Endodoc

In today’s New York Times, there is an article entitled “Diabetic and Determined” written by Abby Ellin (New York Times. Thursday July 26, 2007, p E1). The article is all about type 1 diabetes and “ultra-athletes.” The basic message is that having type 1 diabetes shouldn’t keep a person from being an ultra-athlete if that’s what they want to do. I would agree and I was a bit surprised by the article as I thought this subject a non-issue in 2007. I guess I was wrong?

The effects of exercise on blood glucose

We will start with the assumptions that a person with type 1 diabetes can do any physical activities that a person without diabetes can do and at as as high a level of performance. This has been demonstrated many times in the laboratory and “on the field.” But, to achieve optimal performance, a person with diabetes must learn how to keep his blood glucose level in a reasonable range throughout the activity. This can be quite a challenge and requires much “trial and error” in figuring out what to do about the insulin dosing and caloric intake.

When a person exercises, the metabolic rate increases in proportion to the intensity and or duration of the exercise. This requires enegy which comes from stored carbohydrates, fats, and proteins. Initially, the major share of the stored energy comes from glucose in the blood stream. Unfortunately, there is only a very small amount of glucose in the blood and hypoglycemia (low blood glucose) would develop quickly unless the body could match, molecule for molecule, production of glucose to equal that used up for energy. Initially, that glucose comes from stored glucose in the form of glycogen (long chains of glucose molecules) in the liver and in muscle. As the exercise continues, the body converts stored fats and proteins into energy to fuel the exercising msucles while leaving enough to maintain the blood glucose level in a normal range (proteins can be converted into glucose through a process called gluconeogenesis). This is quite a feat and involves many hormonal and neuronal mechanisms. The key to all of these adaptations is insulin. With exercise and increased glucose utilization, the body decreases insulin secretion which allows stored glucose and other nutrients to be used for energy and to maintain the blood glucose level.

If I go out and jog 10 kilometers (6.2 miles), my blood glucose level will be well maintained or even may go up a bit and I don’t even need to think about it- my body has figured out just how much to lower my insulin level to allow the required amounts of glucose to be made available for the exercise while maintaining my blood glucose level. But, what if I had diabetes and took insulin injections or used an insulin pump and couldn’t count on my body to figure things out? That’s the challenge for a person with type 1 diabetes who wants to exercise.

Getting down to specifics

Today, I do not want to go into great detail on how a person with diabetes figures out how to keep his blood glucose level from falling too low (or climbing too high) while providing enough metabolic fuels for the exercise. Obviously, it involves some combination of adjusting insulin doses and caloric intake. Sometimes, people with diabetes can anticipate the exercise and lower the insulin doses before and during the exercise. Such an adjustment in insulin may allow the normal mechanism of releasing stored glucose into the blood to work as in people without diabetes. Sometimes, taking in calories to mimic the release of stored glucose is necessary (e.g, ingestion of glucose-containing liquids or solids). For very long periods of exercise, ingestion of foods containing protein and fat may also be necessary. My point is that with some practice in figuring out the insulin/calorie factors, anyone with type 1 diabetes can expect to do as much exercise as they choose and do it well.

Most physicians who specialize in managing patients with type 1 diabetes should be quite experienced in helping their patients develop exercise plans. Particularly with the introduction of insulin infusion pumps and multiple injection insulin regimens over the past 25 years, the task is much easier than it used to be. In 2007, no one should be telling people with type 1 diabetes that they can’t do this or can’t do that, and that includes vigorous exercise programs.

The “buzz” today among medical journalists is about an article published today (available to subscribers and news organizations yesterday) in the New England Journal of Medicine. The article was written by Nicholas Christakis and James Fowler and entitled “The Spread of Obesity in a Large Social Network over 32 Years.” The citation is New Engl J Med 2007;357:370-9. There was an article about the study today in the New York Times ( “Find Yourself Packing It On? Blame Friends,” written by Gina Kolata- Thursday July 26, 2007, page A1). There was also a piece on National Public Radio. I’m sure this study will be widely reported on.
The scientists studied a network of people who were part of the famous Framingham Heart Study which was initiated in 1948. The authors actually started with the “offspring cohort” from the original Framinham subjects (n= 5124) and created a network data set which included both original Framingham study subjects and offspring cohort subjects. Linkage between the offspring cohort subjects (called “egos”) and other Framingham study subjects (called “alters”) was based on marriage, sibship, and friendships. A total of 12,067 people ended up as either egos or alters.

So, what’s with these egos and alters?

The authors took their carefully constructed social network and studied if obesity was related to the linkage, much like one might study epidemiology of an infectious disease. Obesity was defined as a BMI 30 or greater (if you forgot what a BMI is check out one of my earlier entries). The study included only people older than 21 years of age. The average age of the study subjects at the start of the study was 38 years and 53% of the subjects were women. The data collection was from 1971-2003. The 5124 egos from the offspring cohort had 38,611 observed family and social ties (e.g., spouse, neighbor friend).

The authors found that obesity in this study population was in clusters related to the social contacts. Thus, if a person (the ego) had a friend (an alter) who became obese during the period of observation, the ego was 57% more likely to also become obese. If the friend was a “close friend,” the risk was increased by 171%. Risks were increased with sibs and spouses but not with friends of the opposite sex or with neighbors. So, what this all means is that having a friend or a spouse or a sibling who is or who becomes obese, means that you are much more likely to also become obese. The converse is also true; if one’s relations and friends are lean, he is more likely to remain lean.

Ok. Now what?

I find the data interesting but not so surprising. Many previous studies have demonstrated, at least within families, the effects of parental obesity on their childrens’ weights independent of genetic influences. The authors of the study speculate that the social influence on the spread of obesity can perhaps be “harnessed” to to slow the epidemic. The authors are a bit fuzzy as to how this actually might be accomplished. It would appear from their data that the best approach would be to have people at risk for obesity (most Americans) or those who are already obese hang out only with thin people. Of course, some of those thin people might be smokers and the person hoping to avoid the bad influence of being around someone who will become or who is already obese might be trading one “evil” for another.

When and if all of this ever gets sorted out, I think it is likely we will find that there are many reasons for the observed clusering of obese people. For some it will be shared acceptance of the obesity resulting in less anxiety about the problem. For others, it will be similar lifestyles, eating, and exercising habits that promote the obesity. I doubt many friendships are based on the idea that “opposites attract.” People generally want to be around people who are like them. I view the data as just one more interesting piece of information about the environmental causes side of the obesity epidemic (the other side is genetics). Whether we can take these data and use them to help people trim down other than by abandoning their overweight friends and relations remains to be seen. I for one intend to screen my new prospective friends by having them submit their BMIs to me for review.

The title of my entry is identical to the title of an article written by Brooks Barnes that appeared in the New York Times today (July 18, 2007, page C1). Basically, the article summarized the recent activity by 11 big food companies to change the way they advertise food to children on TV. The companies are scrambling given several law suits and the prospect of federal intervention. I find all of this quite interesting and it would also be amusing if the subject matter did not involve advertising to children for foods that are probably not so good for them. It is interesting that the food companies differentiate between “family” TV programs and those almost exclusively for children- it’s ok to advertise whatever if some adults are watching, even if many of the viewers are children and the foods being advertised are primarily for children.

Anyway, I think it’s all a little crazy and, in my opinion, the food companies are entirely disingenuous. On the other hand, maybe we are trying to blame the food companies for the poor choices that parents make? When is the last time you saw a 4 year old racing home from the supermarket on his tricycle with a box of Cocoa Puffs under his arm?

So, did you know most of the answers to the nutrition quiz I gave you yesterday? The Hostess Twinkies question was just for fun and I wouldn’t have expected you to know the answer.

1. What is a trans fat- trans fats are unsaturated fats that have been modified by adding hydrogen atoms to them making them more saturated. The term “trans” refers to the way the molecule bonds are configured (bonds can be cis or trans). Trans fats were first synthesized in the early 1900s and their special virtue is that they tend to stay solid at room temperature, making them ideal for processed foods. I think Crisco was the first commercially available trans fat product but I’m not certain. Trans fats are typically made from plant fats, particularly those derived from corn and soy beans. Your Hostess Twinkie wouldn’t be so appetizing if the fat used to make the product was in a liquid form sloshing around in the package. Trans fats are a problem only because they are associated with a greatly increased risk of heart disease. That has turned out to be enough of a problem that food manufacturers are working hard to find ways to make various food products withoiut having to use trans fats. I think New York City has banned trans fats in restaurants and many fast food chains have or are figuring out how to eliminate trans fats in their products. Personally I don’t believe that eliminating all trans fat-containing foods will have much of any impact on health given the very small percentage of total fats we consume that have been trans fats. But, why not?

2. How many calories per gram of fat, carbohydrate, and protein and so what? The answers are 9 calories per gram of fat and 4 calories per gram for carbohydrates and proteins. That means fats really concentrate the calories and that’s not good if one eats lots of fats and is concerned about weight. In scientific terms, it’s a good thing fats pack a lot of calories for the weight- just think how much people would weigh if they maintained the same energy stores as now but doing it in the form of protein or carbohydrate- it would be a disaster. So, think of fat as an engineering marvel not as an unsightly body component (it is also a great insulator on those cold winter days).

3. Supermarkets and corn- about 70% of foods at the supermarket are in part corn-derived. That’s pretty amazing. Much of the corn is in the form of high fructose corn syrup.  That figure also includes the portion of meats that are in part corn-derived (all that “corn-fed beef”).  Scientists can actually track the carbon molecules from corn and see how much of whatever food has the corn carbons.  If we are what we eat, we are mostly corn.

4. Calories and grams of sugar in a “regular” soda- a standard 12 oz soda has about 41 grams of sugar (mostly from high fructose corn syrup) or 8 teaspoonfuls for about 160 calories.

5. Twinkies- according to a program I watched on the Travel Channel the other day, last year 500 million Twinkies were eaten in the U.S.  That’s about 80 billion calories if my math is correct. Wow.  By the way, they get the cream inside the Twinkies by injecting the cream through the bottom of the Twinkie.

There was an interesting article in the New Y0rk Times today written by Roni Caryn Rabin and entitled “Calorie Labels May clarify Options, Not Actions” (NYT Tuesday July 17, 2007, page D6).  The article summarized quite a bit of data on the effects of food calorie information on food choices when people eat out.  In summary, data show that consumers want to have such information available (New York City has a law requiring that fast food and chain restaurants post calorie information on the menu or menu board) but such information does not often get consumers to make lower calorie choices- studies show (no references included) that only 10-20% of diners would choose lower calorie options knowing the calorie content of various menu items.  That’s a rather interesting disconnect between knowledge and action.  It’s like the lecture I gave last week to our University Hospital Pediatric Department entitled “Why there so much childhood obesity and what to do about it.”  The lecture was well-attended and the audience was attentive and asked great questions but guess what they had to eat at the sign-in table?  Glazed donuts!  As part of the talk I gave a “nutrition quiz.”  I was surprised to learn how few people knew even some of the answers.  How would you do on the test?  The questions were as follows:

1. What are trans fats and what’s good about them and what’s bad about them?

2. How many calories in a gram of fat?  Is that good or bad or both good and bad?  How many calories in a gram of carbohydrate?  What about in a gram of protein?

3. What percentage of foods in a supermarket are derived at least in part from corn?

4. How many grams of sugar and calories are in a “regular” soda?

5. How many Hostess Twinkies were eaten in the U.S. last year and how many calories total does that represent?  How do they get the cream filling in the twinkies anyway?

I’ll post the answers to the quiz in the next day or so.

What happens to children with chronic diseases who become adults with chronic diseases?

Over the past 2 weeks I had 2 rather disquieting experiences that demonstrate some of the flaws in the U.S. health-care system (I use the term “system” only for convenience since some would question whether we actually have a health-care system). Both situations involved patients with type 1 diabetes mellitus trying to make the transition between childhood and young adulthood. One patient is a young woman, we’ll call Kathy; the other a young man, Kevin. Both reside in Southwest Missouri and both have been patients of mine since they were diagnosed with diabetes as infants. Both have just finished high school. Kevin is college-bound and Kathy is interested in becoming a phlebotomist. Both have been on Missouri Medicaid long-term; their parents work but have rather low-paying jobs without health insurance.

Kevin

Kevin turned 19 last week and no longer has any health-care coverage. He could obtain high-deductible health insurance through the State of Missouri “High Risk Insurance Pool” at about $800 per month. At present, the patient and family cannot afford the insurance plan thus putting Kevin in the category of “self-pay patient.” Hospitals and clinics use this term for patients who do not have health insurance or have a plan that will not cover health-care costs for the patient at that health-care facility or will not cover a particular diagnosis or procedure. The hospitals and clinics often equate “self-pay” with “no pay,” which is not always true. Regardless, medical facilities generally require a large down payment on the estimated cost of the care before service is given (emergencies are exempt, but one had better be sure it’s really an emergency- you need a medical degree to assess whether it’s really enough of an emergency).

Back to Kevin- he and his parents now have to pay for the diabetes care and supplies out-of-pocket which comes to about $4000 per year (he is on an insulin pump and does very well with his diabetes care). He had planned to attend the University of Missouri and was set to come for freshman orientation a few weeks ago. Unfortunately, the family did the math and determined that even with loans and what scholarships Kevin could obtain, the college costs and the health-care costs were beyond them. Ironically, had he gone to “Mizzou,” he was eligible for a fairly decent health-care plan at about $200 per month provided by the University. So for now, Kevin will attend a local technical school with a goal of obtaining training as a radiology technician. To keep costs down, he will live at home and work part-time. The only good thing about all of this is that he was able to get an appointment with a diabetes specialist for routine care. It was especially good that Kevin was no longer on Medicaid as that physician, like may others in the region do not accept Medicaid patients!

Kathy

Miss Kathy is a nit more complicated than Kevin. She dropped out of high school a year ago and is working at a fast-food restaurant. She intends to get her GED this summer and is interested in becoming a phlebotomist. She is 17 and still on Missouri Medicaid. She has a great primary care physician in the Joplin area who is not afraid of Mediciaid patients. I saw Kathy in clinic the other day and recommended that she transfer to adult diabetes care since she is a young adult. I gave the family the names of several endocrinologists in the Springfield, Missouri area that I know and suggested the family set up a routine clinic visit with one of the physicians. I heard back from the family today that neither physician is accepting any Medicaid patients.

I could have called the physicians and begged them to take the patient but I was not in the mood for begging. I contacted a phycisian in the Joplin, Missouri area (closer for the family than Springfield, Missouri) who is an endocrinologist and she cheerfully agreed to see the patient. The Mediciaid coverage will run out in about 16 months. I hope that by then the patient will have a job with good health coverage.

What is my point?

I don’t mind spending the time to help sort things out for my patients but it’s getting irritating how difficult it is becoming. Medicaid patients are clearly “second class” citizens in the eyes of most health-care providers and medical institutions. Even at my academic medical center, it is a well-known “secret” that many attending physicians will not see Mediciad patients except in their resident physician teaching clinics. Not even professors are immune to class bias.

What is the problem?

There are lots of problems with the U.S. health-car system but one of the most serious is that physicians are not taking the “high road” in the care of patients with no insurance, or even worse, Medicaid. We as physicians have a reponsibility to care for patients whatever their health insurance status. For sure, Mediciad is a very bad system but that’s a different issue than providing patient care. We also need to consider the long-term costs of not providing high quality medical care to patients with chronic diseases, regardless of ability to pay; for example, as I discussed in an earlier entry, the costs of paying for the treatment of preventable diabetes complications, is much greater than just preventing them! What a mess we have.  In a future entry, I will attempt to offer some simple solutions to our health-care chaos.

Background

Last week I heard an interesting piece on NPR radio. A physician from the University of Rochester School of Medicine had just published a study entitled “The Value of Physician Self-disclosure.” I must confess that I am not certain that is the exact title and I have not read the scientific article which was published in ? The Archives of Internal Medicine (I wasn’t listening all that carefully and I was on vacation anyway). Apparently, the author and her colleagues recruited 100 physicians who were willing over a one-year period to see two actors posing as patients. The fake patient visits would be taped and reviewed by the investigators for the quality of the physician interview technique. The physicians would not know who the intruders were.

The results

Apparently, the investigators found that so-called “physician self-disclosure” or MDSD was rampant and took up valuable patient time and was often distracting- by MDSD the investigators meant physician talk about his own life that had nothing to do with the patient’s problems at hand. The NPR interviewer asked if the results suggested that many physicians were just lonely and starving for friendly conversation. The interviewee seemed to think that was a reasonable hypothesis.

What do I think?

I had a number of concerns with the study design and the conclusions but I wanted to wait until I was back in my office and seeing patients again before I took to the website. I am now ready to offer some comments on the study. First, I believe the study design made it almost impossible to assess in any meaningful way if the MDSD was in fact a distraction or a useful part of the interview. Without video, there was no way to tell if the chitchat was during part of the physical examination as a way of allaying possible patient anxiety, or as a way of responding to some patient body language during the interviewing process. Deciding that a physician comment was not relevant to the interview process in some way would have to be highly subjective and I suspect there was an initial biais even before the data were analyzed that physicians waste a lot of patient time. In summary, I would caution people to consider the serious flaws in this University of Rochester study when they think about physician-patient interactions. I do believe that physicians waste quite a bit of patient time but that is mostly while the patient sits in the waiting room for what seems like an eternity before they actually get to see the doctor who often is in such a rush that the patient would have liked more time and maybe even some idle chitchat.

Patient interviews

In my experience, the interview process is a very complicated one and there is a real art trying to get the patient to have confidence in the physician’s skills while trying to get as much necessary information as possible, while trying to allay patient anxiety, and while trying to get the patient to follow the treatment plan (if any) with enthusiasm. That last sentence was quite a mouthful but it’s really what the physician-patient interaction is all about. I don’t think that audio tapes from fake patient visits can assess that complicated process very well. I would hate for some researcher to listen in on my patient visits, particularly those with patients I have been seeing for many years. There is rarely much discussion about anything medical and I surely display a great deal of MDSD (usually because the patient has asked me about my grandchildren or something else of no medical relevance). These patients see me because I am a friend and confidante, and maybe because I am also a medical expert. They rarely need me to give them any specific medical advice; most know just what to do and need mainly encouragement to “keep at it.” Like I said, the physician-patient interaction is very complex. I’d limit those tape recordings to good music.

Background

The other day I heard a report on NPR about a young man who apparently was on an Amtrack train and started to act strangely. The conductor thought the problem was drug or alcohol-related and stopped the train somewhere in New Mexico and escorted the young man off the train which was their policy. The young man apparently then ran off into the woods but fortunately was later retrieved by local officials who eventually sorted things out.

Mystery solved

As it turns out, the young man had been diagnosed with type 1 diabetes the day before and had been started on insulin injections. His strange behavior was in fact drug-related but nothing illicit- it was hypoglycemia (low blood sugar) from his insulin injections. The Amtrack officials claimed they were “just following their written policies.” This is not the first time I have heard of patients with diabetes who were having hypoglycemia thought to be strange behavior due to drugs or alcohol. I remember one patient of mine from several years ago who went to New Orleans for Mardi Gras. He had type 1 diabetes and was generally in excellent control. Apparently he had 1 drink (his blood alcohol level was not elevated) and became hypoglycemic, probably from increased activity and insufficient food intake. He began acting strangely and decked a police officer who was trying to arrest him for likely alcohol intoxication or illicit drug effects. The unfortunate young man was beaten by the police and jailed until he developed diabetic ketoacidosis 3-4 days later- no one had bothered to believe what the young man was saying – that he had diabetes and was having hypoglycemia. The patient did survive the ordeal but barely.

So?

These two stories (I could curl your hair with story after story about the effects of hypoglycemia in patients with diabetes- not all of them ended well) illustrate how important it is for people who take insulin or other medications that can cause hypoglycemia (e.g., sulfonylureas) to take precautions when away from peple who know about their diabetes and how to recognize and treat hypoglycemia. For sure they should wear a medical ID- a necklace or a bracelet that identifies them as having diabetes. They should also carry a wallet card that identifies them has having diabetes (and what should be done if they are found unconscious or acting strangly). They should also carry some form of rapidly-acting carbohydrate such as glucose tablets (available at most every pharmacy). They should also test their blood sugar levels frequently and ALWAYS before driving a motor vehicle or undertaking a potentially hazardess activity (e.g., scuba diving).

What else?

People who deal with the public, particularly those who might have to deal with emergencies (e.g., police, firefighters) need to be trained to consider hypoglycemia when dealing with a person who exhibits stange behavior, has a seizure, or is found unconscious- all EMTs know to always rule out hyopglycemia when dealing with such behaviors (they also know to check for medical IDS!). I would be willing to bet that the youg man on the train was not wearing a medical ID and I know my Mardi Gras patient was not wearing an ID.