Just Read: Environmental Impacts of the U.S. Health Care System – (Carbon as a currency for health)?

This review could be considered an update to the brief analysis that appeared in 2009 describing US Health Care’s contribution to green house gas (GHG) emissions to be 8% of the country’s total.

And now it’s up to 9.8% (or maybe 9.3% since the models used to calculate the number are based on 2002 standards around energy generation).

I took the time in 2009 to review the models used carefully, because in life, I always read the whole paper, not just the abstract, and you should too. It’s fair to say that they are (a) complex, and (b) subject to a lot of uncertainty. I have actually been told that some of the assumptions made may not be correct, however, until I get that info, I’m just going to go with the numbers presented here.

2017.03.23 Impacts of Healthcare on the Environment 0157014
Fig 1. Time series of life cycle GHG emissions from US health care activities. Shown for 2003–2013, in absolute terms (orange bars) and as a share of U.S. national emissions (blue line). Mt = million metric tons.

Eckelman MJ, Sherman J (2016) Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS ONE 11(6): e0157014. doi:10.1371/journal.pone.0157014

2017.03.23 Impacts of Healthcare on the Environment (View on Flickr.com)

This paper goes beyond GHG emissions, though:

These impact categories include global warming; stratospheric ozone depletion (allowing higher levels of short-wave ultraviolet light through the atmosphere, increasing the health risks of skin cancer); respiratory disease from inhalation of primary and secondary particulate matter (PM) and from ground-level ozone (smog) stemming from emis- sions of criteria air pollutants; cancer and non-cancer disease through inhalation and ingestion routes of chemical exposure; environmental effects of acidification (from formation and deposition of acid rain) and eutrophication (algae blooms from excess nutrients) in soils and surface waters; and ecotoxicity that reflects the toxic burden of all emitted chemicals to aquatic organisms.

The tweet being made about the piece is that the US Healthcare System emits more carbon than all of the United Kingdom, but really that’s not a useful comparison because of the population differences.

Carbon as a Currency for Health/Life

It’s probably better to note that the National Health Service in the UK contributes 3-4% of the national GHG emissions, which mirrors to some extent the difference in GDP spend on health care, which was previously highlighted so eloquently to me by Brian Masterson, MD, who was then at the Military Health System in 2014, which I’ll repeat here:

20-20-20, 3-3-3

  • 20: % of GDP spent on health care in the United States
  • 20: % of youth out of high school who are fit for the military today
  • 20: % of the outcomes of health that come from health care

The delta on average between our expenditure on health care and other countries is about 12 %, with which

  • 3: % of the GDP is spent on defense today
  • 3: % of the GDP would fund every eligible student to attend a state university
  • 3: % of the GDP to make Social Security solvent for every American alive today
  • 3: % left over

If carbon emissions parallel use of services/supplies/people, then there’s an interest in using the right amount of these to obtain maximum achievement of life goals for a population (see numbers above). And therefore right amount will result in right amount of GHC emissions.

The physician role

The thing to notice carefully about the GHG emission sources, which are based on the expenditure categories of our health system (Table 1) is that they are 80% directed the things physicians do – not just providing medical services, but ordering tests, pharmaceuticals, hospitalizations.

The group physicians for climate (@DocsforClimate) recently convened in Washington, DC with this understanding:

And I have yet to meet a physician who wakes up hoping to provide too much or the wrong type of health care.

Beyond the right amount of things, there’s the way things are produced

Again the assumption (reality) that physicians work every day to perform well for their patients, it’s easy to walk into any health care environment and see opportunities. From the paint on the wall to the light bulbs in the fixtures, the soap in dispensers, the eventual location of discarded e-waste…

Physicians have a role in this too, as they did in the creation of the new Kaiser Permanente San Diego (@KPSanDiego) Medical Center (click here to see video, – LEED Platinum promotes health and it looks good too) .

Carbon not the goal, a better world is

A simple reminder…

091207usatoday global warming.91

Citation: Eckelman MJ, Sherman J (2016) Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS ONE 11(6): e0157014.

Just Read: Triglycerides and Cardiovascular Disease – American Heart Association Scientific Statement

Yes, all 40+ pages of the American Heart Association’s scientific statement, published in 2011 (the most recent one – citation below), for leisure.

Why?

Triglycerides are that lipid component in our blood that we (or let’s say I) are trained not to pay that much attention to, especially relative to cholesterol (LDL, HDL, etc), and yet its story unlocks a lot of mysteries around nutrition and health (again, for me).

Jumping right in.

  • “It is especially disconcerting that in the United States, mean triglyceride levels have risen since 1976, in concert with the growing epidemic of obesity, insulin resistance (IR), and type 2 diabetes mellitus (T2DM).”
    • As much as we’re fighting LDL, we don’t seem to be winning on this one. Why? And does it matter? (several reasons, and yes)

The dyslipidemic triad and diabetes

High triglyceride levels that accompany either normal or impaired fasting glucose predict the development of Type 2 Diabetes,1and therefore, hypertriglyceridemic states should prompt surveillance to rule out T2DM. In addition, 35% of T2DM adults have fasting triglyceride levels > 200 mg/dL associated with decreased HDL-C and small, dense LDL particles.

Size matters – of LDL particles, that is

LDL particles in patients with DM may be atherogenic even at normal LDL-C concentrations..In addition, hypertriglyceridemia is associated with small, dense, and CE-depleted LDL particles. Thus, individuals with T2DM and mild to moderate hypertriglyceridemia exhibit the pattern B profile of LDL (smaller, denser particles) described by Austin and Krauss; these particles be more susceptible to oxidative modification and catabolism via macrophage scavenger receptors

That’s the not good thing that happens inside blood vessels that causes disease and it’s connected to triglycerides.

In other words (my interpretation), it’s not what triglycerides mean by themselves, it’s the pattern that they are connected to. And therefore, looking at just one number (LDL) has limitations to predict disease. On the other hand, focusing on LDL is easy to do and simple to understand…hence the need for this scientific statement to understand the biology better than most people probably do.

Continuing on.

How we got here. The low-fat diet aka SnackWells USA

The relationship between percent of total fat intake and change in triglyceride and HDL-C concentrations was reported in a meta-analysis of 19 studies published by the Institute of Medicine. In this analysis comparing low-fat, high-CHO diets versus higher-fat diets, for every 5% decrease in total fat, triglyceride level was predicted to increase by 6% and HDL-C to decrease by 2.2%

Overall, optimization of nutrition-related practices can result in a marked triglyceride-lowering effect that ranges between 20% and 50%. These practices include weight loss, reducing simple CHO at the expense of increasing dietary fiber, eliminating industrial-produced trans fatty acids, restricting fructose and SFA, implementing a Mediterranean-style diet, and consuming marine-derived omega-3 PUFA (Table 11). Dietary practices or factors that are associated with elevated triglyceride levels include excess body weight, especially visceral adiposity; simple CHOs, including added sugars and fructose; a high glycemic load; and alcohol.

And the American Heart Association recommended high carbohydrate diets and even candy in the prevention of cardiovascular disease. Oops.

For the biologists/scientists – how carbohydrates may result in higher triglycleride levels and unhealthy lipid profiles

Mechanistically, high CHO intake triggers pancreatic insulin release in response to increased blood glucose. Insulin, in turn, activates sterol regulatory element–binding protein, (SREBP-1c), a transcription factor that regulates fatty acid and triglyceride synthesis. Recently, 2 additional transcription factors, X-box binding protein 1 (XBP1) and CHO response element–binding protein (ChREBP), have been identified as inducers of hepatic lipogenesis in response to ingested CHOs (eg, fructose and glucose) that is independent of insulin.431,432 In contrast, unsaturated fatty acids reduce or inhibit SREBP-1c transcription, thereby reducing hepatic fatty acid synthesis430 and plasma triglycerides.

Using drugs to treat

However, in LIPID, although baseline triglyceride level was not signifi- cantly associated with CVD risk in patients given placebo, each 89-mg/dL decrease in on-treatment triglyceride level in patients given pravastatin significantly decreased CVD risk by 11%, as well as by 14% after adjustment for nonlipid risk factors. However, the lipid-related parameters most strongly associated with CVD risk in LIPID were apo B, LDL-C, and the ratio of TC to HDL-C

Again, the dyslipidemic triad.

Taken together, reductions of 50% or more in triglyceride levels may be attained through intensive therapeutic lifestyle change.

A low fat, high carbohydrate diet increases triglycerides and decreases HDL, the opposite, a higher fat, lower carbohydrate diet reduces triglycerides and increases HDL. For me this explains the non-sequitir of my pathology textbook in medical school stating that high carbohydrate diets are a risk factor for heart disease at the same time high carbohydrate diets were being recommended to prevent heart disease.

A discussion of statins is out of scope here – many many many, many many, articles already cover this.

Andrew Weil, MD’s advice to us in medical school – understand what you’re prescribing to your patients

…I think he may have said that we should try every drug we prescribe to understand its effects (with rationality of course) but human memory can be semi-faulty after so many years…either way it was something of a gift for him to be on faculty at my medical school (University of Arizona) because it promoted an embrace of curiosity that persists to this day, every day.

In any event, I’ve switched to a low carbohydrate diet over the past year. I’m not ready to share my personal health information here, but I will eventually. And my biology is tracking science, as expected, because, well, that’s how science works :).

More to come. In the meantime, here’s a helpful piece on the low-fat diet and what it has done for our health.

Citation: Miller M, Stone NJ, Ballantyne C, Bittner V, Criqui MH, Ginsberg HN, et al. Triglycerides and Cardiovascular Disease. Circulation [Internet]. 2011 [cited 2016 Dec 25];123(20).

Just Read: A Transgender Military Internist’s Perspective – #WhatADoctorLooksLike

This article, published in JAMA Internal Medicine describes the personal journey of a physician who is now serving as their authentic self:

…today I serve as a female physician in every respect within the Department of Defense. Last month, I graduated the Army Medical Department’s Advanced Course with honors, and now I look forward to the sec- ond half of my military career being treated like any other capable military physician.

The commentary, by Jamie Henry, MD (@MAJ_JLee_MD), concerns another paper in the journal

Schvey NA, Blubaugh I, Morettini A, Klein DA, KL M, G B. Military Family Physicians’ Readiness for Treating Patients With Gender Dysphoria. JAMA Intern Med [Internet]. 2017 Mar 13 [cited 2017 Mar 16];104(7):e5–6.

which, sadly, shows an important part of our profession unprepared, and in some cases, unwilling to provide care to their patients in need.

Depending on how full your glass is, the figure that 76% say they can provide “non-judgemental care” is either good or bad.

  • Good, because 24% admit that they have bias. To not admit bias leads to more harm and errors, multiple studies show this.
  • Bad, because 24% of physicians will provide care in a biased fashion, which is harmful
  • Good or bad: The 76% who say they can provide “non-judgemental care” may have hidden biases. The literature here is also helpful – there is the “illusion of objectivity” which describes the idea that people who believe they are not biased can be the most biased in their behavior (see these posts on my blog about this).

As Dr. Henry states, there is still a long way to go.

At the same time, how incredible is it that a person can have this aspiration, and fulfill it, because the only prerequisite is that they are human.

I went to medical school for a number of reasons, but primarily I wanted to heal—myself and others.

  • heal society too, which is what will happen, as we change forever #WhatADoctorLooksLike

Also noting the work of Jesse Ehrenfeld, MD – @DoctorJesseMD – working to be an ally for the LGBTQ community.

Love this century 🙂 .

Just Read: #WhatADoctorLooksLike – Implicit Bias in Academic Medicine – via JAMA

Where I went to medical school (University of Arizona College of Medicine), we had the typical “wall of fame” of all the previous graduating classes prominently mounted, covering the history of the school’s first class from 1967 to the present.

It was amusing to note that as you walked along the wall that the number of women in each class steadily increased, to the year after mine, when for the first time there were more women than men in incoming class.

Except that in retrospect, it wasn’t really funny.

The other thing I noticed was that the Nursing School building, erected a few years after the medical school building next to it, didn’t seem to have very many men’s rooms…

The wall showed another thing, that there were no LGBTQ human beings enrolled in this school. Except that there were. However, all the signs and signals in our curriculum and the behavior of our faculty conspired to keep this just an “allegation.”

And so…we can now measure the impact.

This issue of JAMA Internal Medicine includes three studies looking at sex and racial bias in academic medicine, and as it has been shown in many (many) other studies, the profession tends to mirror the society around it. No more, no less. This is a link to the editorial accompanying the studies, written by Molly Cooke, MD (@mollymcooke) at the University of California, San Francisco.

Cooke M, AJM A, RA G, E M, M N-S. Implicit Bias in Academic Medicine. JAMA Intern Med [Internet]. 2017 Mar 6 [cited 2017 Mar 15]; Available from: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.9643

This wouldn’t be a problem (actually, it would always be a problem, but maybe not as high-stakes) if our society’s health didn’t depend on physicians who understand the life experience of the communities they serve (It does).

Another bank of studies show clearly that people learn better from people who resemble their life experience more closely. It’s just science, not an opinion. And so, when people are selected to present at grand rounds:

To the extent that those role models do not mirror the sex and racial composition of the trainee pool, we are delivering the implicit but powerful message that these leadership roles and examples of excellence are for someone else. Women, blacks, Asians, and Latinos need not apply.

I have previously posted on the environment around LGBTQ trainees, also studied, and also with outcomes that parallel these.

Just Read: Sexual and Gender Minority Identity Disclosure: “In the Closet” in Medical School

This gendered quote from a general practitioner in 1966 (the ancestors of my medical specialty, family medicine) is relevant here:

S/He does more than treat them when they are ill; he is the objective witness of their lives. They seldom refer to him as a witness…that is why I chose the rather humble word clerk: the clerk of their records.

If this is what doctors do (it is), then we have an interest in examining our biases and modulating them. And there’s science to show that can be done, too. Isn’t this century grand 🙂 .

One more from Shania Twain, because it’s my RSS feed.

She’s a geologist, a romance novelist
She is a mother of three
She is a soldier, she is a wife
She is a surgeon, she’ll save your life
She’s, not, just a pretty face
She’s, got, everything it takes

I’ll post again on the actual studies referenced.

Just Read: What should people with diabetics eat? Study of a low-calorie ketogenic diet

Just catching up on my blogging and continuing a closer look at nutrition and health.

This paper discusses a different and emerging approach about diet in people with diabetes, beginning with the declaration that we really don’t know what the optimal diet for people with diabetic is:

The optimal degree of caloric restriction and macronutrient distribution of medical nutritional therapy in T2DM is not well defined.

Traditionally, a low-fat diet has been prescribed, which really is a high-carbohydrate diet that brings with it questions about why feeding carbohydrates to people who are intolerant of them makes sense.

In this intervention, subjects were divided and some were feed a ketogenic (higher fat, lower carbohydrate) diet. In medical school, we’re taught that ketones are a bad thing because of their association with a life-threatening condition known as keto-acidosis. However, in people who have some insulin left, ketones become an alternate fuel from the breakdown of fat.

The diet used here appears to be a little “engineered” compared to what I have read is also done, which is little to no calorie restriction.

And…the results show significant weight loss, glucose control, and as seen in other studies, a significant drop in triglycerides, that other under-emphasized lipid in our training (I’ll post on that later).

Interestingly, I ran across this medical practice based in San Francisco (@VirtaHealth) using this approach to achieve better outcomes in Diabetes. So, I suppose this is becoming a thing. With science attached to it, including its own published intervention trial.

Maybe we are set to really change the way we think about healthy eating….

Just Read: Marriage equality = 134,000 less suicide attempts in adolescents

We estimated that, each year, same-sex marriage policies would be associated with more than 134 000 fewer adolescents attempting suicide. These results reflect an important reduction in adolescent emotional distress and risk of mortality from suicide.

Equality does equal health.

I did read the paper and reviewed the analysis – these numbers are possible because 29% of sexual minority adolescents (lesbian, gay, bisexual) report attempting suicide in the last 12 months compared to 6% in the general population.

This is the impact modeled from just one policy change (that has since been applied across the United States) for a subset of the LGBTQ population.

Imagine if every State in the United States was as supportive of equality as Washington, DC is.

Diversity allows the human species to survive 🙂 .

SCOTUS  26251
More love. Less suicide. 2013.06.26 – SCOTUS 26251 (View on Flickr.com)

Raifman J, Moscoe E, Austin SB, McConnell M. Difference-in-Differences Analysis of the Association Between State Same-Sex Marriage Policies and Adolescent Suicide Attempts. JAMA Pediatr [Internet]. [cited 2017 Feb 21]