Understanding Your Food and Biotechnology (Part 1)

Posted on November 11, 2015 by gutsandgrowth

Yesterday’s blog post summarized a recent talk by Ronald Kleinman, MD: Biotechnology, Nutrition, and Agriculture: A Perspective and Implications for Child Health. Given the prevalence of misinformation on this topic, I am spending the next few days elaborating on this lecture. The full lecture (video and slides) will be available on the Nutrition4Kids website.

Genetic Engineering Has Allowed Development of Vaccines

Biotechnology in Our Foods is Ubiquitous

Biotechnology Has Reduced Mortality Dramatically

Genetic Change in Crops is as Old as Agriculture. There would not be corn as we know it without crop breeding.

Key points:

Genetic engineering has not only improved our food supply but has been essential in innovations like vaccines and insulin.
Biotechnology is ubiquitous. It’s not just crops, but cheese, wine, etc. Biotechnology has led 16,000 fewer children dying each day compared to 1995; this is largely due to biotechnology. Improved food security and less malnutrition results in fewer secondary complications (eg pneumonia, diarrhea).
Genetic change in foods is as old as agriculture. Lots of vegetables/crops were not found in nature, including corn and wheat. Cross-breeding allowed development of modern corn and wheat.

More tomorrow…

War on Science and Genetically-Modified Food

Posted on November 10, 2015 by gutsandgrowth

In the battlefield of ideas, science is losing badly. The problem with science is that many concepts are complex and sometimes difficult to communicate. For anyone interested in the science of food, and not the hysteria, a great lecture on this topic was presented by Ronald Kleinman, MD: Biotechnology, Nutrition, and Agriculture: A Perspective and Implications for Child Health

Stanley Cohen, Jeff Lewis, Evelyn Johnson (Georgia AAP President), Ronald Kleinman, and Jay Hochman at the Georgia AAP Nutrition Symposium.

I had the opportunity to participate and moderate a nutrition symposium at the Georgia American Academy of Pediatrics (AAP) pediatric meeting. This symposium was sponsored by Nutrition4Kids and funded by an educational grant from Nutricia. The first lecture was given by Dr. Kleinman. He is Chief of the Department of Pediatrics at Massachusetts General Hospital and Physician-in-Chief at MassGeneral Hospital for Children (MGHfC) and Partners Pediatrics. This was a fabulous talk and will be available at the Nutrition4Kids website. This blog post is a summary of the talk. Over the next few days, a couple of these ideas will be discussed further. Key points:

Genetically Modified Foods/Genetically modified organisms (GMO). These foods are safer and better than foods that are not genetically modified.
Roundup is not dangerous for humans. With biotechnology, we can kill weeds without killing plants. Thus no till farming is needed. Current herbicides are much safer than prior agents. Humans, unlike plants, do not have the enzyme that roundup targets –so it is safe. Roundup is water-soluble; it is not stored in fat. There is a 30 yr hx/o safe use. There is no data indicating cancer risk in humans or fertility risk. In the past, testing breastmilk for roundup used a flawed methodology. F/u study by McGuire M (sponsored by US govt) showed no roundup in breastmilk.
GMOs are part of a larger “War on Science.” As with vaccinations, there is a great deal of misleading and exaggerated information.
Genetic engineering has not only improved our food supply but has been essential in innovations like vaccines and insulin.
Biotechnology is ubiquitous. It’s not just crops, but cheese, wine, etc. Biotechnology has led 16,000 fewer children dying each day compared to 1990; this is largely due to biotechnology. Improved food security and less malnutrition results in fewer secondary complications (eg pneumonia, diarrhea).
Genetic change in foods is as old as agriculture. Lots of vegetables/crops were not found in nature, including corn and wheat. Cross-breeding allowed development of modern corn and wheat.
Why is it false to talk about genetic modification as a special category? It’s all DNA which is undergoing constant change. Traditional breeding allows selection of random multiple genes and then selecting plant we like. Biotechnology is more precise and safer (eg. only the gene for sweetness for corn is transferred, so can be more safe).
240 Agencies have confirmed that biotechnology is safe because of the testing that shows these agents are at least as safe as ‘natural’ products. 2500 studies of GMO products from across the globe (not just Monsanto!) have proven the safety of these products.
Most of GMO-farming occurs with small farmers (90% in developing world) who are not rich; these products result in income gains of greater than 30%.
Why is there such widespread adoption of GMO products by farmers? They are better: insect resistance, herbicide resistance, viral resistance, and drought/salt resistance
Other examples of beneficial biotechnology: a) BT Corn — safer, less liver cancer, less birth defects (eg. myelomeningocele) b) Golden Rice –can solve iron & vitamin A deficiency. Vitamin A deficiency contributes >1 million deaths/yr due to increased susceptibility to infections. Golden Rice in normal quantities provides RDA of Vit A. This is a lot more effective and less expensive than a supplement. These products are not commercially available even though nonprofits willing to give seeds for free –due to hysteria, politics. Greenpeace has actually burned Golden Rice rice fields.
Drought-resistant crops are becoming increasingly important. Meeting global food production will require more ‘crop per drop’ due to increasing population and less lands available for farming. Not just 3^rd World –look at California. There are low crop yields in areas without biotech (Subsaharan Africa) and higher mortality.

Unfortunately, shortly after hearing this lecture explain in great detail why GMO-containing products should be praised and not shunned, I picked up a drink. Here’s the label:

Bottomline: The science is sound. Biotechnology and GMOs/genetically modified foods are making are food better, safer and reducing mortality. If only we could communicate this fact effectively.

Related blog posts:

Do We Need Lie Detector Tests for Research Participants?

Posted on November 3, 2015 by gutsandgrowth

“Misconduct by research participants is a serious problem” (DB Resnick, DJ McCann. NEJM 2015; 373: 1192-3).

While research deception by investigators receives a great deal of attention, apparently research participants often fabricate or falsify information. Key points in this commentary:

Research participant deception does not violate federal rules or institutional policies.
Among a group of 100 participants who had participated in at least two studies, a recent study found that 25% admitted to exaggerating their symptoms in order to qualify and 14% pretended to have a health problem that they did not have
Other deceptions: concealing other health problems, enrollment in other studies, prescription drug use, and recreational drug use

Why lie?

Economic motives
Embarrassment re: sexual history, mental health, or illegal activities

Are there consequences to this deception?

By including patients who may be ‘destined to succeed,’ it creates a significant bias and reduces the statistical power and effect size of a research study.
Deception could lead to a false conclusion that a drug was not very effective.
By including patients who do not have a condition, the true safety of the medication in the target population cannot be determined precisely.
Participants may place themselves at risk for complications by withholding important information. (Example: Bernadette Gillcrist. Hastings Cent Rep 1980: 10: 5-6).

Potential ways to discourage deception?

Better screening with exams and blood tests (e.g. assays for non-study medications).
Require participants to be listed in a clinical trial patient registry. The U.S. does not currently have a national registry.

Perhaps, a good first step is to let research candidates understand how their deception can be harmful. I suspect that many are interested in the inducements to participate without considering the consequences of exaggerating their health problems.

My take: Given the enormous expense involved in most research studies, assuring that the research subjects are appropriate is crucial. How to achieve this goal is not so clear.

Related blog posts:

Atlanta Botanical Garden, Bruce Munro’s Dome

“More People Than Ever Want To Be Doctors”

Posted on November 1, 2015 by gutsandgrowth

From NBC News: “More People Than Ever Want To Be Doctors”

More people than ever want to be doctors, a new survey shows. Enrollment is up 25 percent this year over 2002, with more black applicants and Hispanic applicants being accepted.

More than 52,000 people applied to medical school in 2015 — up more than 56 percent from 2002 — the survey by the Association of American Medical Colleges (AAMC) found…And 20,630 were enrolled, a 25 percent increase over the 16,488 enrolled in 2002….

“The number of Hispanic or Latino enrollees increased by 6.9 percent to 1,988, and the number of applicants increased by 10.3 percent to 4,839,” the AAMC said in a statement.

“African-American enrollees rose 11.6 percent to 1,576, while the number of applicants increased by 16.8 percent to a total of 4,661.”

Doctor Scorecards: Affecting Care (but not in the way you think)

Posted on October 21, 2015 by gutsandgrowth

A recent perspective article (L Rosenbaum. NEJM 2015; 373: 1385-8) explains how the use of physician scorecards are negatively affecting patients and the pitfalls in their interpretation. Her article describes a situation, that is ‘not uncommon,’ in which a higher risk cardiology patient will not have a surgical consult for a few days because most surgeons “wouldn’t touch our patient with a 10-foot pole.” In several states, the increase reports of cardiac surgery outcomes has resulted in surgeons avoiding the sickest patients. The author notes that transparency/public reporting needs to be balanced against the potential harms. Other key points:

The public reporting thus far has been deeply flawed, based on insurance claims that are “notoriously inaccurate.” The reports have poor reliability, in part, due to too few surgeries to make accurate conclusions.
The public reports amount to “fear mongering” rather than the “professed commitment to protecting patients.”
“The key question, then, is less about transparency with regard to quality than it is about what constitutes quality in the first place.”
“The irony in hailing the scorecard as a victory for transparency is that its purported objectivity obscures its methodologic limitations.”

My take: While you are looking a surgeon’s scorecard, keep in mind, he/she may decide to not operate on you when he/she looks at your scorecard (of illness). Related blog posts:

Working While Sick: Red Badge of Courage or Scarlet Letter?

Posted on October 16, 2015 by gutsandgrowth

With the respiratory virus season fast approaching, a recent study and editorial (J Szymczak et al. JAMA Pediatr 2105; 169: 815-21, editorial 809-10 -thanks to Ben Gold) are worth a look; they focus attention on the practice of working while sick. In the study, the researchers use an anonymous survey of more than 900 physicians and advance practice clinicians working at a large children’s hospital. 83% reported working sick at least 1 time in the past year and 9% reported working while sick at least 5 times. The authors note “some ambiguity persists around what constitutes being too sick to work, and a perception exists that sick leave is impractical.” Most of the respondents understood that their illness could have an adverse effect on patients, but 97% did not want to let colleagues down and 94% did not want to create staffing shortages.

The editorial makes several more points:

Healthcare workers “will likely continue to come to work when mildly ill, especially when they identify their role as being essential for care and unique within the institution.”
“Working while sick was regarded as a badge of courage, and ill physicians who stayed home were regarded as slackers.”
The editorial argues for more clarity and/or use of key symptoms: conjunctivitis, vomiting, bloody diarrhea, fever >38.5, >2 episodes of watery diarrhea, or jaundice
“For many respiratory viruses, individuals are most contagious before they are highly symptomatic, so staying home after symptoms develop may not be effective or practical.”
For influenza, the CDC has recommended that employees “not return to work until 24 hours after they are fever free or 7 days, whichever is longer, with longer periods of time off for HCWs returning to work in a setting of high-risk individuals.” However, with this approach, “staffing shortages would become critical.”

My take: These articles suggest a need for a culture change that supports paid sick leave that is adequate and non-punitive. At the current time, adequate backup is often lacking. Also, these articles serve as a reminder: it is a good idea to get your flu shot!

How Much Does a Doctor Visit Cost a Patient?

Posted on October 13, 2015 by gutsandgrowth

Opportunity Costs of Doctor Visits -YouTube Video

From the Boston Globe:

The study estimates that the typical visit to a doctor consumes 121 minutes of the patient’s time — 37 minutes in travel, 64 minutes waiting for care or filling out forms, and only 20 minutes face to face with the physician.

Based on the average sum a person could earn if working during that time, the researchers figure, it costs patients $43 in lost time for each medical visit — more than the average out-of-pocket cost for the care itself, which is about $32.

Mehrotra’s team drew their results from three national surveys, chiefly the 2003-2010 American Time Use Survey, administered by the Bureau of Labor Statistics. The survey asked randomly selected respondents to recall what they did from 4 a.m. on the previous day until 4 a.m. on the day of the survey. The researchers examined the experiences of the 3,927 respondents who had sought medical care during that 24-hour period.

The initial study: Opportunity Costs of Ambulatory Medical Care in the United States Kristin N. Ray, MD, MS; Amalavoyal V. Chari, PhD; John Engberg, PhD; Marnie Bertolet, PhD; and Ateev Mehrotra, MD, MPH. Published in American Journal of Managed Care (August 2015)

Exorbitant Drug Costs from USA Today

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The Slow March of the Digital Health Revolution

Posted on October 8, 2015 by gutsandgrowth

A recent commentary (SD Dorn. Gastroenterol 2015; 149: 516-20) provides insight on the digital health revolution.

Key points:

“Amara’s law –that ‘we tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run’–seems to apply to digital health. Expect short-term gains to be incremental.”
The promise of ‘big data’ has not translated into big changes yet. “Many systems are not interoperable owing to cost, competition, privacy concerns, and technical barriers.”
Mobile health, mHeath, “is skewed toward those who need the least help: the young, the fit, and the educated.” And, there is “no evidence supporting the effectiveness of the vast majority of mHealth tools.”

What’s wrong with electronic health records?

“The overall evidence that EHRs improve safety and quality is spotty. Cost savings remain elusive.” Some reasons include that more time is needed and/or flaws in EHR design.
EHRs are not very usable –excessive clicks and scrolling.
EHRs “reduce productivity and can add hours to the busy clinician’s day”
Physicians “now spend up to two-thirds of a typical outpatient visit documenting.”
Clinical records may be more legible, but they are often less useful. “Template-generated notes frequently lack coherent narratives, are bloated with extraneous and repetitive information, and sometimes contain obvious errors that are copied forward from one note to another.”
“Physicians suffering from ‘alert fatigue’ may ignore potentially valuable clinical alerts.”
EHRs require frequent sign-ins and computers often have to be unlocked.
EHRs are expensive.
“In total, EHRs significantly worsen physician satisfaction.“

From a patient vantage, EHRs offer the possibility of patient portals to send physician messages, obtain test results, request medication refills, and schedule appointments. Telehealth offers the potential for expert advice from great distances.

Some integrated health systems, including the Veteran’s Health Administration and Kaiser Permanente, have shown that EHRs can be successful.

My take: The transition to digital technologies has great promise but could lead to a less personal approach. So far, the transition to digital health has been a bumpy slow road.

Related blog posts:

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Why D5 1/2NS was the Right Choice in the 1950s!

Posted on October 7, 2015 by gutsandgrowth

For many, a frequent practice is to order D5 1/2NS intravenous fluids for maintenance IVFs. An expert review (ML Moritz, JC Ayus. NEJM 2015; 2015: 373: 1350-60) of this topic explains why this was right in the 1950s but is usually the wrong choice today.