Limit of 500 grams per week urged by cancer society
By Sharon Kirkey, Canwest News ServiceMarch 24, 2009
Eating large amounts of red or processed meat increases the risk of dying, new research involving more than half a million people shows.
The sheer size and quality of the study has led the Canadian Cancer Society to say it will be lowering its recommended limit on the amount of red and processed meats people should consume.
The group now recommends limiting red meat to 500 grams, or 18 ounces per week, to reduce the risk of cancer.
The new study found men and women who eat about 110 grams (four ounces) of red meat per day -- the equivalent of a small steak or quarter pound of meat -- had a higher risk for overall death, and dying from heart disease or cancer than those who ate less than 30 grams (one ounce) of red meat daily.
"Less than an ounce would be around threes slices of ham," says lead author Rashma Sinha, of the U. S. National Cancer Institute.
High intakes of red meat had al-ready been linked to a greater likelihood of developing colorectal cancer, the second leading cause of cancer death in Canada.
"This takes it that next step and actually looks at the impact that has on cancer deaths,"says Heather Chappell, senior manager of cancer control policy at the Canadian Cancer Society. "This really is a significant addition to our body of knowledge in this area."
The study, published this week in the Archives of Internal Medicine, involved 322,263 men and 223,390 women, aged 50 to 71, recruited from eight American states and cities between 1995 and 2005. Volunteers filled out questionnaires that asked about their usual consumption of food and drinks, including a full range of meats.
Overall, "we found that the consumption of red and processed meat was associated with a modest increase in total mortality, cancer mortality and cardiovascular mortality in both men and women," Sinha says.
"For overall mortality, 11 per cent of deaths in men and 16 per cent of deaths in women could be prevented" if people had consumed red meat at the lowest level of intake, the researchers wrote.
March 31, 2009
Benefits of Mammogram Under Debate in Britain
By RONI CARYN RABIN
The conventional wisdom about breast cancer screening is coming under sharp attack in Britain, and health officials there are taking notice.
They have promised to rewrite informational fliers about mammography after advocates and experts complained in a letter to The Times of London that none of the handouts “comes close to telling the truth” — overstating the benefits of screening and leaving out critical information about the harms.
What women are not told, the letter said, is that for every woman whose life is saved by breast cancer screening, up to 10 healthy women are given diagnoses — and, often, surgery — for a cancer that is so slow-growing it would never have threatened a woman’s life.
“The culture is just that mammography is such a very sensible thing to do, so you chug along and have it done,” said one of the signers, Hazel Thornton, in a telephone interview.
Mrs. Thornton, 75, said she became disenchanted with routine screening more than 15 years ago, after a mammogram identified ductal carcinoma in situ, a noninvasive breast cancer that often does not progress. She had a lumpectomy, but was offered such a confusing array of treatment options that she realized doctors knew little about how aggressively to treat this kind of cancer.
“You don’t know about all the uncertainty until you’re one of the unlucky ones, and it happens to you,” she said.
The idea that mammography may do more harm than good may be alien to many American women. The prevention message has emphasized that screening protects women from breast cancer, and one survey of 479 women found that only 7 percent were aware that some cancers grow so slowly that even without treatment they will not affect a woman’s health.
A 2006 analysis by the Nordic Cochrane Center collaborative, an independent research and information center based in Copenhagen, found that for every 2,000 women age 50 to 70 who are screened for 10 years, one woman will be saved from dying of breast cancer, while 10 will have their lives disrupted unnecessarily by overtreatment. The figures were cited in the letter to The Times.
Julietta Patnick, the director of cancer screening programs for the British National Health Service, said the patient handout was being revised and added that information about overdiagnosis might be added.
But in a telephone interview, she dismissed the Cochrane figures as inaccurate. British studies, she said, show that the ratio of lives saved to lives unnecessarily disrupted is more like one to one.
“We know, from statistics, that there are cancers diagnosed through screening that wouldn’t otherwise have been diagnosed — because the woman dies of something else first, because she might get run over by a bus, or she might have a heart attack, or she might live to 90 and it would just sit there, and she wouldn’t have died of breast cancer,” Ms. Patnick said.
But the problem is, “You don’t know who that woman is,” she continued. “You just know that statistically, she exists.”
Experts agree that under a microscope, slow-growing cancers look no different from more aggressive ones, so it is impossible to know which ones can be left untouched.
The author of the Cochrane analysis, Dr. Peter C. Gotzsche, another signer of the British letter, has written an alternative version of a patient handout for women considering mammography. It starts off by saying, “It may be reasonable to attend breast cancer screening with mammography, but it may also be reasonable not to attend.”
Women in the United States are screened much more rigorously than women in Britain, with annual mammography starting at 40. British women start at 50, and get a mammogram once every three years.
Dr. Ned Calonge, chairman of the United States Preventive Services Task Force, says mammography has been oversold to American women.
“The expectation of women is that ‘If I get screened, I won’t get breast cancer,’ ” he said. “I hear that women will say: ‘How can I have breast cancer? I always get my mammogram.’ ”
In fact, Dr. Calonge went on, early detection may not make a difference in survival for many women.
“Some women would have the same outcomes, whether the cancer is detected clinically or by mammography,” he said. “And there are women whose cancer is so aggressive we cannot detect it early enough to make a difference in mortality.”
An expert panel that reviewed the evidence on annual mammography for the task force in 2002 downgraded the recommendation for annual screens to “recommended” from “strongly recommended.” That review raised some of the same concerns mentioned by the critics in Britain: the high incidence of false-positive scares that cause anxiety yet turn out to be nothing serious, and the potential overtreatment of ductal carcinoma in situ and other “indolent” cancers. The panel also expressed concern about the potential for harm from exposure to radiation during the scans.
Mammography is more effective in older women. But even among women 50 and over, the panel concluded, only one death would be prevented after 14 years of observing more than 800 women who had undergone screening.
“That’s a hefty number of women” who must be screened to derive a benefit, Dr. Calonge said.
Similarly, studies about prostate screening for men concluded this month that the P.S.A. blood tests save few lives while leading to unnecessary treatment with potentially serious complications.
Despite the task force’s reservations, most medical societies endorse annual mammography, as does the American Cancer Society. Robert Smith, director of cancer screening for the society, says he believes overdiagnosis is minimal at best, and only 10 percent of invasive cancers found through mammography are harmless and will never be life-threatening.
“I think this is another example of, ‘Here is something your doctor knows and isn’t telling you,’ ” Dr. Smith said. “This is a debate between people who see the glass half full or the glass half empty.”
“Breast cancer screening is a good part of a preventive health care plan,” he continued. “It’s not perfect.”
Ultimately, women have to make their own decision about whether to be screened, said Dr. Lisa M. Schwartz, an associate professor at Dartmouth Medical School, who is co-author of “Know Your Chances” (University of California, 2008), a book about how to interpret health statistics and risk.
“You’re not crazy if you don’t get screened, and you’re not crazy if you do get screened,” said Dr. Schwartz, who also signed the letter to The Times. “People can make their own decision, and we don’t need to coerce people into doing this.
“There is a real trade-off of benefits and harms. Women should know that. There’s no question on one count: if you get screened, it’s more likely you’ll have a diagnosis of breast cancer.”
March 31, 2009
Comforter and Comforted in an Unfolding Mystery
By NELL BURGER KIRST
I never really got to know the young woman. I met her during my third-year psychiatry rotation, when our team was consulted for concerns about depression.
Privacy rules won’t allow me to use her name (where possible, I’ve gotten consent from the others involved in this story). She was terminally ill, sick not just with the disease but with all the complications of its treatment, and confined to bed in the intensive care unit.
By the time I met her she could barely speak. Her face was a vacant yellow moon, and her sparse, colorless hair sprawled tangled and sweat-soaked across her pillow.
What I did come to know of her was through her boyfriend, Josh. They had been together since middle school and had stayed together even as the rest of her life fell apart.
When her strained relationship with her parents became impossible and they were no longer in her life, Josh remained her confidant and closest friend. When she learned she was seriously ill, she and Josh filled out the paperwork required to give him her durable power of attorney.
So it was that he sat by her bed day after day, occasionally rising from his post there to perform the rudimentary maintenance that she no longer could: wiping the tears from her eyes and clearing the caked secretions around her mouth.
In her medical chart, he is referred to not as her “boyfriend,” but as “family” or even simply as “Josh,” and his presence in her record traces much of the agonizing march of her illness.
As she takes a turn for the worse: “Josh feels that [the patient] is still fighting and would like to proceed with treatment.”
As organ systems begin failing: “Family will readdress code status tomorrow.”
And finally, as supportive medical care is withdrawn: “Josh understands that [she] is dying and states that he is struggling to imagine a future without her.”
Five months later, in the dead of winter, a 25-year-old man named David was changing a flat tire on the side of the road when he was struck by a van. He landed in the I.C.U. on a ventilator, with multiple fractures. I had landed there just several days earlier in my capacity as a medical student, and I would follow him as my patient for the next several weeks.
He soon became medically stable enough to move to a general hospital floor, but he had significant behavioral problems that required a sitter to stay with him around the clock. He routinely removed his feeding tube, refused to work with therapists, would not use a bedpan. He was frustrating and difficult to work with, and he was sabotaging his own recovery.
One morning I spoke with his nurse about his progress. His feeding tube had been in place for 30 hours straight. He had begun to cooperate in physical therapy, and he was using the bedpan without complaints.
David’s mother emerged into the hallway to confirm his improvement. It seemed to her to have a lot to do with the sitter who had been assigned to him for the past couple of days.
The sitter, she said, was extremely patient. He was supportive and enthusiastic, listening to David’s stories and sharing stories of his own. He was someone David could relate to, a perfect fit for him. I nodded, encouraged, and walked into the room.
There was David, sitting up in his hospital bed, animated and joking with his sitter. The thick, tedious air that had occupied David’s room effervesced and became light, and it happened so quickly I could not catch my breath.
His sitter was Josh.
It turned out he had taken a job with the hospital after his girlfriend’s death. His story, I realized, was a kind of love story, and in some way it evoked all of our stories, whether we are doctor or patient, comforter or comforted, healer or healed. Josh reaffirmed for me what we medical professionals know but all too easily forget: the human story is not a series of illnesses and treatments that we manage, but is an unfolding mystery — a process with which we ourselves are in ongoing communion, as both witnesses and full as participants.
There, settling into our place in the story, we can see it in its wholeness and let it make us whole. We take part in its healing as it unfolds, and we are healed by its unfolding.
Nell Burger Kirst is a fourth-year medical student.
Breastfeeding has health benefits for mothers too, study reveals
Risks of stroke, diabetes, heart disease reduced
By Sharon Kirkey, Canwest News Service
April 21, 2009
Breast isn't just best for baby: mothers who don't breastfeed their babies may increase their risk of heart attacks and strokes decades later, new research suggests.
The evidence comes from the massive Women's Health Initiative trial and involved nearly 140,000 women.
Researchers found that women who breastfed were less likely when they were older to have developed high blood pressure, diabetes, high cholesterol and cardiovascular disease -- the leading cause of death in Canadian women.
"The longer a woman breastfed her baby, the better it was for both of them," says lead author Dr. Eleanor Bimla Schwarz, of the University of Pittsburgh.
"Ours is the first study that shows that there really is a strong effect in terms of preventing heart attacks and stroke for women who nursed for more than six months,"says Schwarz, an assistant professor of medicine, epidemiology and obstetrics, gynecology and reproductive sciences.
The study appears in the latest issue of Obstetrics and Gynecology.
Health Canada recommends breast milk should be the only food or drink for the first six months of life, and that breastfeeding continue, along with the gradual introduction of solid food, for two years or more.But a national survey released last month found only 14 per cent of new moms in Canada exclusively fed their newborns breast milk by age six months.
Breastfeeding helps protect babies against infections and disease, benefits that are thought to last a lifetime.
"We now know that it's important for mothers' health as well,"Schwarz says.
Her team analyzed data from 139,681 post-menopausal women, average age 63, enrolled in the Women's Health Initiative study, known best for its research on hormone replacement therapy. Researchers looked at the women's lifetime history of breastfeeding, or how many months in total they had breastfed.
Women who had breastfed for one to six months had less diabetes, less high blood pressure and less high cholesterol, all known risk factors for heart disease.
The finding held after researchers took age, income, body mass index, diet, physical activity, family history of heart disease and other factors into account.
April 28, 2009
When Bad Advice Is the Best Advice
By PETER A. UBEL, M.D.
Eighteen years out of training, and I still find myself struggling to understand the moral imperatives of medical practice.
Not long ago, as part of my hospital duties, I cared for a man who could no longer swallow. This dysphagia was his only medical complaint, one that had sneaked up on him over the course of a month. He simply couldn’t find the muscular strength to propel food and liquid down to his stomach.
After some investigation, the medical team discovered he had metastatic lung cancer. That explained the dysphagia: cancer had stimulated his immune system to attack his swallowing muscles.
While the cancer was incurable, we hoped we could slow its progression and give him a few extra months of life — small solace for a man in his mid-50s with a loving wife and several children ready to start new families, but the best we could offer.
On rounds the morning after he received a feeding tube, I stopped by to see how he was doing — checking his abdomen for signs of infection and, more important, assessing his fragile mood. I tried to keep things upbeat, making small talk while examining his belly. But something about his response, and the look he gave his wife, was troubling.
I looked up and asked him how he was feeling, keeping purposely vague about whether I was posing a medical or a social question. It was his wife who replied — angrily. She lashed out at her husband for having sneaked off that morning for a cigarette. He glared back and told her to mind her own business.
She looked toward me for support — I was the physician, after all — and I found myself in a common medical quandary.
Was it my duty to tell this patient what to do or, instead, to give him the medical information he needed to make up his mind?
Medical decisions these days are increasingly recognized as being more than simply medical, with the right choice depending in part on the patient’s preferences.
Should a middle-age woman with mildly elevated cholesterol take a statin, for example? That depends on whether she thinks the pill’s benefits outweigh its burdens, burdens that only she can judge: costs, possible side effects and the inconvenience of taking medications.
Should an elderly man have knee-replacement surgery? That depends on how much he is suffering, how much he cares about the risk of surgical complications and how willing he is to undergo lengthy and painful rehabilitation.
According to this new paradigm of preference-sensitive decision-making, doctors like me shouldn’t tell patients what to do (Take your pills! Stop smoking!), but rather should educate our patients about the risks and benefits of their options.
So going by the book, I should have informed my patient about the pros and cons of tobacco. But I couldn’t stand by, in the role of a dispassionate educator, and let this man hurt himself. Instead, I felt compelled to give him advice that would promote his best interests.
I advised him to smoke.
“You two obviously love each other very much,” I said. Then I turned to his wife.
“I know that you are trying to keep your husband from smoking because you love him and don’t want him to get sicker,” I continued, as I recall. “But those cigarettes aren’t going to hurt him now. If anything, they’ll help him relax. What matters is that you two stick together, because these next few months are going to be really difficult.”
I reminded them that the cancer wasn’t curable, that we were hoping to improve his quality of life, and that the best way to do that was to spend quality time with the people he loved.
Every situation is different, of course. But my duty as a physician is to improve my patients’ lives. And if I can do that by sharing my perspective with them, however strange or uncomfortable it may sound, then that is what I must do.
Even if it means encouraging them to smoke.
Peter A. Ubel is director of the Center for Behavioral and Decision Sciences in Medicine at the University of Michigan.
By Christopher Bruce, For The Calgary HeraldJune 3, 2009
Like columnist Lorne Gunter (Herald, May 2, I have always been inclined to think that those who want to ban cellphone use by drivers are just trying to impose their views on other people.
Unlike Gunter, however, I was not content to just assume there was "no conclusive evidence" that cellphones were dangerous. Instead, I conducted an intensive search to identify what was being said on this topic.
I was surprised to find that not only had a considerable amount of statistically reliable research been conducted, but that that research was virtu-ally unanimous in its finding that the use of cellphones while driving increased the accident rate.
The earliest studies, which investigated driver behaviour under laboratory conditions, found that driver reaction time was slowed when using cellphones.
But, as researchers were concerned that laboratory behaviour might not translate into driving behaviour under actual traffic conditions, innovative techniques were devised to draw connections between cellphone use and accident rates.
In a Toronto study, researchers obtained the cellphone records of approximately 700 drivers who had been involved in accidents that had caused "substantial" property damage. Using these records, they were able to compare the degree of cellphone use of those drivers in the 10 minutes prior to the accidents with the use rates in comparable 10-minute periods on previous days.
They found that when drivers used a cellphone, the risk they would have an accident was approximately four times as high as when they did not use a phone.
Significantly, they concluded this risk was ". . . similar to the hazard associated with driving with a blood-alcohol level at the legal limit." They did not find, however, that the risk of an accident was lowered if drivers used a hands-free phone.
A similar study in West-ern Australia investigated approximately 500 drivers who had been involved in automobile crashes that necessitated attendance at hospital. Using cellphone logs, researchers confirmed the Toronto study's finding, that drivers who had used a cellphone within 10 minutes before a crash were four times more likely than non-users to have been involved in a serious crash.
In a Vancouver study, the Insurance Corporation of British Columbia records concerning automobile insurance claims were compared with data concerning drivers' cellphone use.
It was found that those drivers who were cellphone users were significantly more likely than the average driver to have made at least one "at-fault" crash claim in a previous four-year period. This finding was much stronger for female drivers than for males.
All of these studies shared the problem that there had been no direct observation of the drivers at the time the accident occurred. To resolve this issue, the U. S. National Highway Traffic Safety Administration (NHTSA) fitted approximately 100 cars with both video cameras--to record driver's actions and the events on the road immediately around the vehicle --and electronic sensors to measure such aspects of the automobile's actions as speed, acceleration, deceleration and sudden turns.
The in-car video recorders were able to monitor the drivers' cellphone use and the degree of their attentiveness to the road. The remaining video recorders could record traffic conditions, while the electronic recorders could measure the driver's responses to external events.
After observing each car for more than a year, researchers were able to conclude that the actions of (1) dialing a hand-held device and (2) talking/listening to a hand-held device each contributed to 3.6 per cent of all crashes and near-crashes. The sum of these two figures, 7.2 per cent, is approximately equal to one third of the effect of driving while moderately or severely drowsy.
Perhaps Gunter will argue that these findings are not "conclusive." But even if they are not, they are at least very suggestive. Significantly, in my search, I did not find any studies that reported cellphone use was not dangerous.
At the very least, the research suggests that the Alberta government should seriously consider calls to ban cellphone use by drivers.
Christopher Bruce is a professor of economics at the University Of Calgary.
It may be one of Britain's most popular foods, but curry has not had the
healthiest of images. That may now change.
Dishes drowning in ghee - clarified butter - send alarm signals out to
nutritionists, and for good reason. Recent studies show that those in
the south Asian community have a 50% chance of dying prematurely from
Now the Aga Khan, head of the Ismaili Muslim community, has launched a
project to transform the eating habits of south Asian households. An
online nutrition centre, launched last week by the Aga Khan Health Board
for the UK, in conjunction with the Department of Health, will feature a
library of authentic recipes and is aimed at families who enjoy African,
central and south Asian and Middle Eastern food.
The leading Indian dietitian and TV presenter Azmina Govindji said: "We
know that there is an increasing incidence of certain conditions within
the south Asian community, typically type-two diabetes and coronary
heart disease. And one of the ways to prevent these conditions is by
providing healthy recipes for a diet traditionally eaten within the
south Asian community."
Working on the traffic-light system of red, amber and green, website
users can call up familiar recipes to check their fat content. "For
example, a lamb biryani can have very high levels, but lentil-based
dishes, like a dhal, can be healthy," Govindji said.
The site will suggest which ingredients can be replaced by healthier
alternatives without losing the overall taste.
June 21, 2009
Lettuce From the Garden, With Worms
By NICHOLAS D. KRISTOF
Growing up on a farm near Yamhill, Ore., I quickly learned to appreciate the difference between fresh, home-grown foods and the commercial versions in the supermarket.
Store-bought lettuce was always lush, green and pristine, and thus vastly preferable to lettuce from my Mom’s vegetable garden (organic before we called it that). Her lettuce kept me on my toes, because a caterpillar might come crawling out of my salad.
We endured endless elk and venison — my Dad is still hunting at age 90 — or ate beef from steers raised on our own pasture, but “grass-fed” had no allure for me. I longed for delicious, wholesome food that my friends in town ate. Like hot dogs.
Over the years, though, I’ve become nostalgic for an occasional bug in my salad, for an apple that feels as if it were designed by God rather than by a committee. More broadly, it has become clear that the same factors that impelled me toward factory-produced meat and vegetables — cheap, predictable food — also resulted in a profoundly unhealthy American diet.
I’ve often criticized America’s health care system, and I fervently hope that we’re going to see a public insurance option this year. But one reason for our health problems is our industrialized agriculture system, and that should be under scrutiny as well.
A terrific new documentary, “Food, Inc.,” playing in cinemas nationwide, offers a powerful and largely persuasive diagnosis of American agriculture. Go see it, but be warned that you may not want to eat for a week afterward.
(It was particularly unnerving to see leftover animal bits washed over with ammonia and ground into “hamburger filler.” If you happen to be eating a hamburger as you read this, I apologize.)
“The way we eat has changed more in the last 50 years than in the previous 10,000,” Michael Pollan, the food writer, declares in the film.
What’s even more eerie is the way animals are being re-engineered. For example, most Americans prefer light meat to dark, so chickens have been redesigned to produce more white meat by growing massive breasts that make them lopsided. Who knew that breast augmentation was so widespread in chicken barns?
“When they grow from a chick and in seven weeks you’ve got a five-and-a-half pound chicken, their bones and their internal organs can’t keep up with the rapid growth,” explained Carole Morison, a Maryland chicken farmer who allowed the film crew into her barns. “A lot of these chickens here, they can take a few steps and then they plop down. It’s because they can’t keep up with all the weight that they’re carrying.”
Huge confinement operations for livestock and poultry produce very cheap meat and eggs. But at what cost?
The documentary introduces us to Barbara Kowalcyk, whose two-and-a-half-year-old child, Kevin, went from healthy to dead in 12 days, after he ate a hamburger tainted with E. coli bacteria. Even after his death, it took weeks for the tainted meat to be recalled.
“Sometimes it seems that industry was more protected than my son,” Ms. Kowalcyk complains.
She has a point. Agribusiness companies exercise huge political influence, and industry leaders often fill regulatory posts. The Food and Drug Administration consequently dozed, and the number of food safety inspections plunged.
There is some evidence that pathogens, including E. coli, become much more common in factory farming operations. Move feedlot cattle out to a pasture for five days, and they will lose 80 percent of the E. coli in their gut, the film says. And the massive routine feeding of antibiotics to farm animals is a disgrace that reduces the effectiveness of antibiotics in treating sick humans.
Pathogens are now seeping into the unlikeliest foods. On Friday, the F.D.A. advised consumers not to eat Nestlé cookie dough — cookie dough! — because of concerns about E. coli contamination, after reports of illness in 28 states.
American agribusiness truly is wondrous. When I moved back to the United States after years of living in China, I remember visiting a supermarket and feeling a near-religious awe. Yet one consequence of this wondrous system is that unhealthy calories are cheaper than nutritious ones: think of the relative prices of Twinkies and broccoli. We even inflict unhealthy food on children in the school lunch program, and one in three Americans born after 2000 is expected to develop diabetes.
The solutions aren’t simple, and may involve paying more for what we eat, although we may save some of that in reduced health costs for diabetes and heart disease. In any case, “Food, Inc.” notes that we as consumers do have power. “You can vote to change the system,” it declares, “three times a day.”
I invite you to comment on this column on my blog, On the Ground. Please also join me on Facebook, watch my YouTube videos and follow me on Twitter.
July 16, 2009
Chemicals and Our Health
By NICHOLAS D. KRISTOF
However careful you are about your health, your body is almost certainly home to troubling chemicals called phthalates. These are ubiquitous in modern life, found in plastic bottles, cosmetics, some toys, hair conditioners, and fragrances — and many scientists have linked them to everything from sexual deformities in babies to obesity and diabetes.
The problem is that phthalates suppress male hormones and sometimes mimic female hormones. As I’ve written before, chemicals called endocrine disruptors are believed to explain the proliferation of “intersex fish” — male fish that produce eggs — as well as sexual deformities in animals and humans. Phthalates (pronounced THAL-ates) are among the most common endocrine disruptors, and among the most difficult to avoid. They’re even in tap water, and levels soar in certain plastic water bottles.
They probably are not harmful to us adults, but it is another story for children. In girls, some research suggests that phthalates may cause early onset puberty. Most vulnerable of all, it seems, are male fetuses in the first trimester of pregnancy, just as they are differentiating their sex. At that stage, scholars believe, phthalates may “feminize” these boys.
“Commonly used phthalates may undervirilize humans,” concluded a study by the University of Rochester. The study, which was small, based its conclusion, in part, on measurements of “anogenital distance” — the distance between the anus and the genitals, which is typically twice as long for males as for females. Some scholars believe that shrinkage of this distance reflects “feminization” of male anatomy.
The researchers found that pregnant women with higher levels of phthalates delivered babies with a shorter anogenital distance. It’s possible this won’t cause any complications. But baby boys with shorter anogenital distance were more likely to have undescended testicles and less penile volume, and phthalates have been linked in humans to problems with sperm count and sperm quality.
In China, researchers found that female rats given phthalates gave birth to males with a penis deformity called hypospadias (in which the urethra exits the side or base of the penis, not the tip). Many other animal studies around the world have found similar results.
Some endocrinologists refer to the “phthalate syndrome,” including hypospadias and undescended testicles.
“Accumulating human epidemiological data point to a relationship between adverse fetal development and phthalate exposure,” concluded an article this spring in the journal Trends in Endocrinology and Metabolism. Just last month, the Endocrine Society — composed of thousands of doctors in the field — issued a powerful warning that endocrine disruptors including phthalates are “a significant concern to public health.”
One of the conundrums for scientists and journalists alike is how to call prudent attention to murky and uncertain risks, without sensationalizing dangers that may not exist? Increasingly, endocrinologists are concluding that the mounting evidence is enough to raise alarms.
Indeed, there has also been a flurry of scientific articles questioning whether endocrine disruptors are tied to obesity, autism and allergies, although the evidence there is less firm than with genital abnormalities and depressed sperm count.
The American Chemistry Council argues that phthalates are not a problem, that they do not migrate out of products easily and that they quickly break down in the body. The chemical industry has noted an apparently reassuring study in the Journal of Urology finding that hypospadias does not seem to be increasing in New York State (although different studies showed increases both in the United States and in Denmark).
James Yager, a professor of toxicology at the Johns Hopkins Bloomberg School of Public Health, agrees that there are huge uncertainties but says that pregnant women and children should be cautious. “When my wife was pregnant, we worried about drinking or smoking,” Professor Yager said. Now, he said, he would be more focused on exposure to chemicals such as phthalates in baby bottles.
Dr. Theo Colborn, the founder of the Endocrine Disruption Exchange, goes further. She tells researchers working with her to toss out plastic water bottles and use stainless steel instead. “I don’t have plastic food containers in my house,” she added. “I use glass.”
Certain phthalates have been banned from new toys sold in the United States, but kids continue to be exposed to these chemicals from the moment they are conceived. Dr. Ted Schettler of the Science and Environmental Health Network says that the way regulators examine risks — studying the impact of one chemical at a time — is bankrupt, for we’re exposed to a cocktail of them daily. Regulation is so pathetic that there’s not even disclosure when products contain phthalates.
If terrorists were putting phthalates in our drinking water, we would be galvanized to defend ourselves and to spend billions of dollars to ensure our safety. But the risks are just as serious if we’re poisoning ourselves, and it’s time for the Obama administration and Congress to show leadership in this area.
July 28, 2009
In War and Isolation, a Fighter for Afghan Women
By DENISE GRADY
Everybody wants Pashtoon Azfar. Her government, American aid groups and her own colleagues, the midwives of Afghanistan, all want her to work for them, lead them, help them rebuild a health system from the rubble of war.
Ms. Azfar, 51, is trying to oblige. By day she directs Afghanistan’s Institute of Health Sciences, by night she works for a nonprofit group from Johns Hopkins University that focuses on women and children’s health, and somehow she also manages to serve as president of the Afghan Midwives Association.
Visiting from Kabul recently, she was the star at a Capitol Hill briefing titled “Maternal Health in Afghanistan: How Can We Save Women’s Lives?” Her audience included members of the Congressional caucus for women’s issues.
Afghanistan has the world’s second-highest death rate in women during pregnancy and childbirth (only Sierra Leone’s is worse). For every 100,000 births, 1,600 mothers die; in wealthy countries the rates range from 1 to 12. In one remote northeastern province, Badakhshan, 6,507 mothers die for every 100,000 births, according to a 2005 report in the medical journal Lancet. In all, 26,000 Afghan women a year die while pregnant or giving birth.
The main causes of these deaths are hemorrhage and obstructed labor, which can be fatal if a woman cannot obtain a Caesarean section. Even if the mother survives, obstructed labor without a Caesarean usually kills the baby. Most of the maternal deaths — 78 percent, according to the Lancet report — could be prevented. Against this bleak history, Ms. Azfar told her Washington audience, “I would like to share some successes with you.”
An intense woman with short, graying hair, Ms. Azfar rarely smiles. She ran through statistics showing notable increases recently in the country’s number of midwives, their education and the percentage of women who give birth with the help of a “skilled attendant,” usually a midwife. The United States, the World Bank, the European Commission, Unicef, the Hopkins group (known as Jhpiego) and other donors have all helped Afghanistan’s Ministry of Public Health to make improvements.
But there is a long way to go. Most women in Afghanistan, as many as 80 percent, still give birth without skilled help, and only a third receive any medical care at all during pregnancy.
Afghanistan’s problems mirror those of many other poor countries: shortages of personnel, supplies and transportation to clinics or hospitals, especially in remote regions and mountainous areas that are snowbound half the year. The deeper problems are cultural, rooted in the low status of women and the misperception that deaths in childbirth are inevitable — part of the natural order, women’s lot in life.
During her talk in Washington Ms. Azfar quoted Dr. Mahmoud Fathalla, an Egyptian physician and advocate for women’s health: “Women are not dying of diseases we can’t treat. ...They are dying because societies have yet to make the decision that their lives are worth saving.”
Ms. Azfar works 12 hours a day, seven days a week. She has irked relatives by missing weddings and other family events because of work.
“My children are not happy,” she said in an interview after her speech.
Ms. Azfar grew up in a village about an hour from Kabul.
“Everywhere then, girls went to school,” she said. “Women’s rights before the Taliban were the same as in Western countries. Women had the right to vote.”
Her mother had 10 children, 2 of whom died. She always gave birth alone, behind a closed door. When Ms. Azfar was 9, she began to help, by waiting outside the door to receive the newborn baby and wash and swaddle it, while her mother then delivered her own placenta.
Ms. Azfar never actually saw a birth until she began studying midwifery at age 16, and only then, she said, did she realize how brave her mother had been. She finished the rigorous three-year program at the top of her class in 1976.
“It was a very well-respected profession in my country,” she said.
But decades of war destroyed midwifery and much of health care, she said. Professionals fled the country, and many never went back.
“One day, 100 rockets came into Kabul,” she said. She and her husband, a physician, took their four children and moved to Pakistan, living there from 1992 to 2003. She had a fifth child there.
By the time she returned to Afghanistan, she said, midwifery was in a shambles. Spots in professional schools of all kinds were being filled by people with political connections instead of those with good grades. The midwives who had stayed behind had not received any continuing education. Their skills were outdated, and their attitudes were even worse.
“A culture of war was going on,” Ms. Azfar said. “If a mother came for delivery they didn’t treat her as she deserved or needed to be treated. There was no emotional support.”
Attitude counts in midwifery: if midwives and other health workers seem indifferent or disrespectful, women start to avoid the clinics, and they miss out on the help they urgently need.
Ms. Azfar acknowledged that it was hard to change attitudes, but she insisted that it could be done, by making “interpersonal skills” part of the training and the tests that students must pass to be allowed to practice. In Afghanistan, these things became part of the midwifery curriculum in 2004.
“Does she greet the mother properly?” she asked. “Offer her a chair? A drink of water? Introduce herself? Let the mother ask questions? They are trained. They have to do it.”
She has seen signs of progress, of hope.
“Just five years ago we started the reconstruction of this profession,” Ms. Azfar said. “These midwives, they are champions. Oh, I love them. They are my heart.”
A sample Nutrition Facts label used in the United States.
US Food and Drug Administration
Labels on the foods that we purchase today include measurements of calories, total fat, saturated fat, trans fat, sodium, and fibre, among other nutrients. But what do the numbers actually mean?
Reading nutrition fact labels can sometimes be confusing — the secret is to know what information to look for and how to use it. Although label standards are different from one country to the next, most nutrition labels share certain common elements.
Start by finding the serving size, which indicates what all the nutrient information is based on. Serving sizes are typically standardised around a fixed weight or quantity, so that you can compare similar foods. Consider how many servings you will actually consume when figuring out your nutrient intake.
Once you know the serving size, you can determine how much of a nutrient you will actually be consuming. For example, a package containing two cookies may have a serving size of one cookie. If the label shows 100 calories per serving and you decide to eat both cookies, you will actually consume two servings — a total of 200 calories.
Each person’s daily calorie requirement varies depending on their age and gender. The average adult woman requires 2 000 calories per day, while men require 2 500 calories. Therefore, it is important to know how many calories there are in a serving of the food you are considering.
Of the total number of calories that you consume per day, no more than a third should come from fats. A gram of fat contains 9 calories, so by multiplying the number of grams of fat indicated on the nutrition label by 9, you can work out how many calories per serving will come from fats.
Also, be wary of saturated and trans fats, which can increase your risk of coronary heart disease by raising your bad cholesterol (LDL) and lowering your good cholesterol (HDL) levels. The American Heart Association recommends limiting saturated fats to not more than 7 per cent of your total caloric intake each day, while trans fats should be limited to 1 per cent of your daily calories.
A sample food label from the United Kingdom’s Food Standards Agency. Copyright: Food Standards Agency (UK)Another nutrient to look for on the label is sodium. It is best to limit your sodium intake to 2 400 milligrams per day — roughly the amount of sodium in one teaspoon of salt. Watch out for sodium in packaged masalas, pickles (achar), soy sauce, canned products, frozen foods, and deli meats. Try to select foods listed as low in sodium.
Fibre is an indigestible type of carbohydrate, and is often listed in the carbohydrates section of a nutritional label. Because it is indigestible, it makes no contribution to your calorie intake. Despite this, fibre is associated with significant health benefits and can help in controlling weight and cholesterol levels.
In the United States, adults are recommended to have about 25-30 grams of fibre every day. Breakfast cereals, fruits and vegetables are good sources of fibre. Food with 5 grams or more per serving are considered a high source of fibre, but products containing more than 2.5 grams per serving are also good.
The ingredients label on a food package is also a valuable source of information. In most countries, ingredients are listed in order of weight, with the highest ingredient listed first. This can help you to uncover information that might not be so obvious in the nutrition label.
For example, in the United States a product that contains less than a half gram of trans fats can be labelled as containing 0 grams of trans fat (due to rounding). But if hydrogenated fat appears as one of the first few ingredients, you can be sure that this product is not truly free of trans fats. If you were to eat several products like this in a day, your trans fats would add up!
Also, watch out for sugar. Sugars occur naturally in some foods (e.g. fructose in fruits and lactose in milk), but be wary of products containing high levels of added sugars. You will find added sugars listed among the ingredients, with names like sucrose, corn syrup, sweeteners, honey, and dextrose. Compare the sugar contents of similar foods and give preference to those with lower sugar content that also contain other beneficial nutrients, such as fibre and vitamins.
Nutrition labels can be very useful tools if you know what to look for. Stay away from high-fat, high-salt and high-sugar products, and give preference to high-fibre and low-calorie foods.
Preterm baby deaths top 1 million: study WHO data is first attempt to look at global problem
By Amy Husser, Canwest News Service
October 5, 2009
More than one million infants die every year after being born too early, recently released World Health Organization data suggests--a number that one advocacy group says is likely "very conservative."
When the March of Dimes analyzed 2005 data released this month in an annual WHO bulletin, it found that 10 per cent of the world's yearly births occur prematurely--an estimated 13 million infants. And of those, more than one million die within the first month of life.
"This is a global public health issue that is undernoticed, undercounted and underfunded," said Christopher Howson, vice-president for global programs with the March of Dimes.
The study notes that an estimated four million infants die annually, and 28 per cent of those deaths are linked to premature birth.
It also recognizes that there are "huge gaps" in data collection for developing regions.
"This was a first attempt to estimate the worldwide scale of the problem," said Dr. Mario Merialdi, author of the WHO bulletin.
Preterm birth--defined as birth at less than 37 weeks of gestation--is most prevalent in Africa, where 11.9 per cent of all births occur early.
Second on the list, surprisingly, is North America.
But the reasons for the two high rankings are as dramatically different as the two continents themselves.
Poor overall health, a higher burden of infectious disease and a lack of family planning--all of which are rooted in poverty--are the underlying factors for Africa's high rate, said Howson.
He attributes North America's second-place standing, by contrast, to increases in the number of pregnant women over 35 years of age and the use of assisted reproductive techniques. A rise in late preterm births is also a factor, he said, as induced labour and Caesarean sections become more common.
The percentage of U.S. infants born early is 12.7, compared to Canada's 8.2 per cent, the study notes.
October 11, 2009
21st Century Babies The Gift of Life, and Its Price
By STEPHANIE SAUL
Scary. Like aliens. That is how Kerry Mastera remembers her twins, Max and Wes, in the traumatic days after they were born nine weeks early. Machines forced air into the infants’ lungs, pushing their tiny chests up and down in artificial heaves. Tubes delivered nourishment. They were so small her husband’s wedding band fit around an entire baby foot.
Having a family had been an elusive goal for Jeff and Kerry Mastera, a blur of more than two years, dozens of doctor visits and four tries with a procedure called intrauterine insemination, all failures. In one year, the Masteras spent 23 percent of their income on fertility treatments.
The couple had nearly given up, but last year they decided to try once more, this time through in-vitro fertilization. Pregnancy quickly followed, as did the Mastera boys, who arrived at the Swedish Medical Center in Denver on Feb. 16 at 3 pounds, 1 ounce apiece. Kept alive in a neonatal intensive care unit, Max remained in the hospital 43 days; Wes came home in 51.
By the time it was over, medical bills for the boys exceeded $1.2 million.
Eight months later, the extraordinary effort seems worth it to the Masteras, who live in Aurora, Colo. The babies are thriving and developing their own personalities — Wes, the noisy and demanding; Max, the quiet and serious. Like many other twins conceived through in-vitro fertilization, the Mastera boys will go down in the record books as a success — both for the fertility clinic that helped create them and the neonatologists who nursed them to health.
But an exploration of the fertility industry reveals that the success comes with a price. While IVF creates thousands of new families a year, an increasing number of the newborns are twins, and they carry special risks often overlooked in the desire to produce babies.
While most twins go home without serious complications, government statistics show that 60 percent of them are born prematurely. That increases their chances of death in the first few days of life, as well as other problems including mental retardation, eye and ear impairments and learning disabilities. And women carrying twins are at greater risk of pregnancy complications.
October 12, 2009
21st Century Babies
Grievous Choice on Risky Path to Parenthood
By STEPHANIE SAUL
It was the last piece of advice Thomas and Amanda Stansel wanted to hear. But their fertility doctor was delivering it, without sugarcoating.
Reduce, or you will lose them all, he told them.
For more than a year the Stansels had been relying on Dr. George Grunert, one of the busiest fertility doctors in Houston, to produce his industry’s coveted product — a healthy baby. He was using a common procedure called intrauterine insemination, which involved injecting sperm into Mrs. Stansel’s uterus after hormone shots.
But something had gone wrong. In April, an ultrasound revealed that Mrs. Stansel was carrying not one but six babies, and Dr. Grunert was recommending a procedure known as selective reduction, in which some of the fetuses would be eliminated.
The Stansels rejected Dr. Grunert’s advice and, since then, their vision of a family has collapsed into excruciating loss: the deaths of four children after their premature births on Aug. 4, including one who died late Sunday night. The two other infants remain in neonatal intensive care, their futures uncertain.
“I feel like we bonded with all of them, the short time they were here,” Mr. Stansel said. “We were able to hold them before they passed away.”
The birth of octuplets in California in January placed the onus for large multiple births on in vitro fertilization, a treatment in which eggs are joined with sperm in a petri dish and returned to the womb for gestation.
But the procedure the Stansels used is actually the major cause of quadruplets, quintuplets and sextuplets — the most dangerous pregnancies for both mother and children. While less effective than IVF, intrauterine insemination is used at least twice as frequently because it is less invasive, cheaper and more likely to be covered by insurance, interviews and data show.
October 21, 2009
Cancer Society, in Shift, Has Concerns on Screenings
By GINA KOLATA
The American Cancer Society, which has long been a staunch defender of most cancer screening, is now saying that the benefits of detecting many cancers, especially breast and prostate, have been overstated.
It is quietly working on a message, to put on its Web site early next year, to emphasize that screening for breast and prostate cancer and certain other cancers can come with a real risk of overtreating many small cancers while missing cancers that are deadly.
“We don’t want people to panic,” said Dr. Otis Brawley, chief medical officer of the cancer society. “But I’m admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.”
Prostate cancer screening has long been problematic. The cancer society, which with more than two million volunteers is one of the nation’s largest voluntary health agencies, does not advocate testing for all men. And many researchers point out that the PSA prostate cancer screening test has not been shown to prevent prostate cancer deaths.
There has been much less public debate about mammograms. Studies from the 1960s to the 1980s found that they reduced the death rate from breast cancer by up to 20 percent.
The cancer society’s decision to reconsider its message about the risks as well as potential benefits of screening was spurred in part by an analysis published Wednesday in The Journal of the American Medical Association, Dr. Brawley said.
In it, researchers report a 40 percent increase in breast cancer diagnoses and a near doubling of early stage cancers, but just a 10 percent decline in cancers that have spread beyond the breast to the lymph nodes or elsewhere in the body. With prostate cancer, the situation is similar, the researchers report.
If breast and prostate cancer screening really fulfilled their promise, the researchers note, cancers that once were found late, when they were often incurable, would now be found early, when they could be cured. A large increase in early cancers would be balanced by a commensurate decline in late-stage cancers. That is what happened with screening for colon and cervical cancers. But not with breast and prostate cancer.
Still, the researchers and others say, they do not think all screening will — or should — go away. Instead, they say that when people make a decision about being screened, they should understand what is known about the risks and benefits.
For now, those risks are not emphasized in the cancer society’s mammogram message which states that a mammogram is “one of the best things a woman can do to protect her health.”
Dr. Brawley says mammograms can prevent some cancer deaths. However, he says, “If a woman says, ‘I don’t want it,’ I would not think badly of her but I would like her to get it.”
But some, like Colin Begg, a biostatistician at Memorial Sloan-Kettering Cancer Center in New York, worry that the increased discussion of screening’s risks is going to confuse the public and make people turn away from screening, mammography in particular.
“I am concerned that the complex view of a changing landscape will be distilled by the public into yet another ‘screening does not work’ headline,” Dr. Begg said. “The fact that population screening is no panacea does not mean that it is useless,” he added.
The new analysis — by Dr. Laura Esserman, a professor of surgery and radiology at the University of California, San Francisco, and director of the Carol Frank Buck Breast Care Center there, and Dr. Ian Thompson, professor and chairman of the department of urology at The University of Texas Health Science Center, San Antonio — finds that prostate cancer screening and breast cancer screening are not so different.
Both have a problem that runs counter to everything people have been told about cancer: They are finding cancers that do not need to be found because they would never spread and kill or even be noticed if left alone. That has led to a huge increase in cancer diagnoses because, without screening, those innocuous cancers would go undetected.
At the same time, both screening tests are not making much of a dent in the number of cancers that are deadly. That may be because many lethal breast cancers grow so fast they spring up between mammograms. And the deadly prostate ones have already spread at the time of cancer screening. The dilemma for breast and prostate screening is that it is not usually clear which tumors need aggressive treatment and which can be left alone. And one reason that is not clear, some say, is that studying it has not been much of a priority.
“The issue here is, as we look at cancer medicine over the last 35 or 40 years, we have always worked to treat cancer or to find cancer early,” Dr. Brawley said. “And we never sat back and actually thought, ‘Are we treating the cancers that need to be treated?’ ”
The very idea that some cancers are not dangerous and some might actually go away on their own can be hard to swallow, researchers say.
“It is so counterintuitive that it raises debate every time it comes up and every time it has been observed,” said Dr. Barnett Kramer, associate director for disease prevention at the National Institutes of Health.
It was first raised as a theoretical possibility in the 1970s, Dr. Kramer said. Then it was documented in a rare pediatric cancer, but was dismissed as something peculiar to that cancer. Then it was discovered in common cancers as well, but it is still not always accepted or appreciated, he said.
But finding those insignificant cancers is the reason the breast and prostate cancer rates soared when screening was introduced, Dr. Kramer said. And those cancers, he said, are the reason screening has the problem called overdiagnosis — labeling innocuous tumors cancer and treating them as though they could be lethal when in fact they are not dangerous.
“Overdiagnosis is pure, unadulterated harm,” he said.
Dr. Peter Albertsen, chief and program director of the urology division at the University of Connecticut Health Center, said that had not been an easy message to get across. “Politically, it’s almost unacceptable,” Dr. Albertsen said. “If you question overdiagnosis in breast cancer, you are against women. If you question overdiagnosis in prostate cancer, you are against men.”
Dr. Esserman hopes that as research continues on how to advance beyond screening, distinguishing innocuous tumors from dangerous ones, people will be more realistic about what screening can do.
“Someone may say, ‘I don’t want to be screened’ ” she said. “Another person may say, ‘Of course I want to be screened.’ Just like everything in medicine, there is no free lunch. For every intervention, there are complications and problems.”
November 8, 2009
Chemicals in Our Food, and Bodies
By NICHOLAS D. KRISTOF
Your body is probably home to a chemical called bisphenol A, or BPA. It’s a synthetic estrogen that United States factories now use in everything from plastics to epoxies — to the tune of six pounds per American per year. That’s a lot of estrogen.
More than 92 percent of Americans have BPA in their urine, and scientists have linked it — though not conclusively — to everything from breast cancer to obesity, from attention deficit disorder to genital abnormalities in boys and girls alike.
Now it turns out it’s in our food.
Consumer Reports magazine tested an array of brand-name canned foods for a report in its December issue and found BPA in almost all of them. The magazine says that relatively high levels turned up, for example, in Progresso vegetable soup, Campbell’s condensed chicken noodle soup, and Del Monte Blue Lake cut green beans.
The magazine also says it found BPA in the canned liquid version of Similac Advance infant formula (but not in the powdered version) and in canned Nestlé Juicy Juice (but not in the juice boxes). The BPA in the food probably came from an interior coating used in many cans.
Should we be alarmed?
The chemical industry doesn’t think so. Steven Hentges of the American Chemistry Council dismissed the testing, noting that Americans absorb quantities of BPA at levels that government regulators have found to be safe. Mr. Hentges also pointed to a new study indicating that BPA exposure did not cause abnormalities in the reproductive health of rats.
But more than 200 other studies have shown links between low doses of BPA and adverse health effects, according to the Breast Cancer Fund, which is trying to ban the chemical from food and beverage containers.
“The vast majority of independent scientists — those not working for industry — are concerned about early-life low-dose exposures to BPA,” said Janet Gray, a Vassar College professor who is science adviser to the Breast Cancer Fund.
Published journal articles have found that BPA given to pregnant rats or mice can cause malformed genitals in their offspring, as well as reduced sperm count among males. For example, a European journal found that male mice exposed to BPA were less likely to make females pregnant, and the Journal of Occupational Health found that male rats administered BPA had less sperm production and lower testicular weight.
This year, the journal Environmental Health Perspectives found that pregnant mice exposed to BPA had babies with abnormalities in the cervix, uterus and vagina. Reproductive Toxicology found that even low-level exposure to BPA led to the mouse equivalent of early puberty for females. And an array of animal studies link prenatal BPA exposure to breast cancer and prostate cancer.
While most of the studies are on animals, the Journal of the American Medical Association reported last year that humans with higher levels of BPA in their blood have “an increased prevalence of cardiovascular disease, diabetes and liver-enzyme abnormalities.” Another published study found that women with higher levels of BPA in their blood had more miscarriages.
Scholars have noted some increasing reports of boys born with malformed genitals, girls who begin puberty at age 6 or 8 or even earlier, breast cancer in women and men alike, and declining sperm counts among men. The Endocrine Society, an association of endocrinologists, warned this year that these kinds of abnormalities may be a consequence of the rise of endocrine-disrupting chemicals, and it specifically called on regulators to re-evaluate BPA.
Last year, Canada became the first country to conclude that BPA can be hazardous to humans, and Massachusetts issued a public health advisory in August warning against any exposure to BPA by pregnant or breast-feeding women or by children under the age of 2.
The Food and Drug Administration, which in the past has relied largely on industry studies — and has generally been asleep at the wheel — is studying the issue again. Bills are also pending in Congress to ban BPA from food and beverage containers.
“When you have 92 percent of the American population exposed to a chemical, this is not one where you want to be wrong,” said Dr. Ted Schettler of the Science and Environmental Health Network. “Are we going to quibble over individual rodent studies, or are we going to act?”
While the evidence isn’t conclusive, it justifies precautions. In my family, we’re cutting down on the use of those plastic containers that contain BPA to store or microwave food, and I’m drinking water out of a metal bottle now. In my reporting around the world, I’ve come to terms with the threats from warlords, bandits and tarantulas. But endocrine disrupting chemicals — they give me the willies.
I invite you to comment on this column on my blog, On the Ground. Please also join me on Facebook, watch my YouTube videos and follow me on Twitter.
November 20, 2009
Screening Debate Reveals Culture Clash in Medicine
By KEVIN SACK
This week, the science of medicine bumped up against the foundations of American medical consumerism: that more is better, that saving a life is worth any sacrifice, that health care is a birthright.
Two new recommendations, calling for delaying the start and reducing the frequency of screening for breast and cervical cancer, have been met with anger and confusion from some corners, not to mention a measure of political posturing.
The backers of science-driven medicine, with its dual focus on risks and benefits, have cheered the elevation of data in the setting of standards. But many patients — and organizations of doctors and disease specialists — find themselves unready to accept the counterintuitive notion that more testing can be bad for your health.
“People are being asked to think differently about risk,” said Sheila M. Rothman, a professor of public health at Columbia University. “The public state of mind right now is that they’re frightened that evidence-based medicine is going to be equated with rationing. They don’t see it in a scientific perspective.”
For decades, the medical establishment, the government and the news media have preached the mantra of early detection, spending untold millions of dollars to spread the word. Now, the hypothesis that screening is vital to health and longevity is being turned on its head, with researchers asserting that mammograms and Pap smears can cause more harm than good for women of certain ages.
On Monday, the United States Preventive Services Task Force, a federally appointed advisory panel, recommended that most women delay the start of routine mammograms until they are 50, rather than 40, as the group suggested in 2002. It also recommended that women receive the test every two years rather than annually, and that physicians not train women to perform breast self-examination.
The task force, whose recommendations are not binding on insurers or physicians, concluded after surveying the latest research that the risks caused by over-diagnosis, anxiety, false-positive test results and excess biopsies outweighed the benefits of screening for women in their 40s. It found that one cancer death is prevented for every 1,904 women ages 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women from 50 to 59, and one death for every 377 women from 60 to 69.
On Friday, the American College of Obstetricians and Gynecologists plans to announce a similar revision to its screening guidelines for cervical cancer. It will advise that women receive their first Pap test at age 21; the previous standard had been three years after a woman’s first sexual intercourse or age 21, whichever came first. The group also is recommending that the test be performed every two years instead of annually for women ages 21 to 30.
“A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs and avoids unnecessary interventions that could be harmful,” said Dr. Alan G. Waxman, a professor at the University of New Mexico who directed the process.
The challenge of persuading patients and doctors to accept such standards requires a transformational shift in thinking, particularly when the disease involved is as prevalent, as deadly, and as potentially curable as cancer. How do you convince them that it is in their best interest to play the odds when they have been conditioned for so long to not gamble on health? After all, for the one in 1,904 women in their 40s whose life would be saved by early detection of breast cancer, taking the risk would in retrospect seem a bad choice.
“This represents a broader understanding that the efforts to detect cancer early can be a two-edged sword,” said Dr. H. Gilbert Welch, a professor of medicine at Dartmouth who is among the pioneers of research into the negative effects of early detection. “Yes, it helps some people, but it harms others.”
Dr. Welch said this week’s recommendations could mark a turning point in public acceptance of that notion. “Now we’re trying to negotiate that balance,” he said. “There’s no right answer, but I can tell you that the right answer is not always to start earlier, look harder and look more frequently.”
That concept is proving easier to swallow in the halls of Dartmouth Medical School than in the halls of Congress. Coming as they did at the height of debate over a sweeping health care overhaul, the recommendations have provided fresh ammunition for those who warn that greater government involvement in medical decision-making would lead to rationing of health care. It has not mattered that the breast cancer screening recommendation is only advisory, and that the federal government, the American Cancer Society, and numerous private insurers have said they will not adopt it.
Senator Kay Bailey Hutchison, a Republican who is running for governor of Texas, cited the task force’s screening statistics in a floor speech on Thursday. “One life out of 1,904 to be saved,” Ms. Hutchison said, “but the choice is not going to be yours. It’s going to be someone else that has never met you, that does not know family history.” She added, “This is not the American way of looking at our health care coverage.”
The health care bills in both the House and the Senate would establish commissions to encourage research into the effectiveness of medical tests and procedures, but would not require that the findings be translated into practice or reimbursement policies.
As throughout history, it may take decades for medical culture to catch up to medical science. Dr. Rothman pointed out that it took 20 years for the public to accept the discovery in 1882 that tuberculosis was caused by a bacterium and not by heredity or behavior. More than 160 years after the Hungarian-born physician Ignaz Semmelweis posited that hand-washing could prevent the spread of infectious disease, studies still show that half of all hospital workers do not follow basic hygiene protocols.
“It’s going to take time, there’s no doubt about it,” said Louise B. Russell, a research professor at the Rutgers University Institute of Health who has studied whether prevention necessarily saves money (and found it does not always do so). “It’s going to take time in part because too many people in this country have had a health insurer say no, and it’s not for a good reason. So they’re not used to having a group come out and say we ought to do less, and it’s because it’s best for you.”
This article has been revised to reflect the following correction:
Correction: November 21, 2009
A news analysis article on Friday about recommendations that women should delay screenings for breast and cervical cancer misstated a statistic from the United States Preventive Services Task Force, which released the breast cancer recommendations. The task force concluded that one cancer death was prevented for every 1,339 women aged 50 to 59 who were screened for 10 years — not 50 to 74.
November 20, 2009
Addicted to Mammograms
By ROBERT ARONOWITZ
THE United States Preventive Services Task Force’s recommendation this week that women begin regular breast cancer screening at age 50 rather than 40 is really nothing new. It’s almost identical to the position the group held in the 1990s.
Nor is the controversy that has flared since the announcement something new. It’s the same debate that’s gone on in medicine since 1971, when the very first large-scale, randomized trial of screening mammography found that it saved the lives only of women aged 50 or older. Despite the evidence, doctors continued to screen women in their 40s.
Again in 1977, after an official of the National Cancer Institute voiced concern that women in their 40s were getting too much radiation from unnecessary screening, the National Institutes of Health held a consensus conference on mammography, which concluded that most women should wait until they’re 50 to have regular screenings.
Why do we keep coming around to the same advice — but never comfortably follow it? The answer is far older than mammography itself. It dates to the late 19th century, when society was becoming increasingly disappointed, pessimistic and fearful over the lack of medical progress against cancer. Doctors had come to understand the germ theory of infectious disease and had witnessed the decline of epidemic illnesses like cholera. But their efforts against cancer had gone nowhere.
In the 1870s, a new view of the disease came to be developed. Cancer had been thought of as a constitutional disorder, present throughout the body. But some doctors now posited that it begins as a local growth and remains so for some time before spreading via the blood and lymph systems (what came to be understood as metastasis).
Even though this new consensus was more asserted than definitively proved by experimental evidence or clinical observation, it soon became dogma, and helped change the way doctors treated cancer. Until this time, cancer surgery had been performed only rarely and reluctantly. After all, why remove a tumor, in a painful and dangerous operation, when the entire body is diseased?
The new model gave doctors reason to take advantage of newly developing general anesthesia and antiseptic techniques to do more, and more extensive, cancer surgery. At the turn of the 20th century, William Halsted, a surgeon at Johns Hopkins, promoted a new approach against breast cancer: a technically complicated removal of the affected breast, the lymph nodes in the armpit and the muscles attached to the breast and chest wall.
Doctors widely embraced Halsted’s strategy. But they seem to have paid little attention to his clinical observations, which indicated that while the operation prevented local recurrence of breast tumors, it did not save lives. As Halsted himself became aware, breast cancer patients die of metastatic, not local, disease.
By 1913, the surgeons and gynecologists who started the American Society for the Control of Cancer (later the American Cancer Society) had begun an anti-cancer campaign that, among other things, advised women to see their doctors “without delay” if they had a breast lump. Their message promoted the idea that if cancer was detected early enough, surgery could cure it.
This claim, like the cancer theory it was built on, was based on intuition and wishful thinking and the desire to do something for patients, not on detailed evidence that patients were more likely to survive if their cancer was caught early and cut out. But it did create a culture of fear around breast cancer, and led the public to believe that tumors needed to be discovered at the earliest possible moment.
The “do not delay” campaign reached its heyday in the 1940s, when through lectures, newspaper articles, posters and public health films, doctors exhorted people to survey their bodies for cancer warning signs like breast lumps, irregular bleeding and persistent hoarseness. This campaign generated greater fear, which led to more demand for some means to gain a sense of control over cancer — typically satisfied by more surveillance and treatment.
During the 1930s and ’40s, more and more cancer was being diagnosed. The rising numbers led to even greater pressure to define early stages of cancer and find more cases as early as possible. Meanwhile, the apparent improved cancer survival rates — a result of more people receiving diagnoses, many for cancers that were not lethal — seemed to prove the effectiveness of the “do not delay” campaign, as well as radical cancer surgery.
By the 1950s, some skeptics were pointing out that despite all the apparent progress, mortality rates for breast cancer had hardly budged. And they continued not to budge; from 1950 to 1990, there were about 28 breast cancer deaths per 100,000 people. But calls for earlier diagnosis only increased, especially after screening mammography was introduced in the 1960s.
When the 1971 evidence came along that mammograms were of very limited benefit to women under 50, it ran up against the logic of the early-detection model and the entrenched cycles of fear and control. Detecting cancer in women under 50 should work, according to the model; indeed, younger women are the ones most likely to have the localized cancers that have “not yet” metastasized. And many doctors and women understandably objected, as they do today, to giving up the one means they had to exercise some control over cancer.
Critics of this week’s recommendations have poked holes in the Preventive Services Task Force’s data analysis, have warned against basing present practice guidelines on the older imaging technology used in the studies, and have called for still more studies to be done. They generally sidestep the question of whether the very small numbers of lives potentially saved by screening younger women outweigh the health, psychological and financial costs of overdiagnosis.
You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer, and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail. This doesn’t make sense. We could do more research and hold more consensus conferences. I suspect it would confirm the data we already have. But history suggests it would never be enough to convince many people that we are screening too much.
Robert Aronowitz, an internist and a professor of the history and sociology of science at the University of Pennsylvania, is the author of “Unnatural History: Breast Cancer and American Society.”
November 27, 2009
What’s Your Underlying Condition?
By JEROME GROOPMAN and PAMELA HARTZBAND
ONE of the profound mysteries of medicine is why in the midst of an epidemic some people become severely ill and die while others remain unscathed.
During the great plagues of past centuries, like the Black Death, smallpox and yellow fever, the answer was often cast in religious terms: survival was a miracle and succumbing was a punishment. During this influenza pandemic of H1N1, doctors and health officials invoke “underlying conditions.” This phrase, now so ubiquitous in news reports, is rightly understood to mean concurrent medical problems like diabetes and lung disease. But such underlying conditions are only part of the mystery of why this flu is so mild for some and so serious for others.
When faced with a new infectious outbreak, clinicians treat the sick while epidemiologists collect data on their characteristics: their age, gender, ethnic background, medical history, current medications and social factors like where they traveled and whom they contacted. Early in the H1N1 epidemic, health experts had an advantage in identifying risk factors for severe disease because past cases of seasonal influenza proved, in part, to be prologue. Familiar predisposing conditions like chronic lung disease, diabetes, heart trouble, immunosuppressive disorders and pregnancy were present in many early deaths.
With that knowledge, health officials tried to help the public find the midpoint between complacency and panic. But they were somewhat hamstrung in providing details about individual deaths in order to protect the confidentiality of patients and families; so in many instances, officials resorted to using that general phrase underlying conditions as an explanation. The result was that people who had such conditions appropriately felt increased concern while those without them felt a greater level of comfort.
But over the past weeks, the first scientific papers have been published in prominent medical journals detailing the demographics and medical histories of hundreds of patients who required hospitalization and, in many instances, died. These reports came not only from the United States but also Mexico, Canada, Australia and New Zealand, and expanded on the initial data released by the Centers for Disease Control and the World Health Organization over the summer.
According to these reports, many of the patients who became very ill with H1N1 did, in fact, have the same underlying conditions as those who often develop severe seasonal flu. But these reports pointed to some important differences between the viruses.
First, the early impression of many clinicians was confirmed: seasonal flu is typically harder on the elderly; H1N1 severely hits children and young adults. What’s more, the W.H.O. suggests that H1N1 may be more contagious than seasonal flu, infecting as many as 22 percent to 33 percent of contacts as opposed to 5 percent to 15 percent for seasonal flu.
Epidemiologists also found unexpected correlations between severe H1N1 flu and problems like obesity, hypertension and increased blood lipids. In Australia and New Zealand, aboriginal and Maori peoples were disproportionately stricken — as were Native American and Inuit populations in Canada. These associations had not been prominent in past flu outbreaks.
We also learned that in the United States, more than 25 percent of all those hospitalized seem to have had no major underlying conditions. According to a C.D.C. report in September, 12 of the 36 American children who died of H1N1 by early August appear to have been completely healthy before contracting the flu.
How, then, can we explain the striking differences in outcome after exposure of apparently healthy people to the H1N1 virus, ranging from no infection to a mild respiratory illness to death?
Insight may be gained from another recent and deadly outbreak, the H.I.V. epidemic. We learned important lessons from AIDS by moving from bedside observation to laboratory investigation, as epidemiologists and clinicians worked closely with basic scientists. As the virus spread, individuals were identified who did not become infected despite significant exposure to H.I.V. Even more curious were so-called elite controllers, those who became infected but remained healthy for decades with no evidence of decline in immunity.
H.I.V., like many other viruses, has proteins and sugars on its surface that allow it to attach to human cells at specific docking sites called receptors. Harnessing the power of modern molecular biology, researchers found that some people who were amply exposed to H.I.V. yet did not become infected had a genetic difference in their receptors that prevented the virus from effectively attaching and entering their cells.
This discovery led to a new drug to treat those with AIDS who did not have this genetic advantage, protecting yet uninfected cells from the virus. And those who have carried H.I.V. for years with no apparent effects are still being intensively studied by scientists; these elite controllers may have cadres of certain immune cells that restrain the deadly pathogen. Unraveling the mysteries of the unscathed could lead to still more novel therapies.
A similar strategy of studying the genetics, receptors and immune response of people who appear to resist infection versus those who rapidly succumb is being applied to other deadly pathogens like hepatitis C, and is clearly applicable to influenza as well. There are, in fact, initial findings from researchers in Europe and Japan showing that the new virus can attach not only to receptors that bind seasonal flu, but also to other receptors deep in the lungs. Genetic differences in these other receptors could account for severe respiratory illness in some H1N1 cases.
In an epidemic, each one of us wants to know our personal risk for illness. The current definition of underlying conditions communicates only a level of increased risk, not individual susceptibility. For the first time in history, though, scientists are poised to redefine underlying conditions in a more profound way based on individual immune response. Deep in our genes, there may very well be another underlying condition that determines in part whether a virus will cause us mild or no disease, or severe illness and death.
Jerome Groopman, a staff writer for The New Yorker, and Pamela Hartzband are attending physicians at Beth Israel Deaconess Medical Center and professors at Harvard Medical School.
For all that scientists have studied it, the brain remains the most complex and mysterious human organ - and, now, the focus of billions of dollars' worth of research to penetrate its secrets. The Brain Power series looks in depth at some of the insights these projects are producing.
November 27, 2009After Injury, Fighting to Regain a Sense of Self
By BENEDICT CAREY
Scientists are investigating delusions caused by brain trauma for clues to one of the most confounding problems in brain science: identity.
August 9, 2009In Battle, Hunches Prove to Be Valuable
By BENEDICT CAREY
U.S. soldiers are at the center of an effort to understand how it is that some people’s brains can sense danger before others’ do.
July 28, 2009At the Bridge Table, Clues to a Lucid Old Age
By BENEDICT CAREY
A study of people 90 and over without a trace of dementia has begun to alter understandings of the aging brain.
May 22, 2009Brain Researchers Open Door to Editing Memory
By BENEDICT CAREY
An influx of money and talent into neuroscience has led to an experimental drug that could block certain memories.
April 6, 2009H. M., an Unforgettable Amnesiac, Dies at 82
By BENEDICT CAREY
Henry Gustav Molaison, or H.M., was recognized as the most important patient in the history of brain science.
November 28, 2009 8:44 AM
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If Rom Houben's case proves anything, it is the arrogance of those who think they can pronounce upon the state of a patient's consciousness, and determine his subsequent fate--when humility should force them to admit they cannot possibly know what that patient may be experiencing.
Houben is the Belgian man who spent 23 years misdiagnosed as being in a persistent vegetative state when he was actually conscious and suffering from locked-in syndrome as the result of an auto accident. Locked-in syndrome means the individual is paralyzed, but retains full consciousness.
The misdiagnosis was discovered thanks to state-of-the-art brain scanning technology which neurologist Steven Laureys at Liege University Hospital used to discover that Houben still had activity in his cerebral cortex.
One has to wonder how many other patients through the years have been wrongly diagnosed as being in a coma or cruelly labelled "vegetables"-- a term which should be banished from the language as a reference point for discussing human beings.
Terri Schiavo's case comes to mind. Doctors argued for years over the level of consciousness they thought the Florida woman was capable of -- and their conclusions varied, whether they sided with Schiavo's husband, Michael, who wanted her feeding tube pulled so she would die or whether they sided with Schiavo's parents, who insisted she was conscious, recognized them and expressed emotions, including joy. Schiavo had suffered brain damage in 1990 after cardiac arrest, and she died in 2005, almost two weeks after her feeding tube was removed -- forcing her to undergo a slow death by starvation and dehydration.
Bobby Schindler, Schiavo's brother and executive director of the Terri Schindler Schiavo Foundation, commenting on Houben's case, told ABCNews.com:"We are learning how unscientific the diagnosis is. It's completely subjective and we are using it to sentence people to death, and it's dangerous."
It is indeed dangerous. Had that gross misnomer "the right to die" been at issue in Houben's case, this fully conscious man would have had to undergo the agony of people debating whether he should be allowed to live, and he could have faced the agony of knowing he was being starved to death, unable to communicate with anyone to let them know there was indeed a fully aware person inside his paralyzed body. Particularly poignant was Houben's description, via a special keyboard and computer, of how he tried to alert his caregivers to his conscious state: "I screamed, but there was nothing to hear."
He characterized the day the misdiagnosis was revealed as a rebirth for him: "I especially felt relief. Finally to be able to show that I was indeed there."
December 6, 2009
Cancer From the Kitchen?
By NICHOLAS D. KRISTOF
The battle over health care focuses on access to insurance, or tempests like the one that erupted over new mammogram guidelines.
But what about broader public health challenges? What if breast cancer in the United States has less to do with insurance or mammograms and more to do with contaminants in our water or air -- or in certain plastic containers in our kitchens? What if the surge in asthma and childhood leukemia reflect, in part, the poisons we impose upon ourselves?
This last week I attended a fascinating symposium at Mount Sinai School of Medicine in New York, exploring whether certain common chemicals are linked to breast cancer and other ailments.
Dr. Philip Landrigan, the chairman of the department of preventive medicine at Mount Sinai, said that the risk that a 50-year-old white woman will develop breast cancer has soared to 12 percent today, from 1 percent in 1975. (Some of that is probably a result of better detection.) Younger people also seem to be developing breast cancer: This year a 10-year-old in California, Hannah, is fighting breast cancer and recording her struggle on a blog.
Likewise, asthma rates have tripled over the last 25 years, Dr. Landrigan said. Childhood leukemia is increasing by 1 percent per year. Obesity has surged. One factor may be lifestyle changes — like less physical exercise and more stress and fast food — but some chemicals may also play a role.
Take breast cancer. One puzzle has been that most women living in Asia have low rates of breast cancer, but ethnic Asian women born and raised in the United States don’t enjoy that benefit. At the symposium, Dr. Alisan Goldfarb, a surgeon specializing in breast cancer, pointed to a chart showing breast cancer rates by ethnicity.
“If an Asian woman moves to New York, her daughters will be in this column,” she said, pointing to “whites.” “It is something to do with the environment.”
What’s happening? One theory starts with the well-known fact that women with more lifetime menstrual cycles are at greater risk for breast cancer, because they’re exposed to more estrogen. For example, a woman who began menstruating before 12 has a 30 percent greater risk of breast cancer than one who began at 15 or later.
It’s also well established that Western women are beginning puberty earlier, and going through menopause later. Dr. Maida Galvez, a pediatrician who runs Mount Sinai’s pediatric environmental health specialty unit, told the symposium that American girls in the year 1800 had their first period, on average, at about age 17. By 1900 that had dropped to 14. Now it is 12.
A number of studies, mostly in animals, have linked early puberty to exposure to pesticides, P.C.B.’s and other chemicals. One class of chemicals that creates concern — although the evidence is not definitive — is endocrine disruptors, which are often similar to estrogen and may fool the body into setting off hormonal changes. This used to be a fringe theory, but it is now being treated with great seriousness by the Endocrine Society, the professional association of hormone specialists in the United States.
These endocrine disruptors are found in everything from certain plastics to various cosmetics. “There’s a ton of stuff around that has estrogenic material in it,” Dr. Goldfarb said. “There’s makeup that you rub into your skin for a youthful appearance that is really estrogen.”
More than 80,000 new chemicals have been developed since World War II, according to the Children’s Environmental Health Center at Mount Sinai. Even of the major chemicals, fewer than 20 percent have been tested for toxicity to children, the center says.
Representative Louise Slaughter, the only microbiologist in the House of Representatives, introduced legislation this month that would establish a comprehensive program to monitor endocrine disruptors. That’s an excellent idea, because as long as we’re examining our medical system, there’s a remarkable precedent for a public health effort against a toxic substance. The removal of lead from gasoline resulted in an 80 percent decline in lead levels in our blood since 1976 — along with a six-point gain in children’s I.Q.’s, Dr. Landrigan said.
I asked these doctors what they do in their own homes to reduce risks. They said that they avoid microwaving food in plastic or putting plastics in the dishwasher, because heat may cause chemicals to leach out. And the symposium handed out a reminder card listing “safer plastics” as those marked (usually at the bottom of a container) 1, 2, 4 or 5.
It suggests that the “plastics to avoid” are those numbered 3, 6 and 7 (unless they are also marked “BPA-free”). Yes, the evidence is uncertain, but my weekend project is to go through containers in our house and toss out 3’s, 6’s and 7’s.
R adiation from CT scans done in 2007 will cause 29,000 cancers and kill nearly 15,000 Americans, researchers said on Monday.
The findings, published in the Archives of Internal Medicine, add to mounting evidence that Americans are overexposed to radiation from diagnostic tests, especially from a specialized kind of X-ray called a computed tomography, or CT, scan.
"What we learned is there is a significant amount of radiation with these CT scans, more than what we thought, and there is a significant number of cancers," said Dr. Rita Redberg, editor of the Archives of Internal Medicine, where the studies were published.
"It's estimated that just from the CT scans done in one year, just in 2007, there will be 15,000 excess deaths," Redberg said in a telephone interview. "We're doing millions of CT scans every year and the numbers are increasing. That is a lot of excess deaths."
CT scans give doctors a view inside the body, often eliminating the need for exploratory surgery. But CT scans involve much higher radiation doses than conventional X-rays.
About 70 million CT scans were done on Americans in 2007, up from three million in 1980. Amy Berrington de Gonzalez of the National Cancer Institute and colleagues developed a computer model to estimate the impact of so many scans.
They estimated the scans done in 2007 will cause 29,000 cancers.
"While certainly some of the scans are incredibly important and life saving, it is also certain that some of them were not necessary," Redberg said.
February 25, 2010
Do Toxins Cause Autism?
By NICHOLAS D. KRISTOF
Autism was first identified in 1943 in an obscure medical journal. Since then it has become a frighteningly common affliction, with the Centers for Disease Control reporting recently that autism disorders now affect almost 1 percent of children.
Over recent decades, other development disorders also appear to have proliferated, along with certain cancers in children and adults. Why? No one knows for certain. And despite their financial and human cost, they presumably won’t be discussed much at Thursday’s White House summit on health care.
Yet they constitute a huge national health burden, and suspicions are growing that one culprit may be chemicals in the environment. An article in a forthcoming issue of a peer-reviewed medical journal, Current Opinion in Pediatrics, just posted online, makes this explicit.
The article cites “historically important, proof-of-concept studies that specifically link autism to environmental exposures experienced prenatally.” It adds that the “likelihood is high” that many chemicals “have potential to cause injury to the developing brain and to produce neurodevelopmental disorders.”
The author is not a granola-munching crank but Dr. Philip J. Landrigan, professor of pediatrics at the Mount Sinai School of Medicine in New York and chairman of the school’s department of preventive medicine. While his article is full of cautionary language, Dr. Landrigan told me that he is increasingly confident that autism and other ailments are, in part, the result of the impact of environmental chemicals on the brain as it is being formed.
“The crux of this is brain development,” he said. “If babies are exposed in the womb or shortly after birth to chemicals that interfere with brain development, the consequences last a lifetime.”
Concern about toxins in the environment used to be a fringe view. But alarm has moved into the medical mainstream. Toxicologists, endocrinologists and oncologists seem to be the most concerned.
One uncertainty is to what extent the reported increases in autism simply reflect a more common diagnosis of what might previously have been called mental retardation. There are genetic components to autism (identical twins are more likely to share autism than fraternal twins), but genetics explains only about one-quarter of autism cases.
Suspicions of toxins arise partly because studies have found that disproportionate shares of children develop autism after they are exposed in the womb to medications such as thalidomide (a sedative), misoprostol (ulcer medicine) and valproic acid (anticonvulsant). Of children born to women who took valproic acid early in pregnancy, 11 percent were autistic. In each case, fetuses seem most vulnerable to these drugs in the first trimester of pregnancy, sometimes just a few weeks after conception.
So as we try to improve our health care, it’s also prudent to curb the risks from the chemicals that envelop us. Senator Frank Lautenberg of New Jersey is drafting much-needed legislation that would strengthen the Toxic Substances Control Act. It is moving ahead despite his own recent cancer diagnosis, and it can be considered as an element of health reform. Senator Lautenberg says that under existing law, of 80,000 chemicals registered in the U.S., the Environmental Protection Agency has required safety testing of only 200. “Our children have become test subjects,” he noted.
One peer-reviewed study published this year in Environmental Health Perspectives gave a hint of the risks. Researchers measured the levels of suspect chemicals called phthalates in the urine of pregnant women. Among women with higher levels of certain phthalates (those commonly found in fragrances, shampoos, cosmetics and nail polishes), their children years later were more likely to display disruptive behavior.
Frankly, these are difficult issues for journalists to write about. Evidence is technical, fragmentary and conflicting, and there’s a danger of sensationalizing risks. Publicity about fears that vaccinations cause autism — a theory that has now been discredited — perhaps had the catastrophic consequence of lowering vaccination rates in America.
On the other hand, in the case of great health dangers of modern times — mercury, lead, tobacco, asbestos — journalists were too slow to blow the whistle. In public health, we in the press have more often been lap dogs than watchdogs.
At a time when many Americans still use plastic containers to microwave food, in ways that make toxicologists blanch, we need accelerated research, regulation and consumer protection.
“There are diseases that are increasing in the population that we have no known cause for,” said Alan M. Goldberg, a professor of toxicology at the Bloomberg School of Public Health at Johns Hopkins University. “Breast cancer, prostate cancer, autism are three examples. The potential is for these diseases to be on the rise because of chemicals in the environment.”
The precautionary principle suggests that we should be wary of personal products like fragrances unless they are marked phthalate-free. And it makes sense — particularly for children and pregnant women — to avoid most plastics marked at the bottom as 3, 6 and 7 because they are the ones associated with potentially harmful toxins.
I invite you to visit my blog, On the Ground. Please also join me on Facebook, watch my YouTube videos and follow me on Twitter.
Posted: Mon Mar 08, 2010 9:35 pm Post subject: WHAT ABOUT REAL HEALTH INSURANCE?
There is little talk of something that could drastically reduce healthcare prices in U.S. : Health.
Current numbers vary from 23.6 million to 24 million of U.S. citizens with diabetes, depending on which study you read. From 2007 to 2009, the number has increased by 15%. Most studies predict that in 10 years, about 50 million Americans will have diabetes. If this is not an epidemic, I don’t know what is.
Just 90 miles south of the U.S., there is a country that is combating diabetes: Cuba. About 10 years ago, the government began an education program. From the first grade up, Cuban kids learn of diabetes in school and how to prevent the disease.
The Cubans went even further than education: the government began an organic farming program. Farmers were paid to raise and sell crops to the government, which, in turn, sold them cheaply to the public. If a farmer had a surplus after selling his goods to the government, he was allowed to sell those privately.
Today, there are more than 7,000 plots occupying more than 81,000 acres on which organic food is farmed in Cuba. Many of these are located in urban areas as well as rural venues. In Havana, there are more than 200 gardens, some in small spaces between tower block estates that supply the city’s population with more than 90% of their fruit and vegetables. The farmers are obligated to farm a certain amount of products for the Cuban government. The surplus then belongs to the farmers who sell it for profit, which is divided among them.
After the Soviet Union dropped Cuba like a hot potato, the island country found itself without finances. At that time, Cuba imported much of its food, so it had to change its methods to feed its citizens. The Independent daily newspaper of Great Britain ran a story on August 8, 2006, titled, "The Good Life in Havana: Cuba’s Green Revolution." According to the article:
“...Twenty years ago, following the collapse of the Soviet Union, Fidel Castro’s small island faced a food crisis. Today, its networks of small urban farmers are thriving, an organic success story that is feeding the nation…”
Laura Enriquez, a sociologist at the University of California, Berkeley, who has written extensively on the subject of Latin American agriculture, said, "What happened in Cuba was remarkable. It was remarkable that they decided to prioritize food production. Other countries in the region took the neo-liberal option and exported ‘what they were good at’ and imported food. The Cubans went for food security and part of that was prioritizing small farmers."
Currently, the population of Cuba suffers diabetes at about 10% the rate of U.S. citizens who have the disease. Maybe the malady will be eradicated in Cuba someday.
In addition to diabetes, obesity creates deadly problems with one’s heart, lungs, liver and kidneys. Various estimates put the number of U.S. citizens who are obese at 50-65%. But, there is no national program to dissuade people from over-eating or eating processed foods that create fatal diseases.
A small portion of the U.S. public is aware of the hazards of processed food and attempt to eat organic items. Unfortunately, they are not widely available. Many towns may offer a "Farmer’s Market" for a few hours on one day a week in which farmers can sell their goods. Unlike Cuba, however, the prices of organic food in the U.S. are much higher than those of processed items. In other words, it is a luxury to try to eat healthy food.
The cost of healthcare in the U.S. far exceeds the cost of a preventive educational program about health for the U.S. public. Imagine if the U.S. called off the war in Iraq for one week. The savings in money would allow the government to produce and supply the public with healthy organic food. But, there are two problems with such a plan: 1. Nobody would make a profit, therefore making the plan un-American. 2. Instead of killing people, the money could be spent on helping people live, again another un-American concept.
I have always maintained that those nations who oppose U.S. hegemony are wrong in their approach to bring justice to the world. Instead of speaking up against the imperialist actions of the U.S., they should keep quiet and out of the radar. Within a few decades, the U.S. public just might eat itself to death.
March 21, 2010
Is Any Illness Covered?
By NICHOLAS D. KRISTOF
Health care is etched on my mind these days not only because of the Capitol Cacophony but also because a husband and wife I know, my former neighbors, are undergoing the kind of heartbreak no family should endure.
Zack Liu and Jan Li, along with their two young daughters, lived a few doors away from me. Then a couple of years ago they moved to Hong Kong, and paid $4,500 per year for a health insurance policy for Jan and the girls (Zack was covered through his job).
Last April 24, their world collapsed: Jan was diagnosed with late-stage stomach cancer.
Opponents of the reform proposals argue: If you like the Department of Motor Vehicles, you’ll love Obamacare. But as the drama of Zack and Jan shows, the only bureaucrats more obdurate than those at the D.M.V. are the ones working for insurance companies. The existing system is preposterous: we rely on insurance companies whose business model is based on accepting premiums from healthy people and devising ways to exclude from coverage those who most desperately need medical care.
Jan’s stomach was removed, and she underwent extensive chemotherapy. Then in October, her doctors discovered that the cancer had spread to her intestines. She has been hospitalized ever since.
The insurance company is InterGlobal, based in London, and the policy ostensibly covered up to $1.7 million in costs. But, according to Zack, the company said the policy allowed it to cut Jan off because she suffered from a “chronic condition.” It stopped paying her bills in January, Zack says.
I reached Sophie Walker, the group head of claims for InterGlobal. She said she couldn’t talk about an individual case. But she explained in an e-mail message that with a “chronic condition” the policies can have a much lower limit, $85,000, on lifetime claims. That’s the limit that Jan ran into in January, Zack says.
Then Ms. Walker gave me the company’s definition of “chronic” (you couldn’t make this up):
“Chronic means a medical condition which has at least one of the following characteristics: has no known cure; is likely to recur; requires palliative treatment; needs prolonged monitoring/ treatment; is permanent; requires specialist training/rehabilitation; is caused by changes to the body that cannot be reversed.”
That sounds like a spoof from “The Daily Show.” To translate: We’ll pay for care unless you get sick with just about anything that might be expensive. Then we’ll cut you off at the knees.
I asked InterGlobal if this was an accurate translation. I noted that by its definition, cancer, heart disease, strokes, diabetes, tennis elbow and even athlete’s foot seemed to be “chronic.” I also asked InterGlobal to name any serious disease that it did not consider “chronic.”
The next e-mail message came back from the company’s chief executive, Stephen Hartigan, who sent his “kind regards” but added that because he was “disappointed” at the tone of my inquiries, the company would have no further comment.
Zack and Jan are a special case in the health care arena: although they and their daughters are all American citizens, they’re living abroad and struggling with an overseas-based insurance company. But their plight underscores the fundamental weakness of any system that leaves us dependent on the magnanimity of for-profit insurance companies.
Those opposing reform argue that emergency rooms are always available as a backstop for those without insurance. That rings hollow for a woman with, say, stomach cancer. More broadly, E.R.’s simply cannot solve the larger health needs of the roughly 75 million Americans who are either uninsured or underinsured.
The conundrum is this: It’s in the interest of insurance companies to exclude people who are sick, while it’s in our national interest to see them covered. Plus, it’s the right thing to do.
As the Institute of Medicine, a branch of the National Academy of Sciences, declared in a landmark report last year, “The absence of health insurance is hazardous to your health.” Among the many studies that demonstrate that is one conducted in Kentucky that found cancers are detected later in women who have no insurance than in women who do — so those without are 44 percent more likely to die of breast cancer.
Another study found that for American adults ages 55 to 64, lack of insurance is “third on a list of leading causes of death for this age group, behind only heart disease and cancer.” All told, depending on who does the math, 20,000 to 45,000 Americans die each year for lack of health insurance.
So that’s what’s at stake. Far too many Americans must wrestle simultaneously with mortality and insurance companies, as Zack and Jan are. That must end.
I invite you to comment on this column on my blog, On the Ground. Please also join me on Facebook, watch my YouTube videos and follow me on Twitter.
Maternal health includes contraception
March 28, 2010
The Harper government should include contraception among its maternal and child health measures at this June's G8 summit in Huntsville, Ont. Leaving it out would be tantamount to ignoring the serious challenge from population growth which the developing world faces. A focus on contraception does not mean returning to last week's divisive and failed Liberal motion to get abortion included in the plans, but it does require the government to sensitively promote the subject of smaller families to Third World nations through a variety of family planning efforts.
According to the United Nations, 99 per cent of world population growth to 2050 will be in the developing world, the area least equipped to deal with the strains such an expansion will put on infrastructure, basic services and resources.
Reducing family size brings enormous benefits. Child mortality falls by 13 per cent if women wait two years between pregnancies and plunges by a quarter if pregnancies are spaced at least three years apart, while maternal deaths could be reduced by 27 per cent without unplanned pregnancies.
Parents with fewer children have more time, energy and resources to devote to their offspring and place less of a burden on health services.
Third World parents are not unwilling to be educated about family planning. A study reported through the Geneva Foundation on Medical Education and Research found that "in Cameroon ... 64 per cent of men in the rural areas of Akonolinga and 63 per cent in the rural areas of Obala are favourable to contraceptive practice, while another study among university students in Yaounde showed a favourable attitude in 92 per cent of unmarried couples and 98 per cent of married couples."
The study found that impediments to contraceptive practice include religious beliefs, lack of information, lack of education, high infant mortality, service delivery constraints, reluctance to talk about sexuality, and lack of political will.
However, government attitudes are shifting; the study noted that the government of Cameroon's attitude has gone "from open hostility toward family planning to tolerance under responsible parenthood and to commitment to family planning as a national policy. Most African countries have followed the same pattern of evolution as Cameroon."
Another study out of Johns Hopkins University in Baltimore, which examined attitudes toward contraception in Ilorin, Nigeria, found that 80 per cent of women who were educated about contraception thought it the best method of family planning.
Contraceptive knowledge is essential to maternal health. The Canadian government would not shy away from providing Canadian women with information that would improve their health; it should do no less for the women of the Third World.
Mammograms catch few cancers in young women: study
WASHINGTON (Reuters) - Mammograms detect few cancers in women under the age of 40 but cause expense and anxiety because women frequently get "false positives" that require follow-up to rule out cancer, researchers reported on Monday.
Mammograms did not detect any tumors among women under the age of 25, the researchers reported in the Journal of the National Cancer Institute.
The study of more than 117,000 U.S. women may reinforce controversial recommendations about the use of mammograms to screen for breast cancer among younger women.
Radiologist Bonnie Yankaskas of the University of North Carolina at Chapel Hill and colleagues examined the records of women aged 18 to 39 when they got their first mammograms starting in 1995, following them for a year to see what happened.
There were no tumors among the women under 25. For women aged 35 to 39, 12.7 per 1,000 got called back for further checks after the mammogram produced a suspicious-looking lesion. Very few actually had a tumor.
"In a theoretical population of 10,000 women aged 35 to 39 years, 1,266 women who are screened will receive further workup, with 16 cancers detected and 1,250 women receiving a false-positive result," Yankaskas and colleagues wrote.
"Harms need to be considered, including radiation exposure because such exposure is more harmful in young women, the anxiety associated with false-positive findings on the initial examination, and costs associated with additional imaging," they added.
About 29 percent of U.S. women aged 30 to 40 say they have had a mammogram.
Dr. Ned Calonge of the Colorado Department of Public Health and Environment said the findings suggest that women under 40 should not get mammograms unless they have symptoms of breast cancer, such as a lump.
Last November the U.S. Preventive Services Task Force, a federal scientific advisory panel, said women in their 40s with an average risk for breast cancer did not need annual mammograms to screen for the disease.
The guidelines touched off a debate among cancer doctors.
Calonge noted that most groups agree that women under 40 probably do not need mammograms to screen for cancer and Monday's study supports this approach.
Breast cancer is the most common cancer in women worldwide, accounting for around 16 percent of all female cancers. It kills around 465,000 people globally each year.
(Reporting by Maggie Fox; Editing by Cynthia Osterman)
June 5, 2010
Growing Obesity Increases Perils of Childbearing
By ANEMONA HARTOCOLLIS
As Americans have grown fatter over the last generation, inviting more heart disease, diabetes and premature deaths, all that extra weight has also become a burden in the maternity ward, where babies take their first breath of life.
About one in five women are obese when they become pregnant, meaning they have a body mass index of at least 30, as would a 5-foot-5 woman weighing 180 pounds, according to researchers with the federal Centers for Disease Control and Prevention. And medical evidence suggests that obesity might be contributing to record-high rates of Caesarean sections and leading to more birth defects and deaths for mothers and babies.
Hospitals, especially in poor neighborhoods, have been forced to adjust. They are buying longer surgical instruments, more sophisticated fetal testing machines and bigger beds. They are holding sensitivity training for staff members and counseling women about losing weight, or even having bariatric surgery, before they become pregnant.
At Maimonides Medical Center in Brooklyn, where 38 percent of women giving birth are obese, Patricia Garcia had to be admitted after she had a stroke, part of a constellation of illnesses related to her weight, including diabetes and weak kidneys.
At seven months pregnant, she should have been feeling the thump of tiny feet against her belly. But as she lay flat in her hospital bed, doctors buzzing about, trying to stretch out her pregnancy day by precious day, Ms. Garcia, who had recently weighed in at 261 pounds, said she was too numb from water retention to feel anything.
On May 5, 11 weeks shy of her due date, a sonogram showed that the baby’s growth was lagging, and an emergency Caesarean was ordered.
She was given general anesthesia because her bulk made it hard to feel her spine to place a local anesthetic. Dr. Betsy Lantner, the obstetrician on call, stood on a stool so she could reach over Ms. Garcia’s belly. A flap of fat covered her bikini line, so the doctor had to make a higher incision. In an operation where every minute counted, it took four or five minutes, rather than the usual one or two, to pull out a 1-pound 11-ounce baby boy.
Studies have shown that babies born to obese women are nearly three times as likely to die within the first month of birth than women of normal weight, and that obese women are almost twice as likely to have a stillbirth.
About two out of three maternal deaths in New York State from 2003 to 2005 were associated with maternal obesity, according to the state-sponsored Safe Motherhood Initiative, which is analyzing more recent data.
Obese women are also more likely to have high blood pressure, diabetes, anesthesia complications, hemorrhage, blood clots and strokes during pregnancy and childbirth, data shows.
The problem has become so acute that five New York City hospitals — Beth Israel Medical Center and Mount Sinai Medical Center in Manhattan, Maimonides in Brooklyn and Montefiore Medical Center and Bronx-Lebanon Hospital Center in the Bronx — have formed a consortium to figure out how to handle it. They are supported by their malpractice insurer and the United Hospital Fund, a research group.
One possibility is to create specialized centers for obese women. The centers would counsel them on nutrition and weight loss, and would be staffed to provide emergency Caesarean sections and intensive care for newborns, said Dr. Adam P. Buckley, an obstetrician and patient safety expert at Beth Israel Hospital North who is leading the group.
Very obese women, or those with a B.M.I. of 35 or higher, are three to four times as likely to deliver their first baby by Caesarean section as first-time mothers of normal weight, according to a study by the Consortium on Safe Labor of the National Institutes of Health.
While doctors are often on the defensive about whether Caesarean sections, which carry all the risks of surgery, are justified, Dr. Howard L. Minkoff, the chairman of obstetrics at Maimonides, said doctors must weigh those concerns against the potential complications from vaginal delivery in obese women. Typically, these include failing to progress in labor; diabetes in the mother, which can lead to birth complications; and difficulty monitoring fetal distress. “With obese women we are stuck between Scylla and Charybdis,” Dr. Minkoff said.
But even routine care, like finding a vein to take blood, can be harder through layers of fatty tissue.
And equipment can be a problem. Dr. Janice Henderson, an obstetrician for high-risk pregnancies at Johns Hopkins in Baltimore, described a recent meeting where doctors worried that the delivery room table might collapse under the weight of an obese patient.
At Maimonides, the perinatal unit threw away its old examining tables and replaced them with wider, sturdier ones. It bought ultrasound machines that make lifelike three-dimensional images early in pregnancy, when the fetus is still low in the uterus and less obscured by fat, but also less developed and thus harder to diagnose clearly. “You really need to use the best equipment, which is more expensive,” said Dr. Shoshana Haberman, the director of perinatal services.
Many experienced obstetricians complain that as Americans have grown larger, the perception of what constitutes obesity has shifted, leading to some complacency among doctors. At UMass Memorial Medical Center in Worcester, Mass., Dr. Tiffany A. Moore Simas, the associate director of the residency program in obstetrics, demands that residents calculate B.M.I. as a routine part of prenatal treatment. “It’s one of my siren songs,” Dr. Moore Simas said, “because we are very bad at eyeballing people.”
Dr. Haberman said there was obesity in her own family, and she had seen how hurtful even professionals could be. “We as a society have issues with the perception of obesity; anatomically, you get turned off,” she said.
So she was sympathetic to Ms. Garcia, making sure she got a room with a window, and calling to check on her after hours.
Ms. Garcia, 38, a former school bus dispatcher, is 5 feet tall. She said she had tried diets, weight-watching groups and joining a gym. She was 195 pounds before her pregnancy (B.M.I., 3 and ballooned to 261 pounds, which she attributed to water weight and inactivity.
“I’m the smallest one in my family,” she said. Her older brother weighed more than 700 pounds before having gastric bypass surgery.
She wiped tears away as she confessed that she worried that she might die and leave her baby without a mother.
At Ms. Garcia’s stage of pregnancy, every day in the womb was good for the baby but bad for the mother, Dr. Minkoff said. “She’s making a heroic decision to put her own self in peril for the sake of the child,” he said.
She survived, but was dismayed by the size of her son, Josiah Patrick, who had to be put on a breathing machine. At first she could see him only by remote video. But after a month, Josiah was off the ventilator, taking 15 milliliters of formula and had smiled at his mother, and doctors said he was where he should be developmentally for a preemie his age.
The hospital estimated that the cost of caring for the mother and baby would be more than $200,000, compared with $13,000 for a normal delivery.
Ms. Garcia promised Dr. Minkoff that she would lose weight and see her baby graduate from college. “I’m going on a strict, strict, strict diet,” she said. “I’m not going through this again.”
July 13, 2010
Rules Seek to Expand Diagnosis of Alzheimer’s
By GINA KOLATA
For the first time in 25 years, medical experts are proposing a major change in the criteria for Alzheimer’s disease, part of a new movement to diagnose and, eventually, treat the disease earlier.
The new diagnostic guidelines, presented Tuesday at an international Alzheimer’s meeting in Hawaii, would mean that new technology like brain scans would be used to detect the disease even before there are evident memory problems or other symptoms.
If the guidelines are adopted in the fall, as expected, some experts predict a two- to threefold increase in the number of people with Alzheimer’s disease. Many more people would be told they probably are on their way to getting it. The Alzheimer’s Association says 5.3 million Americans now have the disease.
The changes could also help drug companies that are, for the first time, developing new drugs to try to attack the disease earlier. So far, there are no drugs that alter the course of the disease.
Development of the guidelines, by panels of experts convened by the National Institute on Aging and the Alzheimer’s Association, began a year ago because, with a new understanding of the disease and new ways of detection, it was becoming clear that the old method of diagnosing Alzheimer’s was sorely outdated.
The current formal criteria for diagnosing Alzheimer’s require steadily progressing dementia — memory loss and an inability to carry out day-to-day activities, like dressing or bathing — along with a pathologist’s report of plaque and another abnormality, known as tangles, in the brain after death.
But researchers are now convinced that the disease is present a decade or more before dementia.
“Our thinking has changed dramatically,” said Dr. Paul Aisen, an Alzheimer’s researcher at the University of California, San Diego, and a member of one of the groups formulating the new guidelines. “We now view dementia as a late stage in the process.”
The new guidelines include criteria for three stages of the disease: preclinical disease, mild cognitive impairment due to Alzheimer’s disease and, lastly, Alzheimer’s dementia. The guidelines should make diagnosing the final stage of the disease in people who have dementia more definitive. But, the guidelines also say that the earlier a diagnosis is made the less certain it is. And so the new effort to diagnose the disease earlier could, at least initially, lead to more mistaken diagnoses.
Under the new guidelines, for the first time, diagnoses will aim to identify the disease as it is developing by using results from so-called biomarkers — tests like brain scans, M.R.I. scans and spinal taps that reveal telltale brain changes.
The biomarkers were developed and tested only recently and none have been formally approved for Alzheimer’s diagnosis. One of the newest, a PET scan, shows plaque in the brain — a unique sign of Alzheimer’s brain pathology. The others provide strong indications that Alzheimer’s is present, even when patients do not yet have dementia or even much memory loss.
Dr. Aisen says he foresees a day when people in their 50s routinely have biomarker tests for Alzheimer’s and, if the tests indicate the disease is brewing, take drugs to halt it. That is a ways off but, he said, but “it’s where we are heading.”
“This is a major advance,” said Dr. John Morris, an Alzheimer’s researcher at Washington University in St. Louis who helped formulate the guidelines. “We used to say we did not know for certain it was Alzheimer’s until the brain is examined on autopsy.”
Dr. Ronald Petersen, an Alzheimer’s researcher at the Mayo Clinic in Minnesota and chairman of the Alzheimer’s Association’s medical and scientific advisory council, said adding biomarkers to a diagnosis would be a big improvement.
Today, he says, when a patient comes with memory problems, doctors might say that the person has a chance of developing Alzheimer’s in the next decade, a chance of not getting much worse for several years, and a chance of actually getting better.
Tests like brain scans, Dr. Petersen said, “will allow us to be much more definitive.” If the tests show changes characteristic of Alzheimer’s disease, a doctor can say, “I think you are on the Alzheimer’s road.”
That can be a difficult conversation, but it can allow patients and their families to plan. “At least it’s a conversation the physician can have with the patient,” Dr. Petersen said.
Alzheimer’s experts welcomed the new criteria.
“Over all, I think this is a giant step in the right direction,” said Dr. P. Murali Doraiswamy, a psychiatry professor and Alzheimer’s disease researcher at Duke University who was not involved with making the guidelines. “It moves us closer to the cause of the disease rather than just looking at symptoms.”
But, he added, it also is a huge change.
“This has implications for everybody alive, anybody who is getting older,” Dr. Doraiswamy said. Among other things, he said, it will encourage a lot more testing. And, Dr. Doraiswamy said, “diagnosis rates, like testing rates, only go in one direction — up.”
Doctors will have to learn new terms — preclinical Alzheimer’s; prodromal, or early stage, Alzheimer’s. Patients going to see a doctor with memory problems might be offered biomarker tests, which can be expensive.
The ripple extends beyond doctors and patients, Dr. Doraiswamy said. The new diagnostic criteria also have consequences for lawyers, insurance companies and workers’ compensation programs.
And, he said, people have to be prepared for unintended consequences, which always occur when the diagnosis of a disease is changed. For now, he said: “We ought to be cautious that we don’t stimulate all this testing before we can give people something to manage their disease. There is no point in giving them just a label.”
July 16, 2010
Drug Trials Test Bold Plan to Slow Alzheimer’s
By GINA KOLATA
Marilyn Maldonado is not quite sure why she is at the Memory Enhancement Center in the seaside town of Oakhurst, N.J.
“What are we waiting for?” she asks. About 10 minutes later, she asks again. Then she asks again.
She is waiting to enter a new type of Alzheimer’s drug study that will, in the boldest effort yet, test the leading hypothesis about how to slow or stop this terrifying brain disease.
The disease is defined by freckles of barnacle-like piles of a protein fragment, amyloid beta, in the brain. So, the current thinking goes, if you block amyloid formation or get rid of amyloid accumulations — plaque — and if you start treatment before the disease is well under way, you might have a chance to alter its course.
On Tuesday, that plan got a new push. The National Institute on Aging and the Alzheimer’s Association proposed new guidelines for diagnosis to find signs of Alzheimer’s in people who do not yet have severe symptoms, or even any symptoms at all.
The guidelines are needed for the new approach to Alzheimer’s drug development. Just about every pharmaceutical company and many biotechnology companies have experimental drugs to block amyloid — there are more than 100 in the pipeline. And the companies would like to show that if they give their drugs early, they can slow or stop the disease.
That is the ultimate goal for the drug in the study Mrs. Maldonado wants to enter, sponsored by Bristol-Myers Squibb. The company is, for the first time, testing such a drug in patients who, on evaluation with memory tests and new brain scans and tests for amyloid in cerebrospinal fluid, seem to be in a very early stage of Alzheimer’s. The idea is to attack the disease when there may still be time to stop the worst brain cell death.
But there is a problem. The Food and Drug Administration says it needs to know not just that plaque was reduced or even that it disappeared, but that those who took a drug ended up with better memory and better ability to think and reason as compared with those who did not take the drug.
Alzheimer’s, though, progresses so slowly that showing that a drug, started early, affects symptoms can take far longer than companies can afford to wait.
July 19, 2010
Alzheimer’s Isn’t Up to the Tests
By SANJAY W. PIMPLIKAR
A PANEL of medical experts from the National Institute on Aging and the Alzheimer’s Association last week proposed changes in the way doctors diagnose Alzheimer’s disease — including the use of so-called biomarkers, tests like PET brain scans and analyses of spinal fluids to promote early detection of the disease. Although these recommendations are well intentioned, evidence suggests that it would be a mistake to adopt them at this time. To understand why, it’s important to recognize what these tests mean, in what context the information will be used and what experience has shown us.
First, about the diagnostic tests: A PET scan detects clumps of a deformed protein called amyloid beta, commonly known as plaques. The presence of these plaques has been a gold standard of Alzheimer’s pathology since 1906, when Dr. Alois Alzheimer first identified them in a patient.
However, we now know that roughly one-third of all elderly adults have such plaques in their brains yet function normally. And eleven clinical trials, recently made public by a group of drug companies, that were aimed at reducing these plaques in Alzheimer’s patients all failed to show cognitive improvement, even when the brains were cleared of plaques.
Thus, the presence of plaques cannot predict with any accuracy or specificity that an individual is going to acquire the disease — and researchers are increasingly looking beyond the amyloid hypothesis for an adequate explanation for Alzheimer’s.
Another test being recommended by the panel is spinal fluid analysis — which measures the relative levels of two proteins, tau and amyloid beta. This method does seem quite promising, but its predictive potential remains uncertain.
There are also practical issues to be considered, not least of all the high cost of these procedures. What’s more, the spinal tap procedure is not easy to perform and is painful to undergo, and it is a long way from becoming a routine diagnostic tool. Dr. Janis Petzel, a geriatric psychiatrist in Maine, has noted how unfeasible this test is in “nonacademic, rural or non-Western settings”: “I pray that cerebrospinal fluid findings will never be part of diagnostic criteria for Alzheimer’s disease,” she wrote.
The diagnostic tests themselves can carry a risk of side effects. General imaging scans can expose patients to radiation, for instance; an invasive spinal tap could result in infection or damage to tissue. But there is also the psychological risk of false positives and misdiagnoses that greatly distress patients, at least until further tests show they do not have the disease.
This danger of overdiagnosis is very real, as the history of treatment for prostate cancer shows. A study last year about the prostate-specific antigen test found that in the two decades after the test was introduced, prostate cancer was detected in more than 1 million additional men, many of whom were likely overtreated.
Last, the most dreadful thing about Alzheimer’s disease, next to the slow deterioration of cognition, is that we do not yet have a cure and none seems to be on the horizon. So, even if the new recommendations rendered the diagnosis earlier and unassailable, there is no therapeutic avenue to use this information to effectively treat the patient. Many individuals would simply prefer to be spared the emotional trauma of a diagnosis if no treatment exists.
Taken together, these reasons suggest that the panel’s recommendations are likely to increase the emotional burden on individuals and the financial burden on society without providing proportional benefits. The doctor’s most basic tenet is that of primum non nocere — first, do no harm. Until we have a more definite idea about what causes Alzheimer’s, early-detection tests may do patients more harm than good.
British researchers develop ‘cure’ for Type 2 diabetes: Starve yourself
By Thomas H. Maugh II / Los Angeles Times
Sunday, June 26, 2011 - Added 2 days ago
British researchers have developed what they say is a "cure" for Type 2 diabetes, the most common form of the disease. And all you have to do is starve yourself for eight weeks.
Roy Taylor, head of the magnetic resonance imaging unit at Newcastle University in Britain, and his colleagues studied 11 patients who had developed diabetes later in life and who had had it for several years. The patients averaged 220 pounds at the beginning of the study. Each was put on a 600-calorie-per-day diet that included a special diet drink and non-starchy vegetables, such as broccoli, asparagus and cabbage. The diet was followed for eight weeks.
Taylor reported Saturday at a San Diego meeting of the American Diabetes Association and in the journal Diabetologia that, after one week on the diet, each of the patients’ fasting blood sugar, taken before breakfast, had returned to normal. At the end of the eight weeks, the patients had lost an average of 33 pounds and had no signs of diabetes. Three months after returning to a normal diet, seven of them remained free of the disease. Average weight gain in that three months was 6.5 pounds.
Taylor believes he has an explanation for the results. At the beginning of the study, MRI scans of the patients’ pancreases showed that they held an elevated level of fat, 8 percent compared with the normal 6 percent. That extra fat impairs the organ’s ability to produce insulin, he speculated. At the end of the study, fat levels in the pancreas were down to normal in each patient.
"We believe that this shows that Type 2 diabetes is all about energy balance in the body," Taylor said in a statement. "If you are eating more (calories) than you burn, then the excess is stored in the liver and pancreas as fat, which can lead to Type 2 diabetes in some people. What we need to examine further is why some people are more susceptible to developing diabetes than others."
He added that, "We used the 600-calorie diet to test a hypothesis. What I can tell you definitively is that if people lose substantial weight by normal means, they will lose their diabetes."
An estimated 25 million Americans have Type 2 diabetes, in which the body does not respond properly to insulin produced by the pancreas. Experts recommend that patients consult with a doctor before attempting such an extreme diet.
July 16, 2011
Patrolling Cancer’s Borderlands
By SIDDHARTHA MUKHERJEE
THREE recent events highlight the extraordinary task that lies ahead for cancer prevention.
First: in late May, a World Health Organization panel added cellphones to a list of things that are “possibly carcinogenic” — a category that also includes pickles and coffee.
Second: in mid-June, the National Toxicology Program, countering years of lobbying by certain industries, finally classified formaldehyde (used in plywood manufacturing and embalming) as a carcinogen.
And third: in late June, the Food and Drug Administration issued newer and more graphic warning labels for cigarette packages. These include deliberately disturbing images of a patient with mouth cancer and of a man with tobacco smoke coming out of a tracheotomy stoma.
What connects these events? Together, they serve to remind us of three of the most potent challenges that cancer-control agencies face today. Indeed, it is essential to recognize these events as representing a progression: each corresponds to a crucial stage in the process of patrolling the borderlands of cancer. Effective cancer control depends on successful action at each of these complex stages.
The first challenge is scientific. It concerns the complexity of identifying new carcinogens, and the need for consistent standards for doing so. Take the purported link between cellphone radiation and brain cancer. This link is based largely on the so-called Interphone study. In Interphone, men and women with a variant of brain cancer (called glioma) were asked to recall their level of exposure to cellphone radiation. The results, at first glance, were provocative. Men and women who recalled moderate phone use seemed to have decreased rates of brain cancer compared to those who rarely used cellphones. In contrast, men and women with the highest usage seemed to have an increased rate of brain cancer.
But pivotal uncertainties remain. Trials like Interphone depend on the ability of subjects to recall their prior exposures. Such recollections can be surprisingly inconsistent. Indeed, when some subjects’ actual phone use was logged, there were broad discrepancies between actual and reported usage.
There are other difficulties. Despite a drastic increase in cellphone usage over the past decades, there has been no significant change in glioma cancer rates across the nation. Perhaps it is too early to judge, but the enormous increase in phone usage should have caused at least a minor blip in glioma rates over 20 years — but no such increase is apparent.
And finally, the kind of radiation emitted by cellphones — unlike the radiation emitted by X-rays or nuclear bombs — cannot directly damage DNA. X-rays and nuclear radiation possess the energy required to alter genes and thereby cause cancer. But the frequency of cellphone radiation is more than a million-fold lower. If cellphone radiation is causing cancer, it is doing so through a mechanism that defies our current understanding of carcinogenesis.
Brain cancer is a devastating illness, and it’s worth being cautious, but the current data supporting the link between phone radiation and glioma are weak. The cellphone case is a reminder of how difficult it is to identify a new carcinogen — and how important it therefore is to have standards to make such classifications possible.
Discrepancies in standards for classifying carcinogens have led to confusion and turmoil in the public realm. In contrast to the World Health Organization, many agencies, including the National Cancer Institute, remain skeptical about the link between phone radiation and cancer, and are awaiting more definitive studies to clarify the issue. In part, the problem is semantic: the W.H.O.’s definition of “possibly carcinogenic” is much looser; coffee and pickles are included, even though the evidence for their carcinogenicity remains weak. But the split between the W.H.O. and other agencies on cellphones — emblematic of the split within the scientific community — has had the unfortunate effect of confounding the public, which now does not know which faction to believe.
The second challenge facing cancer control agencies is political. The formaldehyde case illustrates this. Unlike phone radiation, formaldehyde has a well-established mechanism to cause cancer: it is a strikingly reactive chemical that can directly attack DNA. Experiments performed in the 1970s demonstrated that the chemical causes cancer in mice and rats. Following this data, sophisticated trials showed that men and women exposed to formaldehyde — morticians, for instance — had higher rates of leukemia than unexposed people.
But some of these studies were performed three decades ago. Why have 30 years elapsed between them and the National Toxicology Program announcement? In part, because of active lobbying by various industries, in particular, plywood manufacturers, who have tried to thwart this classification.
Identifying a carcinogen, in short, isn’t sufficient. Beyond the science — which, as the cellphone example shows, can be hard enough — cancer-control agencies need to bolster political support, and neutralize lobbying interests, before a culprit carcinogen can be revealed to the public.
The third challenge for the cancer community is social. The F.D.A.’s new labels on cigarette packages are a case in point. The human trials that established that tobacco smoke is a carcinogen were initially performed in the mid-1950s (some even earlier). The tobacco industry mounted an aggressive campaign to discredit the data, and continued marketing tobacco to the public. The landmark Surgeon General’s Report on smoking and cancer was released in 1964. And it took yet another decade of innovative strategies, including powerful antitobacco advertisements and tort cases against tobacco companies, to alter the trajectory of smoking behavior in America.
But young men and women in some parts of the nation are smoking again: consumption in certain regions has been rising, and cancer rates will rise concomitantly. Evidently, identifying a carcinogen or advertising the risk to the public is not enough: cancer-control agencies need to invent and reinvent strategies continuously. Old warning labels generate habitual responses, so new, more disturbing labels are needed to invigorate attention.
Patrolling the world for real carcinogens, in short, is a complex task. Scientific challenges morph into political challenges that lead to social challenges. If reducing the incidence of cancer is a national goal — as it surely must be — then it is essential to recognize the many-dimensional nature of countering carcinogens.
Siddhartha Mukherjee is an assistant professor of medicine at Columbia University and the author of “The Emperor of All Maladies: A Biography of Cancer.”
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