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Tag: public health

Is Obesity a Disease? I Vote No

There is a certain irony in the nearly immediate juxtaposition of the rare introduction of a new FDA-approved drug for weight loss (Belviq) to the marketplace and the recognition of obesity as a “disease” by the AMA. A line from the movie Jerry Maguire comes to mind: “You complete me!” Drugs need diseases; diseases need drugs.

And that’s part of what has me completely worried. The notion that obesity is a disease will inevitably invite a reliance on pharmacotherapy and surgery to fix what is best addressed through improvements in the use of our feet and forks, and in our Farm Bill.

Why is the medicalization of obesity concerning? Cost is an obvious factor. If obesity is a disease, some 80 percent of adults in the U.S. have it or its precursor: overweight. Legions of kids have it as well. Do we all need pharmacotherapy, and if so, for life? We might be inclined to say no, but wouldn’t we then be leaving a “disease” untreated? Is that even ethical?

On the other hand, if we are thinking lifelong pharmacotherapy for all, is that really the solution to such problems as food deserts? We know that poverty and limited access to high quality food are associated with increased obesity rates. So do we skip right past concerns about access to produce and just make sure everyone has access to a pharmacy? Instead of helping people on SNAP find and afford broccoli, do we just pay for their Belviq and bariatric surgery?

If so, this, presumably, requires that everyone also have access to someone qualified to write a prescription or wield a scalpel in the first place, and insurance coverage to pay for it. We can’t expect people who can’t afford broccoli to buy their own Belviq, clearly.

There is, of course, some potential upside to the recognition of obesity as a disease. Diseases get respect in our society, unlike syndromes, which are all too readily blamed on the quirks of any given patient and other conditions attributed to aspects of character. Historically, obesity has been in that latter character, inviting castigation of willpower and personal responsibility and invocation of gluttony, sloth, or the combination. Respecting obesity as a disease is much better.

And, as a disease, obesity will warrant more consistent attention by health professionals, including doctors. This, in turn, may motivate more doctors to learn how to address this challenge constructively and compassionately.

But overall, I see more liabilities than benefits in designating obesity a disease. For starters, there is the simple fact that obesity, per se, isn’t a disease. Some people are healthy at almost any given BMI. BMI correlates with disease, certainly, but far from perfectly.

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Why Texting Public Health Messages Is a Brilliant Idea. Except When It’s Not…

A new service has partnered with a Los Angeles school district – the second largest in the country – to not only deliver STD results by text message, but also to promote the idea children share their “status” as easily as they share the highlight of their day on Facebook. But when it comes to children having sex, it’s never quite that simple now is it?

Qpid.me is the brainchild of Ramin Bastani and operates from the following premise: “We believe that sharing is a good thing and that it can lead to better sexual health decisions, more (safe) sex and fewer STDs.” Bastani went on to tell CNN in an interview: “If it’s cool for a beauty queen to share her STD status [Qpid.me’s celebrity sponsor is Tamie Farrell, Miss California 2009], then maybe kids will start to think it’s cool to share their own results. We want to normalize the idea of sharing your status.”

The process is fairly straightforward. Qpid.me requests patient test results from health clinics (with patient permission, of course) then transmits those results via text, email, and provides access to their online site. The concept of delivering STD results electronically is not necessarily new, or controversial. The danger lies in convincing children there are no concerns about sharing such private information among peers who may not respect their privacy, or, worse may shame them for contracting curable diseases.

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Guahao: VC Fantasy. Online Appointment Registration System for China’s 700 Million Internet Users


The promising platform is called Guahao (挂号网) and it claims to be China’s largest online appointment registration system.  With a national network of nearly 4,000 hospitals, 600 being Level-3 hospitals, and over 300,000 specialists, it is hard to dispute it’s size.*  Guahao began development in Shanghai 2010 in collaboration with the Chinese Health Education Network, Fudan Hospital and Healthcare Management Co., and the Chinese Hospital Association, and later expanded nationally.  Guahao attempts to alleviate the bitterness patients endure during a typical hospital visit.

*It should be known that there are actually several online appointment registration systems in China; However, most are small, regionally splintered and have questionable legitimacy.  Guahao is by far the largest and most well supported system in China.

China historically has not had a call-ahead appointment scheduling system.  Patients throughout China have long lamented the country’s hospital queuing system, or the lack thereof.  Patients arrive at the hospital, literally take a number, and wait for their turn – sometimes for over 24 hours.  It is not uncommon to see throngs of patients and their family members outside of the hospital, camping out in makeshift beds to see a physician.  A lack of appointment system puts pressure on the hospital’s health workers.  Patient scheduling provides predictability of patient flow and allows for more efficient allocation of healthcare resources.  Not to mention it makes for a much more patient-centered approach to healthcare delivery.

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Could Opening Up the Doors to the World’s Medical Research Save Healthcare?

What if you had access to all of the medical research in the world? Or better yet, what if the physician treating your particularly complex or rare condition had access to the latest research? Or what if a public health organization in your community could access that research to inform policymakers of measures to advance public health?

“Wait,” you may think, “can’t they already access that research? Doesn’t the Internet make that possible?” While unfortunately the answer to the first question is “No,” fortunately the Internet can make such access possible. As it is today, most physicians and public health professionals have very limited access to health research, almost all of which is published online. Only about a quarter of the research published today ends up being available to those working outside of universities, where libraries subscribe to a good proportion of the research journals.

So, what are these health professionals missing? What difference to their work would access to research make? Cheryl Holzmeyer, Lauren Maggio, Laura Moorhead and I seek to answer these questions with a new National Science Foundation study for which we are currently recruiting physicians and staff of public health NGOs.

We seek to demonstrate the difference it makes to the daily work of these health professionals to have easy electronic access to all the biomedical and public health research – or at least that large proportion held by Stanford University Library – for a period of eleven months (with one month of limited access as a control). To assess the impact of this access, we provide participants with a special portal to the research literature and track when and what research is viewed, while following up with interviews on the use and value of this access.

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Why You Probably Have a Lot Less to Fear From the Latest Superbug Than You Think

Infectious disease is the most hyperbolic of all medical fields, at least when the media gets ahold of such.

Right now we are to fear a new avian influenza virus. Previously there was another avian influenza strain whose outbreak threatened the world and of course SARS and, more distantly, the ebola virus and the threat of bioterrorism. And on the periphery, as these acute threats come and go, is the persistent threat of super bugs; bacteria resistant to multiple antibiotics. Sometimes all antibiotics.

I remember my pharmacology professor in medical school claiming that within our practice lives we would reach the useful end of antibiotics. A claim, literally, that physicians would no longer have any use for antibiotics by the time I reached the end of my career.

Scary stuff but evidence that such outrageousness sells pharmacology in a classroom as much as it does magazines on a news stand. Time magazine a post called “The End of Antibiotics?” referencing a Guardian article along the same lines. This followed a similar 2009 scare article in Time.

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The Global Cardiovascular Risk Score: A New Performance Measure for Prevention

Everyone loves prevention. It may seem strange then, to learn that one of the biggest barriers keeping prevention from reaching its full potential is the current set of performance measures that, ironically, were created to promote them. The reason is that current measures are promoting activities that are inaccurate and inefficient. It is as though explorers who are trying to reach the North Pole have been given a compass that is sending them to Greenland.

This problem is being addressed by a new project conducted by NCQA and funded by the Robert Wood Johnson Foundation. The objective is to evaluate a new type of measure of healthcare quality called GCVR (Global Cardiovascular Risk). The new measure will have an important effect on the prevention of cardiovascular conditions.

To understand how, we need first to understand the limitations of current measures. For reasons that were appropriate when they were initially introduced – about 20 years ago — current performance measures were designed to be simple: simple to implement (e.g. collect the necessary data, do the calculations), and simple to remember and explain. This was accomplished in three main ways. One was to create separate performance measures for different risk factors. Thus there are separate measures for blood pressure control, cholesterol control, glucose control, tobacco use, and so forth.

While a performance measure for any one risk factor might take into account a few other risk factors to some extent, none of them incorporate all the relevant risk factors in a physiologically accurate way. A second simplification is that current measures are based on care processes and treatment goals for biomarkers, rather than on health outcomes. Thus a blood pressure measure asks if a patient with hypertension is controlled to a systolic pressure below 140 mmHG. A third simplification is the use of sharp cut points to determine the need for and success of treatment. For example, patients with hypertension are counted as properly treated if their systolic pressures are below 140 mmHG, otherwise not.

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Twitter Study of Vaccine Messages: Opinions Are Contagious, But In Unexpected Ways

Remember 2009? The H1N1 pandemic we were all waiting for? I do. I was pregnant; H1N1 was particularly risky for pregnant women. The vaccine wasn’t available until after I had my baby, but when they held a clinic an hour north of where I live, I brought my husband there so we could both get our shots. My infant son was too young to be vaccinated, so I wanted to protect him through herd immunity.

study came out recently on twitter messages from that time. How did pro-vaccine sentiments spread, versus anti-vaccine ones? Which messages were more contagious?

I talked to one of the authors, Marcel Salathe, today. He’s an infectious disease researcher studying the spread and transmission, not (just) of disease, but of information. “We assume people infect each other with opinions about vaccinations,” he said, and the H1N1 scare was a good opportunity to put some of his group’s theories to the test.

They collected nearly half a million tweets about the H1N1 flu vaccine. In 2009, H1N1 wasn’t included in the regular flu shot, and became available partway through flu season as a separate dose. With a possible pandemic looming, people had plenty of motivation to get the vaccine and encourage others to get it—butanti-vaccine sentiments were in circulation too.

The result, striking but perhaps not surprising: negative opinions were more contagious than positive ones. (Specifically, someone who read a lot of anti-vaccine messages was more likely to follow up by tweeting or retweeting negative messages of their own.)

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The Great Influenza of 2013?


The CDC has noted an early and nasty start to the flu season. Perhaps their own website has caught it, because as I’m writing this, the whole thing is down. Assuming it recovers, I will insert relevant links per routine. Otherwise, I wish it well, and leave you to find your way there on your own.

It’s a bit soon to say, but the virus and the outbreak pattern at this point seem to resemble those of the 2003-2004 flu season, in which nearly 50,000 Americans died. At least two children have already died of flu complications this fall.

This is not the sort of stuff a public health physician can ignore.

So, I recently noted on LinkedIn andTwitter that I’ve been vaccinated — as I am every year — and recommend this year’s vaccine, which appears to match the prevailing viral strain quite well, to everyone else. I promptly got comments back from naysayers, including at least one self-identified microbiologist, who noted he never got vaccinated, and had “never gotten the flu.”

I believe him. But this is like that proverbial “Uncle Joe” everyone knows, who smoked three packs a day and lived to be 119. It could happen — but I wouldn’t bet the farm on it. Uncle Joe is that rare character who somehow comes away from a train crash with a minor flesh wound. The rest of us are mortal.

But there is something more fundamentally wrong with the “I’ve never gotten the flu, and therefore don’t need to be vaccinated” stance than the Uncle Joe fallacy. Let’s face it — those who were ultimately beneficiaries of smallpox or polio immunization never had smallpox or polio, either. If they ever had, it would have been too late for those vaccines to do them any good.

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The Health of Nations

If all of us were simply to make better use of our feet, our forks, and our fingers — if we were to be physically active every day, eat a nearly optimal diet, and avoid tobacco — fully 80 percent of the chronic disease burden that plagues modern society could be eliminated. Really.

Better use of feet, forks, and fingers — and just that — could reduce our personal lifetime risk for heart disease, cancer, stroke, serious respiratory disease, or diabetes by roughly 80 percent. The same behaviors could slash both the human and financial costs of chronic disease, which are putting our children’s futures and the fate of our nation in jeopardy. Feet, forks, and fingers don’t just represent behaviors we have the means to control; they represent control we have the means to exert over the behavior of our genes themselves.

Feet, forks, and fingers could reshape our personal medical destinies, and modern public health, dramatically, for the better. We have known this for decades. So why doesn’t it happen?

Because a lot stands in the way. For starters, there’s 6 million years of evolutionary biology. Throughout all of human history and before, calories were relatively scarce and hard to get, and physical activity — in the form of survival — was unavoidable. Only in the modern era have we devised a world in which physical activity is scarce and hard to get and calories are unavoidable. We are adapted to the former, and have no native defenses against the latter.

Then, there’s roughly 12,000 years of human civilization. Since the dawn of agriculture, we have been applying our large Homo sapien brains and ingenuity to the challenges of making our food supply ever more bountiful, stable, and palatable; and the demands on our muscles ever less. With the advent of modern agricultural methods and labor-saving technologies of every conception, we have succeeded beyond our wildest imaginings.

So now, we are victims of our own success. Obesity and related chronic diseases might well be called “SExS” — the “syndrome of excessive successes.”

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