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Rapid Home HIV Testing: Times are Changing

May 17, 2012

With the FDA advisory panel recommending approval of the home rapid HIV test using saliva on a mouth swab the U.S. is making a significant change in tactics in screening for HIV.  I have been in clinical practice for all but the very earliest of the history of HIV.  I was a resident from 1980-1983, and in practice in the Army from 1983-1987.  I remember the first patient of mine diagnosed with HIV was a woman who was just a few years post a blood transfusion for a bleeding duodenal ulcer, and who died within months of her diagnosis of multiple opportunistic infections.

In practice in WA since 1987 I’ve tried to obey the letter and spirit of the law requiring pre and post testing counseling for patients receiving HIV testing, and have grumbled that this state law pushed into place by the gay-rights lobby at a time when little effective treatment was available and serious concerns about confidentiality and discrimination were major concerns.  Now that highly effective treatment for HIV is available the advantages of early HIV diagnosis would seem to make any barriers to testing for HIV counterproductive. An easy to use, affordable, reasonably accurate HIV test is a big change to the current status-quo, where considerable emphasis is placed on protection of the patient via counseling regarding results, and places more value on more widespread testing, early diagnosis and opportunities for prevention of spread of HIV.

Tests have been available for years for use by individuals to obtain their own specimen and mail it away to a test facility for confidential testing without accessing a physician or medical care provider.  These have not been widely used.  If the home oral swab rapid test comes to market it is very likely to be much more widely used. I fully agree with the FDA advisory panel that the benefits of this test will outweigh its risks. Still we should not ignore the risks.  I see the benefits and risks as outlined below:

Benefits                                                                               Risks

More HIV positive patients identified                     Rare false positives may lead to poor decisions

Prevention of some cases of HIV                           Rare false negatives may lead to not getting blood test

Low financial barrier to HIV testing                       Some patients may not get appropriate test results counseling

Convenience of HIV testing                                   What unintended consequences to expect

 

I anticipate that in mass market use the false positive rate and the uninterpretable results rate will be higher than the extremely low rates in the test populations used in the initial studies, but even so I expect the use of a readily available home saliva HIV test will be one more step toward earlier diagnosis and slowing of the rate of spread of HIV in the U.S.

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Is Your Cough a Lisinopril Cough?

May 14, 2012

Lisinopril was the third most prescribed medication United States in 2010 and lisinopril cough is the most common lisinopril side effect seen in everyday practice. (In this article I will refer to lisinopril cough rather than angiotensin converting enzyme inhibitor cough as a matter of convenience because lisinopril is by far the most commonly prescribed medication the class.)  Since it is so common you would expect that making a diagnosis of  lisinopril cough should be quite simple, and sometimes it is. Other times differentiating lisinopril cough from other causes of cough can be pretty complicated. Most of the time in the office we can suspect lisinopril cough because the patient  did not have the cough prior to starting lisinopril and it tends to be a dry twitchy cough that just will not go away. The problem lies in fact that lisinopril cough often doesn’t stop immediately on discontinuation the medication and that many of the patients using lisinopril have other potential causes of cough.

I used to think that lisinopril cough always started in the first month or so of using lisinopril, but it’s clear that a small minority of patients will develop a lisinopril cough months or longer after starting lisinopril. In addition although most patients find their lisinopril cough decreasing shortly after stopping lisinopril and resolving within a few weeks, there are patients where the cough can persist for many weeks or even months.

Although most people think of cough as a symptom of a respiratory infection or an allergic problem like asthma or hay fever, it is becoming increasingly clear that esophageal acid reflux is a common cause of cough. Cough related to reflux can either be due to occult minor aspiration of gastric contents into the trachea or from irritation of the esophagus leading to cough without aspiration. Reflux related cough is another type of cough can take a long time to resolve even on aggressive anti-reflux therapy, and so be difficult to diagnose with certainty. If a patient is also on lisinopril the sorting out which problem is causing the cough can be a challenge.

Lisinopril is used primarily for the treatment of high blood pressure and congestive heart failure. It is also used for prevention of kidney disease in patients with diabetes. All of these conditions are seen more often in older adults, obese patients and often in patients with multiple complex medical conditions. This can make physicians reluctant to discontinue lisinopril because every medication change in a complex patient can upset a delicate balance, so if a patient is doing well except for the cough it is tempting to now want to make any medication changes.  Thankfully now switching to an angiotensin receptor blockers is a fairly easy medication alternative, especially with losartan now available as an inexpensive generic ARB with losartan soon to follow.

Lisinopril cough is felt to happen because the site of action of lisinopril is in the lungs where it prevents the conversion of angiotensin I into angiotensin II.  It is not completely clear what causes the cough but the known fact that angiotensin converting enzyme inhibitors function at a cellular level in the lung seems to be the key. Angiotensin I is produced in the kidney and released to the circulation. The angiotensin I in the bloodstream circulates through the lungs where it is converted into angiotensin II in a process requiring an enzyme called angiotensin converting enzyme. ACE inhibitors like lisinopril block the site where angiotensin I fits at the angiotensin converting enzyme therefore blocking the production of angiotensin II which is the active form of angiotensin. Angiotensin II works in the peripheral arterioles to cause constriction of the tiny arteries and therefore elevation of blood pressure. The angiotensin receptor blockers (ARB) function at this receptor in the peripheral arterioles and so ARB medications are much less commonly associated with cough.  Unfortunately cough is an occasional but very infrequent cause of cough which can further complicate trying to decide whether the cough was related to lisinopril if it doesn’t resolve quickly and switching medications.

The incidence of lisinopril cough is almost certainly higher than the incidence noted in the original studies of lisinopril quoted at 1% for patients with congestive heart failure 3.5% for patients with hypertension, but the exact incidence of lisinopril cough is really unclear.

When I see a patient on lisinopril with cough I first try to put the cough into perspective. If the cough started as part of a typical upper respiratory infection with congestion, fever or chills, sore throat or other similar symptoms I will tend to advise the patient that the cough will likely resolve as the illness passes.  Problems like post-bronchitic bronchospasm, where cough persists for weeks or months after an episode of acute bronchitis can be a challenge sometimes, but usually this approach works. On the other hand if the cough is a fairly mild cough that persists or gradually progresses to be much more annoying then I usually suggest that we stop the lisinopril and use an alternative medication, usually a generic ARB like losartan.  Then we wait and see if cough resolves over the next few weeks. If cough persists more than a few weeks it comes a bit trickier. If the cough seems to be gradually diminishing I usually try to convince the patient with a longer.  If the cough is not improvingat all we need to look harder for another cause.

Most of the time lisinopril cough is usually fairly simple problem to diagnose and manage because most physicians recognize cough as among the most common of lisinopril side effects, but like almost everything in medicine things are sometimes more complicated than they appear and cough is a symptom that can be a diagnostic and therapeutic challenge.

 

 

 

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Lorcaserin for Obesity. Exciting? Safe?

May 11, 2012

Lorcaserin hydrochororide (Lorqess®) yesterday received FDA advisory panel approval recommendation as the first new weight loss drug in the U.S. in 10 years.

I read a very interesting article today in the New York Times wellness blog by Danielle Ofri M.D. where she reminisced about an article in the annals of internal medicine entitled Lemons for Obesity. Obviously this was not to be taken at face value.  I don’t think anyone would consider lemons as an alternative for the grapefruits promoted in the famous grapefruit that. No they are referring to the last several major weight loss drugs to going down in flames and comparing them to flawed products commonly referred to as lemons.

It was a surprise to me just hours later to see that today the FDA advisory panel 18-4 recommendation for the approval of a new medication for weight loss lorcaserin hydrochloride. Lorcaserin hydrochloride, to be marketed by Arena pharmaceuticals as Lorqess® is a drug with serotonergic properties reported to have anorectic benefits and lead to very modest weight loss. At first glance this sounds awfully like Meridia, a drug recently taken off US market because of cardiovascular side effects, in that the weight loss experienced by most patients taking it is quite modest. In the studies presented the FDA there was a 3.3% difference in the percentage of body weight decrease in patients taking locaserin hydrochloride when compared to placebo. The possibly good news that slightly more than 1/3 of patients taking lorcaserin hydrochloride lost 11% of their weight or approximately 25 pounds is somewhat promising.

The big controversy in the approval of lorcaserin hydrochloride appears to be that because it was initially presented the FDA for approval prior to their requirement that new weight loss drugs be thoroughly evaluated for valvular heart disease and other cardiovascular risks Arena pharmaceuticals was not required to present extensive cardiovascular safety data.

In 2010 the FDA rejected lorcaserin hydrochloride when first presented because of a variety of concerns over safety and the very modest claims to weight loss but apparently now with the presentation of additional safety data the FDA advisory committee has changed its position. It’s anticipated that in late June the FDA will present a final ruling on lorcaserin hydrochloride for approval or not.

There’s another drug that has a lot more buzz after 60 Minutes segment called Qnexa. Qnexa is a combination of currently FDA approved phentermine and the anticonvulsant topiramate. Phentermine is an amphetamine that is approved for short-term use but the FDA but is not infrequently prescribed for longer periods of time by some physicians and weight loss clinics. Phentermine gained fame as part of the infamous weight loss drug combination Fen/Phen. Fen/Phen led to huge class-action lawsuits when it became clear that it was associated with valvular heart disease and pulmonary hypertension. Since Fen/Phen many physicians have been much more cautious in jumping on the latest weight loss drugs.

I’m hopeful that both Qnexa and  Lorqess are found to be safe and effective weight loss drugs. UBC academic in America is a gigantic concern and we’re a long ways from understanding obesity and from having effective nonsurgical approaches to weight loss and many patients. You may recall a previous post outlining obesity is the Leading Preventable Cause of Death in America as well as Just How Fat are Americans. It’s not that I’m obsessed with obesity but every day in the office I see several patients where their real underlying health problem is obesity. They usually see me for diabetes, hypertension, osteoarthritis, lymphedema, or any number of other presenting complaints that they and I both understand that the real solution to their health concerns is weight loss. Unfortunately I simply have little to offer as an effective solution. Bariatric surgery is gaining traction as an effective approach for the morbidly obese, but the financial barriers to actually getting the surgery are insurmountable in most cases. In addition the very long term risks and benefits of their after surgery are still somewhat uncertain.

Lorcaserin hydrochloride or Qnexa may turn out to be safe and useful tools in our battle to treat obesity but despite the seriousness of obesity and its associated medical complications I anticipate waiting for some aftermarket safety data prior to prescribing these new drugs if they receive FDA approval.

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One Touch Document Management

May 10, 2012

Do you find yourself buried in paperwork or electronic equivalents? Do you push piles of tasks from one corner of your desktop to another? I am certainly not a time-management consultant, but I have one simple rule that will make your work and home life less onerous and more efficient. So what is the rule?

ONLY TOUCH DOCUMENTS ONCE

Time-management seems far off topic for a family physician to put in a medical blog. While this is probably true, this is DrPullen.com and I can do what I want.  Today I am using my platform to try to help others live your life in line with your real values, and not let necessary but annoying tasks take up more of your time than is necessary. You may find that your mental health is better, and that you use some of the time saved to get more exercise. Who knows.

In my day-to-day practice of medicine one of the major tasks I face is to deal with large numbers of electronic and paper documents. These range from signing prescriptions, completing forms, writing letters, to responding to electronic and telephonic messages. Regardless of the task I have found that making a major effort to “touch” each document only once leads to a much more efficient and less frustrating day.
By touching them once I mean that when I open an e-mail I reply, delete, or do whatever the message requires right then, rather than postponing the action to a later time. When I first look at a patient’s lab or imaging results I do whatever chart review is needed, formulate a plan of action, and put the plan into effect. Sometimes this feels like I am putting off more important time demands. I fight off those feelings though and push ahead because I am very confident that overall if I complete all of these tasks with “one touch” I will spend less time on them, leaving more time for patient care and getting off work and home to my family earlier. These are both things I value and so being efficient with managing the dozens of small tasks daily is behaving in line with my higher values.

Whether you are a physician, attorney, school teacher, homemaker, or retiree my guess is that you are faced with a number of document management tasks on a regular basis. This may be paying bills, it may be your email, or it may be dealing with a large number of other types of correspondence or forms to complete. Whatever the task it takes a certain amount of time to orient yourself to the task. If it is paying bills it involves opening the envelope, looking at the bill, and then getting your checkbook out or logging on to your on-line bank account. If it is completing forms it at a minimum involves briefly looking at the form to see what needs to be done. If you then put the task aside you will need to repeat at least some of this initial effort. That duplication of effort takes time. In addition you are more likely to misplace the documents taking lots of time to find them later, or you’ll need to spend time filing them so you can find them later. The clutter of these documents will also slow you down as you work around them until they are completed.

One touch document management requires some degree of discipline, a moderate level of energy, and purposeful work, but if you make it a real priority of yours you will find that you will have more time left for the parts of your work and personal life that you truly value.

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Cancering: Considering Cancer as a Verb

May 7, 2012

In this fascinating Khan Academy video Dr. David Agus, a professor of Medicine and Engineering at USC postulates on thinking of having cancer as a dynamic state of existence rather than of having some malignant cells gone awry. I’m not sure just how to make use of his discussion, but he makes an interesting case for focusing on the body as a habitat that may be either a place where cancer cells can thrive or where they die off as an inhospitable environment. How this related to the movements towards nutritional, emotional and physical modulations as a part of cancer treatment and prevention is unclear, but it is food for thought.

Leave a comment to let us know what you think about the comments of Dr. David Agus comments on cancering.

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Birdathon Trip Report

May 5, 2012

A follow up on this off topic subject for readers interested in my Tahoma Audubon Society fund raising Birdathon trip. Here is my trip report: Greeting from a tired birdathoner. 2012 has been a breakthrough year for me as a birdathoner for two reasons. First this is the first year I have tried to use social media, e-mail, and DrPullen.com as fundraising tools. Second my good birding buddy and esteemed mentor Ken Brown joined me on the trip, and promises to make it an annual trip together. I’m really excited as birding with Ken is such a pleasure, and because having a top birder along takes a lot of self-imposed pressure off me.
This trip was a one-car event as only Vera Cragin joined Ken and me and we met at Titlow Beach, Tacoma at 3 PM yesterday May 4th. We actually got there a few minutes earlier, and had our first “good bird” in the scope to start counting at 3 PM sharp. With a Red-necked grebe (if you are interested you can find photos and other information on any mentioned species in this report at the Cornell Lab of Ornithology website) to start the list we quickly added another 12 species there, notably including Bald Eagle and all 3 species of cormorant in WA, and notably not including Purple Martin which have reliably nested in boxes there for longer than I’ve lived in WA, but none yesterday. Then quickly off to the Titlow Park pond for some ducks and a Belted Kingfisher, and then off to listen and look in the mixed woodlands on both sides of the road to the Tacoma Outboard Club. The nice finds there included a Pacific-slope flycatcher sallying for insects, a male Western Tanager (good eyes Ken- it was quiet), and several songbirds singing.
Off to Chamber’s Creek where an Ospery watched us from a perch on a tall utility pole, Common Merganser’s were among the ducks on the creek, and the coniferous trees on the hillside trail yielded the hoped for Chestnut-backed chickadee, RB Nuthatch, and Golden-crowned kinglet.
On to Steilacoom Park where swallows and ducks were in good variety, but the usual House wrens were absent. Then we took the back way through Dupont to Nisqually NWR to avoid the 6 PM traffic, where the birds were far quieter than hoped for, blast this cold Washington spring which seemed to make all of the songbirds harder to find on this trip. Still we managed to hear 4 Virgina Rails, found a Long-billed dowicher (nice in spring in WA) but missed Wood Duck again after missing it at Ft. Steilacoom also.
As the sun set we found the missing Purple Martins at Luir Beach, across McAlister Creek from Nisqually NWR, as well as a handful more waterfowl and a Hairy Woodpecker.
On the drive to Ocean Shores we tried in vain to find Barn Owl and other owls on Wenzel Slough Rd in Elma, and checked into our rooms by 10:45. We slept quickly and well with 75 species on our list as a strong first afternoon/evening, and were back out by 6 AM at the Brown’s point jetty.
Here we started finding great birds. Ken noted a constant stream of common terns flying by the tip of the jetty, and suddenly and briefly a Parasitic Jaeger chased them past. Jaegers are expert fliers, and make their living by chasing gulls and terns to get them to disgorge food they have caught. Parasitic Jaegers seem to especially thrive chasing small terns. We had 3 of the 5 possible rock-specialty sandpipers, Surfbird, Wandering Tattler, Black Turnstone at the tip of the jetty, and later got a 4th , Ruddy Turnstone, at the back end of the jetty. At the Ocean Shores Sewer ponds Peregrine Falcon was our 90th species on the list.
From here we returned to the hotel for a nice breakfast, then back to Tonquin Ave, the Marina, the beach behind the Community Center and on to Bill’s Spit for our last Ocean Shores stop. This area is always special to me because at the base of the spit is the vacation home Kay and I had built and owned for several years. Today it was special mostly for gulls, as we added Herring gull, Thayer’s gull, and California gull to our list.
With our list now at 113 species it was getting tougher to add species, but we managed to find some earlier misses with Stellar’s jay and Purple finch, and find Scrub Jay and Sharp-shinned hawk at various places on the ride home. We traversed Brady Loop and Wenzel Slough Rd in the daylight after circling the latter last night looking for owls. These loops were more notable for misses like Wilson’s snipe and Greater Yellowlegs than the finds of a very large flock of 122 Whimbrel and the last bird of the day incredibly was Yellow warbler, singing from across the river at the corner stop on Wenzel Slough Rd.
Overall a terrific trip with 122 species total. My vote for most unusual species is Fork-tailed Storm Petrel off Oyhut Beach at Ocean Shores. These relatively tiny pelagic birds are uncommonly seen from shore, and we had a nice long look as the bird flew north not too far from shore for several minutes. Surprising misses were Northern Harrier, American Kestrel, Wilson’s Snipe and Black-headed grosbeak. Still 122 species is my highest on this route by far, mostly thanks to a great birding group with Ken and Vera.
Here is a full trip list:
1 Red-necked Grebe 3:00 PM
2 Pigeon Guillemot 5/4/2012
3 Glaucous-winged Gull Titlow
4 European Starling Beach
5 House Sparrow WA
6 Double-crested Cormorant
7 Brant’s Cormorant
8 Pelagic Cormorant
9 Surf Scoter
10 American Crow
11 Barn Swallow
12 Bald Eagle
13 Caspian Tern
14 American Wigeon Titlow
15 Mallard Park
16 Bufflehead
17 Canada Goose
18 Belted Kingfisher
19 Wilson’s Warbler Tacoma
20 Black-capped Chickadee Outboard
21 Downy Woodpecker Club
22 Bewick’s Wren] Road
23 Winter Wren
24 Northern Flicker
25 Spotted Towhee
26 American Goldfinch
27 Pacific-slope Flycatcher
28 House Finch
29 Brown-headed Cowbird
30 Western Tanager
31 Rock Pigeon
32 American Robin
33 Osprey Chamber’s
34 Common Merganser Creek
35 Red-breasted Nuthatch
36 Chestnut-back Chickadee
37 Golden-crowned Kinglet
38 Lesser Scaup
39 Common Goldeneye
40 Red-winged Blackbird
41 Yellow-rumped Warbler
42 Horned Grebe
43 Vaux Swift Ft.
44 Violet-green Swallow Steilacoom
45 Tree Swallow Park
46 Cliff Swallow
47 Rough-winged Swallow
48 Ruddy Duck
49 Northern Shoveler
50 Ringed-neck Duck
51 Pied-billed Grebe
52 Red-tailed Hawk
53 Great-blue Heron
54 Ruby-crowned Kinglet
55 Gadwall
56 Green-winged Teal
57 Cackling Goose
58 Savannah Sparrow
59 Marsh Wren Nisqually
60 Common Yellowthroat NWR
61 Virginia Rail (4)
62 Dunlin
63 Least Sandpiper
64 Long-billed Dowicher
65 Western Sandpiper
66 Black-bellied Plover
67 Ringed-bill Gull
68 Rufous Hummingbird
69 Purple Martin Luir
70 Mew Gull Beach
71 Greater Scaup
72 White-winged Scoter
73 Hairy Woodpecker
74 Greater White-fronted Goose
75 Northern Pintail
76 Band-tailed Pigeon
77 Brown Pelican 6AM 5-5
78 Common Loon Ocean
79 Pacific Loon Shores
80 Red-throated Loon Brown’s
81 Wandering Tattler (4) Point
Jetty
82 Surfbird
83 Black Turnstone
84 Western Gull
85 Rhinoceros Aucklet
86 Common Tern (thousands)
87 Parasitic Jaeger
88 Sooty Shearwater
89 Western Grebe
90 Brant (Goose)
91 Peregrine Falcon O.S. Sewer
92 Ruddy Turnstone Treatment
93 Ringed-neck Pheasant Ponds
94 Orange-crowned Warbler OS
95 Swainson’s Thrush State
96 Black-throated Gray Warbler Park
97 Townsend’s Warbler
98 Dark-eyed Junco
99 Sanderling Oyhut
100 Red-necked Phalarope Beach
101 Marbled Godwit
102 Short-billed Dowicher
103 Fork-tailed Storm Petrel
104 Semi-palmated Plover
105 Hooded Merganser Tonquin Av.
106 Killdeer
107 Eurasian Wigeon
108 Golden-crowned Sparrow
109 Eurasian Collared-dove
110 Red-breasted Merganser
111 California Gull Bill’s Spit
112 Thayer’s Gull
113 Herring Gull
114 Stellar’s Jay Driving
115 Purple Finch Burrow’s Rd
116 Turkey Vulture
117 Sharp-shinned Hawk Hoquiam
118 Brewer’s Blackbird Brady Lp.
119 Western Scrub Jay
120 Common Raven
121 Whimbrel (122)
122 Yellow Warbler 2:44 PM
Wenzel Slough

Thanks to all who contributed to the Tahoma Audubon Society Birdathon fundraising effort through this trip, and anyone who has not made a contribution to TAS can do so at this First Giving site. So far thanks to all of you for donation’s totaling $816.

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Obesity, Smoking, Death and Medication Use

May 3, 2012



Somehow I was not in the least surprised when I came across a Huffington Post article showing which states in the US have the highest rates of medication use.  Why am I not surprised?   Intuitively I suspected that these are the states with the highest rates of obesity and smoking.  Look back to a prior post on how obesity has surpassed smoking as the leading preventable cause of death in America. Every one of the top 9 most medicated states is in the highest tier of rates of obesity.  What medical conditions lead inexorably to the use of multiple medications?  Think diabetes, hypertension and chronic pain.  All of these conditions are directly related to obesity in many cases.  Also think heart and lung diseases like asthma, COPD and coronary artery disease, all well documented to be related to both smoking and obesity.  Here are the 9 “most medicated states” from the Huffington Post article with the CDC 2011 rate of obesity in parentheses.  For interest I’ve also put the state’s rank in terms of smoking incidence from the CDC data.
State (Retail Rx per capita)         Rate of obesity             Smoking Rate (national rank)

  1. West Virginia (18.4)                      >30%                               25% (tie for 8th highest)
  2. Tennessee (16.9)                          >30%                              25% (tie for 8th highest)
  3. Alabama (16.9)                             >30%                              25% (tie for 8th highest)
  4. Kentucky (16.5)                             30%                               29% (alone w/top rate)
  5. Arkansas (16.4)                            >30%                              26% (6 way for 2nd)
  6. South Carolina (16.3)                     25%-29%                        24% (4-way tie for 12th)
  7. Mississippi (15.9)                            >30%                             26% (6-way tie for 2nd)
  8. Iowa (15.3)                                  25%-29%                        22% (3-way tie for 17th)
  9. Missouri (15)                                 >30%                              26% (6-way tie for 2nd)

For reference there are nine states with 2009 rates of obesity > 30% of which 7 are here in the top 9 most medicated states. The national average rate of smoking is 21% and all 9 of the states with the highest rates of medication use are in the top 17 states for rates of smoking.

I cannot access the SDI data to see what the rates of obesity are in the states with the lowest incidence of obesity are  but here are some other health related statistics and their relationship to a relative lower obesity rate.

1)      Colorado is alone as the only state in the US with a 2009 rate of obesity at <20%.   Why doesn’t Colorado rank at the very top for the lowest for death rates in adults?  Possibly because of a smoking rate of 20% (tie for 28th highest leaving it pretty good but with  a death rate of 709/100,00 (11th best).

2)      The fifteen states with obesity rates from 20-25% (the best except for Colorado) are listed below in alphabetical order:

                                                      Death rate (rank)                             Smoking Rate (rank)

a)      Alaska                               742 (2oth)                           24% (Tie for 12th highest)

b)      California                         660 (4th)                                15% (50th highest, i.e. 2nd lowest)

c)       Connecticut                   691 (8TH)                               18% (tie for 38th highest)

d)      Hawaii                               590 (1st)                                16% (49th, i.e. 3rd lowest)

e)      Idaho                                 723 (16th)                             18% (tie for 38th highest)

f)       Minnesota                        675 (5th)                                17% (tie for 44th highest)

g)      Montana                           786 (33rd )                            20% (tie for 29th highest)

h)      New Jersey                     717 (14th)                             18% (tie for 38th highest)

i)        New York                        676 (6th)                                19% (tie for 32nd highest)

j)        Oregon                              748 (22nd)                             18% (tie for 38th highest)

k)      Rhode Island                   749 (23rd)                             20% (tie for 28th highest)

l)        Utah                                    659 (3rd)                               11% (51st highest, i.e. lowest)

m)    Vermont:                           721 (15th)                             18% (tie for 38th highest)

n)      Virginia                              762 (25th)                             19% (tie for 32th highest)

o)      Wyoming                           773 (29th)                             21% (tie for 21st highest)

Looking at this data you may note that 4 of the 5 states with the lowest death rates are in the 15 states with the lowest rates of obesity, and that none of them are worse than the 44th highest smoking rates. (only Arizona is missing, in the next 25%-29% obesity rate and at a tie for 21st in rate of smoking)  You may also note that the only two states in the top 15 for lower obesity rates ranking in the bottom half for death rates have smoking rates ranking at 21st and 29th.

Contrast this with the five states with the highest death rates:

  1. West Virginia with >30% obesity and 25% smoking rate (tie for 8th highest)
  2. Mississippi with > 30% obesity and 26% smoking rate (tie for 2nd highest)
  3. Oklahoma with >30% obesity and 26% smoking rate (tie for 2nd highest)
  4. Alabama with > 30% obesity and 25% smoking rates (tie for 8th highest)
  5. Louisiana with >30% obesity and 26% smoking rate (tie for 2nd highest)

In contrast the states with the lowest death rates have the opposite statistics for obesity and smoking rates:

  1. Hawaii with 20-24% obesity and 16% smoking rate (3rd lowest).
  2. Arizona is the exception in these states with 25-29% obesity and a smoking rate of 21% (right at the national average and ranking in a 6 way tie for 20th highest in the U.S.
  3. Utah with in the 20-20% obesity and the lowest smoking rate in the U.S. at 11%.
  4. California with 20-24% obesity and 16% smoking, second only to Utah.
  5. Minnesota with 20-24% obesity and in a tie for 4th lowest smoking rates at 17%.

It appears that states where citizens choose not to smoke and trend to be less obese have both lower rates of medication use and lower death rates. My guess is that the observation of lower death rates and lower rates of medication use are the result of lower rates of diabetes, hypertension, COPD, cardiovascular disease in these same states.   Yes these other health markers also trend directly with obesity and smoking rates.

So what can you as an individual learn from this?  Get fit, avoid obesity and don’t smoke.  No surprises here.

You may also enjoy:

Belly Fat is Bad for Our Health

Just How Fat are Americans?

CDC Widgets  - Go Here to calculate your own BMI and see other cool calculators

Some states have taken measures to reduce tobacco use, you can use this CDC widget to see how your state is doing, and what other states have done.

Tobacco Control State Highlights 2010

Tobacco Control State Highlights 2010 Widget. Flash Player 9 is required.
Tobacco Control State Highlights 2010 Widget.
Flash Player 9 is required.

 

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One Nation – Under Pressure

May 1, 2012

By Brooke Douglas, RD, CD

High blood pressure. The words don’t exactly strike fear into most American’s hearts. After all, it’s not painful, like cancer. It doesn’t sound deadly, like heart disease. But it’s literally a time bomb in our blood vessels that threatens our heart, brain and kidneys. Make no mistake – it’s a killer! So what makes our blood pressure rise? Too much salt, extra body weight and spending too much of your time sedentary. But wait! Don’t blame it all on the salt shaker. Only 7% of the excess salt in the average American’s diet comes from the salt shaker. The remaining 93% comes from all the processed and convenience foods we buy at the vending machine, at the local corner store, at the grocery store (for quick dinners) and at fast food and dine-in restaurants.

If your doctor has told you to cut back on your salt intake…you will have to do more than put the salt shaker away.

As for extra body weight (lose weight) and inactivity (begin a modest exercise program and spend less of your day sedentary), applying the following tips may help you on your quest to lower your blood pressure.

Here are some sodium-cutting tips you can try today:

Introduce additional flavor to your foods with herbs and spices like garlic, oregano, basil, pepper, thyme and sesame. These all add flavor without the extra sodium. If a recipe calls for salt, cut the amount called for in half and taste it before adding more.

Make healthy choices at the grocery store. Processed foods (anything in a box or bag) tend to be high in sodium because it helps preserve foods longer and increase flavor. Always read labels for the foods you buy, including the sodium content on the nutrition facts label and the ingredients list.

Remember that “low-fat” or “low-calorie” doesn’t mean healthy. These diet foods can also be higher in sodium because manufacturers hope that added sodium, a flavor-enhancer, will bring back the flavor that is missing since fat and other higher-calorie ingredients are removed. This is especially true for frozen dinners, which are often loaded with extra salt.

Choose low-, no- or reduced-sodium versions of your favorite soups, frozen meals, canned foods, and snacks. Even butter is available without added salt!

Choose fresh or frozen veggies over canned varieties, which often contain added salt to help increase shelf life. If you can’t find sodium-free varieties of canned vegetables, rinse the can’s contents in a colander under water before cooking to remove excess salt.

Olives, pickles and other items packed in brine are saturated in salt, as are many smoked and cured meats, like salami and bologna. Limit your intake of these high-sodium foods and be on the lookout for lower-sodium varieties.

Fast foods are high in more things than just fat. Many of these meals, sandwiches and fries contain more than your daily recommended intake of sodium in just one serving. When consulting restaurant websites to make healthy choices, pay attention to sodium levels as well. By keeping your portions in check (order a junior burger or small French fry instead of the big burgers and super fries) will help control your sodium (and caloric) intake.

Thanks much to Brooke for returning as our first-of-the-month guest contributor.  She does a great job with nutrition advice, so if you are concerned about your or a loved one’s blood pressure give her a call. Did you know that your insurance might cover several visits with a Registered Dietitian? Let Brooke help you navigate the insurance maze to determine whether your insurance will pay for you to having some nutrition coaching with a Registered Dietitian. You can find her at Nutrition Authority.

You may also enjoy this CDC widget:

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High Five from Dr. P. Vol. 1 #1.

April 26, 2012

As I search the world over for inspiration and ideas I come across some pretty good stuff, and a whole lot of pretty bad stuff too.  I’m going to spare you the ugly, and bring you the best I see with the first of my “High-Five” posts.  Let me know what you think:

1.       At Common Sense Family Doctor Kenny Lin MD gives a much more personal and insightful take on the recent Annals of Internal Medicine article on the costs of an appendectomy in California.  Be sure to check out:

How much does it cost to have an appendectomy?

A few years ago, a good friend of mine who holds bachelor’s and law degrees from Ivy League schools lost his job and became one of the estimated 50 million medically uninsured persons in the U.S. Over the course of several days, he developed increasingly severe abdominal pain, fever, and vomiting. Though reluctant to seek medical attention, he finally was persuaded to visit his local hospital’s emergency department, where he was diagnosed with acute appendicitis. Read more

2.       Dr. Rob Lambert is back now with More Musings (of a Distractible Kind) blog and is a funny and poignant as prior to his mysterious time away from his blog.  You’ll like the Llama photos, and I found this post so right on that the humor is just an added bonus:
The Origin of Feces: 

When I first read it, I thought it said, “Your mother always reminded you to wash your behind…”, which makes sense, given the advertising subject material.  I haven’t read the remainder of the deal, so we can only guess what the last sentence reads:  read more


 3.   There is no free lunch in life, and healthcare is no different.  Dr. Wes at his eponymous blog sets us straight about claims of “free healthcare services” being advertised by our U.S. government of all sources.

When Health Care is Promoted as Free:
Health expenditures in the United States neared $2.6 trillion in 2010, over ten times the $256 billion spent in 1980. The rate of growth in recent years has slowed relative to the late 1990s and early 2000s, but is still expected to grow faster than national income over the foreseeable future.
So imagine my surprise when I saw this Medicare commercial last night that stated preventative health care services provided by Medicare were “free:”  read more

4.   In a post I just came across on the blog Whatever by John Scalzi is an anonymous post by a physician outraged by the coercive laws demanding women have a transvaginal ultrasound prior to an abortion.  Whatever views you have on abortion this post is worth reading to see an impassioned physician’s take on this issue:

Where is the Physician Outrage?

Right. Here.

I’m speaking, of course, about the required-transvaginal-ultrasound thing that seems to be the flavor-of-the-month in politics.

I do not care what your personal politics are. I think we can all agree that my right to swing my fist ends where your face begins.

I do not feel that it is reactionary or even inaccurate to describe an unwanted, non-indicated transvaginal ultrasound as “rape”. If I insert ANY object into ANY orifice without informed consent, it is rape. And coercion of any kind negates consent, informed or otherwise. Read more

5.  In a guest editorial on KevinMD Dr. Steven Reznick MD writes a compelling plea to medical journals to present information statistics in a form non-statisticians can comprehend.  I’m all for this and the KISS (keep it simple stupid) rule of thumb should apply to getting info to physicians too.  I’d have changed the by omitting primary care.  I don’t think subspecialists are more knowledgeable statisticians than me as a general rule.

Keep statistics simple for primary care doctors

“As a primary care physician, out of medical school for 36 years, let me make a suggestion.  Keep It Simple Stupid.   Medical school was a four year program.  The statistics course was a brief three week interlude in the midst of a tsunami of new educational material presented in a new language (the language of “medicalese”) presented en masse in between students being used as cheap labor at all hours of the day to fill in drawing bloods, starting intravenous lines and running errands for the equally overworked interns and residents who were actually being paid to perform these tasks.” Read more

I hope to post annotated links to great stuff I come across as I come across it.  Let these bloggers know that you appreciate their work by leaving them a comment on their sites.  Enjoy.

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Exercise -The Unknown Warrior In The Battle Against Cancer

April 23, 2012

Cancer touches every soul in one-way or another. There are many treatments available for both the mind and the body when living with this disease but the most important treatment option can often be overlooked. With chemotherapy, radiation, surgery, medications and rehabilitation, it is easy to forget that exercise can be a cancer patient’s greatest ally.

Extreme Fatigue is one of the most common complaints heard from patients during chemotherapy treatments but there are ways to help alleviate this uncomfortable side effect without adding additional medications into their day. Numerous studies have shown the merits of exercising throughout treatment to help maintain a normal level of activity. These studies have also shown that continuing to follow an exercise program after treatment may help cancer survivors maintain a quality of life similar to that found before diagnosis.

Exercise can do more than just help reduce fatigue. It can also help many patients address the emotional issues that come with a cancer diagnosis and treatment. Issues such as weight gain, muscle loss, and postoperative healing can create a distorted body image, which may lead to depression. It is widely known that exercise can aid in weight loss and that weight bearing exercises can increase muscle mass but during exercise, the body also releases endorphins that create an elevated mood. This elevated mood could help patients see their situation in a more positive light and aid in their recovery.

Although some form of activity is recommended daily, each patient will require a different exercise program dependent on his or her disease and current treatments or if they are currently in a survivorship plan. For example, a patient receiving Mesothelioma treatment must be more cautious of activities that apply a greater strain on the heart or lungs while a patient being treated for Bone Cancer would avoid any high impact exercises that could lead to a fracture.

Because of these risks, many people choose to have a trainer help them design an appropriate exercise routine. This is a wonderful idea but it is important to remember that the trainer must understand the specific requirements of cancer patients. According to an article published on the National Cancer Institute’s website, the American Cancer Society has developed a certification program for trainers wishing to help cancer patients and survivors. This program ensures that cancer patients and survivors are receiving the best care possible.

by David Haas. David is a writer for the Mesothelioma Cancer Alliance.  Please follow David on Twitter @haasblaag.

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