A few years ago I went to the doctor for a routine appointment, and I was told that my LDL cholesterol was elevated. I was in my early 40s. My lipid profile was the following - LDL: 156, HDL: 38, triglycerides: 188. The LDL was calculated. I was weighing about 210 lbs, which was too high for my height (5 ft 8 in). My blood pressure was low, as it has always been - systolic: 109, diastolic: 68.
My doctor gave me the standard advice in these cases: exercise, lose weight, and, most importantly, reduce your intake of saturated fat. I was also told that I would probably have to take statins, as my high LDL likely had something to do with my genetic makeup. Again, this is quite standard, and we see it all over the place, particularly in commercials for statins.
I told my doctor that I would do some research on the topic, which I am going to save for other posts. Let me get to the point, by telling you what my lipid profile is today - LDL: 123, HDL: 66, triglycerides: 46. Again, the LDL value is calculated. I am weighing about 152 lbs now, with about 13 percent of body fat.
The HDL and triglycerides numbers above are shown in bold font because my research convinced me that these two numbers are the ones most people should really worry about when trying to address what is known as dyslipidemia. Here I am assuming that only standard lipid profiles are available; there are better alternatives, such as particle type analyses, which are not yet standard.
Many people who suffer from cardiovascular disease have low LDL cholesterol, but very few of those have high HDL cholesterol, which is one of the best predictors of cardiovascular disease among lipids. More specifically, if you have an HDL higher than 60, you have a very small chance of developing cardiovascular disease. (It can happen, but it is very unlikely, with a percentage chance in the single digits.)
Interestingly, low HDL cholesterol is also associated with the metabolic syndrome. This syndrome is characterized by the following:
- High fasting serum glucose (hyperglycemia), which is one of many signs of insulin resistance, a precursor to diabetes type 2;
- High blood pressure;
- Abdominal obesity (also known as pot or beer belly);
- Low HDL cholesterol; and
- Elevated triglycerides.
Now, you may ask, how did you increase your HDL? Well, I tried a number of things - diet and lifestyle changes - and had a blood test every 3 months. After a while I was able to put all of the measures in a spreadsheet table, and correlate them using a statistical software that I developed, to give me an idea of what was going on.
Weight was a big factor on LDL, and I was able to bring my weight down to 150 lbs and my LDL to below 100 at some point. For me, and many other people, body weight and LDL cholesterol are strongly and positively correlated (the higher the weight, the higher the LDL cholesterol - actually body fat seems to be the real culprit). Moreover, my LDL seemed to decrease more markedly when my weight was on the way down, and not as much when it was stable, even if low.
But the HDL would only increase if I increased my saturated fat intake. The problem is that every time I increased my saturated fat intake my LDL would go up; it reached 162 at one point, when my HDL went up to a modest but encouraging 47. That was my highest HDL until I eliminated refined carbs and sugars (e.g., bread, pasta, cereals, doughnuts, bagels, regular sodas) from my diet.
When I brought my intake of refined carbs and sugars down to zero, my intake of protein and saturated fat went up. Either that would happen, or I would starve, because you have to eat something. (I figured that I would not die by doing a low carb/high fat-protein experiment for 3 months to see what happened.) Also, I dramatically increased my dietary cholesterol - two to four eggs per day, organ meats, and seafood.
That is when my HDL shot up, to 66, and my LDL went down. Yes, my LDL levels seem to be negatively correlated with dietary saturated fat and cholesterol amounts, as long as I do not consume refined carbs and sugars. Moreover, it is very likely that my LDL particle size increased, and large LDL particles DO NOT cause atherosclerosis because they cannot penetrate the artery walls.
So, the bottom line is that, at least for me, an INCREASE in saturated fat and a DECREASE in refined carbs and sugars, happening together, seem to have taken me out of my previous path toward the metabolic syndrome.
Moreover, I feel a lot more energetic than before, my immune system seems to have gotten better at fighting disease, and even my pollen allergies are not as bad as they were before. Admittedly, these benefits may be strongly associated with the weight loss and the related reduction in body fat percentage.
I hope this post is helpful to others. The standard advice that people with high LDL cholesterol receive, which usually focuses on reducing saturated fat intake, has a big problem. When you reduce your intake of a type of food, you usually increase your intake of other types of food. Most people who try to reduce their saturated fat intake invariably increase their carb intake, usually with the wrong types of carb-rich foods (the man-made ones), simply because they go hungry.
Tuesday, December 8, 2009
Monday, November 23, 2009
New Breast Cancer Screening Guidelines and The Value of Breast Self Exams
Since their release earlier this week, there has been extensive controversy over the new US Preventive Services Task Force (USPSTF) recommendations against routine mammograms for women under 50. These new recommendations have raised the ire of women across the US and have been disputed by the American Cancer Society, the Susan G. Komen Foundation and other cancer information and services organizations. USPSTF also questioned the value of breast self examination (BSE), saying it was not recommended because it has led to a high number of false positive results. That recommendation has also been called into question from a wide range of women’s organizations and individuals who have found breast lumps as a result of a BSE.
This latter recommendation hits home for me as my wife was recently diagnosed with Breast Cancer and is being treated here at the Jefferson Breast Center. The cancer was not caught from a routine mammogram but rather through her own monthly breast self exam. As a result of that exam, she visited our family doctor immediately. After an ultrasound and additional tests confirmed her breast cancer, she started treatment.
Without her monthly breast self exam, who knows when she would have seen her doctor, received her diagnosis, and begun treatment? BSE is an important, individual personal health screening that can and should be done routinely. My wife is Hispanic. A study from the University of Arizona’s Zuckerman College of Public Health earlier this year reported that two-thirds of Hispanic women diagnosed with breast cancer discovered it through BSE and not from diagnostic services provided within the healthcare environment. The USPSTF recommendation against BSE, if applied nationwide, could adversely impact early detection of breast cancer, especially among diverse populations, many of whom do not routinely use our healthcare system.
Rob Simmons, DrPH, MPH, CHES, CPH
Director, MPH Program
Jefferson School of Population Health
This latter recommendation hits home for me as my wife was recently diagnosed with Breast Cancer and is being treated here at the Jefferson Breast Center. The cancer was not caught from a routine mammogram but rather through her own monthly breast self exam. As a result of that exam, she visited our family doctor immediately. After an ultrasound and additional tests confirmed her breast cancer, she started treatment.
Without her monthly breast self exam, who knows when she would have seen her doctor, received her diagnosis, and begun treatment? BSE is an important, individual personal health screening that can and should be done routinely. My wife is Hispanic. A study from the University of Arizona’s Zuckerman College of Public Health earlier this year reported that two-thirds of Hispanic women diagnosed with breast cancer discovered it through BSE and not from diagnostic services provided within the healthcare environment. The USPSTF recommendation against BSE, if applied nationwide, could adversely impact early detection of breast cancer, especially among diverse populations, many of whom do not routinely use our healthcare system.
Rob Simmons, DrPH, MPH, CHES, CPH
Director, MPH Program
Jefferson School of Population Health
Friday, November 13, 2009
Healthcare Reform Needs Patient Adherence
While the debate rages on regarding Healthcare Insurance Reform, several key issues are either severely diminished or completely eliminated from the conversation. Many of the huge costs to the system are associated with the management of chronic illnesses, such as diabetes, asthma and heart disease. Patient compliance or adherence is one of the most critical elements of achieving improved outcomes for patients with chronic illnesses, helping to prevent costly complications and hospitalizations.
Unfortunately, the evidence regarding patient education, behavioral models, care coordinating infrastructure, and perhaps financial incentives to support patients with chronic illnesses lags behind treatment recommendations. While most health professionals are armed with myriad evidence-based clinical guidelines, little is understood or proven on how to engage patients to accept personal responsibility and become active participants in their health care.
Even a coordinated care model runs the risk of failing to achieve improved outcomes if patients do not adhere to recommendations. It is not enough for health professionals to counsel patients to stop smoking, eat a well balanced diet, get screened for markers of cancer and chronic illnesses, take their vaccines, statins, ACE inhibitors, check their blood sugar, etc. Unless there is a funding mechanism to provide the needed resources to support patients in their efforts to comply, we will continue to fail them and add to our ever-increasing cost burden to the system.
Until the system is geared up to support patients and caregivers with the best tools to accept more personal health responsibility and adhere to proper proven recommendations, we will continue to have sub-optimal outcomes no matter what we spend or recommend for healthcare reform changes.
Mike Toscani, PharmD
Project Director
Jefferson School of Population Health
Unfortunately, the evidence regarding patient education, behavioral models, care coordinating infrastructure, and perhaps financial incentives to support patients with chronic illnesses lags behind treatment recommendations. While most health professionals are armed with myriad evidence-based clinical guidelines, little is understood or proven on how to engage patients to accept personal responsibility and become active participants in their health care.
Even a coordinated care model runs the risk of failing to achieve improved outcomes if patients do not adhere to recommendations. It is not enough for health professionals to counsel patients to stop smoking, eat a well balanced diet, get screened for markers of cancer and chronic illnesses, take their vaccines, statins, ACE inhibitors, check their blood sugar, etc. Unless there is a funding mechanism to provide the needed resources to support patients in their efforts to comply, we will continue to fail them and add to our ever-increasing cost burden to the system.
Until the system is geared up to support patients and caregivers with the best tools to accept more personal health responsibility and adhere to proper proven recommendations, we will continue to have sub-optimal outcomes no matter what we spend or recommend for healthcare reform changes.
Mike Toscani, PharmD
Project Director
Jefferson School of Population Health
Friday, November 6, 2009
The “S” Word in the Health Care Reform Debate
Like most of you, I have followed our country’s health care reform debate closely. Unfortunately, the conversation is confusing because the subject is complex and generally not presented in a logical and orderly fashion. The current approach to reform involves tweaking the current “system” rather than starting from scratch to design a rational one. Since the current system evolved in a haphazard fashion, attempts at reforming it will doubtless result in something equally complex.
Because the discussion involves strongly held beliefs about intensely personal and important issues, the discussions around health care reform have become quite heated. Emotions come into play, often vigorously, and can get to a point where objective discussion is no longer possible.
The word that seems to have triggered the most emotional response is socialism (the “S” word). It is used in almost a pejorative fashion, as if it is the worst thing that could possibly happen in America. Students of economics embrace capitalism strongly (others have different reasons) because it has proven unparalleled in raising standards of living for vast numbers of people and for providing innovation in our society.
The “S” word is commonly invoked when the discussion turns to a government-provided public insurance option. Simple definitions can help here. In capitalism, individuals own the means of production for goods and services. In socialism, the government owns them. Curiously, socialism is rarely used to describe Medicare, Medicaid, and the various other government-sponsored plans that account for roughly half of the health care dollars spent in this country, and are bona fide examples of “socialist” services.
My reaction to the use of this word has evolved from frustration to bemusement. First, most people cannot possibly have the facts concerning existing government-funded insurance plans in mind when they drop the “S” word in the context of health care reform. Second, for anyone looking at the matter objectively, it is clear that the United States is not a purely capitalistic country. We have many government-run services such as the military, highways, education, the postal service, social security, Medicare, etc. Thus, the United States contains elements of both capitalism and socialism, a so-called mixed economy.
As has become abundantly clear through our recent financial crisis and the government-sponsored rescue of our financial system, government spending when the private sector couldn’t (or wouldn’t) shortened what otherwise would have been an extended economic downturn. Having a little government (read socialism) mixed in with our capitalism can be a good thing. The flaw in the premise of most peoples’ assumption about capitalism is that free markets are inherently self-correcting. They are not. Simply having a capitalistic system does not guarantee a good outcome.
Similar reasoning can be applied to health care. Let’s examine the facts. The United States occupies 37th place in the World Health Organization’s ranking of healthcare quality in industrialized nations, despite the fact that we pay almost twice as much for health care. Perhaps our “capitalistic” healthcare system could use some “socialist” guidance, since it did not find an optimum outcome on its own. If not the government, who will provide guidance toward better outcomes in health care? As has occurred many other times in health care, the government (in the form of CMS) is leading the way to cost and quality reform through various demonstration projects and programs. Private insurance companies are following the government’s lead.
If we take the possibility of a government provided public insurance option to its extreme, is it so crazy to consider a government run health insurance system?
Let’s examine the premise of how insurance works. With a large number of people in a risk pool, the cost for any one individual is reduced. The larger the pool, the broader the risk is spread, the lower the cost.
How could we spread the risk as broadly as possible? A federal government provided public insurance option covering all Americans would do the trick. In point of fact, many Medicare services are administered by the Blues and other private insurance companies. Combining a single large insurance pool with private administration is a nice mixed economic insurance solution. Certainly not as crazy a scheme as what we endure now as a nation with regard to cost and quality…
Richard Jacoby, MD
Associate Professor
Jefferson School of Population Health
Because the discussion involves strongly held beliefs about intensely personal and important issues, the discussions around health care reform have become quite heated. Emotions come into play, often vigorously, and can get to a point where objective discussion is no longer possible.
The word that seems to have triggered the most emotional response is socialism (the “S” word). It is used in almost a pejorative fashion, as if it is the worst thing that could possibly happen in America. Students of economics embrace capitalism strongly (others have different reasons) because it has proven unparalleled in raising standards of living for vast numbers of people and for providing innovation in our society.
The “S” word is commonly invoked when the discussion turns to a government-provided public insurance option. Simple definitions can help here. In capitalism, individuals own the means of production for goods and services. In socialism, the government owns them. Curiously, socialism is rarely used to describe Medicare, Medicaid, and the various other government-sponsored plans that account for roughly half of the health care dollars spent in this country, and are bona fide examples of “socialist” services.
My reaction to the use of this word has evolved from frustration to bemusement. First, most people cannot possibly have the facts concerning existing government-funded insurance plans in mind when they drop the “S” word in the context of health care reform. Second, for anyone looking at the matter objectively, it is clear that the United States is not a purely capitalistic country. We have many government-run services such as the military, highways, education, the postal service, social security, Medicare, etc. Thus, the United States contains elements of both capitalism and socialism, a so-called mixed economy.
As has become abundantly clear through our recent financial crisis and the government-sponsored rescue of our financial system, government spending when the private sector couldn’t (or wouldn’t) shortened what otherwise would have been an extended economic downturn. Having a little government (read socialism) mixed in with our capitalism can be a good thing. The flaw in the premise of most peoples’ assumption about capitalism is that free markets are inherently self-correcting. They are not. Simply having a capitalistic system does not guarantee a good outcome.
Similar reasoning can be applied to health care. Let’s examine the facts. The United States occupies 37th place in the World Health Organization’s ranking of healthcare quality in industrialized nations, despite the fact that we pay almost twice as much for health care. Perhaps our “capitalistic” healthcare system could use some “socialist” guidance, since it did not find an optimum outcome on its own. If not the government, who will provide guidance toward better outcomes in health care? As has occurred many other times in health care, the government (in the form of CMS) is leading the way to cost and quality reform through various demonstration projects and programs. Private insurance companies are following the government’s lead.
If we take the possibility of a government provided public insurance option to its extreme, is it so crazy to consider a government run health insurance system?
Let’s examine the premise of how insurance works. With a large number of people in a risk pool, the cost for any one individual is reduced. The larger the pool, the broader the risk is spread, the lower the cost.
How could we spread the risk as broadly as possible? A federal government provided public insurance option covering all Americans would do the trick. In point of fact, many Medicare services are administered by the Blues and other private insurance companies. Combining a single large insurance pool with private administration is a nice mixed economic insurance solution. Certainly not as crazy a scheme as what we endure now as a nation with regard to cost and quality…
Richard Jacoby, MD
Associate Professor
Jefferson School of Population Health
Thursday, October 29, 2009
Health Insurance Reform Options
October of 2009 has been an exciting month for health policy wonks. For those of us who enjoy the study of health policy, it doesn’t get much better than this. In this post we briefly describe some of the key health policy ideas still surviving the legislative process. This is not intended to be a thorough review of each measure. As always with complex legislation, the devil is in the details.
The “Mandate”: All the key bills making their way through the House and Senate include a mandate that everyone be required to have health insurance. A health insurance mandate is going to happen, one way or another. Now, for those of us without health insurance, there are provisions (tax credits or “subsidies”) to make insurance affordable. How much those tax credits will offset the cost of buying insurance for each income bracket is still being debated. Likewise, the size of the penalty for not buying insurance is also still being debated.
The “Public Option”: For all the attention this idea is getting from both inside and outside of the Washington beltway, it’s really less interesting to this student of health policy because it’s not as creative or innovative like the other tools being discussed e.g., health insurance exchanges, state-based high risk pools, payment reform, value-based purchasing initiatives… the list goes on. Yet, because the “public option” strikes at a historical, deep-rooted political ideal (the role of government in the private market), it has received the vast majority of attention from the media and the lay public. The audience should know that the “public option” is so fluid in meaning at this point that no one really knows what the “public option” will mean for healthcare. It could be national or state-based; states may be given the option to choose to participate; it might be tied to Medicare, it might negotiate with providers on its own. The point of having a public option is to make premiums affordable by keeping the insurance industry honest and competitive. Recent attention has been given to a maneuver that would create a pathway for the public option in the future only to be implemented (or “triggered”) if insurance companies fail to cover the desired percentage of the population. Votes are needed either way - look for compromises on this issue, not one extreme or the other.
Health Insurance Exchange(s): This is perhaps the most exciting part of health reform, yet few fully understand how important exchanges will be for this health system. For a whole lot of reasons, individuals purchasing insurance on their own have been at a massive disadvantage to those who receive insurance through their employer. An insurance exchange would create a clearinghouse of insurance plans for individuals and families to choose from. For the insurance industry, it also creates a massive pool of potential customers who otherwise might not seek insurance. Like the public option, the exact structure and functioning of the exchange or exchanges is not yet known, i.e., there could be one big national exchange or many “state-based” exchanges. Regardless of approach, there are a few things likely to be included in an individual market exchange. First, the government (either federal or state) will likely set the rules. For insurance companies to participate, the plans they offer would have to meet specific criteria for quality, cost, and access. Furthermore, the ratios by which they can increase or decrease premiums based on age, smoking status, and family size, will likely be fixed.
Subsidies: Finally, the most expensive piece of reform: premium subsidies. Every proposal creates subsidies to buy insurance – so regardless of plan, we will see subsidies. This is where the biggest chunk of the 800 billion to 1 trillion dollars will be spent. The core goal of every reform proposal is to get everyone insured, and health insurance is expensive. Therefore, based on percent of federal poverty level, individuals and families will receive some form of financial support from the federal government to offset the cost of purchasing insurance. The manner in which this financial support is distributed and the size of the subsidies based on income is still being debated.
The mandate, public option, insurance exchanges, and subsidies are 4 key ideas being debated this fall in Congress. There are many more ideas and changes to the system included within each proposal, however. Needless to say, it’s the golden years for health policy wonks – the months of November and December should be very exciting. Stay tuned.
Rich Toner, MS
The “Mandate”: All the key bills making their way through the House and Senate include a mandate that everyone be required to have health insurance. A health insurance mandate is going to happen, one way or another. Now, for those of us without health insurance, there are provisions (tax credits or “subsidies”) to make insurance affordable. How much those tax credits will offset the cost of buying insurance for each income bracket is still being debated. Likewise, the size of the penalty for not buying insurance is also still being debated.
The “Public Option”: For all the attention this idea is getting from both inside and outside of the Washington beltway, it’s really less interesting to this student of health policy because it’s not as creative or innovative like the other tools being discussed e.g., health insurance exchanges, state-based high risk pools, payment reform, value-based purchasing initiatives… the list goes on. Yet, because the “public option” strikes at a historical, deep-rooted political ideal (the role of government in the private market), it has received the vast majority of attention from the media and the lay public. The audience should know that the “public option” is so fluid in meaning at this point that no one really knows what the “public option” will mean for healthcare. It could be national or state-based; states may be given the option to choose to participate; it might be tied to Medicare, it might negotiate with providers on its own. The point of having a public option is to make premiums affordable by keeping the insurance industry honest and competitive. Recent attention has been given to a maneuver that would create a pathway for the public option in the future only to be implemented (or “triggered”) if insurance companies fail to cover the desired percentage of the population. Votes are needed either way - look for compromises on this issue, not one extreme or the other.
Health Insurance Exchange(s): This is perhaps the most exciting part of health reform, yet few fully understand how important exchanges will be for this health system. For a whole lot of reasons, individuals purchasing insurance on their own have been at a massive disadvantage to those who receive insurance through their employer. An insurance exchange would create a clearinghouse of insurance plans for individuals and families to choose from. For the insurance industry, it also creates a massive pool of potential customers who otherwise might not seek insurance. Like the public option, the exact structure and functioning of the exchange or exchanges is not yet known, i.e., there could be one big national exchange or many “state-based” exchanges. Regardless of approach, there are a few things likely to be included in an individual market exchange. First, the government (either federal or state) will likely set the rules. For insurance companies to participate, the plans they offer would have to meet specific criteria for quality, cost, and access. Furthermore, the ratios by which they can increase or decrease premiums based on age, smoking status, and family size, will likely be fixed.
Subsidies: Finally, the most expensive piece of reform: premium subsidies. Every proposal creates subsidies to buy insurance – so regardless of plan, we will see subsidies. This is where the biggest chunk of the 800 billion to 1 trillion dollars will be spent. The core goal of every reform proposal is to get everyone insured, and health insurance is expensive. Therefore, based on percent of federal poverty level, individuals and families will receive some form of financial support from the federal government to offset the cost of purchasing insurance. The manner in which this financial support is distributed and the size of the subsidies based on income is still being debated.
The mandate, public option, insurance exchanges, and subsidies are 4 key ideas being debated this fall in Congress. There are many more ideas and changes to the system included within each proposal, however. Needless to say, it’s the golden years for health policy wonks – the months of November and December should be very exciting. Stay tuned.
Rich Toner, MS
Sunday, October 18, 2009
Health Insurance Reform---NOT REAL REFORM
I am struck that most of the national conversation about "health reform" has really been all about "insurance reform". Missing from the national conversation are the crucial issues that face our dysfunctional system----unexplained clinical variation, waste, the epidemic of medical errors, solving the tort crisis and much more. NONE of the proposals coming from the Senate or the House even begins to get at these critical issues. We need leaders in Washgington and elsewhere to confront what is really broken and begin the difficult process of self evaluation to fix these core issues. We spend the most and get the least. Sure, on a particular case by case basis we might be fortunate enough to have insurance and to get great medical care---this is not the issue. The issue remains as to how to create value, how to reorganize the system to promote coordination of care, how to realign the financial incentives and finally, how to make the whole thing patient centered. I don't know about you, but my patience is almost running out. I hope we can get the conversation back on track to address these issues that truly matter, and that can help us deliver real reform. DAVID NASH
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