Environmental Pollution Linked to Decreasing Lifespan and Increased Deaths

Worsening air pollution is killing more people at a younger age. We read on a daily basis about a White House sponsored movement back to the use of coal for fuel. At the same time, rules and regulations designed to keep our air and water clean are being relaxed by Administration appointees to the Environmental Protection Agency.

Instead of protecting the environment so that future generations have clean air to breathe, and water to drink, we see rule after rule put in place to protect our countries environment scraped by officials who cite economic profit and jobs over environmental concerns for future generations. When the discussion gets heated, officials cite the fact that even if we use clean energy, developing countries like China and India and third world nations produce enough environmental pollution to offset our best efforts.  The rhetoric goes back and forth between advocates for developing and exporting clean energy (solar, wind, natural gas and nuclear) versus coal products. But, what do the facts say?

A recent study published in the Journal of the American Medical Association Open Network directly linked air pollution and its contribution of fine particulate matter to the atmosphere with an increased burden of death from several causes. The researchers followed 4,522,160 military veterans in the USA from 2006 to 2016 and linked their exposure to increased particulate matter or pollution to increased deaths from nine causes including:

  1. Heart Disease
  2. Cerebrovascular Disease
  3. Chronic Kidney Disease
  4. Chronic Obstructive Pulmonary Disease
  5. Dementia
  6. Type II Diabetes Mellitus
  7. Hypertension
  8. Lung Cancer
  9. Pneumonia

The increased death rate was more noticeable in persons of color living in poor socioeconomic communities. The causes of death were in no way related to accidents.

The concentration of pollutants the study population was exposed to was actually lower than the new relaxed standards the current Environmental Protection Agency has approved. Last month a similar study was presented at a worldwide meeting of the World Health Organization.

The message is quite clear.  Unless we want to see a rising death toll due to air pollution, we need to improve the air quality and ask for more stringent standards. At the same time, the USA needs to support the development of clean fuel and energy sources that we can export to developing countries so that their reliance on coal and polluting sources diminishes.

We need to do what we can to control the issue rather than continuing policies that increase the deaths of our citizens in the name of profits.

Generics and Therapeutic Substitution – Safety and Efficacy?

Excuse me for being a “doubting Thomas,” but when I saw articles in JAMA Internal Medicine and commentaries supporting use of generics instead of brand name drugs I asked myself “Where is the proof of equivalent results and safety?”.  Generic substitution implies that the original product is no longer patented and exclusive and another firm is now producing an identical chemical version which produces the same beneficial effects on the patient.  Therapeutic substitution means your pharmaceutical insurance company or pharmacy changes the drug you are prescribed to one in the same drug class. Think of drinking Coca Cola and having the supermarket substitute a comparable brand instead.

The reason for this is simply to spend less money. Many pharmaceutical insurance companies realize if they put an obstacle in your path of obtaining your medication you likely will pay for it independently saving them money.  The authors of the JAMA articles estimate between 2010 and 2012 therapeutic substitution would have saved $73 billion. The out-of-pocket savings to the patient would have amounted to $25 billion.

I’m for saving money and spending less with certain guidelines. However; I want to know that a generic medicine is produced in a factory inspected by the Food and Drug Administration (FDA) at least as frequently as the drugs produced in North American factories. I like to know where the drug was made including country of origin, city, location and the plant’s track record for health and safety. I also want to know the generic medication produces the same drug levels and positive effects as the brand name medication and is made with no more contaminants than the original branded product.

I need reassurance that my patient isn’t receiving a counterfeit product with stolen original labeling, which has been a scam fooling pharmacists and Customs agents for years.   I would additionally like to know that the generic product, or therapeutically substituted product, works as well as the original. We know for example that Levothyroxine generics and substitutions are problematic.  We additionally know that the beta blocker carvidilol (Coreg) has certain unique properties that other beta blockers do not provide making therapeutic substitution for less expensive medications in the beta blocker class problematic.

Once this information is available it should be distributed in package inserts, online and taught in pharmaceutical, nursing and medical school courses as well as CME courses for health care professionals.

There is an abnormally perverse concern that if a pharmaceutical representative takes a health care provider out for a meal and a drink while explaining their product, we will prescribe it even if it is more expensive or doesn’t work as well.  I doubt sincerely that most physicians would do that but do believe if the cost is comparable, or less, and the efficacy is as good, they might choose the product as a viable alternative.

Lipid Testing Continues After LDL Target Met

A study performed at a Veterans Affairs medical center in Houston, Texas claims that physicians are ordering too many lipid levels on patients with coronary artery disease who have met the LDL (low density lipoprotein) guidelines of <70mg/dl. They looked at 35,191 patients and found that 9200 of these patients had already achieved the desired lipid levels however their clinic physicians ordered a repeat lipid panel on subsequent tests. The researchers cited the Institute of Medicine guidelines which suggest testing your lipid levels only once a year once you have achieved goal levels. If that annual test reveals an elevation of your lipids outside guidelines and it leads to an intensification of your treatment, then they believe it is acceptable to recheck your cholesterol and its subtypes to assess the effectiveness of the treatment.

The study was published in the online edition of the Journal of the American Medical Association (JAMA) by Salim S. Virani, MD PhD of the Michael DeBakey VA and Baylor College of Medicine in Houston. They concluded and an accompanying editorial questioned whether this was an overuse of resources and wasteful spending that was not being discussed by health policy experts because this was low expense non procedural waste and not a big ticket item. They stressed the need to get this wasteful spending under control if we expect to reduce overall health care costs.

In my internal medicine practice, an individual who achieves goal levels of lipids by losing weight, or eating a different diet, or exercising more vigorously or by taking a medicine may in fact alter their habits over a 3-6 month period. They may gain back the weight they lost. They may reduce their exercise due to scheduling conflicts or physical injury and health problems. They may alter their medication regimens or be placed on medicines by other doctors that influence their lipid levels. There are very few patients in my practice that are static and have no changes from quarter to quarter of the calendar year. I make no money sending off blood tests. The lab makes a great deal of money. They have a very high fee schedule for uninsured patients. Their fee schedule for private insurances and Medicare is still far higher than the fee they will charge your doctor if the doctor charges the patient directly and pays the wholesale cost to the lab for that test. Maybe the researchers and cost effective analysts should be looking at the actual cost to the lab of performing the test and insuring that the profit they make is appropriate not price gouging instead of worrying about an additional two or three lipid panels per patient per year. When I send your blood to a reference lab I earn no money on it but do bear the responsibility for interpreting the result and conveying it to you. It seems to me some of the research on cost effectiveness is getting very penny wise and pound foolish.

Benefits of Smoking Cessation Outweigh Negatives of Weight Gain

A196HJ Woman smoking a cigarette Exhaling tobacco smokeIf you wish to extend your life and stay healthy then giving up smoking tobacco is a major positive step. The benefits include an immediate drop in your cardiovascular disease risk profile, a drop in the possibility of developing numerous types of cancer and a decrease in the likelihood of developing chronic obstructive lung disease.

Smoking is an expensive, dirty habit that not only sickens you but exposes those around you to an increased chance of disease due to others breathing in your second hand smoke. Asthma in children is now believed to be related to the children’s exposure to their parents’ second hand smoke. One of the negatives of stopping smoking is that individuals tend to put on weight. Weight gain and obesity are known risk factors for the development of heart disease and vascular disease.

In the March 13th issue of the Journal of the American Medical Association (JAMA), Carole Clair, MD, of the University of Lausanne in Switzerland examined the question of whether the weight gain was detrimental to your heart health. She accessed data from the famed and long term Framingham Offspring Study looking at the years 1984 through 2011 for 3251 study participants who were free of cardiovascular disease at the start of the analysis. These participants underwent a checkup every four years and were placed into categories such as “recent quitter” (stopped smoking within 4 years),” long term quitter” (nonsmoker for > 4 years) and nonsmoker.

As anticipated, smoking cessation was associated with a weight gain of 5.9 lbs. in the recent quitters and 1.9 lbs. in the long term quitters. Smokers also gained weight during the study period while the country underwent and obesity epidemic. Smokers gained an average of 1.9 lbs. while nonsmokers gained about 3 lbs.

They followed these people for 25 years and defined 631 “cardiovascular events.” In reviewing the data they concluded that former smokers had about one half the risk of developing cardiovascular disease as smokers. When they factored in the weight gain associated with smoking cessation it had no effect on the reduction in cardiovascular disease.

They concluded that the findings support, “a net cardiovascular benefit of smoking cessation, despite subsequent weight gain.” The goal is clear. Stop smoking and then we will work on the weight gain.

Today’s Seniors Are Not as Healthy as Their Parents

Baby Boomer Couple, cropped

In the online version of the Journal of the American Medical Association an analysis of data compiled by the National Health and Nutrition Examination Survey ( NHANES) suggested that today’s baby boomers are not as healthy as their parent’s generation. The baby boomers, born between 1946 and 1964, may live longer but they do so with more complaints and more chronic illnesses.  The study compared the two generations at ages 46 and 64 on several health measures using the years 2007- 2010 for the baby boomers and comparing it to data they had from 1988- 1994 for the prior generation.

The demographics in the two groups indicated a larger number of Hispanics and non-Hispanic Blacks in the baby boomer generation than the previous generation.  The data in many cases was self-reported with only half as many baby boomers 13% reporting their health as “excellent” while their parents’ generation had 32% respond excellent to the same question.  The baby boomers reported that more were using walking assisted devices, more were limited in work and more had functional limitations than their parents’ generation. As a group, obesity is more common in the baby boomers (39% vs. 29%), as is high blood pressure, elevated cholesterol and diabetes.

The prior generation got more physical exercise than the baby boomers by a margin of 50% compared to 35% when asked if they were getting exercise at least 12 times per month. Smoking was more common in the prior generation.  The study authors concluded that we need to “expand efforts at prevention and healthy lifestyle promotion in the baby boomer generation.”

It is hard for me as a clinician to gain much insight from this data. Clearly the previous generation lived through a depression and fought two major wars. Their definition of “excellent” may be different than baby boomers whose expectations may be completely different from reality.

An epidemic of obesity has contributed to an increase in its associated diseases including diabetes, high blood pressure and lipid abnormalities. The goal of education and prevention is a wise one and needs to start in the preschools and elementary schools if we wish to be a healthier society

 

Antibiotic Use in Sinusitis

In the Journal of the American Medical Association researchers reported that treatment with antibiotics did not improve the speed of recovery or perceived symptoms in patients who took antibiotics.   One hundred sixty-six (166) adults were either given a course of amoxicillin or a placebo three times a day for acute rhino sinusitis. There was no difference in symptomatology at day three or day 10 between the two groups.

If a physician documented severe nasal obstruction the use of antibiotics did produce some perceived improvement in symptoms. There were no differences in the groups for any secondary outcomes, including days missed from work or school, additional health care consultation or recurrence of symptoms .   All the patients were allowed to take medications other than antibiotics for symptom relief during the study.  The conclusion is that antibiotics are not necessary for the treatment of acute rhino sinusitis.