Why Healthcare Spending is Slowing – A New Normal?

The growth in healthcare spending has slowed in recent years.  Many experts and pundits have sought to explain why – while also worrying, (or predicting), that this slowing is only temporary, i.e. past performance will predict the future.

Healthcare Delivery and Financing are Dynamically Evolving

The future will be significantly different than the past because our healthcare system, society, and economy are evolving into what might be called a “New Normal” state.  Assuming current priorities and pressures continue, public and private sector organizations at all levels will increasingly emphasize value¹ in their decisions about spending and preferences for healthcare services – including choices about substituting one treatment option for another.  For public entities, these choices involve coverage and budgeting for programs ranging from Medicare, Medicaid, and Veterans’ healthcare, to benefits for government employees – as well as rules for insurance exchanges. For private organizations, these choices range from health insurance benefits provided by large employers to the decisions individuals make for their insurance coverage – as well as the clinical and lifestyle choices individuals make inside and outside doctors’ offices.

While those choices will collectively mold our future healthcare system, many changes have occurred in the last five years that are creating a new environment for making these choices and pushing us into a “New Normal” state, i.e., these evolutionary forces have already started bending the cost/spending curve.  This progress towards more value oriented healthcare will continue unless the driving forces are hampered, hindered, or blocked by future actions.

The Times They Are a-Changin”
                             Robert Zimmerman

Listed below – in my estimated rough order of importance – are reasons why healthcare spending has slowed and will continue to be less than had been projected.

  1. Dipping Economy: The economic slowdown has decreased the amount of healthcare people are seeking – as well as creating a temporary disruptive environment for making other changes in stakeholders’ attitude and latitudes of practice. Whether the decrease in healthcare utilization is because people have mostly declined or delayed unnecessary or truly discretionary healthcare services and treatments, or are foregoing many important preventive actions and therapies – which will lead to higher costs and morbidity in the future – remains to be determined.
  2. Private Insurance Benefit Design Changes: People with private insurance have shifted to higher deductible plans², (a.k.a. consumer directed plans), which have lower monthly premiums and higher deductibles, and sometimes increased co-payments/co-insurance.  This change has been in both employer sponsored plans – where individuals may not have a choice – as well as for people (and families) buying insurance as individuals or through small business plans.  Like #1 above, economic incentives have led people to be more selective in what healthcare services and products they are using, but the wisdom of these choices and their long-term effects on costs and quality of care (and life) are not yet fully understood.
  3. Medicare Outpatient Prescription Drug Benefit: The Medicare outpatient prescription drug benefit, (a.k.a. Part D), started in 2006.  If the general premise that prescription medicines are the most clinically and cost-effective form of healthcare is correct, then the greater use of prescription medicines by Medicare enrollees should be reducing spending growth in other Parts of Medicare, e.g. hospitalizations and doctor visits.
  4. Mindset Changes for Patients and Clinicians: The economic downturn, various provisions of the Accountable Care Act, and changes in healthcare benefit design – particularly more high deductible health insurance plans – are making patients and clinicians more attuned to the economic implications of healthcare choices and the value of integrated, multidisciplinary, (a.k.a. team-based), care delivery. Resistance to shifting to such integrated care from the old one-patient/one-doctor Marcus Welby, MD-esque mindset will impede progress in some areas – particularly the adoption of EMRs and regional health information systems, which require up-front spending, and where the long-term benefits are derived from providers participating in such team-based care paradigms.
  5. Change to Healthcare Delivery System:
    1. Integrated care delivery systems and the purchase or affiliation of physicians’ practices;
    2. Geographically uneven changes;
    3. Accountable Care Organizations (ACOs);
    4. Patient Centered Medical Homes (PCMH);
    5. Concierge medical practices;
    6. Greater use of tele-medicine for remote monitoring, management, and consultations;
    7. Greater use of non-physician clinicians, community based healthcare coordinators, and home care services – including more old-fashioned house calls.
  6. Change to Financial Incentives: (Besides high-deductible insurance plans)
    1. Pay for Reporting (P4R) – usually tied to quality metrics, but also used for EMR capabilities;
    2. Pay for Performance (P4P) – similar to P4R, but for actually performance, not just reporting;
    3. Global or bundled payments, e.g. ACOs shared savings and risk sharing arrangements with Medicare and private payers;
    4. Non-payment for “never events”.
  7. Trans-Fat Labeling: FDA regulations have required food labels to list trans-fats since 2006, which has had a two-fold effect which should be driving down long-term health spending: Making people more aware of trans-fats as an unhealthy choice, and inducing food companies to both remove trans-fats from their products and advertise that fact. The results have been significant. Earlier this year the CDC reported that blood levels of trans-fats have declined from 2000 to 2009: “The 58 percent decline shows substantial progress that should help lower the risk of cardiovascular disease in adults”. I suspect that CBO or others didn’t project savings to Medicare or Medicaid from the food labeling requirement.  However, shifts to healthier lifestyles will need more environmental changes like these, e.g. bike sharing programs; walking paths; programs connecting individuals with shared goals; healthier food options at cafeterias, restaurants, and grocery stores, etc.
  8. Price Transparency and Accountability for Outcomes: More transparency about prices and quality of care delivered by individual clinicians and providers is placing greater pressure on healthcare prices. In addition, since healthcare prices in the US are higher than in other countries, globalization will increasingly create downward pricing pressure – especially for products and services where people, (or their specimens), can easily travel to other countries, such as for elective surgery, or DNA testing. [Note – accountability for quality, accuracy, and fraud prevention will be necessary to ensure that foreign services with lower prices represent higher value rather than just greater waste and harm to patients.]
  9. Innovations – Better Therapies, Diagnostics, and Prevention:
    Healthcare innovations range from biopharmaceuticals, genetic tests, HIT/tele-medicine, to validated best practices including checklists and clinical decision support.  Some innovations increase costs. Some improve clinical outcomes. Some do one but not the other. Some do both.  As metrics demonstrating the value of innovations become more granular and can be determined more rapidly, clinicians and providers will be under greater pressure to demonstrate – and be accountable for – the outcomes they are delivering. However, this will only occur in a balanced way as long at patient-centric quality outcomes are measured alongside economic outcomes.  The danger is that clinical outcomes will only be determined on a population basis, but then applied to patient care decisions without considering individual patient characteristics or priorities.
  10. Smoking Restrictions.  Restrictions on smoking in public places is reducing exposure to second-hand smoke.  Some studies have shown rapid declines in heart attacks for people working in restaurants and bars after smoking in those workplaces was prohibited.  (FYI – LEED certified residential buildings treat second-hand cigarette smoke as a pollutant and often prohibit smoking inside the entire building – including people’s apartments, as well as outside doors and windows. And the DC Department of Health has been publicizing the toxic nature of second-hand cigarette smoke from adjacent apartments.)
  11. Tougher Enforcement Against Fraud and Abuse. Cracking down on fraud and abuse may be reducing healthcare spending by deterring such criminal activity.  These efforts have been aided by improvements to healthcare IT – and this will only improve in the future.
  12. There certainly should be a 12th reason – since all good lists have 12 items – but I can’t think of one right now…. Any suggestions?

Not a Simple Picture

The dynamic interactions among many of the factors listed above makes it very difficult to determine the contribution each one makes to reducing healthcare spending for a particular condition, population, or US healthcare spending overall. For example, improvements to healthcare IT are enabling improvements to delivery system operations and financial incentives – which are also linked to each other.  Each of these also affect the mindsets of  patients and clinicians, i.e., HIT systems are elevating patients’ and clinicians’ expectations for better information about treatment options and less waste. And financial incentives are evolving to support the use of such information to achieve better outcomes. Together these and other changes are altering patients and clinicians attitudes and actions towards the entire healthcare system to be accountable for delivering greater value. This hyper-cross-connected situation is analogous to the biomedical research field of systems biology, which is seeking to understand how multiple physiological systems cause specific diseases – and how combination therapies may be needed to treat such complex illnesses.

 

1. Value in healthcare can be a tricky concept, but it generally encompasses the clinical and economic outcomes produced by the intervention compared to the total costs, risks, and potential adverse effects of the treatment option.
2. Haviland A., et. al., “Growth Of Consumer-Directed Health Plans To One-Half Of All Employer-Sponsored Insurance Could Save $57 Billion Annually,” Health Affairs, May 2012 31:5,1009-1015

Digesting Medical Progress

One of the challenges for improving the healthcare system is creating a vision for what is achievable in a timeframe of months or years.  The first step for creating such a realistic vision is to understand how progress has been made in the past.

A microcosm of such progress was described in a recent article in The Economist.  This article describes advances in our understanding of stomach ailments – one of my favorite areas of biomedical progress because in the last several decades dramatic changes have occurred in our basic knowledge about this area, and so many people can relate to stomach problems.

The most significant change occurred in 1982 when two Australian scientists disproved the dogma that because of its very acidic pH the stomach was sterile.  They showed that the H. pylori bacteria could live in the stomach and cause the stomach inflammation associated with an upset stomach.  Subsequent research showed that H. pylori could be the cause of ulcers and stomach cancer. Following those discoveries, medicines were developed to change the pH of the stomach to treat the stomach inflammation and eliminate the H. pylori.

H. Pylori

While lowering the acidity of the stomach with medicines would often improve symptoms, it also raised the question about what bacteria might be able to live in the stomach under less acidic conditions?  This question is more intriguing because it has been observed that when people taking medicines to lower their stomach’s acidity stopped taking these medicines, they have a resurgence in their symptoms.  This could be because their stomach had become accustomed to the less acidic conditions and then reacts to the renewed acidity; Or it could be because the bacteria that were living in the less acidic stomach are not happy with the greater acidity; Or perhaps the H. pylori that had been struggling in the less acidic stomach multiply very happily with the return of the acidic conditions.

H. pylori – Obesity and Asthma
The Economist article discusses some even more interesting ideas about the role of H. pylori in the stomach.  For example, they cite researchers who speculate that the elimination of H. pylori from the stomach may be linked to rising rates of obesity and cancer in the esophagus. These researchers at NYU School of Medicine also found that children who had not been infected with H. pylori were more likely to have asthma.  The article summarizes these observations with the speculation from NYU’s Dr. Blaser that perhaps H. pylori should be viewed not as a pathogen, but rather as a symbiotic organism “that is sometimes helpful and sometimes harmful.”

One of Dr. Blaser’s key observation is that H. pylori appears to not just be a passive resident of the stomach, but may actually regulate the stomach’s acid levels to keep the stomach’s pH in a range the bacteria prefer.  However, the substance that H. pylori secretes to get the stomach to produce less acid may be toxic to the stomach and result in ulcers and local cancers.  Thus, while eliminating the H. pylori would eliminate the toxic source of ulcers and cancers, it can also allow the stomach to produce too much acid – which can lead to cancer of the esophagus, as well as “acid reflux disease,” a.k.a. “heartburn.”

The H. pylori-obesity link is based upon the possibility that the bacteria modify the secretion of certain hormones effecting how people feel hungry, and the H. pylori-asthma link is based upon the effects the bacteria may have on children’s developing immune system.  (See The Economist article for more information about these areas.)

Conclusions
These findings lead to the conclusions that perhaps treating stomach ailments and preparing peoples’ stomachs for healthy lives should be based upon their genetic makeup, and seeding children with strains of H. pylori that don’t produce the toxins that can lead to ulcers and stomach cancer, could benefit them without doing harm in the long run.

Overall, this is a great example of how once more knowledge is obtained about a disease and the relevant human physiology, scalpel-like treatment and prevention strategies can be developed and implemented.  Of course, educating clinicians, patients, payers and others about these advancements – and why they are important – are also important challenges, because improving health care treatments and our healthcare system involves not just determining what should be done, but also how to actually accomplish those things.

Colon Cancer Insights – Vitamin D and Cannabis – “Good and Good for You”

A couple of recent reports provide new insights into preventing and treating colon cancer.  These studies remind me of the scene in Woody Allen’s movie Sleeper, where he wakes up in the future to find out that all the things he thought were bad for you are really healthy.

The first study was in the Journal of Clinical Oncology which found that people who had higher levels of circulating Vitamin D and later developed colon cancer had a better survival rate than people with lower Vitamin D levels. An accompanying editorial points out that this could be because people who exercise more are outside for longer periods of time – which gives them more sun exposure leading to higher Vitamin D levels – and that more exercise itself might provide a better survival rate.  The editorial also notes that Vitamin D does not appear to promote the growth of cancers at higher concentrations like some other compounds which have been investigate for preventing cancer, such as folic acid.

The second article, (in the journal Cancer Research), describes how inactivating the cannabinoid receptors in human colon cancer cells (which had been implanted into mice) caused the cancer to grow faster.  And conversely, reactivating and stimulating these receptors slowed the growth of the cancer cells and led to their death.

These basic research studies are only starting points for changing how patients are actually treated, or advising people how to lower their colon cancer risks.  But like all good research, they can narrow the focus for future investigations.  In the case of Vitamin D, there is an ongoing study to see if providing Vitamin D supplements to people who have had precancerous colon polyps can prevent the development of more polyps and cancer.  And the cannabinoid receptor study may break new ground into treatments for colon cancer, just as more understanding of the hormone receptors in breast and prostate cancer led to new treatments for those malignancies.

Clearly, these are good scientific advancements, but I don’t think they will soon lead to doctors recommending a big glass of milk and “magic” brownies for all their patients – although more milk may becoming part of standard nutritional advice – particularly low-fat milk. [See previous posts about Vitamin D here and here.]

As the saying goes, “Good and Good for You.”

Updates on Vitamin D

Since I wrote about the importance of Vitaim D a few weeks ago, some new information has come out.

A report was released this week from researchers in Australia about Vitamin D reducing the risk of all causes of death.  The study was in the Archives of Internal Medicine, about their evaluation of 3,258 men and women scheduled to have a angiogram of their heart arteries.  They found that the people who had below average Vitamin D levels had about twice the risks of dying than those with levels in the highest 25% of the group.

While looking for the report of the Austrlian study, I found another study from a group of reserachers in Boston, that looked at 18,225 men who had no diagnosed heart disease.  This study found that during 10 years of follow-up, the men who were deficient in Vitamin D (?15 ng/mL) were about twice as likely to have a heart attack as those considered to have sufficient levels of Vitamin D (?30 ng/mL).

It may be coincidence that both studies found a 2:1 effect from high/normal v. low levels of Vitamin D, but there seems to be growing interest and consensus that Vitamin D is important for overall health.  What do you think?

Increasing Diabetes Rate and Awareness in US

The Centers for Disease Control and Prevention released some interesting data yesterday.  They reported that in 2007 an estimated 23.6 million people (7.8% of the total US population) have diabetes.  Of these people, only 17.9 million know they have diabetes, while 5.7 million have not been diagnosed.  The good news is that the percentage of people with diabetes who don’t know it has decreased from 30 to 25% The bad news is that the number of Americans with diabetes is increasing.

Number  of People in the US (in Millions) with Diagnosed Diabetes: 1980- 2005

Growing Rate of Diabetes in US(from http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm)

How Bad Is a Little Sugar?
As the CDC’s Fact Sheet states, “Overall, the risk for death among people with diabetes is about twice that of people without diabetes of similar age.” Diabetes causes high blood pressure, heart disease and stroke, and is the leading cause of blindness and kidney failure in adults.  Diabetes – because it affects the small blood vessels – also predisposed people to infections, and can lead to amputations from lack of adequate blood flow.  It also increases the risk of pregnancy complications, and leads to nervous system impairments.

How Many People Have Diabetes Where I live?
The CDC doesn’t have county level data for 2007 yet, but the map below shows the percentage of people with diabetes in counties across the country.  [Note – People in Colorado do have diabetes, but in Colorado the country with the highest incidence of diabetes falls just below the threshold for the second color in the map.]

Diabetes Rate By County Across the US

(from http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx)

What to Do About Diabetes?*
There are lots of good resources of information for patients about diabetes (see below), but without getting into too many specifics, people should talk to their doctors about three different types of things:

  1. Testing: Get tested – both for diabetes as well as pre-diabetes, a condition which indicates impaired metabolism of sugar and a higher risk of developing diabetes.
  2. Treatment: Get treated if you have diabetes.  Get treated for the diabetes itself and for other conditions that increase the risk of developing the complications of diabetes, such as high blood pressure and high cholesterol.  And be sure to take your medicines as instructed by your physician, and test your blood sugar as they recommend.  If you don’t understand how to take your medicines or have any questions about them, just ask your doctor or pharmacist.  Quality healthcare professionals would rather answer your questions and prevent problems from developing, than have to help you resolve any problems you develop from taking medicines incorrectly.
  3. Personal Choices – Eat Right and Exercise: Whether you have diabetes or are at risk for developing diabetes diet is crucial, and exercise and weight loss can help improve diabetes and lowers the risk of developing diabetes and its complications.

Resources About Diabetes
American Association of Diabetes Educators – www.diabeteseducator.org
American Diabetes Association – www.diabetes.org
Centers for Disease Control and Prevention – www.cdc.gov/diabetes
National Diabetes Information Clearinghous – http://diabetes.niddk.nih.gov/ and http://diabetes.niddk.nih.gov/dm/pubs/stroke/#connection

*DISCLAIMER – THIS INFORMATION IS NOT SPECIFIC MEDICAL GUIDANCE, IT IS NOT INTENDED TO DIRECT TREATMENT OR PREVENTION FOR INDIVIDUALS,  AND SHOULD NOT BE SUBSTITUTED FOR ADVICE FROM PHYSICIANS AND OTHER HEALTHCARE PROFESSIONALS INCLUDING NUTRITIONISTS, AND DIABETES EDUCATORS.

Vitamin D – It’s Not Just About Bones

Today’s Boston Globe has an article about a study from Children’s Hospital in Boston that explores the high rate of insufficient vitamin D in otherwise healthy infants and toddlers. (12% deficient in vitamin D and 40% with suboptimal levels.) The study also noted that one-third of these children with low levels of vitamin D had pathological bone changes seen on x-rays.

What Does Vitamin D Do?
What the research study did not examine – but the Globe story does mention – is that in recent years there has been extensive investigation and speculation about the role of vitamin D plays in many other areas of health besides strong bones and teeth. For example, the NIH’s Vitamin D Fact Sheet notes that vitamin D may play a role in lowering the risks of certain cancers:

Laboratory and animal evidence as well as epidemiologic data suggest that vitamin D status could affect cancer risk. Strong biological and mechanistic bases indicate that vitamin D plays a role in the prevention of colon, prostate, and breast cancers. Emerging epidemiologic data suggest that vitamin D has a protective effect against colon cancer, but the data are not as strong for a protective effect against prostate and breast cancer, and are variable for cancers at other sites. Studies do not consistently show a protective effect or no effect, however. One study of Finnish smokers, for example, found that subjects in the highest quintile of baseline vitamin D status have a three-fold higher risk of developing pancreatic cancer.

The NIH’s Fact Sheet goes on to note that vitamin D may play a role in preventing diabetes, high blood pressure and multiple sclerosis. A July 2007 review article by Dr. Holick in the New England Journal of Medicine expands upon this information:

The discovery that most tissues and cells in the body have a vitamin D receptor and that several possess the enzymatic machinery to convert the primary circulating form of vitamin D, 25-hydroxyvitamin D, to the active form, 1,25-dihydroxyvitamin D, has provided new insights into the function of this vitamin. Of great interest is the role it can play in decreasing the risk of many chronic illnesses, including common cancers, autoimmune diseases, infectious diseases, and cardiovascular disease.

The fact that vitamin D plays more than one function in the body should not be surprising, since many physiologically compounds serve multiple functions – from neurotransmitters that act in both the GI and CNS systems, to proteins whose breakdown products also have cellular activity. What this points out is that people (and all animals) are not simple biological systems. While I’ll leave a discussion of the exploding field of systems biology for another time, I do want to point out that once we “know” something in medicine it usually means “what we know right now.” As a professor in medical school said “Half of what we’re going to teach you is wrong, we just don’t know which half.” (I think every medical student gets this in some lecture – it must be in the “Medical School Professor’s Crib Notes.”)

So How Much Vitamin D?
This evolving scientific certainty brings us to the question of how much vitamin D people should be getting – and by what route. There is still no academic agreement as to how much vitamin D people should have – although individual needs do depend upon age, gender, skin color, and medical condition (including pregnancy). But there is a growing consensus that most people need more Vitamin D than they are getting.

The three basic routes for getting more vitamin D are supplements, diet, and sun exposure: The latter is somewhat problematic as the rising incidence of skin cancers places greater emphasis on using sunscreen. Supplements are great – particularly for time limited use in select populations like infants who are breast fed. (That was a risk factor in the Children’s Hospital study.) This leaves us with food.

While milk has long been supplemented with vitamin D, milk consumption in adults is very variable – so more foods are being supplemented. Because vitamin D is much more effective when consumed with calcium, vitamin D is increasingly being added to fortified juices, cereals, and now yogurts. In fact, last year, after seeing several articles about the expanding importance of vitamin D (including the NEJM review article) I called Stonyfield Farms to ask why their yogurt didn’t have vitamin D added to it – as did some of their competitors. The person I talked to was very nice, but didn’t have a very convincing answer. However, I recently noticed that Stonyfield yogurts now have added vitamin D. After making this discovery, I found their October 2007 “Moos From The Farm” newsletter that discussed their plans for adding vitamin D to their products over the winter:

Vitamin D in Our Fat Free
When we converted our fat free yogurts to organic on the 1st of this month, we also added vitamin D, which offers a bunch of important health benefits. Vitamin D…

  • increases calcium and phosphorous absorption, which decreases the risk of osteoporosis;
  • has immune-boosting properties;
  • may help to reduce 17 different types of cancer;
  • may decrease the incidence of multiple sclerosis;
  • helps to maintain optimal muscle strength;
  • benefits diabetics and those with hypertension.

We’ll be adding vitamin D to more of our yogurts this winter, so stay tuned!

I would be tempted to say that Stonyfield added the vitamin D as a marketing pitch, but I haven’t seen any ads or labeling changes that now tout, “Now Healthier – With Added Vitamin D!!!,” so I think they did it because it was a good thing to do, they saw the trend towards a greater emphasis on consuming more vitamin D and wanted to be ahead of the movement – and maybe, possibly, perhaps because I called last summer and asked the question.

So while the optimal level of vitamin D consumption is uncertain, taking too much through food seems hard to do. The NIH’s Fact Sheet notes that there doesn’t seem to be any risk of toxicity from too much vitamin D until you get above 2,000 International Units (IUs) per day, and Holick’s NEJM review states that toxicity doesn’t start until you reach 10,000 IU/day. And as the NIH Fact Sheet notes, “High intakes of dietary vitamin D are very unlikely to result in toxicity unless large amounts of cod liver oil* are consumed; toxicity is more likely to occur from high intakes of supplements.” [*Cod liver oil has 1360 IU per tablespoon.]

Talk With Your Doctor and Summertime Eating
So when you’re deciding about what you’re going to eat – or you’re talking with your doctor and other healthcare professionals about diet and its impact on disease risks – think a bit more about vitamin D and how much you’re getting. This is particularly true for people with some medical problems, risks, or who are taking certain medications that can interfere with vitamin D’s actions or calcium absorption. But also remember, while increased sun exposure increases your vitamin D, ice cream – although great in the summertime – unfortunately it’s not a great source of vitamin D, and it has lots of fat and calories. So think of it as a treat and not a vitamin D supplement….. Or maybe just think of it as a “supplemental treat.”

Michael’s Dairy T-Shirt at the beach

A friend wearing a t-shirt from our favorite dairy on a very cloudy day at the beach.

Toxic Dietary Supplements

I’m usually either supportive or neutral about alternative therapies because they generally aren’t harmful, and can be beneficial. However, there seem to be more and more recalls of these products by the Food and Drug Administration (FDA) for mislabelings that are significant, although seemingly not extremely dangerous.

On the other hand, I was struck by a press release I got yesterday from the FDA about a recall for the dietary supplement products “Total Body Formula” and “Total Body Mega Formula.” The recall was because these products had more than 200 times the amount of selenium than was printed on the products’ label – and the press release noted that, “Excessive intake of selenium is known to cause symptoms to include significant hair loss, muscle cramps, diarrhea, joint pain, fatigue, loss of finger nails and blistering skin.”

I guess this is another instance of how too much of something that is normally good, can be, well, not so good. And with 43 adverse reactions reported to the FDA, the recall seems like a very good thing.

UPDATE: The FDA updated their warning and information on this issue this afternoon – click here to see the FDA website notice.

Ben Franklin’s Virtues and the Pennsylvania Primary

While reading a Ben Franklin biography (“The First American,” by H. W. Brands), I was struck by a list of 13 virtues he wrote while in his mid-20s to guide his life:

1. Temperance. Eat not to dullness. Drink not to elevation.
2. Silence. Speak not but what may benefit others or yourself. Avoid trifling conversation.
3. Order. Let all your things have their places. Let each part of your business have its time.
4. Resolution. Resolve to perform what you ought. Perform without fail what you resolve.
5. Frugality. Make no expense but to do good to others or yourself: i.e., Waste nothing.
6. Industry. Lose no time. Be always employ’d in something useful. Cut off all unnecessary actions.
7. Sincerity. Use no hurtful deceit. Think innocently and justly; and, if you speak, speak accordingly.
8. Justice. Wrong none, by doing injuries or omitting the benefits that are your duty.
9. Moderation. Avoid extremes. Forbear resenting injuries so much as you think they deserve.
10. Cleanliness. Tolerate no uncleanness in body, clothes or habitation.
11. Tranquillity. Be not disturbed at trifles, or at accidents common or unavoidable.
12. Chastity. Rarely use venery but for health or offspring; never to dullness, weakness, or the injury of your own or another’s peace or reputation.
13. Humility. Imitate Jesus and Socrates.

The thesis of the book is that Franklin was the first person to fully embody what it meant to be an American – as opposed to a Colonist. So, reading this list, and constantly hearing perspectives about the upcoming Democratic Presidential Primary in Pennsylvania, led me to wonder – since Franklin spent most of his adult life in Philadelphia – “who would Ben Franklin support?” My tally came out at 6-4 with 3 ties.

What do you think?

Trans Fat Shocker

A couple of days a week I work out of shared office space in Cambridge, MA that is part of a multi-floor incubator/start-up facility. One of the benefits in the office is the food stocked in the kitchens – including lots of healthy things, like fresh fruits, nuts, dried fruit, bagels, etc….. Now not all the food is purely healthy…. They have sodas and M&Ms, etc. But today I did a double-take, when I saw that the Drakes Apple FruitPies had 8 grams of Trans Fats per serving.

For those of you not familiar with Trans Fats, they are chemically created by taking naturally occurring oils and heating them in the presence of a metal catalyst (like nickel or platinum) to add extra hydrogens to the oil. This process creates “partially hydrogenated oils” which are solid at room temperature and easier to bake with etc. Chemically modifying the oils also causes the naturally occurring double bonds within the oil’s carbon backbone to rearrange so that the hydrogens on the same side of the carbon chain (see A bel0w), get flipped around so that the hydrogens are on opposite sides (See B below)

Cis Fat Molecular Structure Trans Fat Molecular Structure

A: Cis – Fat  . . . . . .B: Trans-Fat

So why does this matter. Numerous studies have shown that Trans Fats increase blood levels of triglycerides and lower good cholesterol (HDL) — both of which increase risks for cardiovascular disease and death. The biochemical reasons for this are not clear, but it seems to me that Trans Fats are acting like a metabolic poison.

The process that keeps so-called foods that contain Trans Fats from spoiling, is the same that messes up human physiology: In Trans Fat “foods,” microorganisms that normally cause food to spoil can’t digest the trans fats, so the food doesn’t spoil. In the human body, our natural molecular processes for breaking down fats can’t easily “eat” Trans Fats either – so it literally gums up the works. An analogy might be if you put your shoes on the wrong feet and tried to run. You could move, but it would be awkward, inefficient, and sooner or later something connected to your feet would start complaining and eventually break. It’s not that the shoes doen’t look like shoes, but they don’t fit the feet so things don’t work right. Trans fats look like oils (just like the oil in your car looks like oil), but trans fats are not the shape of oils your body’s cells are expecting, so problems arise when they have to deal with them.

Now if you don’t like this situation, (and crave those snack cakes), don’t blame your body’s cells – they didn’t ask for the Trans Fats – you’re the one who decided to eat them – your cells are doing their best to figure out what to do with them. But unfortunately they aren’t equipped to easy break them down – they’d rather have real food, not Trans Fats.

Health Groups Lobbying & Executives’ $$$s

The February 16th issue of National Journal has its biennial salary report (2006 data) for national advocacy and trade associations. Since most of my posts have been too long I’ll keep this one short with two (OK – actually three) interesting points:

First, in addition to salary information, National Journal reports on lobbying spending of various organizations. It’s not surprising that 3 of the top 10 trade associations [501(c)(6) organizations] in lobbying dollars are from the health industry: PhRMA, AMA, Am. Hosp. Assoc. But what is interesting, is that all of the top 5 non-profits [501(c)(3) organizations] in lobbying spending are health related organizations: Am. Cancer Soc., Am. Heart Assoc., Am. Red Cross, Am. College of Physicians, Am. Diabetes, Assoc. [FYI – it’s also interesting to note that the non-profit which spent the most on lobbying spent less than the #7 trade association: $13.9 million by the Am. Cancer Soc. v. $15.0 million by the AHA.]

Second – and what I think is more interesting – is that in the listing of salaries for the heads of 125 health trade association, the bottom five (all with salaries less than $90,000 – not including other benefits) in alphabetical order were:

  • AIDS Action Foundation
  • American Association for Homecare
  • American Society for Clinical Nutrition
  • Association of State and Territorial Health Officers (a.k.a ASTHO)
  • Council for Affordable Health Insurance

I think this is quite an interesting snapshot – statement about healthcare priorities in the US.

And to put a broader perspective on health as part of our national priorities, the three labor unions with the highest paid heads were:

  1. National Football League Players Association ($1.86M compensation w/o benefits)
  2. Major League Baseball Players Association ($1.0M)
  3. Screen Actors Guild ($774,000)

What do you think of these interesting numbers and comparisons?