Monthly Archives: March 2010

FYI: What About Health Care Reform?

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I want to call to your attention a series of very interesting and important articles published in the New York Times Science Times Section yesterday (Tuesday, March 30, 2010).  The articles do a pretty good job of summarizing what’s what about the new health care bill passed by Congress.  I would particularly recommend two of the articles.  The first is entitled “What you need to know in the first year” and was written by Tara Parker-Pope.  The second is entitled “Law may do little to help curb unnecessary care” and was written by Gina Kolata.  Some of the other article titles include:  “No matter what, we pay for others’ bad habits,” “Overhaul will lower the costs of being a woman,” and “What the health care overhaul could mean for you: do you have health insurance now?”  I think the various articles provide a fairly good overview of what the new law is likely to do and not do.  I will offer no opinions on the subject except to say that I hope the new health care legislation is “a work in progress.”  What I mean is that if the new health care bill was a college course exam, the grade would be “incomplete.”  It is interesting, however, that so far every patient I have talked to has  told me the new law would help them out.  We’ll see.

A TV Show about School Food in West Virginia, a New York Times Story on Workplace Efforts to Improve Health, and an Article in the New England Journal of Medicine Article on the Prevelance of Diabetes in China: What do They Have in Common?

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I just want to give you a heads-up on 3 very interesting media pieces that address a common theme: why are people in the U.S. (and now elsewhere) so unhealthy and what can be done about it?  The first is on ABC-TV and called Jamie Oliver’s Food Revolution.  It is a series of shows on every Friday evening but I don’t know for how long.  I saw the first show on Hulu.com last evening.  Even if you hate TV except for the NCAA basketball tournament, this is “must see” TV.  Don’t take my word for it.  Check out Marion Nestle’s blog today on Huffingtonpost.com.  In summary, the show is about Jamie Oliver’s efforts to improve school lunches in Huntington, WVA.

The second media piece was in the Business section, page 5 of the New York Times, Sunday March 26, 2010.  The piece is entitled “Carrots, Sticks and Lower Premiums” written by Steve Lohr.   The article addresses the mostly unspoken truth that health care reform in the U.S. would benefit in an extraordinary way if all of us lived healthier lives.  Data do show that 50-70% of our nation’s health care costs are preventable, mostly attributable to treatment for chronic complications that mostly related to unhealthy behaviors.  The article is about how employers are beginning to wake up to the fact that it is good business to have healthy employees.  Read the article.

The third piece is an article that appeared the other day in the New England Journal of Medicine (March 25, 2010).  The title of the article was “Prevalence of Diabetes among Men and Women in China” and written by Wenying Yang and colleagues.  The investigators studied whether the rapid change in lifestyle in China has increased diabetes prevalence.  The study population included 46,239 adults, 20 years of age or older, from 14 provinces and municipalities tested between June 2007 and May 2008. The results were astonishing.  China is catching up with the U.S., and I’m not talking about their economy.   The age-standardized prevalences of total diabetes (previously undiagnosed and previously diagnosed diabetes)  were 10.6% in men and 9.7% in women.  For prediabetes (abnormal blood glucose levels but not diagnostic for diabetes), the prevalences were 16.1% in men and 14.9% in women.  The data showed a sharp and steady increase in the national prevalence of diabetes from surveys conducted in 1980, 1994, and 2001 (e.g., prevalence in 1994 was 2.5%).  Not surprisingly , the prevalence was considerably higher in urban residents than among rural residents.  The investigators concluded the following: “that diabetes has become a major public health problem in China and that strategies aimed at the prevention and treatment of diabetes are needed.”

So?

I don’t think I really need to explain how the 3 media pieces relate to one another.  The prevalence of diabetes in China is now just about the same as the prevalence in the U.S. (prevalence of 9.6% based on the National Health and Nutrition Examination Survey 2003-2006).  It’s the price we now pay globally for our economic advances coupled with our genetic predisposition to obesity and diabetes (check out some of my old entries if you have forgotten).   Jamie Oliver knows what do do about the problem in both the U.S. and China and so do employers trying to get their employees healthier, and so do you.

A Guest Entry: Benefits of Exercise in Patients with Type 2 Diabetes

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With this entry I want to try something new- a guest blogger.  I hope you like the article and the idea of having guest articles from time to time.  If you have comments, let me know or contact the guest blogger directly.  I should mention that the opinions in guest articles are not necessarily how I might think about things but I think it’s good to get different points of view.

What Everybody Ought to Know About the Benefits of being fit if You Have Diabetes: Effects of Exercise on Blood Glucose Levels

Written by Sue Rollins

Did you know that you can more easily manage your diabetes just by engaging in regular exercise?  Exercise generally has a very beneficial effect on blood  glucose levels in people with type 2 diabetes. When you engage in exercise, you expend a lot of energy.  This first comes from the glucose stored in your liver and your muscles.  At first, the body simply uses up the stored glucose (in the form of glycogen).   Thus, engaging in exercise does not mean your blood glucose levels will necessarily fall to dangerously low levels.   The situation is somewhat different in people with type 1 diabetes and in people with type 2 diabetes who take medications that can cause hypoglycemia.  Often these people need to take snacks at regular intervals during exercise to avoid hypoglycemia.  The body is very clever and has a number of mechanisms to prevent the blood glucose level from falling too low.  For example, with exercise and also if the blood glucose level drops below normal, glucagon, a hormone stored in the pancreas gets released.  This hormone promotes further release of glucose stored in the liver.  The same is true of the hormone epinephrine, stored in the adrenal cortex.  If one does enough exercise to use up most of the stored glucose, the body can make “new” glucose from the breakdown of proteins.  Also, breakdown of fats will occur, providing an alternative source of  energy, thereby “sparing” glucose stores.  In addition, regular exercise actually increases a person’s insulin sensitivity, making the insulin they produce (or take), more effective in controlling blood glucose levels.

Why is the effect of exercise on glucose levels important to those with type 2 diabetes?

Exercise indeed has a good effect on a patient’s glucose level. This is good news for people who have type 2 diabetes. A lot of research indicates that patients of diabetes gain more control over their diabetes as soon as they get into to a regular exercise program.  Since exercise improves your insulin sensitivity, you may need less medication in order to control the diabetes.

Should patients with type 2 diabetes exercise more often or differently than otherwise healthy people?

Experts recommend that people who have type 2 diabetes should exercise about 30-60 minutes (usually only moderate aerobic activity) at least 3 days a week.   Any amount of exercise is better than no exercise.

What type of exercise is best for patients with type 2 diabetes?

Most experts believe the frequency of the exercise routine is more important that the specific kind of exercise one engages in. Ideally, the exercise program will include aerobic activities and include some weight training.

When should patients be discouraged from exercising?

Some patients have a higher risk of developing injuries from the stress of an intense exercise program. Such patients include those with preexisting diabetes eye disease, hypertension and other cardiovascular risks.  Obviously, those who have been  leading sedentary lifestyles. need to take it slow and easy.  All patients should be thoroughly evaluated by their physicians before beginning a new exercise program.

About the Author – Su Rollins writes for <a
href=”http://www.hypoglycemicdiet.org”>reactive hypoglycemic diet</a> ,
her personal hobby blog focused on tips to prevent and cure hypoglycemia
using the right diet and nutrition.

To Test Or Not To Test, That Is The Question: A Patient With Enlargement Of The Thyroid?

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The Question

The other day I got into a discussion with a primary care physician (PCP) about a hypothetical patient.  We had been discussing a case history for an upcoming medical student examination.  The patient was a 40 year old female with a medical history suggesting hypothyroidism.  The physical examination revealed an enlarged thyroid gland.  The question was as follows: what thyroid function studies should be ordered?

The Answer

The PCP said that he would order total thyroxine (TT4), free thyroxine FT4), and thyroid-stimulating hormone (TSH).  I was a bit surprised by his answer and asked if he didn’t also want to order thyroid peroxidase (TPO) antibodies?  He replied something to the effect that in the “real world” docs don’t mess with that kind of stuff.  I became even more surprised and then asked him whether he thought it was important to know what one was treating.  He got a bit hostile and replied that if the TSH were high and the FT4 and TT4 levels low, he would have a diagnosis, primary hypothyroidism.  He explained that the cost of the TPO antibodies (about $50-$80) depending on the laboratory) was not worth the benefit.  My response was “hmmmm.”

What did I really think?

I did not agree with the PCP’s approach to the hypothetical patient but I did not go ballistic since there was some merit to his argument.  On the other hand, it is my opinion that testing for TPO antibodies in the patient described above is worth the modest extra expense.  First of all, as a general principle it is important to know what one is treating.  While primary hypothyroidism is a diagnosis, there are many different causes for the condition and the approach to treatment might well be dictated by the specific etiology.  In those parts of the world where iodine deficiency is not endemic, the most common reason by far for primary hypothyroidism is chronic lymphocytic thyroiditis (CLT) or Hashimoto’s thyroiditis as it is commonly called.  This is an autoimmune disorder which is highly prevalent in females, particularly those over 40 years of age.  As I have discussed in previous entries, the physical examination often offers clues to the diagnosis; in my experience, careful examination of the thyroid gland will reveal a small lymph node on the left, just above the thyroid isthmus.  This node is called a delphian node and its presence means the patient has either CLT or autoimmune hyperthyroidism or Graves disease.  I can’t remember if I have ever had a patient with a delphian node who did not have positive thyroid antibodies.

Anyway, the differential diagnosis of primary hypothyroidism includes CLT, goitrogens (mostly iodine-containing products), familial inborn errors of metabolism (genetic abnormalities of the various steps to synthesis of thyroid hormones or their degradation), gland dysplasia (e.g., hemithyroids), and other rather uncommon entities.  I find thyroid antibodies most helpful when the TSH and FT4 come back normal (I can’t think of any reason to order TT4 but that’s a topic for another time).  The question becomes why is the gland enlarged (here we are assuming that the physician is skilled at telling when a thyroid gland is enlarged rather than there just being a prominent fat ring around the neck)?  It is still likely that the patient has CLT or possibly a so-called simple colloid goiter an entity I don’t understand; I don’t even know if the disorder exists even though almost all textbooks that cover thyroid disorders list it in the differential diagnosis of goiters (a goiter is just another way of describing an enlarged thyroid gland).  If the patient has CLT and enlargement of the thyroid, many endocrinologists will recommend treatment with replacement doses of L-thyroxine to “put the gland at rest.”  There are some data suggesting that such treatment can prevent progressive destruction of the gland which can occur; a number of studies have shown that TPO antibodies are cytotoxic even though most of the inflammation in CLT is lymphocyte-mediated.

So, it’s not so simple deciding what laboratory tests to order or not to order.   I will return to my original argument that whenever possible it’s good to know what specific disorder is being treated with medications, or  maybe, even if the treatment is just observation.  But I can sort of see the PCP’s point of view, sort of.

Health Care Reform: Status Report

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As those of you who have been reading my various entries over the past 18 months may have noticed, I have been a bit heavy on the U.S. health care debate and light on the endocrine issues.  I apologize to those of you who are weary of hearing anything more about health care , but for me as an endocrinologist who cares for many patients with chronic medical conditions, particularly those with diabetes, having a first rate health care system is important; it doesn’t matter how brilliant a physician I might be if my patients can’t afford to get the services they need or to buy the medications they need.   Anyway, I wanted those of you who may be skeptics about the  benefits of health care reform as proposed by President Obama to check out an op-ed piece that deserves attention.  The article was written by Paul Krugman, the Nobel Prize-winning economist and entitled “Health Care Reform Myths,” and published in the New York Times March 11, 2010. I agree with most of what Dr. Krugman wrote and I liked the fact that he kept the rhetoric reasonably apolitical.

My Westminster College Lecture

As long as I’m writing about health care, I might as well tell you that the other day, I gave a lecture at Westminster College in Fulton, Missouri.  Fulton is only about 25 miles from my home town, Columbia, Missouri, and the county seat of Callaway County, named for James Callaway,the grandson of Daniel Boone.  Fulton (population 13,000) is  known mostly for having 2 excellent colleges, Westminster and William Woods, and for the Winston Churchill Memorial and Library(WCML).  The WCML is located on the campus of Westminster College and is the site of Churchill’s famous “Iron Curtain” speech.  Many world leaders have visited the site and have given important speeches, including the one by then Soviet President Mikhail Gorbachev who announced the end of the Cold War and the fall of the “Iron Curtain.”  My not yet famous speech in Fulton was entitled “Chaos theory in action: The U.S. health care system.”

I spoke to a class of about 35 students in a course that examined a wide range of controversial contemporary issues.  I have no idea why the course director, Professor Margot McMillen thought U.S. health care might be a controversial issue.  Anyway, I tried my best to provide the students with a framework for understanding the current U.S. health care reform debates rather than focusing on my opinion on how to fix the problems.  I tried to keep the discussion apolitical which, I have learned, is the best way to get people on both sides of the debate to listen.  I focused primarily on describing the cost-generating components of the system.  I divided those components into 2 large categories, government and non-government.  On the government side was Medicare, Medicaid, U.S. Public Health Service (Indian Health, Etc.), Veteran’s Administration, Military (active duty members and their families), and miscellaneous (e.g., Community Health Centers).  On the other side was private insurance and self-pay (this included out-of-pocket health care expenses for even people with insurance or Medicare or Medicaid).

For each  component I tried to describe its history and current status, including costs and my take on its weaknesses (e.g., difficulties that many people on Medicaid have in finding physicians willing to see them).  I then tried to address what most experts feel are the 2 most important problems with the current U.S. health care system, lack of access and high and ever increasing costs.   By the end of the hour, I think most of the students understood enough about the issues to critically critique the various health care proposals that  bombard us if we read newspapers, watch television, or listen to the radio.  Apparently, each student will be required to write a paper about the lecture.  If Professor McMillen will give me permission, I want to read the students’ papers.  Did I actually teach them anything or do I need to “go back to the drawing board” to find a better way to educate people about the U.S. health care system?  Maybe, as the title of my lecture suggested, I should just give up trying to bring order to chaos?