regulations alone fill 130,000 pages, which have made for soaring administrative costs and headaches for doctors and providers. According to reporter Regina Herzlinger:

Increasingly, independent physicians, accountable only to their patients and the Hippocratic oath, have been replaced by salaried doctors who are accountable to the hospitals or insurers that employ them. Salaried physicians are closely policed for productivity, leading to ever-shorter and more numerous appointments per day.

Meanwhile, academic medical journals routinely publish studies...lauding the virtues of single-payer health-care systems, such as those in Canada or Britain, in which the physician is paid only by the government. German physicians unhappy with their salaries and work hours under this kind of system had no recourse against their monopolistic bosses but to go on strike last year.

Or not practice medicine. When it comes to cable or telephone service, most people understand the idea that monopolies and government mandates can be detrimental for consumers — raising costs, eliminating competition and reducing choice, and creating shortages. But that insight vanishes when we believe we might be able get something free.

Of course, free is a myth. While it would once have been unimaginable in the United States, Massachusetts may soon need to take a lesson from Canada and launch a website to help its residents navigate the exorbitant wait times for medical care.

© 2007 Sandy Szwarc

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Thinking inside the box again

That didn’t take long. Texas didn’t even wait for the Fitnessgram results to come in before following other states in “doing something about” the numbers of “unfit” children.

Last May, Texas legislators proposed spending up to $8 million to require schools to measure kids’ shapes. The following month, it became law. School children in Texas will now be weighed, measured and tested, with fitness report cards sent home to their parents. These ill-considered reports, as one experienced mother of a recovering anorectic daughter noted, put everything into an “anorexic’s way of seeing the world—only in terms of what burns the most calories.”

As the Cooper Institute, which sells the Fitnessgrams used by growing numbers of state schools around the country, reported, the year after California began using their Fitnessgrams, they increased their state budget in 2006 to $40 million for gym teachers and $500 million for fitness supplies and PE teachers training.

Texas Comptroller Susan Combs just announced the launch of “Texas Fitness Now” which will spend $20 million of the Texas state budget for middle-school physical fitness and nutrition programs “in the continued fight against childhood obesity.”

In her press release she said:

The U.S. Surgeon General’s office reports that overweight children have a 70 percent chance of becoming overweight or obese adults. Texas Fitness Now will help teach kids the importance of physical activity and fitness and lay the foundation for a life of healthy choices and lifestyles as they grow into adulthood....

“This program rewards innovative thinking in the fight against childhood obesity,” said Julie Shields, Texas Association of School Boards’ Assistant Director of Governmental Relations. “... Hopefully, all Texas students will benefit from lessons learned at those schools thinking outside of the box and getting results.”

Texas Fitness Now grants may be used to support and enhance physical education, including buying PE equipment; buying equipment to track students’ progress, such as heart monitors and pedometers; selecting or developing an effective physical education curriculum and instructional materials; and training teachers and school administrators to help their students become fit and adopt healthy lifestyles. Schools must use at least 25 percent of the funds for nutrition education....

“We believe we will see measurable, positive results from incorporating more activity into the school day and teaching students to make healthier choices,” Combs said.

Beliefs, not quality scientific evidence, are behind yet another costly childhood obesity initiative. There is no evidence to suspect its results will be any different than countless others.

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Taking advantage of parents' fears

Two terribly sad stories of loss are worthy of note. Another child has died after being given chelation therapy. His parents, desperately seeking for ways to help their autistic son, had been led to believe that he had “high” mercury levels and that chelation could help him. As Fox News reported:

Parents Sue Doctor Over Death of 5-Year-Old Autistic Son After a Chemical Treatment

...Mawra and Rufai Nadama, of Plymouth, England, accused Dr. Roy Kerry of causing their son, Abubakar Tariq Nadama, to die of cardiac arrest at Kerry's office immediately after the boy received chelation therapy on Aug. 23, 2005.

Chelation removes heavy metals from the body and is approved by the U.S. Food and Drug Administration only for acute heavy-metal poisoning that has been confirmed by blood tests. Some people who believe autism is caused by a mercury-containing preservative once used in vaccines say chelation may also help autistic children....

The Department of State, Pennsylvania's physician licensing agency, filed six disciplinary charges in September against Kerry, including unprofessional conduct and breaching the standard of care. Those charges were still pending and could result in fines or his license being suspended or revoked....

Some doctors have used chelation to treat autism, believing mercury or other heavy metals cause the condition's symptoms. However, medical evidence does not support that belief, and the drug is not approved for that use, officials with the Centers for Disease Control and Prevention said.

In February 2005, a 2-year-old girl with lead poisoning was treated with three chelating agents and died at a hospital hours later from what an autopsy concluded was cardiac arrest due to depleted levels of calcium.

Parents of autistic children are especially targeted by alternative practitioners eager to capitalize on mercury and chemical fears to sell bogus testing, detoxification treatments, supplements and chelation. A recent post for worried parents reviewed the science — which has remained consistently strong — finding no link between mercury in childhood vaccines or mercury levels in autistic children, and no efficacy for chelation in treating autism. For more than forty years, people seeking cures for just about everything have been misled by claims surrounding chelation, but according to Dr. Saul Green, Ph.D., there is no scientific evidence to support it.

Dr. Saul Green, a retired biochemist and cancer researcher from Memorial Sloan-Kettering Cancer Center, was devoted to investigating questionable medical practices and cancer treatments. Debunking chelation therapy was a topic he wrote about extensively, driven by the senseless loss of innocent children and adults to chelation quackery. Dr. Green’s comprehensive review of the science on chelation written on Quackwatch was ranked #1 by Google for more than five years, said Dr. Stephen Barrett, M.D., of Quackwatch and the National Council Against Health Fraud.

Today’s issue of Consumer Health Digest reports that Dr. Saul Green has died, at the age of 82. His passing is a great loss. His writings on alternative modalities remain archived on his blog. Please make time to visit while his blog is still available. Hopefully his expertise will continue to help others not be taken in by “nonexistent toxic states” and cures that aren’t.

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July 24, 2007

Booster shots with mercury?

It’s time for another critical thinking booster shot... for the media. No matter how many times science injects a dose of reality to refute hair-raising claims, the shots last only a short while before the media is trying to scare us again — using the exact same claims! Saddest of all, the scares needlessly target young parents who are naturally concerned for the welfare of their babies and children.

Here we go again with headlines reporting on “high” mercury levels that aren’t really high.

Employees at the Division of Environmental Health at New York City Department of Health & Mental Hygiene performed biomonitoring tests on 1,811 New Yorkers for levels of mercury and other metals in their blood. The results were just published in Environmental Health Perspectives Online. The findings reported by the New York Times were spun to sound frightening and especially dangerous for women and babies:

High Mercury Levels Found in One-Fourth of Adults

One-quarter of adult New Yorkers, roughly 1.4 million people, have elevated levels of mercury in their blood, mainly from eating certain fish.... The elevated mercury levels that were found pose little, if any, health risk for adults, but may increase the risk of neurological damage in fetuses and infants whose mothers pass on the mercury through their bloodstreams during pregnancy or through breast milk....

Nationally, said Mr. Kass, research showed that about 10 percent of women of childbearing age had blood mercury levels at or above five micrograms per liter, the threshold considered the low end for potential health risks....The survey, conducted among 1,811 adults in 2004, found that one-quarter of women ages 20 to 49 had a blood mercury level at or above five micrograms per liter, while nearly half of Asian women had a blood mercury level at that threshold.

The department’s report linked the higher mercury levels among Asians to eating more fish, finding that foreign-born Chinese New Yorkers eat an average of three fish meals a week, compared with about one a week among New Yorkers over all. About one-quarter of Chinese New Yorkers eat fish five or more times a week....

We’ve covered this scare numerous times, so there’s no need to rehash the science in detail again...just a quick little painless booster shot of reality.

As we know, there is no evidence that levels of methylmercury in the fish Americans consume is cause for health concerns. In fact, the U.S. Centers for Disease Control continually finds that American women of childbearing age are many times below exposure levels even speculated as possibly posing risks for themselves or their babies.

Reading today’s media stories, however, we’re led to believe that 5 micrograms per liter — that’s parts per billion — found in the blood is “high.”

It’s not.

It is every bit as negligible as it sounds. Homeopathic levels of “active” ingredients, in fact.

The EPA’s risk assessment, the most conservative in the world, has set its benchmark dose at 58 parts per billion in the blood — more than ten times the “high” level reported in this story.

What’s a benchmark dose? As Dr. Joseph Jacobson, of Wayne State University and a member of the National Academy of Sciences’ Committee on Methylmercury, explained, the benchmark dose is “the lowest dose they thought safe from any effect over a lifetime of daily exposure in the most sensitive population of children.” They then added in an arbitrary ten-fold safety factor to that, to arrive at a “reference dose” which they use for regulatory reporting. But reporting thresholds are not the same as health risks.

Here’s that adage about ‘the dose makes the poison’ again. While a physiological basis for the neurodevelopmental effects of toxic levels from mercury poisoning is understandable — as seen in the Japanese spills during the 1950s where blood levels were a hundred times the New Yorkers in this study — there is no biological basis why our natural, low-level exposures would pose any risks, according to methylmercury toxicology expert Dr. Gary J. Myers, M.D., at the University of Rochester Medical Center, in Rochester, NY.

The participants in this study were New York residents recruited from four areas of the City and were paid $100 to answer interview questions and provide a blood sample. Most were poor, with the largest group of participants having family incomes under $20,000. The average blood mercury level found among the New Yorkers was 2.73 ppb.

No one came anywhere near the benchmark dose.

Those who had the very highest percentile of mercury concentrations, 2.8% of those tested, had levels of 15 ppb. Still several times below the safe level.

The environmental workers found the highest levels among foreign-born Asians. While claims abound that it must be their high fish diet, these authors didn’t measure the fish eaten by a single person. But more importantly, they didn’t evaluate the use of mercury-containing products, such as medicinals and candles. The Agency for Toxic Substances and Disease Registry, for example, found metallic mercury sold as botanicas and burned in devotional candles by certain ethnic and religious groups had accounted in a number of Americans who tested at the high-end values.

Scientists have found no credible evidence of neurotoxicity or anything remotely resembling brain damage, retardation or learning disabilities even among those eating many times more fish than Americans eat. The FDA Food Advisory Committee held scientific meetings in July 2002 to critically evaluate the evidence on methylmercury and found that, even among populations eating ten times more fish than Americans eat, the most careful research demonstrated no harm to the children’s health or development.

It is easy to become frightened when we hear something might be endangering babies and children. But the fact remains, there is no evidence that American mothers need worry about the methylmercury in the fish they and their children eat. Just as this study showed.

© 2007 Sandy Szwarc

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July 23, 2007

Not bound by age

Many of those struggling with disordered eating don’t fit the popular image of a teenage girl. A sufferer may be a young man, fat woman, elementary school child, babyboomer or grandmother. In fact, eating disorder treatment centers across the country are reporting that they’re seeing more older Americans...notably more:

Doctors Treating Older Anorexics

...Eating disorders such as anorexia and bulimia have long been considered diseases of the young, but experts say in recent years more women have been seeking help in their 30s, 40s, 50s, and older....Nicollet Health Services' Eating Disorders Institute saw 43 patients age 38 in 2003 - about 9 percent of its total patients. For the first six months of this year, the institute has treated nearly 500 patients over 38, about 35 percent of its total.

The Renfrew Center, a network of treatment centers in the eastern U.S., said about 20 percent of the 522 patients treated at its Philadelphia center in 2005 were 30 or older. In 2006, about 13 percent of the 600 patients were in that age group. “Whatever this is - if it's an increased awareness, if it's a response to being in midlife - those numbers are staggering," said Carol Tappen, director of operations for the Eating Disorders Institute.

Women over 30 who seek treatment tend to fall into three categories, said Holly Grishkat, who directs outpatient programs at Renfrew. Some have had an eating disorder for years. Others had a disorder in remission that resurfaced because of new stress in life, such as a divorce or loss of a parent. A third group, the smallest of the three, includes women who develop an eating disorder late in life....

While body image is an issue for any age group, women over 30 are dealing with problems that teens don't have, such as work, divorce, stepchildren and aging parents...They also are dealing with an aging process....

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July 22, 2007

The real tragedy

Eating disorder experts are increasingly recognizing that the panic about child "obesity" is having a dangerous effect on young people. Dr. Jenny O’Dea, of the University of Sydney and internationally-recognized eating disorder researcher, reported on her research finding that the rate of disordered eating among teenage girls has doubled just since 2000.

The Australian news reported "20 percent of girls [are] starving, vomiting to control weight:"

A national survey of almost 9,000 children has shown ... one in five teenage girls starve themselves for two-day stretches or vomit their food to control their weight. The survey also showed 8 percent of girls use smoking for weight control.

Dr. O'Dea says these methods of weight control are dangerous. “The use of starvation, vomiting and laxative abuse in girls is not only useless - they don't lose fat, they lose fluid - but it's very dangerous, it can result in sudden heart attack for example," she said....

Dr. O'Dea says teenage girls are being influenced by media reports about obesity.... “There's been a moral panic about obesity and I think the teenage girls are picking up on that, girls from all different social class levels."...

The study, Youth Cultures of Eating, was funded by the Australian Research Council. Interviewing 8,950 children and adolescents, ages 12 to 18, Dr. O’Dea found that teenagers’ fears of being fat were driving their eating disordered behavior and contributing to the dramatic increase in the numbers who were “starving themselves, vomiting, abusing laxatives and smoking in an effort to shed weight.” Ten percent of teen girls also drank no milk at all, attempting to control their weight, putting them in danger of calcium deficiencies, she said. As the Sydney Morning Herald added:

Teens’ fear of fat fuels eating disorders

...Youth Cultures of Eating showed 18 percent of girls surveyed in 2006 had starved themselves for at least two days, up from 9.9 percent in 2000. The study, funded by the Australian Research Council, also showed 11 percent used vomiting for weight loss, up from 3.4 per cent. Eight percent smoked to suppress appetite, up from 2.4 per cent.

The report noted that obesity declined among wealthy teenage girls, from 4.6 percent in 2000 to 3.9 percent in 2006. The number of obese children, boys and girls, was “levelling off," Dr O'Dea said, with a rise from 5.1 percent in 2000 to 6.4 percent in 2006.

She said the heavy focus on childhood obesity and media attention on “skinny celebrities" such as Paris Hilton were to blame for the increase in eating-disordered behaviour. “I think there has been undoubtedly a media panic and a moral panic about childhood obesity in the last six years and I would certainly suggest that some of that comment has got into the minds of teenage girls.... What schools need to do is tread very, very carefully with obesity prevention and only give positive messages and never do anything that is critical and negative." ...

This tragic story and one behind it continue to be ignored by the media. Not surprisingly. There are immense interests that need an epidemic of childhood obesity to sell anti-obesity initiatives; healthy eating and wellness programs; school exercise and BMI surveillance mandates; clinical management of fat children, including testing, medication and surgery; hundreds of millions of dollars for research; community zoning and design legislation; and regulations from what children can watch on television to what they can play and, most of all, what they can eat. It goes beyond the fact that there is little evidence that any of these initiatives are founded on good science or are effective, or that being a fat child leads to greater health problems as an adult.

“Levelling off”

Years before the marketing of an “obesity epidemic” went into overdrive, the facts — from here in the United States to the UK — were already showing no significant changes in rates of overweight or obesity among children (or adults).

But for most consumers, this inconvenient data has remained virtually invisible.

Instead, if it’s on television, it must be true. The obesity “epidemic” issue shows the power of media to convince people to believe and fear things that aren’t factual. Show enough images of headless fat children and repeat frightening and outrageous claims of a crisis often enough, and it becomes real in our minds. Even medical professionals can be taken in, rather than turn to the documentation in the medical literature.

Remember when Surgeon General Richard H. Carmona made the “year of the healthy child” his office’s 2005 agenda? The Dept. of Health and Human Services and National Institutes of Health went into high gear and made childhood obesity a high priority, saying this “public health crisis” was putting children at risk for chronic diseases. That year, alone, about $440 million was spent on research and more obesity legislation was enacted than ever before.

The kicker was that they already knew that claims of skyrocketing childhood obesity rates weren’t accurate. The National Health and Nutrition Examination Survey (NHANES) data had been published in a June 2004 issue of the Journal of the American Medical Association. There had been no significant increases in the numbers of U.S. adults or children considered “overweight” or “obese” since 1999-2000, according to the CDC analysis. [It was spun into bad news, saying there were so signs the obesity crisis was decreasing.]

The story was the same in the UK. The Social Issues Research Council, an independent research group there, analyzed data from the Health Survey for England in 2003 and reported there was no evidence of any deterioration in the health status of children and that “there have been no significant changes in the average weights of children for nearly a decade.” The “claims of obesity ‘epidemic’ are not supported by evidence,” they found. Instead it was “hype and exaggeration” of the data.

The war on childhood obesity that’s been fought for years has been built upon a lot of overstated scares, statistics and unwarranted panic. While everyone’s attention is focused on inflated “obesity-related” chronic diseases in children, the deadliest one of all has been allowed to escalate.

© 2007 Sandy Szwarc

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More psuedo-advocacy

Patient advocacy and support groups used to lobby for special interests aren’t just common in the weight loss and bariatric industries. In a nearly identically titled post, Dr. Roy M. Poses, M.D., writes of another nonprofit disease organization funded by special interests. Not only is caution important when we hear information and advice from biased sources, but their lobbying is often effective, which means we pay the price:

Advocacy in Whose Interest?

Just in time for another lazy summer weekend comes this article from the Wall Street Journal about another instance of cozy ties between the pharmaceutical industry and a disease-specific not-for-profit organization. (We posted about another such instance here.) The article's focus is how the Epilepsy Foundation has been campaigning against generic anti-epileptic drugs on a state level, while accepting significant funding from and leadership by pharmaceutical companies that make name brand anti-epileptics…

[T]here is ample evidence that conflicts may affect how people think and what they do. Try a thought experiment. If you knew that your organization were getting a large amount of money from donor x, would you be more likely to take a position that directly goes against the interests of donor x, or the opposite?

In any case, this case appears to be yet another example of stealth health policy advocacy or stealth lobbying, and one that may succeed in keeping the costs of drugs rising ever higher.

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