Author Archives: jpwmd

In recent years, patients have been able to readily access their medical records, and this includes lab results.  This is a good trend, especially as timely results can alleviate anxiety relevant to ordered tests.  Caveats are necessary, though, and patients should be aware of the limits of diagnostic testing.

When to Order Tests

To be useful, a lab test must be accurate.  That is, if a test is designed to detect a disease, it should have a high true-positive rate (a positive test means the disease is likely present) and a high true-negative rate (a negative test means the presence of the disease is unlikely).  In the Covid era of self-administered tests, people who read the instructions carefully understand the concept. 

The home Covid test kits caution that results can be misleading.  There can be false positive results and false negative results, with the likelihood of a positive test increasing the sicker the patient.  So testing may not be definitive.  If you have had a significant exposure (e.g., had close contact with someone with proven Covid), have upper respiratory symptoms, experience impaired taste and/or ability to smell, and have unusual lassitude, you almost certainly have a Covid infection, regardless of the results of testing.  

Which brings up the question: why do a test anyway?  A general guide is that a test should be done to make a decision.  If a test is not going to change a therapeutic course of action or does not reveal a situation that requires intervention, why do it?  You might consider a chest x-ray to detect lung cancer in a patient with a long history of smoking, but if the patient has too great a respiratory compromise to survive a surgical intervention and/or a course of chemotherapy, you could reasonably forgo the search for lung cancer.

Special Considerations

On the other hand, doing a test for a condition for which there is no immediate therapy can be reasonable.  Genetic testing for the uniformly fatal neurological disease called Huntington’s Disease (an inexorably fatal neurological condition) reveals whether a person has the gene that will inevitably lead to symptomatic disease.  Although a “positive” result may not dictate any immediate clinical action, many people with a strong family history  may want to assess their risk.  Having the gene, for instance, may have a major impact on family planning.    

Some patients want to do testing for social reasons.  Knowing a more precise expected prognosis in patients with advanced cancer is another reason to perform a test that will not result in any clinical intervention.  In my hospice work, the issue of expected life span was often critical, as patients’ estranged children, for instance, mobilized to come home from far away.

When I was a hospice physician, I helped care for a patient with terminal heart disease that would obviously take the patient’s life within months.  He had a small basal cell carcinoma on his left cheek.  Although it can be disfiguring in the long term if not treated, this is a skin cancer that rarely, if ever, results in mortality.  And in this patient’s case, the skin cancer bore no impact on his longevity.  

Because the test (a skin biopsy) would have no therapeutic implications, I explained my aversion to doing the diagnostic biopsy.  But neither the patient nor his family could tolerate the thought of ignoring a cancer.  The biopsy would be a completely useless test, but, out of respect for the patient and family, I ordered the biopsy.  The patient died before the pathologic results came back.  

Prostate-specific Antigen

This is a simple blood test in common use to detect prostate cancer.  The trouble lies in the characteristics of the test: three out of four men with a “positive” do not have prostate cancer and one in seven men with a negative test do have prostate cancer.  The false positive rate is a real problem–it leads to painful biopsies and further testing, not to mention attendant worry.  All in the name of a cancer that may not exist or will never cause any clinical symptoms (Almost 50% of men over the age of 80 have prostate cancer upon autopsy, a condition that never affected their lives one bit).

This is a complicated clinical area, and making recommendations is beyond the scope of this blog.  Preventive task forces urge informed discussion with one’s physician before making a decision to get the blood test.

Be Careful in Assessing Test Results

I could go deeper into the weeds on medical diagnostic tests.  The point I am making is simply that the interpretation of tests can be very tricky and requires the knowledge and judgment of a professional.  If you are alarmed by the result of a test that shows up on your computer, talk to your doctor before becoming overly concerned.

Falls in Old Folks 

 (not the kind with pretty leaves)

When I was a resident physician, I attended a lecture on falls in the elderly.  I was mightily bored–like most 30 year oldish males, I was an idiot.  I felt that the real stuff was heart attacks, blood clots, kidney disease, etc.  I eventually became sensitized to the importance of the problem, and therefore I was very interested in an article in a recent edition of The American Family Physician: Falls in Older Adults: Approach and Prevention (May, 2024, pages 447 to 456).

The Problem

The definition of a fall is unintentionally coming to rest on the ground.  A fall occurs in 27% of adults 65 years or older, with an injury rate of about 10%.  Fractures are common, especially hip fractures, which carry a one year mortality rate of 20 to 30%.  

The cost to healthcare of falls in older adults was $64.8 billion in 2023.

Risk Factors 

In addition to advanced age, prominent risk factors for falls that are modifiable include, but are not limited to, balance disorders,  chronic pain, use of medications that increase fall risk, visual impairment, alcohol ingestion, and depression.  Lack of physical activity  is also important.  Nonmodifiable factors include dementia, female sex, a history of falls, peripheral neuropathy, and almost any chronic medical condition such as heart disease and Parkinson disease.

Evaluation 

The Center for Disease Control (CDC) has developed methods to help clinicians evaluate older adults at risk for falls.  Three questions are asked: 1) Do you feel unsteady when walking or standing? 2) Do you worry about falling? 3) Have you fallen in the past year?  If the answer to any of the questions is “yes,” further screening tests are warranted.

You can gauge your vulnerability yourself.  Three easy to administer tests are useful, and they are readily accessible on the internet: the Timed and Go Test; the 30-Second Chair Stand Test; and the Four-Stage Balance Test. Underperformance indicates increased risk of falling.

Prevention

Optimizing medical regimes is critical.  Polypharmacy in the elderly population is dangerous, and patients taking five or more medications have a 20% increase in fall risk compared to those without polypharmacy.  Good clinicians help patients weigh the benefits of drugs known to put patients at risk for falls, and the judgment may be made that the benefit of taking a drug outweighs the risk of falls.  For instance, drugs commonly used for high blood pressure and heart disease may come with an increased risk of falling, but are necessary in the treatment of medical disease.  

Many drugs, such as benzodiazepines (Ativan, Valium, Xanax, etc.) are particularly dangerous and are often of marginal usefulness in the elderly, so their benefits must be carefully scrutinized.  Diphenhydramine (Benadryl) usage increases the risk of falls by 50% compared to those who take later generation antihistamines.  Geriatricians are particularly tuned into the problem of polypharmacy and are expert in devising pharmacological regimes that maximize safety and effectiveness. 

Approaches to Reducing Fall Risk

To minimize the risk of falling, attention to both personal and environmental factors is necessary.  One should receive maximal medical interventions for any chronic disease such as heart or lung conditions.  Foot care, especially for diabetics, is critical, and custom footwear may be appropriate.  Poor visual acuity is implicated in many falls and regular ophthalmology visits are important.  Even hearing impairment should be addressed as severe hearing loss elevates the risk of falling.  As noted above, critical evaluation of medications is one of the most important things you can do to minimize the risk of falling.

The benefits of personal activity extend to reducing the risk of falls (for more on of physical activity, see my blog entry from August 31, 2023).  An exercise regime that includes aerobic and anaerobic activity should be habitual, and exercises to specifically strengthen the lower extremities are indicated.  Effective and safe use of walking assistive devices is important. Balance training is beneficial and instruction is widely available on the internet.

Just as important as personal physical characteristics is evaluation of environmental factors.  Is lighting adequate?  Are throw rugs present?  Do staircases have banisters?

Last year, my wife and I, both of us in our mid-seventies, had a sturdy banister installed between the first and second floor.  The psychological boost that has come with it is remarkable. 

At the 25th anniversary of the Columbine shootings, the New England Journal of Medicine ran a perspective piece on where our nation stands now on gun ownership and regulation.

After the shooting, in which 12 students were killed, Smith and Wesson, a major manufacturer of firearms, took measures to increase gun safety.  These included not allowing dealers to sell high capacity magazines (i.e., bullet clips that allow ten rounds or more to be rapidly discharged before reloading), including safety devices on handguns that alerted users to the presence of live ammunition in the guns, imprinting barrel “fingerprints” that aid tracing the origin of a firearm.  The gun industry boycotted the company and the CEO was forced to resign.

The Stats

Sometimes putting numbers to obvious problems helps to understand the depth of the problem.  

Statistics from 1999 to 2021 (the last year for which reliable data are available) are illustrative.  Before 1999, long gun sales, predominantly used for hunting, dominated sales of firearms.  Now, most purchases (that we know about) are for handguns, many of which are military weapons.  

Gun-related deaths in 1999 were 28,874, while the total in 2021 was 48,830.  During the 22 year period up to 2021, firearm homicide rates increased by 70%.  Firearm suicide rates increased by 33%.  In 2021, over 80% of homicides, and 55% of suicides, involved guns.

Lobbying and Legal Rulings

The firearms industry spent over $13 million on lobbying in 2021, up from about $6.5 million in 2002.  This resulted in part in the non-renewal of the 1994 10 year ban on the sale of assault weapons.

The Supreme Court has made several impactful rulings since the turn of this century.  In 2005, the court found the Protection of Lawful Commerce in Arms Act to be constitutional.  This reduced industry liability from potential tort lawsuits.  

In 2008, in contrast to previous understanding of the 2nd Amendment, the court ruled that individuals, along with “well regulated militia,” enjoyed the protection of the amendment.

Regulation

While many obstacles to curbing gun violence in our country remain, polls show that the majority of Americans, even gun owners, favor more effective regulation.  Measures that that would undoubtedly result in less gun violence include: universal registration of all new gun purchases, universal background checks, safe storage laws, proscription of assault weapons and high capacity magazines, cooling-off periods (a period of waiting from the time a gun is ordered to the time the weapon is possessed), required training for gun owners/purchasers, and many more.

The Intersection of Politics and Healthcare

The graphs below (from The New York Times) show some of the most arresting data I have yet seen during the Covid era.  The graph on the right displays Covid mortality statistics in US counties over time, broken down by the percentage of population that voted for Trump in 2020.  The bottom curve shows that in counties where less than 30% of the population voted for Trump the Covid mortality rate thru January of 2024 was about 200 per 100,000 people.  In counties where over 70% voted for Trump, the death rate was about 450 per 100,000–two and a half times the rate in the counties with the least morality.  The divergence has grown over time and continues to do so.  The mortality rates increase the higher the percentage of Trump voters. 

“Red” states, which have the highest percentage of Trump voters, have a much lower vaccination rate for Covid, with a strong correlation between mortality and non-vaccinated status.

Test refers to the graph on the right.

Out-of-Date Drugs

On October 22, 2023, I posted a blog about out-of-date drugs.  The bottom line was that almost all drugs (except vaccinations, creams, ointments) retained potency far longer than expiration dates listed on their containers.

A recent study in the Journal of the American Medical Association supports the conclusion. A research trial that compared the use of “out-of-date” beta blockers (standard-of-care drugs in the treatment of patients who have suffered a heart attack) with those who had “current” beta blockers.  There was no difference in mortality between the groups, nor in any of the other common measures used in assessing treatments (e.g., length of hospital stays, time missed from work, incidence of heart failure, etc.) of heart attack victims.  Follow-up for patients in the study averaged three and half years.

New Cancer Stats

There were about two million cases of cancer diagnosed in the US in 2021, an increase compared to previous years.  The increase was almost entirely due to an aging population, in which cancer rates are historically higher than in younger populations.

Nevertheless, cancer mortality rates declined.  The decrease was due to: less smoking of cigarettes; early detection of many cancers; and improved therapy.

Eugenics springs from the belief that the genetic quality of a population can be improved with policies that favor the reproduction of “normal” people over the genetically inferior.  Starting around the 1900 and into the 1930s , the eugenists dominated discussion on the quality of our population, and many of the advocates included the medical profession .

The Argument

Dr. William Mayo, one of the founders of the Mayo Clinic in Minnesota, provided a nice summary of his position on “population improvement.”  This italicized passage is excerpted from the article referenced in the NOTE at the end of this blog post.  Mayo amplified the phobias and fed the moral panic stemming from the eugenic thought of that time, saying that municipal hospitals were swamped by the poor, as cities were besieged by criminals and the country threatened with demise by waves of defective immigrants. While Congress debated increased restrictions on immigration, Mayo traced poverty to “constitutional inferiority and mental instability,” declaring both “to a large extent hereditary.”

He went on: one of the goals of public hospitals… should be to “reduce the number of people whom it must care for at the expense of the taxpayer.” A robust sterilization program and limits on immigration of the “defective” would serve that goal. His search for “the final solution”  (my bold) of the immigration problem” rested on the assertion that poverty and disease were proof that “the alien is a public health problem, just as he is a social problem,” and he saw “alien lawbreakers” as the cause of rising crime. 

Candidates for Eugenic Intervention

The candidates for eugenic intervention included: “retarded” people, dwarfs, cripples, criminals, mental defectives, idiots, morons, the feeble minded, paupers, epileptics, illegitimates, migraine sufferers, Negroes, and immigrants (particularly immigrants from southern Europe such as Italians and Greeks, and Chinese).

Rationale

Proponents of eugenics envisioned a healthier, wealthier population.  By reducing the “bad” gene pool, society would save money by eliminating unproductive people, and the need for government programs to help out the needy would eventually be drastically reduced.  

Proposed Solutions

Strategies to achieve a more pure population ranged from immigration restrictions to institutionalization of the unfit to sterilization of the “defectives.”  Adolph Hitler was particularly enamored of the eugenics initiative in the US, and Germany passed laws designed to support the goals of eugenics, sterilizing 400,000 people, mostly Jews and other “undesirables.”

Medicine’s Complicity

Actually, a more accurate characterization of medicine’s participation in the eugenics movement was one of leadership.  It was thought that doctors were best positioned to identify inadequate people.  One survey showed that 80% of the physician workforce favored eugenics policies. Dr. Mayo proudly identified himself as “ an apostle of the school of eugenics.”  A medical school in London endowed a chair of eugenics.  

The New England Journal of Medicine (then, and now, a highly respected source of medical research and information) was in the lead.  In the 1920s, The New England Journal of Medicine published hundreds of articles and editorials that brought attention to eugenics and provided important support among medical professionals to the burgeoning eugenics movement in the United States. 

The journal focused on three issues relevant to eugenics.  One, the domestic cost traceable to the “scourge of mental defective and feeble minded, who populated groups of criminals and the poor.”  Two, the need to restrict immigration of foreign “defectives” whose presence led to “social deterioration.”  And three, the need for involuntary eugenic sterilization. 

Couched in scientific terms, article after article fanned the fears of general population decline.  At least in medicine, the official eugenics movement petered out by the late 1930s.  The case could be made, however, that the modern application of gene therapy is the new form of eugenics.  A crucial difference is choice.

NOTE

All of the information in this blog post comes from a “perspective” piece published in the March 7, 2024 edition of the New England Journal of Medicine.  This statement precedes the article:  

This article is part of an invited series by independent historians, focused on biases and injustice that the Journal has historically helped to perpetuate. We hope it will enable us to learn from our mistakes and prevent new ones.

The next time you pay for your healthcare insurance premium, you should deduct about 25% of the cost. That way, you will save your private health insurer the trouble of throwing it away.

And that is what American healthcare insurance does.  According to a study in a 2019 edition of the Journal of the American Medical Association (JAMA), at least 25 to 30% of the healthcare dollar in the US is useless, even dangerous.

Where is the waste?

In 2022, American expenditure for healthcare was about 17.3% of the GDP.  Up to $945 billion was wasted.  For example, inefficient spending and/or mistakes in clinical care were rife: clinical failings such as postoperative infections, inadequate use of preventive measures like vaccines and monitoring of cholesterol, and redundant ordering of tests due to inability to get results of the same test from another venue.  And many more.  This category amounted to a waste of about $166 billion.  

Another major category of waste is fraud: up to $84 billion was the cost for services that were never provided or for services the value of which were vastly inflated.

It goes on and on, but the most notable category of waste involves administration, to the tune of $266 billion in 2022.

Waste Due to Administrative Complexity

David Himmelstein, a respected physician and healthcare expert, published an article that explored this issue.  He compared administrative costs in the Canadian healthcare system to those in the US.  

The Canadian system as we know it was started in 1984 and reached maturity at the turn of the century.  The most salient point is the percentage of administrative expenses between the two systems.  

Prior to 1999, administrative costs for healthcare in both countries were similar.  However, after 1999, administrative costs in American healthcare accounted for 31% of healthcare expenditures, while the comparable figure In Canada was 16.7%.  Another way to put it: based on data from 2017 (the last year for which comprehensive data were available), each American paid $2,497 for healthcare administration, while Canadians paid $551 per capita.  The estimated time spent dealing with bills and related matters was worth $68,000 per physician. 

Is It Worth It?

Does all this administrative encumbrance result in a better product?  

Life expectancy in selected  countries, in years

Canada 82

United Kingdom 81.3

Germany 81

United States 78.6

Perhaps an aging population accounts for the difference?  No.

Percentage of people over the age of 65

Canada 17.5

United Kingdom 18.5

Germany 21.5

United States 16.5

Cost of healthcare per capita

Canada $5,418.30

United Kingdom $4,653.06

Germany $6,645.76

United States $11,071.72

In contrast to all other developed countries, the US has tens of millions of people without health insurance.

Nothing New

Data like the above have been available for years.  When I first encountered them, I was aghast.  Now I am simply in a constant state of exasperation.  And things are not getting better.

In 1960, the total national healthcare expenditure was $27.12 billion.  This figure increased steadily and by 2000, it was $1.366 trillion.  In the last year for which figures are available (2022), spending on healthcare rose to $4,464.57 trillion.  

The Future

Except for determinedly obtuse politicians, anyone can see that our healthcare system as constituted is not sustainable.  Some healthcare economists look to the single payer Canadian model, with its universal coverage and beguilingly lower administrative burden.  If there is magic in that system, it is that citizens do not pay anything for healthcare up front.  Of course they pay taxes, but individuals never pay providers explicitly.  All financial transactions are between providers and the government.  This is one reason administrative expenses are so much lower than in the US.  

Too many powerful forces are financial winners in our healthcare system.  They have no incentive to see the system change and they stage formidable lobbying efforts to keep the system intact ($713.6 million in 2020, representing 20% of the total lobbying expenditure).  Eventually, something has to give.

*Obamacare was passed in 2010 and fully implemented in 2014.  Though the national cost of healthcare has steadily increased by about 4% per year since 2010 (on a par with recent historical trends before 2010), the rate of increase has not changed, even though tens of millions of previously uninsured people now have health insurance.

Recently documented cases of measles in New Jersey and Washington State have caught the attention of the healthcare community, especially pediatricians.  The last outbreak occurred in New York City in 2018 among orthodox Jews.  The common denominator in these outbreaks was the lack of vaccination against this highly contagious virus.

Measles on the Run

Due to the absence of any cases of measles in the US in 2000, the US public health officials declared that measles had been eliminated in this country.  Due to low use of the MMR (measles, mumps, and rubella) vaccines in other countries, however, importation of cases of measles still occurs.  This would not be much of a problem if our population adhered to guidelines for the MMR vaccine (one shot between the ages of 12 to15 months of age, and a booster between the ages of 4 and 6 years).  Individuals who are not vaccinated are very effective vectors for the spread of the disease among the unvaccinated population.  Epidemiologists think that a MMR vaccination rate of 95% in children is necessary to prevent outbreaks.  We hover around 91%.

Does It Matter?

Those of us old enough to have lived in the measles era associate it with a flu-like illness that had a characteristic rash.  Recovery was usually not an issue, but it can be a dangerous disease.  Before the vaccine became available in 1963, three to four million people (mainly children) contracted the disease per year.  Of these, 48,000 were hospitalized, and 400 to 500 died each year.  Rare non-fatal complications include blindness, encephalitis, and pneumonia.  Currently, for every 1,000 children who get measles, one or two will die from it.

How Good Is the Vaccine?

The vaccine for measles is safe and is 97% effective in preventing the disease.  Given these data, one might conclude that almost any death from measles, or severe complications, is unacceptable. 

Anti-Vaccination Movement

Opposition to vaccines is as old as vaccines themselves.  Some of this springs from a purely libertarian anti-government sentiment, but the largest part is probably linked to religious beliefs.  For instance, orthodox Jews will not take vaccines if pigs are used in the process of making the vaccines.  Some religious sects oppose vaccines that are derived in part from aborted fetal tissue.

A big bump in anti-vax sentiment was the result of an article published in the respected British medical journal, The Lancet, in 1998.  Using data fraudulently, Dr. Andrew Wakefield linked the measles vaccine to autism.  The gathering of information was flawed and it was discovered later that his research was being funded by parents who were suing vaccine manufacturers.  

A fusillade of research debunked Dr. Wakefield’s findings, and the journal eventually withdrew the article.  But the fuse was lit.  From 1994 to 1997, the MMR vaccination rate in the United Kingdom was 91%; in 2003/04 the rate was 80%.  In the US, vaccination rates fell by two percent.

Celebrities and politicians got on board with the anti-vax movement.  Using the formidable tool of social media and appearances on sympathetic talk shows, such luminaries as Robert DeNiro, Bill Maher, Jim Carrey and Eric Clapton fear- mongered with the best of them.  Most startling was Senator Rand Paul’s contribution to vaccine skepticism.  He said “I have heard of many tragic cases of walking, talking normal children who wound up with profound mental disorders after vaccines.”  Paul is a physician, apparently trained at an institution that does not teach the basics of epidemiology.

Vaccine Hesitancy with Covid

As the grand champion of the spread of harmful and false information on vaccines, Dr. Wakefield continues his mission.  He speaks at anti-vaccination gatherings and has not backed off on his original findings.  He has fueled, and continues to fuel, the anti-vaccination movement… with remarkable results.  This has leaked into the vaccine hesitancy movement against the Covid vaccine.  

What is the import?  In March of 2022, the CDC (Center for Disease Control), assessed the effectiveness of vaccination against Covid.  Unvaccinated people had a mortality rate of 1.71, deaths per 100,000, while those vaccinated had a rate of .22 per 100,000.  If boosted, the rate was .1 per 100,000.  Vaccinated people with Covid enjoyed a 8 fold decrease in mortality compared to those not vaccinated, and a 17 fold advantage if boosted.

Upshot

It is impossible to definitively connect the dots between Dr. Wakefield’s work and Covid mortality.  But one physician in Britain observed Wakefield’s fraud was “the most damaging hoax in 100 years.”  It is possible (probable?) that Dr. Wakefield bears the responsibility for hundreds of thousands, maybe millions, of deaths worldwide.

Alzheimer Disease (AD) is the most common cause of dementia, a condition that impairs intellectual functioning, including, but not limited to, memory impairment, social dysfunction, and compromise of abstract thinking.  It is the most common cause of dementia in the US.  Currently, almost six million Americans are afflicted with dementia, and demographers project this number to be 14 million in 2060.  Dementia is already a true public health problem and threatens to be a disaster if the projections are correct.  This is why recent, though modest, advances in the search for the treatment of Alzheimer’s Disease are so important

Background 

The hallmark of AD is the presence of amyloid plaques in the brain.  Demonstrable by PET scanning, or examination of cerebral spinal fluid obtained by means of a spinal tap, these are clumps of protein that are associated with damage to the brain cells of people with AD.* 

The question is whether they are a cause of the disease or a result.  It is a complex question, especially since many cognitive normal people also have these plaques. 

Monoclonal Antibodies

Nevertheless, research has centered on these plaques, and there are now interventions that attack, and remove, these plaques.  They are anti-amyloid monoclonal antibodies, and they have won FDA (Food and Drug Administration) approval.

Recent Clinical Trials

In August, the Journal of the American Medical Association published the results of a clinical trial of the newest anti-amyloid drug, donanemab.  1736 patients with mild dementia were randomized to a trial of donanemab vs. placebo.  They were observed for 18 months and were tested for cognitive decline (Alzheimer Disease Rating scale).  

At the end of the trial, those who got the drug on average showed significantly slower clinical progression to worsening dementia compared to those who got placebo.  47% of the group who received donanemab had no disease progression, while 29% of placebo recipients did not progress to worsening dementia, as measured by cognitive testing. The drug showed an impressive ability to remove the amyloid plaques from the brain.  In no patients was the progress of disease reversed.

The upshot is that donanemab slowed progression to a worsening cognitive state in patients with mild dementia by a quarter to a half a year.  The worse the dementia, the less effective was the drug.

Side Effects and Cost

The intervention group had a greater number of side effects, notably brain swelling and micro-hemorrhages.  These were usually clinically unimportant and resolved with cessation of the drug.  There were three deaths in the treatment group and one in the placebo group.

Treatment required monthly intravenous infusions.  The launch price for the drug is $28,000, and at least a similar amount is necessary to cover the cost of required monthly MRIs, follow-up visits, and more.  Medicare is reimbursing the expense, provided patients are enrolled in a registry that collects data that monitor safety and efficacy.  Copays will amount to about $15,000 a year.

Genuine Progress

Unlike some highly advertised and ineffective therapies for memory problems (see my blog of May 28, 2022: “Prevagen!… Prevagen?”), the anti-amyloid antibodies represent authentic advances in the treatment of AD.  However, much work remains to determine whether this line of research will become a mainstay in the treatment of AD.  A critical question is whether the healthcare system can afford it.  I don’t know the answer, but I do know what those afflicted with AD and their families will say.

Science Marches On

Like all good science, the current research engenders more questions than answers.  Perhaps the most compelling area of inquiry concerns the possibility of prevention of AD. For instance, what if you give the anti-amyloid antibody to people at risk for the disease before they develop symptoms or plaques?  Would this actually prevent, or at least ameliorate, AD?  No one knows but trials to test this notion are underway.

*Other causes of dementia include cerebrovascular disorders (which is the result of multiple strokes, often subclinical), Lewy body dementia, frontotemporal dementia, and Parkinsons.  None of these is associated with the amyloid plaques, although AD may overlap with any of these disorders.

Last summer, the Journal of the American Medical Association published research on the association of sugar-sweetened beverages (SSBs) and liver disease, including liver cancer. Over 100,000 women, who were participants in a long term study on women’s health (“Women’s Health Initiative”), participated in the study.  

On average, women who drank more than one sugar* sweetened drink per day were compared to those who drank less than three per month.  The follow-up was over a median of 20 years.  Those who drank daily had almost twice the incidence of liver disease and liver cancer compared to the more abstemious group.  The number of those with disease was small, but the difference was real.  

This study is hardly the first to document the health problems associated with sugar intake of any kind.  Numerous studies have linked sugar ingestion to diabetes, obesity (including childhood obesity), heart disease, tooth decay and many other medical problems.  For instance, children risk becoming obese by a 60% increment per year for every additional serving of a SSB per day.

Nor is the study the first to demonstrate an association between sugar and cancer: sugar has been implicated in both prostate and breast cancer.

Sugar Fights Back

The sugar industry has not taken this research lying down.  It has produced its own studies, for instance, that contradict the association between childhood obesity and sugar ingestion.  The scientific community has repeatedly shown such efforts to be methodologically inadequate.

Taking a page from the tobacco industry’s advertising campaign to maintain sales of cigarettes, the sugar interests have targeted children in ads to keep the sweet train chugging.

The granddaddy of attempts to obfuscate the adverse health impact of sugar go back at least 50 years ago.  The New York Times recently uncovered internal industry communications that documented strategies to divert the public’s attention on the deleterious health effects of sugar.  The idea was to play up the danger of dietary saturated fat so as to dilute concern about sugar.  Given our nation’s preoccupation with dietary fat, I cannot help but think this initiative has had at least some success.

Pressure tactics to preserve sugar’s prominent standing in the American diet are part of the tool kit too.  When legislators in New York were considering bills that would decrease sales of soda,  Pepsico threatened to move its corporate headquarters out of New York City.  

In 2017, the Cook County Board of Commissioners in Illinois actually passed a measure to tax SSBs by a vote of 15 to 1.  A coalition of anti-tax groups, led by the American Beverage Association, mobilized, spending over three million dollars on radio and TV ads in opposition to the measure.  It also promised campaign funds to commissioners who reversed their votes.  Four months later, the tax was revoked.

Public Health Interventions: Mixed Results

The average American ingests 175 calories worth of sugar per day, and public health officials have viewed excessive sugar intake as a health crisis.  Even in the face of an assault by sugar interests, many measures to curb the sugar epidemic have been undertaken.  These efforts have centered on taxation strategies, the most common of which is the imposition of a one cent per ounce tax on SSBs.  This would result in an increase of a 15 to 20% in the cost of a bottle of soda.

These initiatives have met with limited success.  People who live in municipalities that have taxed SSBs simply travel to stock up on soda in neighboring towns.  To prevent “cross-border” shopping, it is obvious that regulation needs to encompass larger jurisdictions like states, or even the whole nation.

A more daunting impediment to reducing sugar consumption is the “sugar-gap.”  This term refers to peoples’ apparent need to consume a certain amount of sugar, no matter the source.  In cities that have actually imposed a tax on SSBs, sales of other sugared items (cookies, sweet rolls, cakes, etc.) have skyrocketed.  Despite the tax on SSBs, sugar use seems to become a zero sum game.

Going Forward

There is no question that Americans’ apparent need for sugar is dangerous, and difficult to dislodge.  Legislative attempts to deal with the problem have had limited success.  A new strategy is necessary —maybe something akin to public health initiatives like the successful media campaign against tobacco use.  The American Beverage Association can save its money, for now.

*Sugar is defined as: table sugar, brown sugar, high fructose corn syrup and fruit juice concentrate. 

Many Americans commonly find themselves using “what” in conversation, or its popular variations, “pardon me,” or “excuse me.”  The cause of course is hearing loss, which afflicts about 30 million people over the age of 50.

Does it Matter?

The most common causes of hearing loss are age and exposure to loud noises over time.  It is more than a social inconvenience.  Even mild hearing loss triples the chances of falling.  People with moderate hearing impairment are 60 to 70 percent more likely to have been injured in an auto accident.  With severe loss, this figure jumps to 90 percent.  

And most devastatingly, inability to hear well leads to social isolation and eventually puts the victim at higher risk for neurological complications.  Dementia prevalence is 61 percent higher among people with moderate to severe hearing loss compared to those with normal hearing.  

Prevention

As with all medical conditions, prevention of disease is the best approach.  22 million American workers are exposed to potentially damaging noise at work each year.  Accordingly, The Occupational and Health Safety Administration requires employers to implement a hearing conservation program when noise exposure is at or above 85 decibels (the average school cafeteria weighs in at this level) averaged over 8 hours.

And personal responsibility is huge.  The hearing damage that listening to LOUD music causes is not an urban myth.  

Treatment 

And then there are hearing aids.  Remarkable advances in recent years in hearing aid technology have helped millions.  In one study, hearing aid use was linked to a 32 percent decrease in dementia prevalence.  But there is nothing like the original equipment, no matter how good or expensive the hearing aids are.  And cost is a significant factor.

Cost and Health Insurance

One could make the case that hearing deficiencies are a significant public health problem.  But the insurance industry doesn’t think so.  Most insurance plans either do not cover the expense of hearing aids, or have stultifying co-pays.  Medicaid covers the expense, though, and a few types of Medicare plans cover hearing aids.

Recently, regulatory agencies have now allowed the over-the-counter sale of hearing aids for people with mild to moderate hearing impairment, with savings that are usually less than a third of the cost of hearing aids obtained through the conventional healthcare channel.  The expense if born by the patient, with no help from the insurance plan. Preliminary research indicates that self fitted hearing aids are as effective as hearing aids fitted by an audiologist.

This holds great promise for the hearing impaired.  I remain puzzled, however, that hearing deficiencies have received such spotty coverage in our healthcare system.  If you need a new knee, insurance covers the expense.  If the arteries to your heart are clogged, you can get cardIac stents, no problem.  But in the pantheon of diseases that insurance usually covers, hearing loss is a second class citizen.