Surgeon General for the Ages Dies at 96

March 19, 2013 Dr. Pullen

Dr. C. Everett Koop, the outspoken activist and controversial surgeon general appointed by president Ronald Reagan in 1981 who served in that office until 1989 died this week at age 96. Dr. Koop had the qualities many of us would like our surgeon general to possess. First and foremost he tried to do the right thing. He recognized that tobacco was the leading cause of preventable death of American, and led the charge to warn of tobacco dangers. Although he was a political and religious conservative he was a major force in pushing the U.S. government into more aggressive and compassionate approach to the HIV/AIDS epidemic that became apparent during his tenure as surgeon general. He had a letter sent to every U.S. household with a frank discussion of HIV transmission, sexual practices that were proven to be high risk, and was unapologetic when he faced criticism about the frank and politically unpopular content of the letter. Check out this as an example of a frank public health info letter. It may look pretty straight forward now, but in 1988 it was a courageous and unpopular mailing. Gay rights activists felt it targeted them unfairly. Religious leaders felt it was too frank. Koop felt is was data driven and important. He simply put out the best information available at the time to give citizens information on how to avoid contacting HIV. He was personally against abortion but refused to allow this personal belief to bring him to use his position to influence his public position on the issues, standing up to pressure from the Reagan administration to write a statement on the psychological harm of abortion to pregnant women. Again he looked at the data and stood fast in refusing to bow to political pressure.

In short he behaved like a physician should. He looked at the data, decided on an appropriate response, and then did what he could in his position to help the problem. He did not fold to public criticism or political pressure. He just did what could to do the right thing for America and his citizen constituency. Our current surgeon general could take a lesson from his example. The office of surgeon general now seems to be little more than a political position to promote our government’s policies, not to guide our nation’s health initiatives.

I read in KevinMD a great article by Dr. Suzanne Kowen calling for a new U.S. surgeon general to move us in the direction Dr. Koop would be proud to notice. I agree that she is right on target. Say a prayer for Dr. Koop, and for future U.S. surgeon generals to learn from his example and to stay strong.

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Atherosclerosis in Antiquity

March 13, 2013 Dr. Pullen

I stumbled across a really interesting article in the Lancet where CT scans were done of 137 mummies and naturally mummified remains looking at the extent of vascular calcium deposits in blood vessels. It looks like atherosclerotic cardiovascular disease is not just a disease of modern stress, diet and lifestyle. It turns out that the mummified remains from 4 separate geographic areas over a 4000 year time frame showed a high incidence of vascular atherosclerotic changes.

So although our diets are undoubtedly different, and our lifestyles different though maybe not more stressful, getting arterial disease from calcium deposits in atherosclerosis is not unique to modern humans. 34% of the mummified remains showed probable of definite atherosclerosis. The conclusion of this article is, “Atherosclerosis was common in four preindustrial populations including preagricultural huntergatherers. Although commonly assumed to be a modern disease, the presence of atherosclerosis in premodern human beings raises the possibility of a more basic predisposition to the disease.” (1)

I’m not sure what this means, but it is likely that early humans simply did not live long enough to develop symptoms from or die from coronary disease or stroke as often as we do now that infectious disease and traumatic deaths are less common. The good news is that with reduced smoking rates, better care of coronary disease with medications, stents and surgery the death rate from atherosclerosis seems to be less than it was a quarter century ago. Check out the data below from the CDC site.

Figure 2. Percentage of all deaths due to five leading causes of death by year: United States, 1935–2010

So we are doing better than in the 1960-1980 time frame at not dying of heart disease, but it still remains the leading cause of death in the US.

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Send a Birthday Card That Could Save Your Life.

March 6, 2013 Dr. Pullen

Colon cancer is the second leading cause of cancer death in the U.S. and one of the few types of cancer that is often preventable. A recent headline-grabbing article in the Annals of Internal Medicine suggests that regular colonoscopy every 10 years in non-high risk patients can reduce the incidence of advanced colon cancer by up to 70%. It is important to know though that there is no evidence that colonoscopy, a test with a 1 in 1200 incidence of colonic perforation (1)which in some cases can be lethal, and which is quite expensive has never been shown to be more effective than annual fecal occult blood testing. Interestingly according to an article on WebMD the lead author of this article recommends fecal occult blood testing annually for colon cancer screening.

Traditional fecal occult blood testing is done by simply smearing a small amount of feces onto a card after a bowel movement. This is done on three separate bowel movements and then the stool is tested for hemoglobin, the oxygen carrying protein in red blood cells, at your doctor’s office where they simply put drops of a special liquid onto the card. This is quite inexpensive and carries only the risk of false negatives and false positives, i.e. no chance of colon perforation etc. Some clinicians choose similar but somewhat easier to use variations to test for fecal occult blood.

Colonoscopy has the theoretical advantages of finding precancerous polyps that can be “harvested” prior to malignant transformation, and preventing colon cancer. The cost, need for an extensive colon preparation, need to take a day off work, have someone to drive you home from the procedure, fear or other impediments may make colonoscopy something you don’t choose to get done. If so, or if you simply prefer fecal occult blood testing you don’t need to feel neglectful. Just choose this different type of birthday card each year around the time of your birthday. This one can do more than make you smile. It could save your life.

You may also enjoy: Colon Cancer Screening: The Rest of the Story.

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Mediterranean Diet Can Reduce Cardiovascular Deaths by 0.3% / year

February 25, 2013 Dr. Pullen

But only if you are high risk to begin with, much less otherwise. Not a headline likely to motivate you to make major dietary changes, but one more in touch with the complex realities of prevention of cardiovascular disease than the message of the “TimesCast” my wife sent me as a link by email today.

The video reported on a new NEJM report touting a primary prevention article showing a 30% reduction in cardiovascular end points in a study comparing an augmented Mediterranean Diet to a control group of patients counseled to just reduce their dietary fat. At the headline level this sounds really exciting. We had a salad full of beans and greens for dinner, and fish is on the menu for tomorrow. Still, this is a great example of how statistics can be presented to exaggerate a benefit or risk. Let’s look at the data of this study, which seems to be nicely designed and executed.

Headline: 30% reduction in Cardiovascular events with Mediterranean Diet!

Reality check.

This population was a high risk population where enrolled members either had diabetes, or three cardiovascular risk factors like hypertension, smoking, overweight or obesity, high LDL, low HDL or a family history of premature coronary artery disease. Of these I only have overweight, so my likelyhood of a cardiac event is probably less than 1/3 that of those in the study.
The absolute risk reduction in this high risk population was 3 events per 1000 participant years. This is accurately described as a 30% relative reduction from 11.2 to 8.0 events per 1000 patient years, but a 0.3% reduction in absolute risk per year is considerably less exciting. Given that our family has a far lower innate risk given no smoking, no hypertension, good lipid levels, and no family history of premature coronary disease the number for us is likely closer to a 0.1% absolute risk reduction per year.

Does this mean the value of the Mediterranean Diet is insignificant? Heck no. I strongly recommend it, and hope Kay keeps cooking this way and I believe we will be healthier for the change. I just want to keep the expectations of benefits real.

For more about the Medeterranean diet see a prior post: Dr. Pullen Lives the Medeterranean Diet.

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Breakthrough Prizes in Life Sciences are Cool

February 25, 2013 Dr. Pullen

Research we need even more is boring, uninteresting, and has little or no funding. I was pleased to read the news last week of the Breakthrough Prizes in Life Sciences, giving $3 million each to 11 actively working basic scientists in medical and biological research. This is a great idea and a way to promote basic research. Hopefully one or more of these scientists will produce research results that lead eventually to progress in the treatment of cancer, neurologic disease management or other fields of medicine. Still these prizes reward researchers in areas where there is already enough interest, money and sexiness to have attracted these brilliant researchers. Hopefully the awards will attract even more.

Unfortunately we also need to find some way to incentivize someone to do less intellectually attractive studies to help us with mundane but also important decision options we face daily in practice. Treatment of such common and high-morbidity problems as hypertension, osteoarthritis and diabetes have many questions still unanswered and with little hope of definitive answers coming soon or ever. This is because there is little incentive to anyone to do the studies needed. They don’t involve a new high-profit drug so big pharma has no financial incentive. Physician groups have little incentive to see if non-physician providers can assume some of the things we now get paid to do ourselves. Many questions that need answers are simply head-to-head studies of commonly used treatments or treatment models. Another problem is often we don’t even have appropriate outcomes to use to measure the results of the things we do.

As a primary care physician

I was pleased to read the news last week of the Breakthrough Prizes in Life Sciences, giving $3 million each to 11 actively working basic scientists in medical and biological research. This is a great idea and way to promote medical basic research. Hopefully one of more of these scientists will produce research results that lead eventually to progress in the treatment of cancer, neurologic disease management or other fields of medicine. These prizes reward researchers in areas where there is already enough interest, money and sexiness to attract brilliant researchers. Unfortunately we also need to find some way to incentivize someone to do less intellectually attractive studies to help us with mundane but also important decision options we face daily in practice. Treatment of such common and high-morbidity problems as hypertension, osteoarthritis and diabetes have many questions still unanswered and with little hope of definitive answers coming soon or ever. This is because there is little incentive to anyone to do the studies needed. They don’t involve a new high-profit drug so big pharma has no financial incentive. Physician groups have little incentive to see if non-physician providers can assume some of the things we now get paid to do ourselves. Many questions that need answers are simply head-to-head studies of commonly used treatments or treatment models. Another problem is often we don’t even have appropriate outcomes to use to measure the results of the things we do.

It is frustrating a as a primary care physician that there is almost no money to fund research to get answers to many questions we routinely face in our practice of medicine. There is little or no data to tell us which of several options are best for the treatment of numerous health conditions. Here are just a few examples of questions to which we do not have answers or any expectation of answers on the way:

Which thiazide diuretic is the best choice to treat hypertension? Hydrochlorothiazide certainly dominates the U.S. market, but much of the early research to support the benefits of thiazide use to prevent stroke from hypertension was done using chlorthalidone, and more than a few practitioners feel that chlorthalidone is a better option. Those of us who practiced long enough ago to remember using chlorthalidone regularly preferred hydrochlorothiazide because of frequent hypokalemia (low potassium) using chlorthalidone, but this was also when use of digoxin was common and the risk of hypokalemia when on digoxin was a concern. Indapamide, an infrequently used thiazide is also a consideration. A head-to-head trial of some sort using these three drugs, along with a potassium sparing combination like triamterene-hydrochlorothiazide should be relatively easy to do and the information obtained could be practice changing and powerful.
Which of the many supplements commonly used by patients and recommended by providers really work, and what is the best way to use them? Controlled and appropriately powered trials of many of the commonly used supplements would really help patients know what is worth trying. Does glucosamine-chondroitin sulfate work well enough to try for most patients with osteoarthritic pain? If so at what dose is needed, and how long does a patient need to take the it to see if it works, and for which areas of pain? Is red-yeast-rice effective at lowering cardiovascular risk by lowering LDL? Is it safer than the prescription statins and is it safe to try in patients who have not tolerated statins? What conditions is fish oil really good for and what types work best? The list of studies needed in this arena is long.
What model of primary care is most effective, gives the best outcomes and meets patient’s needs and expectations the best? Are physicians better than, as good as or inferior to teams of physicians and physician assistants in primary care outcomes? How do either of these compare to nurse practitioners? How are other professionals like nurses, therapists, counselors, coaches, nutritionists, and case managers best used, and does their use save money, lead to better outcomes, or have other benefits? Do alternative care providers like naturopaths, chiropractors, etc. give equal, better or inferior outcomes to traditional medicine. There are hints that some of these models are good, but no solid evidence guides us in trying toward change in our care models.
What method of payment for health care will best serve our populace and be acceptable to physicians, patients and payers? This is a question that the Affordable Care Act hopes to try to address, but prior attempts to promote behavior change by financial incentives have led to undesirable unanticipated consequences. Somehow the incentive is going to have to lead to proven high-quality care choices by providers while reigning in costs. Words like rationing, cookie-cutter care, and best-practice come to mind with the positive and negative connotations attached.

For me the answers to this type of questions could lead to more breakthroughs in medical care than the basic science the Breakthrough Prizes in Life Sciences are seeking to reward and make popular.

that there is almost no money to fund research to get answers to many questions we routinely face in our practice of medicine. There is little or no data to tell us which of several options are best for the treatment of numerous health conditions. Here are just a few examples of questions to which we do not have answers or any expectation of answers on the way:

Which thiazide diuretic is the best choice to treat hypertension? Hydrochlorothiazide certainly dominates the U.S. market, but much of the early research to support the benefits of thiazide use to prevent stroke from hypertension was done using chlorthalidone, and more than a few practitioners feel that chlorthalidone is a better option. Those of us who practiced long enough ago to remember using chlorthalidone regularly preferred hydrochlorothiazide because of frequent hypokalemia (low potassium) using chlorthalidone, but this was also when use of digoxin was common and the risk of hypokalemia when on digoxin was a concern. Indapamide, an infrequently used thiazide is also a consideration. A head-to-head trial of some sort using these three drugs, along with a potassium sparing combination like triamterene-hydrochlorothiazide should be relatively easy to do and the information obtained could be practice changing and powerful.
Which of the many supplements commonly used by patients and recommended by providers really work, and what is the best way to use them? Controlled and appropriately powered trials of many of the commonly used supplements would really help patients know what is worth trying. Does glucosamine-chondroitin sulfate work well enough to try for most patients with osteoarthritic pain? If so at what dose is needed, and how long does a patient need to take the it to see if it works, and for which areas of pain? Is red-yeast-rice effective at lowering cardiovascular risk by lowering LDL? Is it safer than the prescription statins and is it safe to try in patients who have not tolerated statins? What conditions is fish oil really good for and what types work best? The list of studies needed in this arena is long.
What model of primary care is most effective, gives the best outcomes and meets patient’s needs and expectations the best? Are physicians better than, as good as or inferior to teams of physicians and physician assistants in primary care outcomes? How do either of these compare to nurse practitioners? How are other professionals like nurses, therapists, counselors, coaches, nutritionists, and case managers best used, and does their use save money, lead to better outcomes, or have other benefits? Do alternative care providers like naturopaths, chiropractors, etc. give equal, better or inferior outcomes to traditional medicine. There are hints that some of these models are good, but no solid evidence guides us in trying toward change in our care models.
What method of payment for health care will best serve our populace and be acceptable to physicians, patients and payers? This is a question that the Affordable Care Act hopes to try to address, but prior attempts to promote behavior change by financial incentives have led to undesirable unanticipated consequences. Somehow the incentive is going to have to lead to proven high-quality care choices by providers while reigning in costs. Words like rationing, cookie-cutter care, and best-practice come to mind with the positive and negative connotations attached.

For me the answers to this type of questions could lead to more breakthroughs in medical care than the basic science the Breakthrough Prizes in Life Sciences are seeking to reward and make popular.

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Suicide and Gun Ownership

February 15, 2013 Dr. Pullen

It has been known for some time that if you have a gun in your home you are more likely to die a violent death by firearm than if you do not have a gun in your home. Access to a lethal means of effecting suicide is a major risk factor when assessing a patient with major depression. A recent article in the New York Times eloquently outlines the concern that death by suicide from a gun is really common. 85% of suicide attempts by firearm result in death vs. 2% of attempts by overdose with pills. Of the 30,000 U.S. deaths by firearm in 2010 nearly 2/3 were from suicide. This article is a must read for anyone who owns or is considering keeping a firearm in their home:

To Reduce Suicide Rates, New Focus Turns to Guns

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Millenials: The Most Stressed of Americans

February 11, 2013 Dr. Pullen

I just finished reading a report released by the American Psychological Association stating that the millennials, youth aged 18 to 33, are more stressed out than the rest of the US population (1). The reason for this stress is stated to most often be jobs and money. Somehow this doesn’t surprise me. Young adults in this age range face challenges that the current high unemployment environment presents without the life experiences that older adults facing the same economic situation can fall back upon. The report also suggests that about half of these anxious youth are not managing the stress particularly well and that a significant number don’t feel that their physicians are helpful in guiding them towards lifestyle and behavioral changes that might give relief. The conclusion of the American psychological Association that professional counseling helps them better achieve their goals is coming from the organization of the professionals who provide that type of therapy, maybe self-seving but still probably reasonable.

The crux of the report is that patients of all ages, but especially our young adults, are not getting the psychological support that they need and want from our health care system. Unfortunately the exact demographic segment most in need of these mental health services is the least likely to have health insurance to help pay for the counseling. The persons most at risk of being uninsured are young adults. This is especially true of young men who are not eligible for medical assistance in most situations. 59% of uninsured Americans are under the age of 35, and the uninsurance rate in the 18-24 age group is 29% according to a Pfizer study. I cannot find age specific rates of being uninsured in this age range by gender, but overall ages males are about 1.2x as likely to be uninsured as females. If this holds true in the millennials too then the uninsurance rates for males age 18-24 is likely well over 30%.

Stress induced depression , anxiety and other mental health issues without access to mental health care is a recipe for underachievement and unhappiness. I’m hopeful that as the affordable care act become fully implemented in 2014 the rate of uninsurance for young adults will drop significantly, and many of these young adults will have better access to psychological support. I’d love to see discussion in the comments below of reader’s experience on the subject.

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Downton Abbey: Eclampsia. Lady Sybil’s Death. What Fans Ought to Know

February 7, 2013 Dr. Pullen

Would Dr. Clarkson’s Recommended C-Section Have Saved Sybil On Downton Abbey? Did Dr. Clarkson breech medical ethics by reassuring the family that the decisions of Earl Robert did not doom Sybil to an otherwise preventable death? These and other questions will be addressed in this post.

It took my wife’s questions about the death of the BBC Masterpiece Theatre hit series Downton Abbey’s Lady Sybil’s death to prompt me watch these episodes. In this post I’ll give a 21^st century family physician’s analysis of the medical issues surrounding eclampsia, physician ethics and the physicians involved in the obstetric care of the youngest Crawley daughter. For non-fans Downton Abbey is in the third year of a series that depicts the aristocratic Crawley family and their household servants in the time surrounding WW1 in England on an estate called Downton Abbey. On Downton Abbey Robert Crawley, the Earl of Grantham, has absolute decision-making control of the household. He chooses to invite Sir Phillip Tapsell, a renowned and blatantly arrogant obstetrician from London, to attend and manage the delivery of his youngest daughter Sybil’s first baby. The rest of the family would prefer to have their longtime trusted family physician, Dr. Robert Clarkson care for Sybil and her delivery.

In Season 3, episode 4 Sybil is late in her third trimester and begins to exhibit signs and symptoms that Dr. Clarkson correctly recognizes as preeclampsia based on his medical knowledge and his experience with Sybil. Sir Philip confidently pronounces her symptoms as normal. He considers Sybil’s behavior and state to be the result of stress, anxiety and female fragility. He arrogantly guarantees that everything is normal. The symptoms presented in the episode are classic for preeclampsia; headache, confusion, swelling, and poor fetal growth. An objective sign proteinuria is even documented. Although no mention of blood pressure is made during the show, the relationship of high blood pressure and eclampsia was discovered as early as the very late 19^th century. For an excellent and detailed history of preeclampsia-eclampsia see the NIH manuscript of a 2010 Journal of Obstetric and Gynecologic Neonatal Nursing.

Downton Abbey FAQ about Sybil and the Circumstances Surrounding Her Death:

Would a Cesarean section delivery have saved Sybil at the time proposed by Dr. Clarkson? A better question would be; what is the chance that performing a C-section then would have saved Sybil? This of course is unknown, but at least in part depends on the timing. It is somewhat unclear how much time passes between the initial recommendation for C-section by Dr. Clarkson and the actual delivery. It cannot be very long, as the discussion happened after dinnertime and Sybil delivered well before sunrise. I estimate 3-4 hours at most. It would have taken at least an hour or two to transport Lady Sybil to the hospital and accomplish a C-section, so at most an hour or two of time would have been saved, maybe less. It is likely that eclampsia and the attendant complications and death would have still occurred if C-section was attempted at this very late time.

What were the clues Dr. Clarkson used to suspect impending eclampsia? Preeclampsia is much more common in first pregnancies, so Sybil was at risk for that reason. Sybil’s complaints of headache, edema, delirium, and proteinuria were emphasized and these are the classic signs and symptoms of preeclampsia. The suspicion of the baby’s small size was mentioned repeatedly. Poor fetal growth is a clue that the common preeclampsia complication of placental damage may be leading to poor fetal weight gain. This is now usually called intrauterine growth retardation (IUGR). Since the 1980’s we have used ultrasound to monitor suspected IUGR, obviously not available to Sir Philip and Dr. Clarkson. Sybil’s delirium was the most important clue, correctly recognized by Dr. Clarkson and patronizingly discounted by Sir Philip, because it is a very late and ominous symptom of preeclampsia. It suggests that her blood pressure was so high that she was having signs of brain dysfunction we would now diagnose as hypertensive encephalopathy. The family and Dr. Clarkson who knew Sybil well recognized this as highly out of character for Sybil. The latecomer Sir Philip with his paternalistic and stereotypical view of women discounted this cognitive dysfunction.

Was delivery known to be the best management of preeclampsia and how could it have been accomplished? In the 1920’s the condition of eclampsia was widely known, but the prodromal condition now called pre-eclampsia was just beginning to be recognized. Even now we don’t know what causes preeclampsia-eclampsia, but we know how to recognize and diagnose the condition. We also have the means to safely accomplish delivery to prevent progression to eclampsia. Even today once eclampsia (the onset of seizures is when pre-eclampsia becomes eclampsia) occurs things are very dire. The key to reducing mortality of eclampsia is the recognition of preeclampsia and finding a way to accomplish delivery before eclampsia is likely to occur. Today a major part of good prenatal care is the monitoring for early signs and symptoms of pre-eclampsia. Once pre-eclampsia is diagnosed, very careful monitoring for worsening of the condition, and for the welfare of the fetus is undertaken. Delivery remains the only real cure of pre-eclampsia and many inductions of labor and C-section deliveries are done to avoid progression to eclampsia. Dr. Clarkson suspected something was wrong at least a day or two prior to Sybil’s death, but he lacked the tools we now have to further assess the condition, and also lacked the means of labor induction that now are commonplace. Could Dr. Clarkson have reasonably recommended a C-section days earlier when it nearly certainly would have prevented eclampsia and Sybil’s death from eclampsia? Given that the surgery carried a high mortality making this decision would have been bold and very controversial. Treatments such as intravenously magnesium sulfate and treatment of hypertension were just not available.

Did Dr. Clarkson lie to the family about Sybil’s fate, and if so was that wrong? As a family physician I stand behind Dr. Clarkson’s presentation of the facts of the case to the grieving parents. The family conference was at the insistence of Sybil’s grandmother, Violet Crawley the Dowager Countess of Grantham. It seems that he was pressured into the discussion for selfish reasons from the Dowager. Dr. Clarkson reasonably stated the facts; Sybil had advanced pre-eclampsia, eclampsia is highly unpredictable and has a very high fatality, no treatments were available, in fact the chances that his recommended C-section would have saved her life were very low. He graciously and reasonably gave the family the opportunity to heal by not overstating the chances that the poor decisions by Sir Philip and the Earl prevented a life-saving procedure. He may have overemphasized the slim chance that Sybil might have been saved, but if so his heart was in the right place and giving a chance for healing to Sybil’s mom was completely appropriate.

Although the setting for Downton Abbey is in the 1920’s in England, preeclampsia and eclampsia remain major causes of maternal and fetal morbidity and mortality today. I encourage Downton Abbey fans to ask any other questions you have in the comments below and I will try to answer them.

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Don’t Just Wear Red: Do Something

January 31, 2013 Dr. Pullen

Tomorrow, Friday Feb. 1, is national Wear Red Day, to spread awareness that heart disease is the number one killer of women in the U.S. Breast cancer gets a lot of press, sells a lot of pink football gear, and is feared by women, but more women die every year of heart disease than all cancers combined, not just breast cancer. About one in four deaths in U.S. women is from heart disease. The good news is that there are actions you can take to avoid dying of heart disease. The good news is also the bad news. I’m not talking about going to your doctor, getting testing, taking medication or anything that easy. I’m talking about really hard things; lifestyle changes that can save your life. Here are 5 things you can do to reduce your risk of dying of heart disease:

Quit smoking: If you smoke, the biggest single thing you can do to reduce your risk of developing and dying of coronary disease is to quit smoking. Although obesity may rival or surpass smoking as the leading preventable cause of death in the U.S. quitting smoking is the number one change you can make to reduce your chance of a heart attack and cardiac death. It’s not easy, but it is possible. Quit today. It’s far more helpful than wearing red.
Eat Healthier: Eat more fruit and vegetables and reduce your meat ingestion. Evidence abounds that reducing your intake of saturated fats primarily found in animal fats including meat, dairy products and eggs can reduce your cardiac risk. Eating real fruits and vegetables has far more benefit than taking vitamins or supplements to try to get the same healthy vitamins and other healthy ingredients.
Exercise more: Regular exercise that increases your heart rate and respiratory rate is an effective way to improve your cardiac health. It’s not called “cardio” exercise for nothing. If you are concerned about your cardiac status see your physician to get clearance and advice about exercise.
Control your blood pressure and cholesterol: If you don’t know your blood pressure, get it checked periodically. If you don’t know your cholesterol numbers see your physician and get them checked. High blood pressure is one of the biggest risk factors for heart attack and stroke, and it is almost always manageable. In the U.S. we do a terrible job of detecting and managing hypertension. Don’t be one of the millions with undiagnosed or undertreated high blood pressure. Find out and treat it.
Secondary Prevention: If you have known atherosclerotic disease, including peripheral artery disease, coronary disease or cerebrovascular disease (stroke), be aggressive about secondary prevention. Many interventions including all of the above as well as daily aspirin use and in some situations medical or surgical interventions can make huge differences.

So wear red tomorrow if it makes you feel better, but if you really want to make a difference do something to improve your cardiac risk profile and heart health. Wardrobe changes are easy, but it is more important that you take action to prevent cardiac death using the steps above. You can make a difference. Do it today!

To see more about what causes heart disease see an earlier post.

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Barriers to Contraception: or “Why Is Every Other U.S. Pregnancy Still Unplanned?

January 28, 2013 Dr. Pullen

Nearly one out of every two U.S. pregnancy is unplanned, a statistic that has remained unchanged for the last 20 years. Other ways of looking at this statistic is that approximately 5% of women aged 15-45 in the U.S. have an unplanned pregnancy in any given year. Of these unplanned pregnancies about 20% ar unwanted, and about 30% are mistimed. One consequence of this is that there are about 1.2 million abortions in the U.S. annually. The reasons for these depressing statistics are many. It is easy to place the blame on this on the men and women who together generate these unplanned conceptions, but it may be more fruitful to look at institutional policies and barriers to contraception that play at least some role. Let’s look at some of the policies, misconceptions, myths, and beliefs that together create significant barriers to adequate contraception in the U.S. today.

Financial Barriers: In the U.S. large numbers of people lack affordable access to medical care. The most effective means of contraception, the set-and-forget options including IUDs and implantable contraceptive rods, as well as birth control pills and other hormonal means of contraception require a prescription, i.e. access to medical care. The American Congress of Obstetricians and Gynecologists (ACOG) recommended that birth control pills become available without a prescription last year. Still no manufacturer has applied to the FDA for approval to sell the pill over-the-counter (OTC). I recently posted about a large study showed that free and aggressively marketed contraception might reduce unplanned pregnancies by up to 80%.
Non-compliance with Contraceptive Use: Most means of contraception require at least some degree of user compliance. On the high end of user-dependent compliance are condoms, the diaphragm, and “natural family planning” (timing intercourse to the less fertile times of the women’s cycle). All of these methods have high actual-use failure rates and lead to millions of unplanned pregnancies due to user non-compliance and to a lesser degree to method failure. Even birth control pills and their non-oral similar means like the patch and intra-vaginal ring require significant user compliance. Actual failure rates with birth control pills are much higher than their theoretical efficacy rates, largely due to forgetting to take the pill daily, to use of antibiotics that can reduce efficacy rates, or other user related errors. This unacceptably high failure rate has led to leading groups like ACOG recommending set-and-forget methods as the best choice for adolescent sexually active women.
Emotional, Religious and Family Issues: I regularly see teens in the office who are sexually active yet who choose not to use effective contraception because they are afraid that their parents will find out that they are sexually active if they use the pill, or get a more effective set-and-forget method. I speak with parents who feel that helping their daughters get effective contraception is giving their blessing to sexual behaviors they do not condone. I much less commonly see Catholic women who do not want to conceive but do not feel they can use contraception. I hear young patients often who use condoms only as their contraceptive method of choice, even though they know the failure rate is high. Part of this is a failure to clearly understand the need for condoms to reduce sexually transmitted infection risks, but the additional need for more reliable contraception to avoid unplanned and undesired pregnancy.
Contraceptive Failure: Only abstinence as a means of contraception is perfect, and abstinence-only as a population based approach just does not work. All others have failure rates that are not 0%, but some are much less perfect than others. Many physicians and patients alike believe that birth control pills are nearly always effective, but their failure rate is about 5% annually. The set-and-forget methods are very effective. Failure rates of less than 1% annually can be expected with IUDs, Depo-Provera® and Nexplanon®. Failure rates with every other non-permanent method is significantly higher. Condoms have failure rates in actual use studies ranging from 11-16%. Diaphragm with spermicide use has a failure rate of about 15% annually. No contraceptive use at all has an approximately 85% chance of conception annually in sexually active couples. I have become convinced set-and-forget methods of contraception are the best option for prevention of unplanned pregnancy in teens, young single women, and others who strongly want to avoid conception. The rate of unplanned pregancy is enough higher with all of the other methods that the set-and-forget methods should be used in their situations most of the time.

So what could we as a nation do to markedly reduce unplanned pregnancies?

Make contraception free to all Americans.
Remove financial barriers and work to reduce emotional and cultural barriers to contraceptive advice and implementation.
Make many types of birth control that do not require provider instrumentation available without prescription. In the case of birth control pills this may require a “white-knight” type company to apply to the FDA for approval first to remove the financial disincentive the pharmaceutical industry has to losing their monopoly on prescription-only pills. Payment for an OTC pill may be a barrier in and of itself, but I suspect providing this option would overall improve access.

Leave a comment if you have thoughts on this topic, or ideas of better ways to reduce the unacceptable rate of unplanned pregnancies in the U.S.

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