Beauty Health for Life

Playing whacamole

"Immunizations cause autism." 

"Health care blogging will never lead any serious beer money."

"Disease management coaching focuses exclusively on just one disease."

These are three falsehoods that bubble up in the unlikeliest of places, including cable news outlets, replying to the DMCB spouses asking "and what did you do today?" and webinars, webcasts and other educational meetings about population health and disease management.

While the Disease Management Care Blog finds all three vexing, the most irksome is the canard that the commercial health coaching service providers purposely limit their programs to just one chronic condition, like diabetes, weight loss or readmission prevention.

While that may have been the case in the earliest versions of disease management, that narrow approach was dropped years ago. Thats because patients typically seek advice for a wide range of overlapping concerns and the good nurses hired by the vendors will respond to them.  The vendors also understand that their shared risk and performance guarantees depend on claims expense that is driven by the synergies of multiple co-morbidities. 

While a purchaser, insurer or accountable provider organization may start out with a focus on a population defined by a single condition - such as diabetes mellitus - that doesnt mean their protocols and care plans wont span the continuum of care and include hypertension, tobacco abuse, depression, housing, chatting about the grandkid and responding to concerns whether this will be finally be NBA superstar LeBron James year.

And the published literature supports the DMCBs contention that modern population health management is multifaceted.  Examples include this seven-condition program for dually eligible Medicaid beneficiaries in Georgia, this Midwest employer-sponsored program that enrolled persons with multiple care needs and this physician-focused program that used pay-for-performance to improve measures across multiple conditions.  Check out some vendor web sites and youll see erences to "whole person health," the "interrelated aspects of social, emotional, and physical health" and "a holistic view of member health across internal and external care management initiatives."

That being said, the DMCB knows that perception and reality can be two different things. Given the whac-a-mole persistence of the "single disease" myth, the DMCB says the population health management community may benefit clarifying the broadness as well as the depth of their offerings as they continue to build their brand.

Image from Wikipedia

Low levels of vitamin D have been implicated as a potential cause of diseases ranging from cancer to diabetes. Now an extensive review suggests its really the other way around: Low levels of the "sunshine vitamin" are more likely a consequence -- not a cause -- of illness.

In their review of almost 500 studies, the researchers found conflicting results. Observational studies, which looked back at what people ate or the kinds of supplements they took, showed a link between higher vitamin D levels in the body and better health.

But, in studies where vitamin D was given as an intervention (treatment) to help prevent a particular ailment, it had no effect. The one exception was a decreased death risk in older adults, particularly older women, who were given vitamin D supplements.

"The discrepancy between observational and intervention studies suggests that low [vitamin D] is a marker of ill health," wrote review authors led by Philippe Autier, at the International Prevention Research Institute, in Lyon, France.

Vitamin D is known to play a key role in bone health. Low levels of vitamin D have been found in a number of conditions, including heart disease, autoimmune diseases, diabetes, cancer and Parkinsons disease. These findings may explain why so many Americans are currently taking vitamin D supplements.

Its nicknamed the sunshine vitamin because the body produces vitamin D when exposed to the sun (if someone isnt wearing sunscreen). Its also found in some foods, such as egg yolks and fatty fish, and in foods that have been fortified with vitamin D, such as milk.

The current review, published online Dec. 6 in The Lancet Diabetes & Endocrinology, looked at 290 observational studies. In these studies, blood samples to measure vitamin D levels were taken many years before the outcome of the study occurred. The review also included results of 172 randomized clinical trials of vitamin D. In randomized trials, some people receive a therapy while others do not.

The observational studies showed a potential benefit from vitamin D. For example, vitamin D was associated with a 58 percent reduced risk of cardiovascular events, a 38 percent decreased risk of diabetes and a 34 percent decreased risk of colon cancer in these studies.

But, when the researchers looked to the randomized clinical trials that used vitamin D as a treatment, they failed to find any effect on disease occurrence or severity from raising vitamin D levels.

However, vitamin D did reduce the risk of dying from any cause in older people taking 800 international units a day, according to the review.

Dr. Shaun Jayakar, an internal medicine and geriatric specialist from St. John Hospital and Medical Center in Detroit, said the findings in elderly people "are likely due to a reduction in falls and fractures. Supplementing with vitamin D would lead to stronger bones, which would reduce falls and factures."

Because the majority of interventional trials failed to find any benefit from vitamin D, the reviews authors conclude that low vitamin D levels dont lead to ill health, rather theyre caused by ill health.

They theorize that inflammation that occurs in many illnesses may be what depletes vitamin D levels.

Dr. Robert Graham, an internist from Lenox Hill Hospital in New York City, said, "This comprehensive review did a really good job at trying to tease out the effects of different study designs, and the findings will be controversial."

He said there are currently five, large ongoing interventional trials that will help to better define vitamin Ds role in disease. However, the results of those studies wont be available for a number of years. Until then, he recommended, "Try to achieve homeostasis [equilibrium]. You dont want to get to a low level of vitamin D."

The Institute of Medicine recommends 600 international units of vitamin D for adults, and 800 international units for people over 70.

Both Graham and Jayakar agreed that those are reasonable supplement levels. Jayakar said that for most people, vitamin D supplements are harmless, but added that "its a pocketbook issue. Almost 50 percent of the population is taking vitamin D supplements. Thats a lot of money for something that likely has no benefit," he said.

Jayakar added that this reviews findings suggest that low vitamin D levels could be used as a marker -- a sign -- of disease in younger people. "If someone isnt feeling well and they have low vitamin D, maybe we should use that to start searching to see if something else is going wrong," he said.

Health conscious individuals have been closely following Vitamin D research for the past decade as volumes of scientific evidence prove this prohormone has been selected through our evolution to provide critical protection against many inflammatory and immune mediated diseases.

The opening Supreme Court Affordable Care Act (ACA) deliberations focused on the obscure 1867 Anti-Injunction Act and whether the mandate is a "tax." Its not until the day two of arguments that The Nine Lawyers will take on the "individual mandate."

That day of reckoning yet awaits.

Obliging more health persons into the insurance "risk" pools is fundamentally an exercise in spreading the same risk and health care costs over a larger population. While individuals may see their health insurance premium decline thanks to more persons paying into the system, the total consumption of health care services has no reason to slow down. A mandate by itself will not reduce costs.*

Speaking of saving money, the omnivorous DMCB, spent some of its teenage years living on a country farm. The family did its own butchering and, never leaving anything to waste, did everything it could to use every scrap of meat. As far as the DMCB is concerned, "pink slime" a.k.a. "boneless meat trimmings" is a virtuous confluence of that same thrift on an industrial scale combined with centrifuges and ammonia. Talk about a slaughter.

Last but not least, the DMCB got one more population health management insight from Charles Duhiggs book The Power of Habit. In it, Mr. Duhigg describes how Targets brainiacs discovered an association between the emergence of new buying habits in young women and early pregnancy. While that classic exercise in predictive modeling is not new, what happened next was insightful: creeped out Target customers pushed back when they unexpectedly started getting maternity and baby product coupons. In response, Target learned to camouflage its recruitment efforts by disseminating its coupons with random and unrelated product offers. The DMCB wonders if the same surreptitious approach could somehow be adapted to recruit high risk patients into population health management.  $5 toward text messaging if we can ask you some questions about your wellness.... and diabetes.

*Assume for a moment that 90 persons have health insurance which costs $500 a year.  That "pools" 90 x $500 or $45,000 in resources that are available pay for persons that need to be in a hospital.

Then assume 4 persons get sick - one gets appendicitis, one is involved in a car accident, one gets gets an infected paper cut  and the last one neglects to follow a DMCB spouse preventive health recommendation and gets what he deserves.  If the average cost per hospitalization is $10,000, the total cost is $40,000.  That leaves $5000 left over.

Cost of the insurance for each of the 90 persons: $500.
Cost of the illness for each of the 90 persons : $444.
Total amount of money going to the insurance company: $45,000.
Total cost of the illness: $40,000.
Amount that goes to the insurance companys bottom line: $5000

One year later, the 90 persons realize that there are ten persons living in their community who are not buying insurance.  Assume these freeloaders are healthy.  The 90 persons have a majority and pass an ACA with a mandate.  Over the next year, four other persons get sick again.

Cost of the insurance for each of the 100 persons: $500.
Cost of the illness for each of the 100 persons : $400.
Total amount of money going to the insurance company: $50,000.
Total cost of the illness: $40,000
Amount that goes to the insurance companys bottom line: $10,000

Of course, its more complicated than that.  Of the ten forced to buy insurance, some have preexisting conditions and the cost of a hospitalization rises year after year, but that doesnt change the basic math underlying a mandate: total health care costs are the same, but theyre spread over a larger base population.

How, you ask, does the Disease Management Care Blog spouse approach the days ahead?

Male pattern baldness is linked to an increased risk of coronary heart disease, but only if its on the top/crown of the head, rather than at the front, finds an analysis of published evidence in the online journal BMJ Open.

A receding hairline is not linked to an increased risk, the analysis indicates.

The researchers trawled the Medline and the Cochrane Library databases for research published on male pattern baldness and coronary heart disease, and came up with 850 possible studies, published between 1950 and 2012.

But only six satisfied all the eligibility criteria and so were included in the analysis. All had been published between 1993 and 2008, and involved just under 40,000 men.

Three of the studies were cohort studies - meaning that the health of balding men was tracked for at least 11 years.

Analysis of the findings from these showed that men who had lost most of their hair were a third more likely (32%) to develop coronary artery disease than their peers who retained a full head of hair.

When the analysis was confined to men under the age of 55-60, a similar pattern emerged. Bald or extensively balding men were 44% more likely to develop coronary artery disease.

Analysis of the other three studies, which compared the heart health of those who were bald / balding with those who were not, painted a similar picture.

It showed that balding men were 70% more likely to have heart disease, and those in younger age groups were 84% more likely to do so.

Three studies assessed the degree of baldness using a validated scale (Hamilton scale). Analysis of these results indicated that the risk of coronary artery disease depended on baldness severity, but only if this was on the top/crown of the head, known as the vertex.

Extensive vertex baldness boosted the risk by 48%, moderate vertex baldness by 36%, and mild vertex baldness by 18%. By contrast, a receding hairline made very little difference to risk, the analysis showed.

To compensate for differences in the methods of assessing baldness in the studies included in the analysis, the authors looked at four differing grades of baldness: none; frontal; crown-top; combined.

Once again, this indicated that the severity of baldness affected the risk of coronary heart disease.

Men with both frontal and crown-top baldness were 69% more likely to have coronary artery disease than those with a full head of hair, while those with just crown-top baldness were 52% more likely to do so. Those with just frontal baldness were 22% more likely to do so.

Explanations for the reasons behind the association vary, but include the possibility that baldness may indicate insulin resistance, a precursor to diabetes; a state of chronic inflammation; or increased sensitivity to testosterone, all of which are involved directly or indirectly in promoting cardiovascular disease, say the authors.

But they conclude: "[Our] findings suggest that vertex baldness is more closely associated with systemic atherosclerosis than with frontal baldness. Thus, cardiovascular risk factors should be reviewed caully in men with vertex baldness, especially younger men" who should "probably be encouraged to improve their cardiovascular risk profile."

The British Dental Health Foundation believes new scientific research presented is a further indication of a possible link between pancreatic cancer and gum disease.

The latest research, presented in the journal Gut, found one of the bacterium key in the development of gum disease was associated with a two-fold increase in risk for pancreatic cancer. The study also discovered those with non-harmful oral bacteria had a 45 per cent lower risk of pancreatic cancer.

Although researchers cannot confirm whether gum disease contributes towards a higher risk of developing pancreatic cancer, the research is a further indication of a potential link between the two diseases.

Previous research has also drawn an association between bacteria responsible for gum disease and pancreatic cancer, although in both cases it remains unclear whether the presence of particular types of bacteria are a cause or effect of pancreatic cancer.

The papers corresponding author Dominique Michaud, epidemiologist at Brown University, commented: "This is not an established risk factor. But I feel more confident that something is going on. Its something we need to understand better."

Co-lead author Jacques Izard, of the Forsyth Institute and Harvard University concurred. He said: "We need to further investigate the importance of bacteria in pancreatic cancer beyond the associated risk."

Pancreatic cancer accounted for 7,901 deaths in 20104, while only four per cent of people in England survived the disease for more than five years. Given these statistics, Chief Executive of the British Dental Health Foundation, Dr Nigel Carter OBE, believes any link between the two diseases should provide a timely reminder about the importance of good oral health.

Dr Carter said: "This research provides further ammunition to the growing belief these two diseases could be related.

"There is no escaping the fact poor oral health has some role to play, as a number of studies are now starting to show. What we must remember is oral health is relatively simple to maintain. The Foundations three key messages - brushing your teeth for two minutes twice a day using a fluoride toothpaste, cutting down on how often you have sugary foods and drinks and visiting the dentist regularly, as often as they recommend - are a great starting point for maintaining good oral health.

"If you have swollen gums that bleed regularly when brushing, bad breath, loose teeth or regular mouth infections appear, it is likely you have gum disease. If any of these symptoms persist, your dentist may be able to help you."

Earlier this year, researchers reported finding insulin being produced in an organ other than the pancreas:

"Researchers at Rhode Island Hospital and Brown Medical School have discovered that insulin and its related proteins are produced in the brain, and that reduced levels of both are linked to Alzheimers disease."

The amounts were low. But the idea that Alzheimers Disease (AD) could be a form of diabetes specific to the central nervous system prompted additional study. Subsequently, a supportive follow-up report was published in November that described a link between the progressive nature of AD and the availability of insulin and insulin-like growth factors - the lower the quantity of insulin and functioning insulin receptors in the brain, the more advanced was the stage of AD.

The type of diabetes described here as associated with Alzheimers Disease (coined "type 3 diabetes" by researchers) is not the same as type 2 diabetes, which affects approximately 18 million Americans. Type 2 diabetes is characterized by higher than normal levels of blood glucose (throughout the body) which result from malfunctions in the production or utilization of insulin made in the pancreas.

A connection between the two disorders may exist, but has yet to be clarified. If a relationship can be shown, the possibilities for therapies that could target both type 2 diabetes and Alzheimers Disease are promising.

________
For press release on "brain insulin" finding:
Researchers discover link between insulin and Alzheimers

For some summaries of the recent study:
Evidence Grows That Alzheimers Is A Type Of Diabetes
and
Alzheimers Disease May Be Type 3 Diabetes

For the abstract and review article:
Review of insulin and insulin-like growth factor expression, signaling, and malfunction in the central nervous system: Relevance to Alzheimers disease

Impaired insulin and insulin-like growth factor expression and signaling mechanisms in Alzheimers disease - is this type 3 diabetes?

Prospective study finds clinically significant difference in atherosclerosis progression based on changes in periodontal health

Taking care of your gums by brushing, flossing, and regular dental visits could help hold heart disease at bay. Researchers at Columbia Universitys Mailman School of Public Health have shown for the first time that as gum health improves, progression of atherosclerosis slows to a clinically significant degree. Findings appear online in the Journal of the American Heart Association.

Artherosclerosis, or the narrowing of arteries through the build-up of plaque, is a major risk factor for heart disease, stroke, and death.

"These results are important because atherosclerosis progressed in parallel with both clinical periodontal disease and the bacterial profiles in the gums. This is the most direct evidence yet that modifying the periodontal bacterial profile could play a role in preventing or slowing both diseases," says Moïse Desvarieux, MD, PhD, lead author of the paper and associate professor of Epidemiology at the Mailman School.

The researchers followed 420 adults as part of the Oral Infections and Vascular Disease Epidemiology Study (INVEST), a randomly sampled prospective cohort of Northern Manhattan residents. Participants were examined for periodontal infection. Overall, 5,008 plaque samples were taken from several teeth, beneath the gum, and analyzed for 11 bacterial strains linked to periodontal disease and seven control bacteria. Fluid around the gums was sampled to assess levels of Interleukin-1β, a marker of inflammation. Atherosclerosis in both carotid arteries was measured using high-resolution ultrasound.

Over a median follow-up period of three years, the researchers found that improvement in periodontal health—health of the gums—and a reduction in the proportion of specific bacteria linked to periodontal disease correlated to a slower intima-medial thickness (IMT) progression, and worsening periodontal infections paralleled the progression of IMT. Results were adjusted for potential confounders such as body mass index, cholesterol levels, diabetes, and smoking status,

Clinical Significance

There was a 0.1 mm difference in IMT change over three years among study participants whose periodontal health was deteriorating compared with those whose periodontal health was improving. Previous research has shown that a .033 mm/year increase in carotid IMT (equivalent to approximately 0.1 mm over three years) is associated with a 2.3-fold increased risk for coronary events.

"When it comes to atherosclerosis, a tenth of a millimeter in the thickness of the carotid artery is a big deal. Based on prior research, it appears to meet the threshold of clinical significance," says Tatjana Rundek, MD, PhD, a co-author of the study and professor at the University of Miami whose lab read the carotid ultrasounds.

Even subtle changes to periodontal status had a dose-response relationship to carotid IMT. "Our results show a clear relationship between what is happening in the mouth and thickening of the carotid artery, even before the onset of full-fledged periodontal disease," says co-author Panos N. Papapanou, DDS, PhD, professor of Dental Medicine at Columbia Universitys College of Dental Medicine, whose laboratory assessed the bacterial profiles in the gums. "This suggests that incipient periodontal disease should not be ignored."

Bacteria in the mouth may contribute to the onset of atherosclerosis in a number of ways, scientists speculate. Animal studies indicate that they may trigger immune response and high levels of inflammatory markers, which may initiate or exacerbate the inflammatory aspect of atherosclerosis.

The results build on previous findings. In earlier cross-sectional results, Dr. Desvarieux and colleagues had reported that higher levels of disease-causing bacteria were associated with thicker IMT. The current study takes the next step by looking at the cohort over time.

"Our results address a gap identified in the AHA statement on periodontal disease and atherosclerosis, by providing longitudinal data supporting this association," says study co-author Ralph Sacco, MD, professor and chairman of Neurology at the University of Miami, Miller School of Medicine and former president of the American Heart Association. Concludes Dr. Desvarieux, "It is critical that we continue to follow these patients to see if the relationship between periodontal infections and atherosclerosis carries over to clinical events like heart attack and stroke and test if modifying the periodontal flora will slow the progression of atherosclerosis."

A new study by the Centers for Disease Control and Prevention (CDC) links too little sleep (six hours or less) and too much sleep (10 or more hours) with chronic diseases – including coronary heart disease, diabetes, anxiety and obesity – in adults age 45 and older. The American Academy of Sleep Medicine (AASM) encourages patients suffering from these common chronic conditions to speak with a sleep medicine physician who can evaluate their sleep patterns.

“It’s critical that adults aim for seven to nine hours of sleep each night to receive the health benefits of sleep, but this is especially true for those battling a chronic condition,” said Dr. M. Safwan Badr, president of the AASM. “Common sleep illnesses – including sleep apnea and insomnia – occur frequently in people with a chronic disease and can hinder your ability to sleep soundly. So if you’re waking up exhausted, speak with a sleep physician to see if there’s a problem. If you are diagnosed with a sleep illness, treating it could significantly improve disease symptoms and your quality of life.”

“Some of the relationships between unhealthy sleep durations and chronic diseases were partially explained by frequent mental distress and obesity,” said study co-author Janet B. Croft, PhD, senior chronic disease epidemiologist in CDC’s Division of Population Health. “This suggests that physicians should consider monitoring mental health and body weight in addition to sleep health for patients with chronic diseases.”

In the study, published in the October issue of the Journal SLEEP, short sleepers reported a higher prevalence of coronary heart disease, stroke and diabetes, in addition to obesity and frequent mental distress, compared with optimal sleepers who reported sleeping seven to nine hours on average in a 24-hour period. The same was true for long sleepers, and the associations with coronary heart disease, stroke and diabetes were even more pronounced with more sleep.

“Sleeping longer doesn’t necessarily mean you’re sleeping well. It is important to understand that both the quality and quantity of sleep impact your health,” said Badr. “A healthy, balanced lifestyle is not limited to diet and fitness; when and how you sleep is just as important as what you eat or how you exercise.”

The study involved more than 54,000 participants age 45 or older in 14 states. Nearly one third of participants (31 percent) were identified as short sleepers, meaning they reported sleeping six hours or less on average. More than 64 percent were classified as optimal sleepers, and only 4 percent of participants were long sleepers.