Tips from gaining health

Travelers’ diarrhea is often used as a generic term  for any illnesses ranging from an upset tummy to  loose stools during or after travel. It could mean just excess gas, or a variety of symptoms that can occur from a change in the types of food or beverages we are used to – or, most commonly, to contamination of food or beverages. And its not just food and beverages. Touching your mouth or nose with contaminated hands may be all it takes.
How can I prevent travelers diarrhea?

People often discuss the importance of care in selecting "safe" foods and beverages for consumption. We recommend that foods be freshly cooked and be piping hot; such foods are safer than those on a buffet that have been sitting out for hours. Water should be bottled and sealed, or boiled. Alcohol is OK, but ice cubes are not.

Can medications prevent travelers diarrhea?

Yes. Pepto-Bismol has been used for a number of years to prevent travelers diarrhea. Studies show that if adults take the equivalent of two tabs four times a day, it can decrease the incidence of travelers’ diarrhea up to 60%.

Now, many people who take that amount of Pepto-Bismol end up with severe constipation. I take two tabs twice a day when I go into a risky situation. I do believe that it is very helpful, but most recommend if you’re going to do this, that it should just be for short-term -- up to three weeks.

While this helps many people, those allergic to aspirin cannot take it. And if youre taking prescription medications, you should check with your doctor to see if you can take this.

Some swear by probiotics like lactobacillus for preventing travelers diarrhea. But studies of this strategy in limited numbers of subjects are inconclusive.

And some people are given prophylactic antibiotics, which are very effective in preventing travelers diarrhea, but the problem there is we dont feel very good about prescribing antibiotics for a number of reasons for someone if they don’t need them. There are issues such as side effects, or of diarrhea caused by the antibiotics themselves, and increased antibiotic resistance in the normal organisms we harbor in our bodies. Rarely, if it is just for a very important weekend, or occasionally for government officials or someone in an athletic competition, we may prescribe preventive antibiotics.

How can a change in diet trigger travelers diarrhea?

Its due to eating different kinds of foods, such as much more spicy food or more fat than in our normal diets. That is not something we typically pay as much attention to avoiding when we travel, but we have to be wary of these things. Not every change in our bowel habits is due to infection. Infection is the most important cause of travelers diarrhea and most is caused by bacteria.
Who is most likely to get travelers diarrhea?

Some people are more susceptible than others, its not clear why that is. You can be with a group and all consume the same thing, and some get sick while others do not.

There are a host factors involved. Stomach acid is our first defense mechanism against organisms that we ingest. Theore, those on antacids, or who just have low stomach acid, often get travelers diarrhea more easily. People who have underlying diseases of the gut, such as Crohn’s disease or AIDS, may be more susceptible to certain types of organisms causing travelers’ diarrhea.
What kinds of infection cause travelers diarrhea?

For the most part, were talking about bacterial infections. Almost 90% of travelers diarrhea cases are caused by bacteria. The enterotoxigenic E. coli [ETEC, strains of common bacteria that produce a toxin affecting the gut] are most important cause. And then there  are others such as salmonella, shigella, campylobacter, vibrio, and others that are less common.

Travelers diarrhea may also be caused by viruses, such as norovirus, which is in the news a lot because of how quickly it can spread through a cruise ship.

Parasitic travelers diarrhea is yet another kind. Giardia intestinalis is the most common of these, but there is a large number of parasites that can cause diarrhea. These are less frequent.
Aside from the obvious, how do you know youre coming down with travelers diarrhea?

Sometimes it starts with fever and chills. You may get cramps, and then, of course very urgent loose stools in various amounts. Sometimes there is vomiting or bloody diarrhea. With norovirus, onset can be sudden, and vomiting is a much more prominent feature.

For bacterial and viral travelers diarrhea, the incubation period is typically six to 48 hours after infection.

For protozoan travelers diarrhea, there is usually more of a gradual onset with a few loose stools  per day and increased gas and nausea. The incubation period can be one to two weeks.
What is the main treatment for travelers diarrhea?

Hydration is the primary treatment. Often people with a bout of travelers diarrhea feel so weak. A good deal of  it is due to dehydration. Its not OK just to take a few sips of cola. You need to make the effort to drink a lot of fluid, because often youve lost a lot more than you think. In a lot of cases, just clean water is OK. Better, if you are very dehydrated, is a rehydration solution. Rehydration packets are a great thing to have, especially if you are going to remote areas or places off the usual tourist paths.

What antibiotic should I take for travelers diarrhea?

It depends. For adults, ciprofloxacin is used most commonly. Sometimes, for those traveling to certain places in Southeast Asia, where bacterial pathogens have increased resistance, some doctors like to prescribe azithromycin. In some cases where you feel that the traveler may likely be exposed to just the coliform pathogens such as E. coli, some prescribe rifaximin.

Of course, antibiotics work only for bacterial causes of travelers diarrhea. Know that even bacterial travelers diarrhea usually gets better without antibiotic treatment, although rehydration is always advised and symptoms may take 3 to 5 days or more to subside without treatment.

For those with diarrhea due to parasitic infections, there are agents that are specific for each type of infection. However, for Giardia infections, tinidazole [Tindamax] is often prescribed and is very effective.

All of this advice applies to adults. What about children?

Kids can become dehydrated far quicker than adults. Rehydration solutions are more important for children right from the outset.

Doctors are now becoming more open to prescribing antibiotics that children can take in case they get travelers diarrhea. Azithromycin can be useful in children. Parents should check with their pediatricians before leaving home.

Nursing mothers should continue to breastfeed. The time to wean a child is not in the middle of travel. Continue even if the mother has diarrhea -- but she must ensure that she is getting plenty of hydration.

Weak Muscles Lead to Back Pain

Dunn was erred to the sports medicine program at Life-Bridge Health and Fitness Center, part of a regional health network in Maryland overseen by medical director Michael Kelly, MHSc, a certified neuromuscular therapist. Kelly soon found that, although Dunn was very fit for a man his age, hed neglected some areas of his body. "The muscle groups I was using were in good shape, but then Id isolate other muscle groups, and I could barely lift the weight. I was like an infant," Dunn says.
About 25% of Americans are affected by back pain in a given year, and they spend more time at the doctors office for back pain than for any other medical condition except high blood pressure and diabetes.
Instead of jumping for pills or surgery, says Kelly, people with chronic back pain should first seek out a thorough functional assessment from a qualified trainer with experience in sports medicine.

Exercising for Back Pain

"A lot of back pain is due to postural alignment problems," Kelly says. "If you catch it soon enough and correct the problem with exercise and strengthening, you can avoid future pain."
Today, Dunn has learned a number of ways to use exercise to relieve and prevent back pain. For example, he works hard on strengthening the muscles involved in the bodys core stabilization such as the glutes, a key element in a golfers swing.
"When your torso and hips are moving rapidly from back to front, your back can keep your torso rotating and put incredible strain on your spine," he says. "When you engage your glutes at the end of the swing, its like a brake on the spine."
Back pain can be relieved by many different types of exercises. For instance, a knees-to-chest exercise can be a big help if your pain is due to spinal stenosis, a narrowing of areas in the spine that can put pressure on the nerves. Thats because lying on your back and pulling the knees to the chest for about 60 seconds opens up the disc space in the back, which  relieves pressure on the nerves, says Kelly.
Today, Dunn says, "I still have a tight back from time to time, but the pain has almost completely gone away." Even better: "I havent had to give up golfing!"

One in three Americans over the age of 60 have some degree of hearing loss. That figure jumps to 1 in 2 for those over 80.

For those with diabetes, the prevalence may be even higher.

An article that appeared in the Fall 2003 issue of Hearing Health explored the relationship between diabetes and hearing loss:

"Since vascular and nerve tissues play predominant roles in auditory function, any disease that has the capacity to damage their cells has potential to negatively affect the various hearing organs. A link between hearing and diabetes seems likely indeed if the rich blood supply to the cochlea and/or the nerve centers in the hearing pathways, including the brain, are affected."

The National Institute on Deafness and Other Communication Disorders (NIDCD) has an easy-to-read and comprehensive tutorial on hearing loss, including its causes, symptoms, treatment, and prevention. It recommends that if you answer "Yes" to three or more of the following questions, you have your hearing checked by a doctor.

• Do I have a problem hearing on the telephone?
  
• Do I have trouble hearing when there is noise in the background?
  
• Is it hard for me to follow a conversation when two or more people talk at once?
  
• Do I have to strain to understand a conversation?
  
• Do many people I talk to seem to mumble or not speak clearly?
  
• Do I misunderstand what others are saying and respond inappropriately?
  
• Do I often ask people to repeat themselves?
  
• Do I have trouble understanding the speech of women and children?
  
• Do people complain that I turn the TV volume up too high?
  
• Do I hear a ringing, roaring, or hissing sound a lot?
  
• Do some sounds seem too loud?

Finally, if youre having difficulty hearing, it may not be just a problem with your ears. Comprehension of what we hear takes place in the brain. As we age, the brain may lose some of its ability to filter out background noise.

Audiologists from the University of California, San Francisco, believe we can train our brain to recover listening skills - with or without a hearing aid. Theyve helped design an interactive software program with listening exercises that can be used on a personal computer. Free demonstration software is available at neurotone.com.*

________
For Hearing Health article:
Diabetes and Hearing Loss: Exploring Connections

For NIDCDs tutorial:
NIH Senior Health: Hearing Loss

For NeuroTones Listening Software
Listening & Communication Enhancement (LACE) Training System

* Not an endorsement. For information only.

A valuable nugget & more on the way

Welcome to the Disease Management Care Blogs hosting of the Feb. 28 Health Wonk Review.

This HWR is a summarized compendium of submitted posts by the smartest health policy bloggers in the known universe.  The DMCB assures you that youre in for a special treat because youll find some insightful nuggets that generally go unseen in the mainstream media and academic literature.

When its not mining the HWR for information, the DMCB combines acumen, skepticism, modesty, peer-reviewed science and occasional humor about health policy, care coordination, population health management as well as primary care, the medical home, health insurance and the electronic record.

Its so glad you stopped by.

The DMCB has organized the posts by topic: Obamacares key orms, various health economists latest divinations on health care costs, hospitals, Medicaid, the internet, California, medical education and some British humor.  The quotes that head each section should give you a hint about what youre in for.

“This is a big f—-ing deal.” – Vice President Joe Biden

Whats to Know About the Go-Go Growth of ACOs?

Lots, thanks to this Health Affairs Blog post by Leavitt Partners David Muhlestein. He counts 428 accountable care organizations (ACOs). While all eyes are on the Medicare versions, it turns out the private sector has been on a less visible parallel track with "full or partial capitation models, bundled payments, retainer agreements, in-kind services and subsidies provided by payers, and pay-for-performance incentives." Did you know that most ACOs are in the West Coast and Northeast, or that theres an even split between physician and hospital-led sponsors? Mr. Muhlestein also points out that 2013 will be the year that well get to see some early ACO data. David and the DMCB will be watching very caully and, if we report Medicares outcomes are less than expected, the DMCB is looking forward to getting a "youll regret it" email from somewhere in the Administration.

Whats to Love About the Individual Insurance Market?

Could be lots, says Nicole Fisher of Wright on Health. She wonders if there is a silver lining in the growing evidence that some employers will drop their sponsored health insurance benefit and force their workforce into the individual market. That may force the individual market to have better transparency, less discriminatory underwriting, more choice and increased competition. As result, costs could be lower than expected, consumers will better understand the true costs of health care and portability could paradoxically improve. If things go really well, we could see a self-reinforcing cycle of market demand. And, wonders the DMCB, long lines outside doctors offices.

Maybe, But Whats NOT to Love About the Individual Insurance Market?

Louise of the Colorado Health Insurance Insider blog worries that persons who arent poor but who are also not wealthy are in for some bad news if they believe that the ormed individual market will translate into affordable health insurance.  Unlike todays market, individuals will be less able to trade lower premiums for HSAs, high deductibles and (for persons over 30 years of age) catastrophic coverage. While minimum coverage requirements are a good idea, Louise says theyre also expensive. She suggests it would be good public policy to flexibly accommodate a demand for higher deductibles and lower premiums.

An economic forecaster is like a cross-eyed javelin thrower: they dont win many accuracy contests, but they keep the crowds attention - Anonymous

Persistent Partisan Perfidy on the ACAs Costs

Maggie Mahar, over at healthinsurance.org, indicts the latest libel against Obamacare.  Her ire is directed at those repugnant conservative pundits who should have known better than to glom onto an ill-considered U.S. Internal Revenue Service document about 2016s health insurance costs. Beware, says Maggie, no one really knows what costs will be in 2016. The DMCB is shocked, shocked that economists and actuaries inaccurate predictions are being intentionally misinterpreted for political gain.

Numbers With A Lot of Zeros

Speaking of economists, The Hospitalist Leader has compiled a linked list of peer-reviewed erences that estimates the health care costs for the big name medical conditions. He senses that theres something amiss, because adding them up is much like finding Italys olive oil exports far exceeds that countrys domestic production. He thinks science writers, patient advocates, policymakers and yes, us bloggers, should promote better numeracy and, for starters, contrast any absolute dollar figures with helpful comparisons. Thats why the DMCB is pleased to post this short instructional video on some math basics courtesy of the health insurance professionals who staff the IRS:



100% Coverage of Screening Services Is Not Good Enough?

Guess what?  When health care consumers are thinking about the cost of undergoing screening for a disease, theyre also thinking about the next steps if disease is found.  Quoting a study in the Journal of Health Economics, Jason Shafrin of Healthcare Economist points out that zero dollar coverage for services - while noble - will have less of an impact than anticipated unless its linked to meaningful coverage of treatment of the underlying condition.  In other words, health screening subsidies are not enough to maximize consumer buy-in.  No wonder the DMCB spouse is unfooled by offers to screen some sales prices for a jumbotron-sized flat screen for the living room!

"Phlegm free zone" - Sign seen at a local hospital

The Riddle of Readmissions

In this posted podcast (here), David Williams asks the Robert Wood Johnson Foundations Anne Weiss about the recent depressing report on hospital readmissions.  Based on 2010 Medicare numbers, it doesnt look like the national rate has gone down all that much and that the considerable variation between different areas of the country remains.  David and his guest also chat about some promising best practices that being used in some settings to reduce readmissions, what patients and their families can do about lowering the likelihood of a readmission and whether the practice style of hospitalists is part of the problem or a potential solution.  Despite evidence that population management can reduce readmissions, Ms. Weiss rejects for-profit vendor participation, believing that hospitals should be happy to hire more personnel in lieu of partnering.  Let the "build or buy" games continue, says the DMCB.

"Governor Browns budget plan also counts on $488.4 million in savings from a 10% cut to Medi-Cal reimbursements. Medi-Cal is Californias Medicaid program." 1/30/13 News Report.

Heres A Free Baby Elephant!

Joe Paduda cant blame many of the nations governors for bowing to the common sense and fiscal reality of expanding Medicaid in their states, even though it can be viewed as distasteful.  The 100% federal financing is free money and their politically connected hospitals per Medicaid to uncompensated care.  Many states are likely to cut their Medicaid fee schedules, so providers have one more incentive to go along with testing new reimbursement strategies and delivery models.  All in all, he muses, "this is a very good thing."  Next step, muses the DMCB, is to convince the docs.

The Internet is the most important single development in the history of human communication since the invention of call waiting. - Dave Barry

Time To Take On Medical Tourism By Getting "Lean"

Jonena Relth of Healthcare Talent Transformation points out that the times they are a changin. The steady increase in medical tourism is challenging the notion that U.S. domiciled health care is the best, especially when international health systems are adopting U.S. methods and employing U.S. trained physicians who are using state-of-the-art electronic health records that are modeled on U.S systems. The salvation, according to Ms. Relth, is the "Lean" approach that, according to a LinkedIn discussion group, helps providers 1) put patients first, 2) cut waste and 3) eliminate tasks that dont add value.  The DMCBs experience leads it to believe that many of its physician colleagues can accomplish much of that third goal by staying away from LinkedIn.  Maybe its time to change its mind.

"There is science, logic, reason; there is thought verified by experience. And then there is California." - Edward Abbey

Californias Health Insurance Exchange Chassis Unveiled. Next Up: The Hard Part

Health orm advocate Anthony Wright of Californias Health Access Blog really extols the virtues of Covered California, the Golden States health insurance exchange web site. Anthony can be forgiven for his use of terms like "conveniently," "breakthrough," "easier" and "bold" because the sites very existence is an important step forward in having a real functioning web presence where consumers can actually buy health insurance. Whether this leads to marketplace transparency, consumer ease-of-use and increased insurance coverage for Californians remains to be seen. The DMCB took the web sites calculator for a test drive and discovered it and the spouses unsubsidized monthly premium would be $1723 per month, which is about $700 more than it currently pays in Pennsylvania. Nuff said.

A Ballooning Benefit Bonanza, Courtesy of Sacramento

Speaking of California, John Goodman of his eponymously named blog examines the states tax policy, blaming it for a plethora of generous employee benefits. Since higher wages are taxable, loopy loopholes are prompting companies to compensate their employees with home cleaning, personal trainers and the daily delivery of fresh fish. Mr. Goodman faults the unraveling of the 1980s tax orm movement and suggests now is the time for a "progressive flat tax."  Now is also the time for the DMCB Inc. Board of Directors to consider installing a tax deductible gas-powered backyard fire-pit for its two employees. 

Income from Injuries

And Calfornia doesnt stop there. Jon Coopelman of the Workers Comp Insider Blog writes that professional athletes from across the U.S. have discovered that Californias generous workers comp law allows out-of-state players to file claims long after any in-state injury that could have contributed to a disability. Thanks to clever attorneys and vague inclusion criteria, its not hard for any ex-jock who played in the state to convince a California judge that a sports team should cover all future related medical expenses. Jon says its time for the California legislature to stop the abuse and for sports teams to address this in their labor contracts. Until then, the DMCB  invites readers to pay $6 to play to enter an upcoming wiffle ball tourney in Golden Gate Park; participants will receive $1 in California taxable income, $5 worth of beer and a certificate of a compensible injury. Date TBA.

How Much Is That Hospital CEO Worth?

Roy Poses of Health Care Renewal looks at examples of small town hospital CEOs being compensated with lavish pay. Dr. Poses is particularly exasperated because the hospitals are not only public, but theyve had to make tough trade-offs between being profitable and having enough nurses and docs to care for their underserved populations. Roy has little difficulty finding numerous news reports - and most are from California -  that amply demonstrate that there is little correlation between hospital administrators $800K salaries and their institutions financial performance. Roy blasts the gimmicky talking points that have been used justify these outlandish compensation packages, the cluelessness of hospital boards and the publics need to wake up and smell this coffee. The DMCB looks forward to what Roy discovers in 2013 when he compares ACOs financial success with their executives compensation packages.

 "Beware of the young doctor and the old barber." - Benjamin Franklin

Strange Bedfellows

Did you know that 15 new allopathic and 10 osteopathic medical schools have opened since 2002 and that most operate campuses located in Republican Congressional districts?  Wing of Zocks James Lewis reviews the political implications of this, pointing out that these Republicans will gain a new appreciation for the value of our national health care infrastructure. Whats more, theyll probably be reluctant to go along with their House colleagues enthusiasm to reduce the U.S. budget with sacrifices in graduate medical education funding. What delicious irony!

"Bollocks!" An oft-heard exclamation "with a long and distingished history." - Wikipedia

Merry Old En-gland?

Ouch!  The InsureBlogs Mike Feehan looks at a London Daily Mail report on the lowball rate of £20,000 that is used by the Brits National Health Service when it needs to compensate men for a nutty type of wrong side surgery.  The DMCB points out that one historical explanation for higher U.S. jury awards is the need to compensate for future medical services.  Thats less necessary, thanks to the NHS universal coverage.  The comments that follow testily debate whether the incidence of this complication is higher in the Sceptered Isles compared to the U.S.   The DMCB will never be able to think about NHS "budget cuts" in quite the same way.

Thats it for this HWR.  Mark your calendar for the next iteration, due to appear on David Williams smartly written Health Business Blog on March 13!

Experts tout the health benefits of low-dose aspirin and omega-3 fatty acids found in foods like flax seeds and salmon, but the detailed mechanisms involved in their effects are not fully known. Now researchers reporting in the February 21 issue of the Cell Press journal Chemistry & Biology show that aspirin helps trigger the production of molecules called resolvins that are naturally made by the body from omega-3 fatty acids. These resolvins shut off, or "resolve," the inflammation that underlies destructive conditions such as inflammatory lung disease, heart disease, and arthritis.

"In this report, we found that one resolvin, termed resolvin D3 from the omega-3 fatty acid DHA, persists longer at sites of inflammation than either resolvin D1 or resolvin D2 in the natural resolution of inflammation in mice," explains senior author Dr. Charles Serhan of Brigham and Womens Hospital and Harvard Medical School. "This finding suggests that this late resolution phase resolvin D3 might display unique properties in fighting uncontrolled inflammation."

The researchers also confirmed that aspirin treatment triggered the production of a longer acting form of resolvin D3 through a different pathway. "Aspirin is able to modify an inflammatory enzyme to stop forming molecules that propagate inflammation and instead produce molecules from omega-3 fatty acids, like resolvin D3, that help inflammation to end," explains coauthor Dr. Nicos Petasis of the University of Southern California.

These are a few of my favorite thinnnngs.  Sorry, nostalgia.

Women are not men. That should be obvious to everyone. Women have a different balance of sex hormones than men do, they have a higher body fat requirement, they can grow a baby in their bellies for 9 months, and they really like romantic comedies. Despite their inexplicable love for Matthew McConaughey movies, however, the scientific research world likes to pretend these differences dont exist. Over my years of studying cholesterol and cardiovascular disease research, Ive noticed a bias here. But its time to wise up... the research on cholesterol and heart disease shows a stark difference between the sexes. If youre a woman, and theres a 50% chance that you are, then youve been fed a load of shit. Heres why.

Cholesterol Levels in Women
In men, there has historically been an association between cholesterol levels and risk of heart disease.  Take the MRFIT trial for example, one of the landmark studies in this area... (1)


If youre a middle-aged man, risk of heart disease and dying overall increases with your cholesterol level.  Theres SO much more to it than just this, of course... theres HDL, LDL, triglycerides, and most importantly LDL particle number. All of these are more important markers than total cholesterol in my opinion, and each case should be evaluated on an individual basis.  Just because your cholesterol is a little high doesnt mean youre going to die.  But for the purposes of this article, you cant deny the relationship above.  It exists. 

It exists in men, that is. Women? Not so much. Take the Norwegian HUNT 2 Study, for example (2). The researchers followed 52,087 Norwegians aged 20-74 who were free of cardiovascular disease (CVD) for 10 years, then assessed the relationship of total cholesterol with total mortality, CVD mortality, and heart disease mortality. Most importantly to the purposes of this article, they studied both men and women, and they analyzed each of their data separately.  As youve probably already assumed, they each yielded very different results.

Note: Since this study comes from Europe, the units for blood cholesterol are shown in mmol/L, rather than the mg/dL that we are used to. The researchers classified the participants into four groups, based on their blood cholesterol. Here are the converted unit values in mg/dL for the four groups... <193, 193-229, 230-269, and >270.

This is the all-cause mortality data, the most important information from the study.  Just take a moment and compare these graphs to the MRFIT graph above.  Do it.  For men, we see a similar U-shaped trend, although this study shows a lesser risk with high cholesterol than with low.  But just look at the women... those with the highest total cholesterol, over 270, were least likely to die! And thats statistically significant. Of course there are other studies that show this gender difference as well (3).

The relationship between cholesterol and risk of imminent death clearly differs between men and women.

Women and Cholesterol-Lowering Drugs
Ive written of cholesterol-lowering drugs (aka statins) a couple times, once about the potential side effects and once concerning their efficacy (4, 5).  The truth is, statins dont save any lives in women, and the potential side effects make these drugs a definite no-go.  I know its hard to believe; these drugs are given out to women like candy, just like they are to men.  On top of that, your doctor likely isnt aware theres any difference between sexes.  Thats why I provide evidence.  Prepare to be mindblown.

The most positive, statin-supporting study ever done is known as ASCOT-LLA (6).  It was a secondary prevention study, meaning that the study participants had pre-existing heart disease. In other words, taking statins in this case was more treatment than prevention.  The results were fantastic.  So fantastic, in fact, that the researchers ended the study early for ethical reasons; the drug supposedly saved so many lives that they thought it unethical to continue.  The drug did reduce heart-disease-related deaths dramatically... it even reduced all-cause death.  But there was one group in which the results werent so peachy... women.

Effect of atorvastatin vs. placebo on risk of death from heart disease

Yup, sticks out like a sore thumb... the women who took the placebo fared better than those who took the drug!  And this is for heart disease only... the data for all-cause death would inevitably be skewed more to the placebo side.  Unfortunately theres no handy dandy chart for that.

Surely this an aberration Burn!! My doctor would have told me about this! Nope, sorry. Its real. Two major meta-analyses have confirmed this finding (7, 8). In women without pre-existing heart disease, the drugs have no benefit whatsoever and likely increase all-cause death.  And in women who do? Well statins tend to reduce their risk of dying of a heart attack, but dont change their risk of dying overall.  In other words, they increase the risk that youll die of something else. I dont know about you, but I care more about overall survival than arbitrarily lowering my risk of just ONE mode of death.

Its clear that if youre a woman, regardless of whether or not you have heart disease, youre gaining nothing by taking statins. Except maybe an early grave. Or some wacko neuromuscular side effects. Dont do it.  And if your doctor insists on it? Send him/her here. Argument over.

Synthesis
Now, synthesize all of this information in your mind and what do you get??  Cholesterol levels in women just arent an issue.  I dont think its something we need to concern ourselves with. Again, each case should be evaluated on its own, but Ive talked to far too many women with "high cholesterol" who are unnecessarily worried for their health.  They come back from the doctor with a cholesterol level of 230, thinking they have to change their entire life around to fix it. FIX WHAT?? PLEASE TELL ME. And if he/she wants to get you started on statins? Time to find a new doctor, Toots, because this one obviously doesnt have a frickin clue.

Ill just leave you with this thought... Remember that time you heard you shouldnt eat saturated fat because it raises your cholesterol? Seems kind of irrelevant now, doesnt it? Dont fucking worry about it. Just dont.

Burn, out.

In the two years following college, I lived semi-large with three ladyfriends in a medium-sized Brooklyn apartment. We had starter jobs, very little money, and an unnatural obsession with singing Jock Jams in Ross Perot voices. (Try it! Its fun.) We were also not very interested in cooking, except for K.

Born in upstate New York, K was the only one who actually used our pots and pans. She bought things like “produce,” and “dairy products.” A few times, she whipped up this Saltine-butter-chocolate dessert that I can’t even think of without salivating all over my desk. (Seriously, Saltines? Who knew they didn’t have to taste like drywall?) One of her favorite concoctions, which I had never heard of at the time, and now order/make at every opportunity, was the lassi.

Essentially a thick Indian yogurt drink, lassis are intended to calm taste buds during a spicy meal. But, much like its fruity cousin the mango lassi, the sweet lassi is also delicious on its own.

While there were a bazillion options online, the recipe attached below is adapted from the Whole Foods website. It seemed simple enough, and turned out well. Only changes: I used low-fat yogurt and cut out the rosewater, since, uh, I don’t know what it is or where to find it. (I will rectify this situation for next time.)

Nowadays, K is married to a wonderfully awesome dude, who I am sure is benefiting from her years of experience and experiments. I wish I had appreciated it more when we were roomies. (Besides the Saltine thing. I appreciated that constantly.)

P.S. Just to clarify - this is NOT a milkshake. It is a yogurt drink. If you do not like yogurt, you will vomit profusely.

Sweet Lassi
Serves 2 (12 oz each) or 3 (8 oz each)
Adapted from Whole Foods.

2 cups plain lowfat yogurt
1/2 cup cold water
1/4 cup sugar
1/2 teaspoon ground cardamom
6 ice cubes

1) Blend yogurt, water, sugar, and cardamom together until smooth. Add ice cubes and blend again, until mixture is smooth. Serve cold.

Approximate Calories, Fat, and Price per Serving
2 servings: 248 calories, 3.8 g fat, $0.65
3 servings: 165 calories, 2.5 g fat, $0.43

Calculations
2 cups plain lowfat yogurt: 309 calories, 7.6 g fat, $1.15
1/2 cup cold water: negligible fat and calories, $0.00
1/4 cup sugar: 186 calories, 0 g fat, $0.06
1/2 teaspoon ground cardamom: negligible fat and calories, $0.08
6 ice cubes: negligible fat and calories, $0.00
TOTAL: 495 calories, 7.6 g fat, $1.29
PER SERVING (TOTAL/2): 248 calories, 3.8 g fat, $0.65
PER SERVING (TOTAL/3): 165 calories, 2.5 g fat, $0.43

How you can Whiten Teeth Naturally ~ Who does nt need glowing white teeth and, needless to say, all people want pearly white teeth shining. Gigi can be one area of the body that will support a lovely smile and sweet. Picture if our teeth yellow, surely we might not feel confident to berintraksi with friends.

Tooth is one part that is often overlooked by others when were berintraksi / communicate. Insurance firms clean teeth, beamed and white, this all can easily supply a greater sense confidence to talk with friends. This certainly varies inversely if our teeth yellow, we would feel embarrassed to cangguh and chat.

Theore, if my good friend wants the prosperity of various things. Ensure the oral health care always my pal, and pal dental hygiene. Tips on how to Whiten Teeth in truth it takes patience along with a routine that is not as easy when we imagine. But isnt going to hurt to utilise these days at all.

Actually, what the hell will we make teeth turn yellow? Well usually people who smoke often have brown or yellow teeth, together with coffee smoke may also cause yellow teeth. Theore whenever possible eliminate smoking buddy, but sometimes make yellow teeth smoking is a source of various diseases.

Well after last factors determine explanation for yellow teeth, plus a little elaboration. Now Ill attempt to review exactly what are the main things we could do today to whiten your teeth naturally:

The best way to Make teeth whiter Naturally

* Using Strawberries
 Certainly from my buddy all felt strange is not it? Why Strawberries fruit can make teeth whiter, but this has proved to be a genuine strawberries can make teeth whiter. Pemutihannya far too simple, just bite Strawberries then rub gets our teeth, then brush your teeth by employing toothpaste. But theres a crucial note about strawberries, namely: do not consume an excessive amount of fruit since it has acids that may damage enamel.
* Using the Orange rind Lemon
Lemon fruit has already been familiar towards the lover of skin care, as this fruit good to create your skin layer firmer and healthier. In addition, it is additionally useful fruit great for our teeth. Concerning how its application the following: grab the lemon rind and separate from the meat, then rub the skin-rubbing which weve needed to prepare our gear, peggosokannya approximately 5-7 menitan. As well as the last step is usually to brush my teeth using toothpaste buddy.
* Using Sayuaran And Fruits
Vegatables and fruits is equipped with very many benefits, besides Helpful for body health, fruit and veggies seems we are able to use to make teeth whiter naturally. The vegatables and fruits that may whiten teeth naturally is as follows: pears, carrots, Apples, Strawberri, Lemon, and many others. Fruits and veggies are also best for keep the tooth enamel, hence the email is not easily broken.
* Saleratus
As for how a using bicarbonate of soda to clean teeth naturally can be as follows: prepare Baking soda, sodium bicarbonate after which it spread on the tooth surface kearea really evenly, next the friend will feel more teeth neat and white. Important note: using saleratus dont try many times as it can break the teeth mate, use baking soda 1-twice a month.
* Make teeth whiter With Cheese
Cheese meals is produced from the fermentation strategy of milk, cheese usually consumed seetlah one big meal. Benefits cheese alone can grant more strength towards teeth, because cheese contains calcium, as well as providing strength on Teeth, Calcium is thought to be make the White Teeth And Strong We naturally.
* With Siwak
Siwak or miswak is considered to provide 70 proven benefits we naturally whiten teeth.

What a little review regarding how to make teeth whiter naturally might be applied buddy buddy to generate more confident and certainly helps make the teeth white buddy. May be useful.

The grocery store is a dangerous place.  Its a constant battle between you and the the big food companies, constantly throwing their health claims at you, hoping to reel you in like a Largemouth Bass.  The truth is, theres very little truth to what they say.  Here are 5 of the most common misleading claims...


1.  "0 Grams Trans Fat"
A few years back, the FDA decided to crack down on the amount of trans fat in the food supply, since its just about the worst thing you can ever put in your body.  Trans fat, for those of you who dont know, is created by the chemical process of hydrogenation, which turns liquid oils into solid fats (think vegetable oil into Crisco).  It was (and still is, to some extent) common in a lot of processed foods, especially baked goods.

Recently, the FDA added trans fat to the nutrition label, so that consumers could easily see if a product contained trans fat.  Unfortunately, they also created the term "0 grams trans fat", in which "Zero" doesnt mean zero at all, and instead means "less than 0.5 grams per serving".  So if you were a food manufacturer, what would you do??  Obviously reduce the serving size until the amount of trans fat per serving drops below 0.5 grams.  Nice little trick!  In many cases though, the regulation has forced manufacturers to replace hydrogenated oils with other fats or other ingredients.  Probably a good thing.

But still, zero doesnt mean zero.  If you see "0 grams trans fat" on the label, theres a good chance that product actually does contain trans fat (ironic isnt it?)  Check the ingredient list.  If you see "hydrogenated oil" anywhere in that list, youre eating trans fat.  Put it back on the shelf.


2.  "Nitrate/nitrite-free" or "Uncured"
If youve ever been to Whole Foods, these claims are on every single package of bacon they sell, as well as hot dogs, sausages, and deli meats.  Sodium nitrate or sodium nitrite are commonly used in the curing process; thats how you make bacon.  In "nitrate-free" bacon though, no sodium nitrate is used.  But what is it replaced with?  Celery powder... which contains sodium nitrate.  As far as the "uncured" claim, I dont even know how they get away with that.  It IS cured.  Its always cured, unless literally nothing was added to it... in which case its not bacon, its just pork belly.

As you might guess, nitrates and nitrites are a health concern for a lot of people; you may have heard theyve been linked to cancer.  But newer research shows that they might not be a problem at all, and in fact they could even be good for you, benefiting immunity and heart health (1). 

And I bet you didnt know that we get about 93% of our dietary nitrites from VEGETABLES!  In fact, one serving of arugula has more nitrite than 467 hot dogs (2).  And an even crazier statistic... 70-90% of our nitrite exposure comes from our own saliva!!

So what about that "nitrite-free" claim?  It is meaningless, nonsensical, inaccurate, and irrelevant, all at the same time. 


3.  "All Natural"
This may be the most widely used food claim out there.  On my recent trip to the grocery store, I saw this claim on nearly every product I looked at.  Frito-Lay has an entire line of snack foods labeled "Natural", with confusing items like Blue Corn Chips.  Has anybody ever seen a blue stalk of corn?  Goldfish have been labeled as "natural" for years.  Youll see it on baked goods, meat, eggs, snacks, bread, peanut butter, soft drinks... the list just goes on.

But what does it mean?  Well, it turns out the FDA doesnt have a strict definition for the term "all natural".  In the FDAs words, it "has not objected to the use of the term if the food does not contain added color, artificial flavors, or synthetic substances."  What about genetically modified foods?  Vegan cheese?  High-fructose corn syrup?  Refined vegetable oils?  Well I guess the FDA wouldnt object to any of these, but Ive yet to see any of them out in nature.  Isnt that what natural ers to?


4.  "Vegetarian-Fed"
I see this one most often on eggs.  "Vegetarian-fed chickens".  Sounds good right?  Except for the fact that chickens arent herbivores.  Theyre omnivorous animals; they eat both plant and animal foods.  If chickens are raised in the outdoors, like theyre meant to be raised, theyll run around and play in the dirt and eat all kind of bugs and worms.  Bugs provided them with protein, omega-3 fats, and important nutrients like zinc and vitamin B12.

So what does it mean to be a "vegetarian-fed chicken"?  Most likely, they were raised in a cage, or at least in a barn, with no access to the outdoors, fed a diet based on corn and soy, and given synthetic vitamins to cover up the inevitable nutrient deficiencies from eating a grain-based, vegetarian diet.  Doesnt sound so glamorous now huh?

What you really want, and its not easy to find, is "pastured" eggs, meaning the chickens are allowed to run around in the yard, play in the dirt, eat bugs, and cluck wildly at passer-byes .  "Pastured" isnt strictly enforced either, but youll probably only see it at a farmers market or at the farm itself, so just ask the farmer how the chickens are fed.  In the grocery store, youre shit out of luck when it comes to quality eggs.  The best you can do is likely organic, or a local brand like The Farmers Cow if there is one.


5.  "Natural Flavors"
The first thing to recognize with so-called "natural flavors": its listed on the food label because it has been added to the food.  In other words, it wasnt there naturally.  Immediately you can see this claim is nonsense.

But it goes deeper.  Natural flavors are made in a food science lab, just like artificial flavors are; the only difference is that the former is derived from a natural source, while the latter is created artificially.  Same chemicals, same junk.  In fact, the artificial version may even be safer since the compounds are well known and theyve been tested, while a natural flavor may contain additional unknown compounds.

Youll find these in all sorts of processed food... flavored water, soda, frozen chicken products, chocolate milk, raspberry lemonade, french fries.  Again, the list goes on and on.  Will they kill you?  Probably not.  But are they good for the body?  Will they help keep you vibrant and full of energy?  Shit no.


Heres some advice to live by.  If a food makes health claims, theres a good chance its junk.  Real food doesnt need a label; fresh fruits and vegetables, meats, potatoes... they are what they are.  So eat real food, and watch out for them tricky food manufacturers.  Theyre verrrrry sneaky.

Now you know; dont take the bait.

Data from more than 180 research papers suggests fish oils could minimize the effects that junk food can have on the brain, a review by researchers at the University of Liverpool has shown.

The team at the Universitys Institute of Ageing and Chronic Disease reviewed research from around the world to see whether there was sufficient data available to suggest that omega-3s had a role to play in aiding weight loss.

Research over the past 10 years has indicated that high-fat diets could disrupt neurogenesis, a process that generates new nerve cells, but diets rich in omega-3s could prevent these negative effects by stimulating the area of the brain that control feeding, learning and memory.

Data from 185 research papers revealed, however, that fish oils do not have a direct impact on this process in these areas of the brain, but are likely to play a significant role in stalling ined sugars and saturated fats ability to inhibit the brains control on the bodys intake of food.

Dr Lucy Pickavance, from the Universitys Institute of Ageing and Chronic Disease, explains: "Body weight is influenced by many factors, and some of the most important of these are the nutrients we consume. Excessive intake of certain macronutrients, the ined sugars and saturated fats found in junk food, can lead to weight gain, disrupt metabolism and even affect mental processing.

"These changes can be seen in the brains structure, including its ability to generate new nerve cells, potentially linking obesity to neurodegenerative diseases. Research, however, has suggested that omega-3 fish oils can reverse or even prevent these effects. We wanted to investigate the literature on this topic to determine whether there is evidence to suggest that omega-3s might aid weight loss by stimulating particular brain processes."

Research papers showed that on high-fat diets hormones that are secreted from body tissues into the circulation after eating, and which normally protect neurons and stimulate their growth, are prevented from passing into the brain by increased circulation of inflammatory molecules and a type of fat called triglycerides.

Molecules that stimulate nerve growth are also reduced, but it appears, in studies with animal models, that omega-3s restore normal function by interfering with the production of these inflammatory molecules, suppressing triglycerides, and returning these nerve growth factors to normal.

Dr Pickavance added: "Fish oils dont appear to have a direct impact on weight loss, but they may take the brakes off the detrimental effects of some of the processes triggered in the brain by high-fat diets. They seem to mimic the effects of calorie restrictive diets and including more oily fish or fish oil supplements in our diets could certainly be a positive step forward for those wanting to improve their general health."

The research is published in the British Journal of Nutrition. Dr Pickavance will also be discussing the effects of high-fat diets on meal patterns and the impacts of high-saturated fats on muscle composition at the 20th European Congress on Obesity at the Liverpool Arena and Convention Centre later this month.

Dr Pickavance will exhibit her work on obesity at Liverpool World Museum for members of the public on the 8 June, as part of the Universitys Institute of Ageing and Chronic Disease Meet the Scientist event.

Corporatization

The Disease Management Care Blog is ashamed to admit it, but its reading Edward Kleins The Amateur. While much of the book is a conservative-partisan rehash of Mr. Obamas alleged personal and political shortcomings, it did raise one issue that intrigued the DMCB:

"Corporatization."   It seems this White House likes it.

As the DMCB understands it, this is a policy agenda that favors the formation of huge corporate organizations that dominate the national business climate. Its argument is that, thanks to their size and scope, these gigantic private, public and not-for profit corporations are better able to marshal the resources it takes to launch transformative programs, achieve efficiencies, take risks and make profits that are beyond the normal reach of traditional commerce. Think about the hundreds of billions-of-dollars-approaches to housing, financial services, battery operated cars, high speed rail, solar power, privatized space travel and, last but not least, health care insurance and delivery.

A key ingredient of corporatization is "partnering" with government in a way that blurs the line between private enterprise and the public interest. Ingredients include government-backed financing, special tax breaks, loans, grants, mixed Boards of Directors and sovereign investment funds.  The downsides are quite familiar also: crony capitalism and too-big-to-fail status 

The best example of corporatization is China. Beijing centrally orchestrates many of its key economic sectors including finance, banking, housing, public transportation and heavy industry with an opaque mix of public and private companies. While political orms and respect for human rights have been found wanting, the prospect that China could eclipse the United States in the next 25 years has prompted many in the U.S. to admire China and reexamine the merits of old fashioned capitalism and unfettered markets. For an interesting example of that thinking, see this editorial by Andy Stern that recently appeared in the Wall Street Journal.

What could this explain and what are the implications?

1. The abandonment of the government-run "public option" early in the course of creating the Affordable Care Act. Despite his hostile anti-insurer rhetoric, Mr. Obamas ultimate belief in large mega-insurance corporations, a) regulations and b) public subsidies that bind the behemoth insurers to D.C. won the day.  And it aint going away anytime soon.

2. The near ideological support by this Administration for Accountable Care Organizations. Despite little track record that ACOs offer a viable business model, the notion of large regional providers partnering with and led by CMS is fully consistent with a belief in corporatization.  This makes the DMCB wonder if Mr. Obamas intent is to assure that ACOs succeed, no matter what.

They did it again!

Before too long, the Disease Management Care Blog will start getting bored with the accumulating evidence (for example, here, here and here) that telephonic disease management (DM) reduces medical claims expense in excess of program costs.  Theres only one thing thats more tiring, and that is the lingering ideological assumption among many academics that the Medicare programs inability to save money with DM means theres a problem with DM and not with Medicare.

Enter this study on diabetes telephonic care management that was just published in the American Journal of Managed Care.  This was about as real world as you can get.

The Denver Healths Westside Family Health Center, a federally funded community health center, randomly assigned 381 patients with diabetes to a 20-month telephone outreach program and another 381 to usual physician care.  In the intervention arm, patients not only saw their physicians, but had the involvement of 3 nurses sharing a ".75 full time equivalent" position.  The nurses used motivational interviewing and clinical protocols to guide these patients in self-care.  The nurses also independently ordered labs, initiated and titrated medications (with the use of pre-signed prescriptions as necessary), arranged vaccinations and facilitated physician appointments.  The nurses focused on control of lipids, blood glucose control and treatment of high blood pressure.

 Since many of these patients had no insurance, linear regression models were used to evaluate costs "from the perspective of the health care system" with "cost to charge ratios."  Patients with no primary care visit in the year preceding the end of the study were excluded from the analysis and the use of health care services outside of the Center was not counted. 

Aside from a slight gender imbalance (64% vs. 57% female in the intervention and control groups, respectively) as well as different rates of cerebrovascular disease (14% vs. 9%) and use of insulin (24% vs. 38%), the two patient populations were mostly similar in multiple baseline labs and co-morbid conditions.  In terms of the baseline costs, the control group had higher baseline hospitalization rates and total costs.

At the end of the study, 58% vs. 47% had achieved a target cholesterol LDL, but there was no difference in blood glucose or blood pressure control. 65 patients were lost to follow-up. The remainder were contacted an average of three times over the course of the study.

There was a significant drop in costs in the intervention group.  Over 18 months, their costs decreased from a baseline of $6390 per patient to $6217, while the control group went up from $7694 to $9033.
When the cost of the program was rolled in, the intervention resulted in $60,902 in total savings, which included the costs of $134,750 for the nurse-based intervention.  The savings appeared to be due to fewer hospitalizations.

While this study didnt use remotely positioned telephonic disease management and instead used nurses that were on-site, the DMCB points out that many telephonic programs use the same playbook. If the nurses have a good working relationship with the clinic physicians, they can do great things by telephone.  Last but not least, while the nurses pursued lipids, blood sugar and blood pressure, the DMCB suspects the real secret sauce was the countless and immeasurable other pieces of advice and help that were provided to the intervention patients.

The link between fructose consumption and many forms of cancer are quite evident, as this form of sugar derived from fruit provides fuel to cancer cells, causing them to divide and proliferate. Fructose is an inexpensive sweetener used in many processed foods and drinks, and is most frequently found in its super-charged form, high fructose corn syrup. You can dramatically lower your risk for developing many of the most deadly types of cancer as you naturally lose weight by diligently reading nutrition labels to eliminate fructose from your diet.