Category Archives: General Health

Fizzy Drinks and Sugar Intake

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A report on the “Effect of Carbonation on Brain Processing of Sweet Stimuli in Humans” (Gastroenterology 2013; 145: 537-39) highlights how the addition of carbonation could lead to increased consumption of sugar products.  The authors examined neural activity in response to carbonated beverage consumption with the aid of functional MRI.  An easy-to-read analysis of this study can be found at this link:  Carbonation affects brain processing of sweet stimuli : Family …

An excerpt:

Carbonation produces a decrease in the neural processing of sweetness-related signals, particularly those from sucrose, a small functional neuroimaging study shows.

The findings, which suggest that the combination of CO2 and sucrose might increase consumption of sucrose, could have implications for dietary interventions designed to regulate caloric intake, according to Dr. Francesco Di Salle of Salerno (Italy) University and his colleagues.

To assess the interference between CO2 and perception of sweetness, as well as the differential effects of CO2 on sucrose and aspartame-acesulfame, (As-Ac, an artificial sweetener combination commonly used in diet beverages), the investigators performed two functional magnetic resonance imaging (fMRI) experiments to evaluate changes in regional brain activity…

The first experiment, performed in nine volunteers, analyzed the effect of carbonation in four sweet Sprite-based solutions, including one carbonated and sweetened with sucrose, one noncarbonated and sweetened with sucrose, one carbonated and sweetened with As-Ac, and one noncarbonated and sweetened with As-Ac. The second experiment evaluated the spatial location of the strongest neural effects of sour taste and CO2 within the insular cortex of eight subjects.

On fMRI, the presence of carbonation in sweet solutions “independently of the sweetening agent, reduced neural activity in the anterior insula (AI), orbitofrontal cortex (OFC), and posterior pons … the effect of carbonation on sucrose was much higher than on perception of As-Ac,” they noted, explaining that “at the perceptual level … carbonation reduced the perception of sweetness and the differences between the sensory profiles of sucrose and As-Ac.”

This effect may increase sucrose intake, but is also favorable to diet beverage formulations being perceived as similar to regular beverage formulations, the investigators reported…

It may be that taste and CO2-related information influence food choices and intake through integration in the tractus solitarius with input from the gastrointestinal tract, they suggested, explaining that “the reduced discrimination between sucrose and As-Ac induced by CO2 would promote the consumptions of low-calorie beverages and would converge with CO2-induced gastric distention in limiting caloric intake.”

This study was supported in part by the Coca-Cola Company. One author, Dr. Rosario Cuomo, was sponsored by the Coca-Cola Company. The remaining authors reported having no disclosures.

Related blog posts:

 

Food Safety: Confusion with Use-by and Sell-by Dates

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From the LA Times, http://t.co/9Tt2C4EOPf, an except:

Sell by, use by, best by. Most consumers use the dates stamped on foods to decide what to toss out — and they are often discarding food that’s good to eat, according to a report…

Those dates are manufacturers’ suggestions for when an item is at its peak, or efforts to help stores manage their inventory, and not indications of food safety, the report from the Natural Resources Defense Council and the Harvard Food Law and Policy Clinic says.

More than 90% of Americans say they use date stamps to decide whether to discard food, the report notes.

“I don’t know of any data that consuming a product beyond the date has caused illness,” said Ted Labuza, a professor of food science and engineering at the University of Minnesota who has studied shelf life for decades.

There are several ways that products can be contaminated and can cause illness, including poor handling on farms or in factories and stores, and improper treatment by consumers.

Wednesday’s report follows one about food waste from the NRDC showing that 40% of our food is discarded, resulting in losses of $165 billion a year….People are throwing away food because they believe it’s not safe, she said. And they also may be eating unsafe food because they put too much trust in those date labels.

While there is no research of the exact role those dates play in the 160 billion pounds of annual food waste in the U.S., estimates based on British studies suggest it could be $275 to $455 worth of food per household per year, the report said.

Business suffers, too, as millions of dollars of food is discarded before it’s sold based on those dates, the report said. There is a “dizzying” array of state laws regarding date stamps on food, including no regulations in nine states, Gunders said….

The NRDC report calls for three major changes:

—Putting sell-by dates — meant for businesses — into code so they are invisible to consumers.

—Establishing a uniform date labeling system that differentiates dates for safety from those for quality.

—Increasing the use of safe-handling instructions.

… Among the possibilities being considered is a two-date system that’s clearly marked for the retailer and the consumer.

U.S. Rep. Nita Lowey (D-N.Y.) said she planned to reintroduce the Freshness Disclosure Act, which she had previously proposed, to establish a consistent food-dating system. She said in a statement Wednesday that consumers now were “left in the lurch, forced to decipher the differences between ‘sell-by’ and ‘best if used by,’ and too often food is either thrown out prematurely, or families wind up consuming dangerous or spoiled food. The status quo is really quite absurd.”

NASPGHAN Preview

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I had a few free minutes so I decided to take a look at a bunch of upcoming lectures from the 2013 NASPGHAN upcoming meeting.  With electronic media, it is easy to take a quick glance.  Here’s the master link to all of the following talks:

Annual Meeting page.

Some of the power point lectures that I’ve seen so far:

  • Is my PPI dangerous for me? Eric Hassall MBChB, University of British Columbia One point in his slides that I had not seen much about was a hypothesis that PPI use may predispose to the development of eosinophilic esophagitis by allowing food proteins to be more intact ( attributed to Merwat, Spechler. Am J Gastro ’09).  He explains that “acid reflux” is a clever marketing term and has a slide with Madmen actors.  If there is “acid,” one must need acid suppression.
  • My child doesn’t go to school Lynne Walker MD, Vanderbilt University.  Lynne shows an interesting fax from a parent that asks if the problem is physical, how will she help? And, if it is psychological, how can this be remedied?  She outlines a lot of pain theory and indicates that parents need to become health coaches, avoid catastrophizing (?spelling), and encourages mental health evaluation.  Use the parents words ‘I’m going to refer xxx for relaxation and stress management.’
  • My child’s H. pylori will not go away – (the resistant bug) Benjamin Gold MD, Children’s Center for Digestive Healthcare. Ben manages to stuff so much information into his talk.  His talk is like one of those clown cars where more and more people keep coming out.  He has slides with worldwide resistance maps, slides with treatment regimens and algorithms, and the reasons for treatment failure. Perhaps I can convince him to give a live preview.
  • Administrative/executive functioning Richard Colletti MD, Fletcher Allen Healthcare. Offers personal and pragmatic advice for career advancement.  His slides indicate that he started his GI fellowship at age 40.  One of his quotes, “80% of success is showing up” (Woody Allen) is definitely true.  It’s pretty much akin to what I learned about success in medical school.  You need the three As: availability, affability, and ability.  My mentor said the first was what people needed most.
  • The changing face of intestinal transplantation
    Simon Horslen MD, Seattle Children’s Hospital.  Lecture notes that number of intestinal transplants have decreased dramatically, particularly in children. In 2012, only about 100 intestinal transplants were performed whereas it had peaked at nearly 200.  Much of the credit is due to intestinal rehabilitation work and adjustments in parenteral nutrition (eg. lipid minimization, line care).  Two most common reasons for intestinal transplantation at this time are gastroschisis and volvulus.
  •  Gluten sensitivity: Fact or fiction Alessio Fasano MD, MassGeneral Hospital for Children. This blog has covered a lot of the same material, but Alessio’s slides are pretty impressive.  Also, I was not aware that Lady Gaga consumes a gluten-free diet
  • Controversies in parenteral nutrition Christopher Duggan MD, Boston Children’s Hospital.  This lecture provides a timely update on nutrient deficiencies due to component shortages and discusses lipid minimization compared with fish oil-based lipid emulsions.
  • Vitamin D and immunity James Heubi MD, Cincinnati Children’s Hospital and Medical Center.  In the beginning of the slides, Jim provides a very user-friendly definition of an expert and a suitable picture.  He indicates that in 2011 there were 3746 vitamin D publications but inexplicably only chooses to review a tiny fraction.

At the time of this posting, I haven’t had a chance to look through these talks:

 

 

Safety initiatives -the first 10 items

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A recent review (Ann Intern Med 2013; 158: 365-8) notes that “over the past 12 years, since the publication of the Institute of Medicine’s report, ‘To Err is Human: Building a Safer Health System, ‘ improving patient safety has been the focus of considerable public and professional interest.”  The following is a summary of this report (Epocrates docalert summary):

Patient-safety experts in North America and the U.K. systematically reviewed the growing evidence base for 158 patient-safety topics, including 41 strategies designated as most important to practitioners and patients. All reviews are published in the Agency for Healthcare Research and Quality (AHRQ) evidence report entitled “Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices” to update the original 2001 publication. After carefully analyzing each patient-safety problem and its related safety strategy, the authors strongly recommend immediate adoption of the following 10 strategies:

  • Preoperative and anesthesia checklists to prevent operative and postoperative events
  • Bundles (with checklists) to prevent central line–associated bloodstream infections
  • Interventions to reduce urinary catheter use
  • Bundles to prevent ventilator-associated pneumonia
  • Hand hygiene
  • Do-not-use list for hazardous abbreviations
  • Multicomponent interventions to prevent pressure ulcers
  • Barrier precautions to prevent healthcare-associated infections
  • Real-time ultrasonography for central line placement
  • Interventions to improve prophylaxis for venous thromboembolism

The authors also provide a list of 12 “encouraged” (rather than “strongly encouraged”) patient-safety practices, these are listed in Table 2 of the paper.

When you gotta go…looking for a clean bathroom

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According to consumer advice guru, Clark Howard, clean bathrooms are a necessity for businesses and now there are mobile apps (eg. SitorSquat) to help people find them.  For patients with GI disorders, this app may be very helpful as well.

Here’s the link from Clark Howard:

Clark Howard: Valued workers translate into a company’s success …

An excerpt:

“Now USA Today reports that dirty bathrooms can hurt business in some very direct ways. Nearly 50 percent of restaurant patrons who experience a dirty bathroom will tell friends. Almost three in 10 restaurant patrons won’t give a place a second chance if they encounter a dirty bathroom. And if you’re a restaurant owner, remember, this is the era of the smartphone where customers are taking pictures of your dirty bathroom and sharing it on social media.

Of course, when you gotta go, you gotta go. That’s why several different smartphone apps like SitorSquat have been developed (for both Android and iOS), pointing you to the nearest clean bathrooms.”

For IBD patients, sometimes taking your own toilet can be helpful, here’s a link to portable products:

Top 5 Portable Toilets – IBD – About.com

Noninvasive prenatal testing and why statistics matter

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New assays for detecting chromosomal abnormalities with prenatal testing are being adopted clinically without enough data to allow appropriate interpretation (NEJM 2013; 369: 499-501).

The assays are cell-free DNA (cfDNA) tests which can be performed as early as 9 weeks and require only a maternal blood sample.  The potential advantages also include avoiding invasive testing, like amniocentesis or chorionic villus sampling, which can result infrequently in miscarriage.  The tests are reported to have high sensitivity and high specificity for detecting abnormalities.

The problem is that these assays have not been tested adequately in more general populations and the manufacturers have not provided positive predictive values (PPV) for these tests.

Here’s why the statistics matter:

If you perform testing with samples that have a chromosomal abnormality prevalence of 1 in 8 with sensitivity/specificity of 99.9% and 99.7% respectively, then you derive a PPV of 98% and negative predictive value of 99.99% which are excellent.  However, when one uses the exact same sensitivity/specificity, then when the prevalence drops to 1 in 200, the PPV drops to 62.6%.

As a result, professional organizations like the American Congress of Obstetricians and Gynecologists have recommended cfDNA only for “high-risk” pregnancies and to confirm positive results through invasive testing.  These recommendations negate much of the potential benefits of early screening and avoidance of invasive testing.  In addition, the costs of these tests range from $795 to more than $2000 (though some discounts or “introductory pricing” are available).

Ultimately, cfDNA may prove to be extremely useful.  Until more data are available in the general population, this remains unproven.

What it takes to adopt good ideas

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A New Yorker article by Atul Gawande highlights the importance of spending time and talking about good ideas on a person-to-person basis as the best way to help innovations take hold.  Specific innovations that are discussed include the introduction of anesthesia, the control of germs/Lister’s theories of sepsis, adoption of oral rehydration solutions, and preventing hypothermia in newborns. The link to the article and a brief video review on the Colbert report:

Tell me about your mother

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The following except from the New York Times (nyti.ms/1cvUprv ) by Haider Javed Warraich provides some useful advice when families members ask “What would you do if this were your mother?”  In pediatrics, the question is similar: “What would you do if this were your child?”

The patient was an elderly woman, admitted to our unit just a few hours earlier, with a breathing machine keeping her alive. We proceeded with the meeting as we were trained to do. We kept our elbows off the table, maintained eye contact (but not too much) and gave the family an update of where we stood.

A healthy family meeting, we’d been told, involved us speaking for about half the time, with the family speaking for the rest – venting, questioning, grieving and hoping, in no particular order. This meeting, though, was dominated by long periods of silence that unearthed the dull, low-pitched drone in the background.

The son, quiet for most of the meeting, broke the silence and, with a hint of anger and a big dollop of frustration, asked the one question I had dreaded being asked the most: “Doc, give it to me straight. If this were your mother, what would you do?”

While the patient-doctor interaction varies widely across cultures and continents, this question seems to be a universal constant…

From a patient or family member’s perspective, though, this question helps them make sense of the confusion, desolation and powerlessness that so often defines the hospital experience, which usually involves a full-on assault of numbers, jargon and ‘expert’ opinion. They are confronted with difficult choices, like whether they want to go ahead with a particular high-risk procedure or wait for the tincture of time to kick in…

Yet I still find this question hard to answer. See, my mother is the sort of person who spends two hours each day on the treadmill, even during vacations, so that she can eat to her heart’s content. Often described as a “fighter,” any additional moment she can spend with her children or future grandchildren would be worth the extra mile. My father, on the other hand, is someone who avoids getting his blood sugar level tested to evade medications and dreams of spending his last days in the quiet serenity of the village he grew up in. Thus my answer to the question would be very different, as it would be for anyone, depending on which parent you asked me about.

So I have come to believe that the right answer to the question, “If this were your mother, doctor…” is: “Tell me more about your mother.”

This response gives patients’ families the chance to think about their loved ones, about what they would value and what they would consider a good life, what they would think was worth fighting for if they were available to answer the question for themselves….And then, slowly, the family started sharing stories of the woman we had met only a few hours before, unconscious and intubated. She loved being independent, would hate for people to open doors for her or hold her hand as she tried to get up, they told us. She loved the sun, the beach. She loved walking, loved being out and about. She would never, ever want to go to a nursing home…

We then told them that based on a combination of her vital signs and lab values, as well as our clinical judgment, that while we could hope for some progress, it would likely not be enough to allow her any real shot at experiencing life outside a nursing facility again…

They turned to us and asked us to make her comfortable, and to turn off the breathing machine.

Related blog post:

Advice for doctors after the death of a child | gutsandgrowth

Global Disease Burden

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In 1991, the World Bank and the World Health Organization launched the Global Burden of Disease Study.  A recent article reviews the key findings (NEJM 2013; 369: 448-57).

The goals of the study are to compare the burden of one disease with others; as such, it is “necessary to consider the age at death and life expectancy of persons affected by each disease and to take account of the degree of disability (eg. discomfort, pain, or functional limitations.”  A comprehensive measure of disability, disability-adjusted life-years or DALYs, was used for comparisons.

The study examined 291 types of diseases and injuries as well as 67 risk factors in 187 countries, looking at the years 1990, 2005, and 2010.

Findings:

  • In 2010, there were 2482 million DALYs which is a decrease of 0.6% from 1990.  On the basis of population growth, DALYs would have increased by 37.9% without improvements in disease burden.
  • Major causes of death in 2010: Ischemic heart disease-far ahead #1 (21.1% of deaths, 7850 thousand DALYs), Stroke (6.5% of deaths, 2574 thousand DALYs), Lung/airway cancer (6.1% of deaths, 3033 thousand DALYs), Alzheimer’s (5.9% of deaths, 2022 thousand DALYs), COPD (5.8% of deaths, 3659 thousand DALYs).
  • Global DALYs in 2010 (top ten -starting with #1): Ischemic heart disease, Lower respiratory tract infections, stroke, diarrhea, HIV-AIDs, Malaria, Low Back pain, Preterm birth complications, COPD, and road-traffic injury.
  • Top risk factors (starting with #1): High blood pressure, tobacco smoking (including 2nd-hand smoke), household air pollution, diet low in fruit, alcohol use, high body-mass index, high fasting plasma glucose level, childhood underweight, exposure to outside pollution, physical inactivity, diet high in sodium

Since 1990, there has been a shift.  “In general, communicable, maternal, neonatal, and nutritional conditions decreased in absolute terms.”  The main exceptions were HIV and malaria. Noncommunicable diseases, especially diabetes, have been increasing in terms of percentage and absolute numbers.

Another important change has been a relative increase in disability compared with premature death.  In addition, of the “top 25 causes of years lived with disability, only COPD, diabetes, road-traffic injury, ischemic heart disease, and diarrhea are also among the tope 25 causes of years of life lost.”  “What ails most persons is not necessarily what kills them.”

Bottom-line: While collecting this type of data has many potential limitations, the broad picture it provides should help inform policymakers with priorities for research and intervention.  This data also allows the US to benchmark its efforts compared to other countries.  For example, according to the authors, currently the US has the best global performance with respect to stroke and the worst with respect to lung cancer and Alzheimer’s disease; however, “data and analyses are lacking to elucidate the drivers of these changes in relative performance.”

Fewer Intern Hours & No Change in Patient Safety

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Excerpt from Gastroenterology & Endoscopy News (Shorter Workweeks for Interns Do Not Promote Patient Safety) :

A policy to shorten the workweek for interns in the United States has failed to improve their quality of life and has possibly put patients at greater risk for medical errors, a new study has found (Sen S et al. JAMA Intern Med 2013;173:657-662).

The 2011 policy change, recommended by the Accreditation Council for Graduate Medical Education, capped at 16 continuous hours the longest shift a first-year resident could work in the hope that doing so would ease the strain on physician trainees.

But although the new rules have shortened the typical intern’s workweek from 67 to 64.3 hours, they haven’t encouraged residents to sleep more, helped them to avoid depression or increased their overall sense of well-being, the study found…The study was based on email surveys of 2,323 residents …entered training in 2009, 2010 and 2011, after the rule change.

“Given that increased sleep was a key [mechanism] through which the new duty-hour restrictions were intended to improve the health of residents, the lack of such an effect in the postimplementation cohort in our study is a cause for concern,” wrote the authors, led by Srijan Sen, MD, PhD, a psychiatrist at the University of Michigan in Ann Arbor. “Designing work schedules that account for circadian phase and explicitly training residents on practices to increase sleep time and improve sleep quality may be necessary.”