June 6, 2017 link-a-dink

The idea that good diabetes care isn't strictly an obsessive quest for an A1c level of 7% or less is finally hitting the mainstream press. This article also touches on the very real dilemma that doctors and patients face: Do we use old, cheap drugs that are effective at lowering the hemoglobin A1c level, or do we use new, astonishingly expensive drugs that have better evidence of actually reducing death?

Most people will never understand my eating disorder. "I am six feet tall and between 180 and 190 pounds, depending on the month. I am by no means the picture of health or even particularly muscular-looking—not for someone who exercises this much, and definitely not compared to most of the men I see at my gym. Or maybe I am? That's the problem, or one of them: What I see when I look in the mirror doesn't correspond with reality. I see a fat piece of shit, and then I think to myself that it's time to punish my body for letting me down."

Do patients make mistakes during doctor visits because they're put in a position that forces them to rely on intuition and makes them vulnerable to biases? 

June 2, 2017 links to skim

Michael Bliss, author of The Discovery of Insulin, has died. RIP. I read his book while I was an endocrine fellow, overlapping, ironically, with a trip to Toronto for the Endocrine Society conference. His work was accessible, non-academic, and revealing.

“Family-based weight loss therapy sessions worked just as well whether children attended or not, as long as their parents did,” researchers found in a “two-arm trial” that included “150 overweight or obese children ages 8 to 12 and their parents.” Parents, your work with your children matters a lot. 

Whole-body vibration may be as effective as exercise in mice. Color me skeptical. I first heard of vibration for metabolic disease in a presentation by an astronaut in college in the nineties. And, in spite of the plethora of machines available claiming to vibrate you to better health, the science just doesn't seem to have advanced that much. I'll skip my vibration sessions for the time being. 

Summer sausage link-fest May 25, 2018

If you're overweight, combining aerobic exercise with strength training has the biggest effect on frailty. This is a small, but exceptionally well-conducted trial that is getting press because 1) it got into the New England Journal of Medicine, easily the most influential medical journal in the world, and 2) it addresses a functional outcome, not just weight. It seems to go under-recognized that obesity leads not only to inferior cosmesis and an increase in heart disease, sleep apnea, arthritis, and what not, but that it actually makes people frail. In my time running a medical/surgical weight loss clinic, we routinely asked incoming patients if they were able to get themselves off the floor in case of a fall. The patients were almost always surprised by the question, but many of them, after some thought, said that no, they would not be able to get themselves up after a fall. They were that frail. 

Speaking of exercise, your watch or other wearable sucks at telling how many calories you've burned. This isn't a surprise, given the disparate results I've seen from my old, broken Nike Fuel Band, my Garmin GPS, and apps like MyFitnessPal. And even though I've never heard of the Journal of Personalized Medicine before ten minutes ago, the methodology of the paper is solid. But the results were best, strangely, with cycling. This gives ammo to the old argument that people who like data (speed, weight, power, HR, etc) are naturally drawn to cycling.

Links for May 17, 2017

A patient once 3-D printed this owl for me. It was pretty badass. But nowhere near as badass as a functioning 3-D printed ovary that allows mice to get pregnant(!).

Kids who eat meals at regular times, go to bed on time, and don't drool in front of a screen hours a day have a lower risk of obesity later in life. Huh. "Three-year-old children who had regular bedtimes, mealtimes, and limits on their television/video time had better emotional self-regulation. Lack of a regular bedtime and poorer emotional self-regulation at age 3 were independent predictors of obesity at age 11."

Are the flame retardants in your house putting your cat (and you?) at risk of hyperthyroidism? As much as I'm fascinated by the topic, I'm even more in love with the idea of an "animal endocrine clinic." 

Links to wrap your head around May 10, 2017

Your dog won't protect your kid from type 1 diabetes. This goes against the theory (which I tend to agree with) that "eating dirt protects us from autoimmune diseases."

Gluten-free diets don't appear to cut heart disease risk. Let me get this straight: celiac disease affects (thankfully) a very small fraction of people. For the rest of us, going gluten-free may increase our risk of diabetes and doesn't seem to have other beneficial effects. So why are so many people going gluten-free?

More and more companies are bringing out closed-loop insulin pumps.

Link the Hylian May 2, 2017

This author says the diabetics will be the first to meld with machines. I think everyone with a pacemaker may take issue with that statement. The first closed-loop insulin pump is a sign of what's to come though. 

Alternate-day fasting is no more effective than good ol' fashioned dieting for weight loss. Aaaand, people on alternate-day fasting were a lot more likely to quit the diet. HDL went up a little more in the alternate-day fasting group, but other markers didn't differ between the groups. I think there is promise to "fasting" insofar as that means just not continually stuffing food into your mouth between meals. I'm less convinced of any benefit of intentional witholding of calories for days at a time. 

The weakest link-fest April 27, 2017

Man, Kottke.org has been on fire lately with health-related videos and links. Above is a sweet demo of four ways to put roads on diets to reduce congestion and increase safety. 

And then there's this little micro-documentary on a guy who tries to do a DIY-style fecal (and skin and nasal) microbiota transplant. This definitely falls outside the guidelines for the procedure. 

And finally, the story of a science writer who turned a Seinfeld episode into a "case report" for an open-access journal and got it published. I've linked Kottke's page because he does such a good job of explaining it and has all the relevant links. The chief complaint and history (but minimal physical examination) are here:

Spring link 5-pack April 26, 2017

What are Americans dying of? Spoiler alert: obesity. Second spoiler alert: complications of diabetes.

Artificial sweeteners may be associated with stroke and dementia risk. I've mostly given up artificial sweeteners, but not because of this paper. I'm making a bit of a Pascal's wager on artificial sweeteners: they're surely not good for us, even though they may not be as bad as sugar itself. So I take steps to avoid them, just like I take steps to avoid sugar itself. The fact that this paper didn't show any risk associated with sugar-sweetened beverages makes me a little suspicious of its results. Maybe the editorialists' note that people sometimes switch to diet soft drinks after they are flagged as "high risk" by their doctors is right. They're on their way to a stroke one way or the other, and they just happen to have switched to a diet drink beforehand.

Garden City, Kansas voted to raise the legal age for the purchase of tobacco or e-cigarettes to 21 years. The decision "grew from a request made by a group of Garden City High School students earlier this year." Garden City is the fifteenth (!) city in Kansas to make such a decision.

Exercise may help cognition (that's the thinking part) in the elderly. Seemingly if you work moderately hard for at least 45 minutes. What is moderate? According the ACSM guideline they used, it is hard enough to use "40%-60% heart rate reserve." That means halfway between your normal resting heart rate and your maximum heart rate, which is usually calculated by subtracting your age from 220. So if your normal heart rate is 70 and you're 50 years old, you have a maximum heart rate of ~170, so using 50% of your heart rate reserve would mean getting your heart rate to ~120. Confused? Well, "moderate" intensity is also about a 5 or 6 out of 10 in perceived exertion. There. 

The FDA is warning (again) about bogus internet cancer treatments. A couple observations here: 1) I can't believe it's only 65 products. That must barely scratch the surface. 2) I don't know if the fact that so many of the products are co-marketed for cats and dogs is a good sign or a bad sign. 3) Even a casual observer must be astonished that we know so much about how to prevent cancer, and it's not complicated, and it's generally cheap or even money-positive (don't smoke, get a little exercise, eat fruits and vegetables, wear sunscreen)

But yet we as a society are so much more interested in giving our money to snake-oil salesmen for untested bunk.

Sausage Linkfest April 21, 2017

Like them or not, soda taxes seem to work. That is, they work to reduce sugar-sweetened beverage consumption. Time will tell if we can trace any health benefit back to them, like we did with trans fat bans. 

School shouldn't start before 8:30, say the sleep people.

Biking to work is associated with a 41% reduction in the risk of dying over five years. Biking was also associated with 45% lower rates of cancer and a 40% lower risk of dying of cancer. And, as has been noted here before, it's associated with having a shitload more money in your bank account.

Even short-term corticosteroid use is harmful, says a review in the BMJ, with accompanying coverage from the NYT. This is ironic, considering a very recent well-publicized study advocating for 10 mg of dexamethasone in place of antibiotics for sore throat. So a couple comments: first, even the "low-dose" steroids the BMJ article talks about constitute a potentially huge dose (20 mg daily). Second, 10 mg of dexamethasone is just a gigantic, chemotherapy-level dose. It is saved by the fact that dexamethasone has a half-life of only ~3 hours, so most of it is gone by the second day. But still...whatever happened to chicken soup and time for things to get better? *sigh* I guess dexamethasone isn't any worse than the cursed "Z-Pak" that urgent cares seem to hand out like Halloween candy. 

Richard Link-later April 18, 2017

Banning Trans Fats in NY reduced heart attacks by 6%. If this is true, it's astonishing. Researchers compared admission rates for the composite of myocardial infarction and stroke between New York counties implementing the ban in its eateries versus those that did not. The restricting counties showed an additional 6% drop in admissions relative to non-restricting counties after adjustment for an already-declining trend across the state. The difference became significant 3 years after implementation of the bans and benefitted men and women equally.

Newer, novel (and astonishingly expensive) diabetes drugs seem to have lower hypoglycemia, heart, and death risk than good old insulin: even though this study had a lot of warts (industry-funded, retrospective, yada yada), I'm having a harder and harder time justifying the addition of insulin to high-risk patients' regimens.

"My V-steam cost $50, which is a lot to pay for sitting over hot vapor. Is your money well spent on this stuff? It depends on what you’re looking for."

It's a "fear social media" bonanza! First up was Hidden Brain on the dangers of curating your social media presence to look universally positive:

And then (and then!) Ezra Klein, a journalist I've heard my fair share of thoughts from in regards to how social media doesn't make him happy, interviewed Cal Newport about his notoriously fuddy-duddy views on social media, which I'll cover briefly in the very near future on this very blog.

I was asked recently to name a book that changed my life. The book I chose was Cal Newport’s “Deep Work,” and for the most literal of reasons: it’s changed how I lived my life. Particularly, it’s led me to stop scheduling morning meetings, and to preserve that time for more sustained, creative work. Which is all to say that I’m a bit obsessed with Newport’s work right now, and especially his account of how the digital environment we inhabit is training us out of concentration and into distraction in ways that are bad for us, bad for our work, and ultimately bad for the world. Most of the conversations on this podcast are how to think about things differently. This one is too, but it’s more importantly about how to do things differently, and why you should do them differently. We discuss: -How Newport defines depth when it comes to work -Why the information revolution boosted productivity up until the 2000s, but then stagnated -What he thinks is problematic about the constant accessibility of technologies like email, Slack, and other communication tools -His perspective about how we’re still in an early age of the internet, and what looking back at periods like the Industrial Revolution can teach us about using new technology to work smarter -How to take productive breaks, rather than flicking through email and Facebook and Twitter -How “flow work” and deep work overlap, and how they’re distinct from each other -Why he consumes and produces information more slowly and more traditionally—through newspapers and radio, and why that might benefit people who work in the knowledge economy -His vision of the workplace of the future I hope you get as much out of Newport’s ideas as I have. Books: -Jaron Lanier, “You Are Not A Gadget” and “Who Will Own The Future" -Douglas Rushkoff’s “Throwing Rocks at the Google Bus”

For past thoughts on social media, check here and here.

And PS--I mean fuddy-duddy in the most admiring, sincere way, obviously.

Have a linkboy, not a poolboy April 10, 2017

Most of us eat chocolate bunnies ears-first. Better to not eat them at all, but...

The FDA has given clearance to 23andMe to perform genetic testing for ten diseases. The links are theirs, not mine:

• Parkinson’s disease,
• Alzheimer’s disease,
• Celiac disease, a disorder resulting in the inability to digest gluten that everyone thinks they have; maybe this will set their minds at ease,
• Alpha-1 antitrypsin deficiency, a disorder that causes your lungs and liver to literally digest themselves,
• Early-onset primary dystonia, a movement disorder,
• Factor XI deficiency, a blood clotting disorder,
• Gaucher disease type 1, an organ and tissue disorder in which white blood cells get abnormal sphingolipid deposits,
• Glucose-6-Phosphate Dehydrogenase deficiency, also known as G6PD, a condition that makes red blood cells fragile,
• Hereditary hemochromatosis, a disorder of iron metabolism that leads to excess iron build-up,
• Hereditary thrombophilia, a blood clotting disorder

Vitamin D supplementation probably doesn't prevent heart disease. After all the vitamin D promise (hype?) in the oughts, it's one negative trial after another nowadays.

Big swings in weight may be associated with increased risk of heart attack and stroke. I'm skeptical of the result, but if true, this is yet another way you can improve your chances of a long, healthy life. Eat good foods, get yourself around under human power, get some sleep, and watch your weight hit a natural level for your body. If you're very heavy or having complications of your extra weight, think about bariatric surgery. No need to have your weight swing back and forth 50 pounds a year for the rest of your life. 

Re-link-uishment April 6, 2017

Genetically modified organisms are safe to eat. Period. Anyone who tells you otherwise is misinterpreting the data or deliberately misleading you. But food safety is only part of the picture. Some uncertainty remains about the safety of the organisms to the environment. Agricultural monoculture, with hundreds of acres repeatedly planted to one, two, or three crops, is surely a bad idea. Reducing pesticide use with GMO crops is surely a good idea, but it has the specter of downstream effects that may currently be unknown hanging over it.  

Would Silicon Valley rather make death less likely or life better? Evidence seems to point to #1; most social media and apps turn out to be tools for either wasting our precious time or toys for rich people. 

Is it foolish for a woman to cycle alone across the Middle East? It is stories like this that make me miss social media. But not enough to go back to it.

Levothyroxine didn't make older people with subclinical hypothyroidism feel any better in an RCT. Huh.

Switching poorly controlled people with type 1 diabetes to an insulin pump before "optimizing" their diabetes education may not be helpful. The training only took five days, and at 24 months, both groups (pumpers vs. educated) had similar reductions in their HbA1c level. "These results do not support a policy of providing insulin pumps to adults with poor glycemic control until the effects of training on participants' level of engagement in intensive self management have been determined." How to determine their level of engagement seems to be the bugaboo, then. 

Out like a lion links for March 31, 2017

What happens when diagnosis is automated? From the always excellent Siddhartha Mukherjee. Spoiler alert: some good things, some bad things. Reminiscent of the discussion of genomic diagnosis from a few days ago.

UK grocer Tesco has struck a deal to give ALL unsold food to charity, which temporarily restores my hope for the future of humanity.

Aaaaand there it went. Hope is gone: Bodegraven, Netherlands, has installed LED traffic lights on the sidewalk at pedestrian crossings so that phone worms can’t miss them even if they are staring open-mouthed their smartphone screens.

Linque dump March 29, 2017

Whaaa? Joakim Noah was suspended for using an androgen receptor modulator, and he don't care who knows it. The science of these is fascinating. LGD-4033 is one of several new-ish compounds designed to stimulate the anabolic effect (think muscles) of the androgen receptor without tickling the androgenic effects (think beards and penises). It will not surprise you to know that they are meant for treating muscle-wasting diseases and not NBA players with bad haircuts in career downturns. 

When CVS stopped selling cigarettes, it dropped the smoking rate by 1% in the states CVS operates in. “It shows that responsible behavior by a pharmacy has public health benefits for the whole population,” Stanton Glantz said...

Is it more dangerous to be a black pedestrian in the US than it is to be a white pedestrian? "...when the women were in the middle of the road, cars in the high-income area with the faster, wider road were seven times less likely to yield to the black pedestrian than the white pedestrian."

There are at least 79 rare genetic syndromes that have obesity as a feature. This finding underscores the likelihood that in the future, much diagnostic work will be done genomically and not clinically. Real-life paper here. 

Spring has sprung link dump March 27, 2017

Men today have weaker grips than their fathers. From my own study of this topic (n=1), I've known this since I was a wee little boy.

Drinking fruit juice (aka "all-natural bug juice") is associated with weight gain in young kids.

You'll soon be able to use your smartphone to 1) access the masturbation superhighway*, and 2) do a semen analysis on the results. *the internet, of course. But not this little corner of it.

Link dump March 20, 2017

Everything old is new again. Whole-body vibration may improve metabolism in mice. I fully expect vintage vita-masters to become the new hot thing on eBay:

Click here if you wanna buy this baby. Time's running out!

People without diabetes are wearing continuous glucose monitors (CGM) for reasons I completely fail to understand. 

Myron Rolle, former All-American defensive back for Florida State, will enter a neurosurgery residency in July. This counters the frequent narrative of the under-performing college football player, and further counters the infrequent college football player who makes a big deal out of his intentions for medical/graduate school and never follows through. See also John Urschel, NFL offensive lineman and badass MIT mathematics grad student. 

Delta Dental has shockingly good data on what your kid's tooth is worth to the Tooth Fairy. Spoiler alert: $4.66: 

The combination of good drugs and cheap, immersive technology is driving millenial men away from even seeking work. "It is not always clear when gaming is the refuge of the trapped and when it is the trap." But see also, "A life spent buried in video games, scraping by on meagre pay from irregular work or dependent on others, might seem empty and sad. Whether it is emptier and sadder than one spent buried in finance, accumulating points during long hours at the office while neglecting other aspect of life, is a matter of perspective."

Howard County, Maryland reduced consumption of bug juice by 20% without a soda tax. 

Leprechaun link-a-dink March 17, 2017

From Bike Snob NYC:

This video "...articulates the relationship Americans have with cars better than perhaps anything else I've ever seen...  Really, this video has everything, included but not limited to:
--"American" car ostensibly with all-terrain capability [ed: note that you could get almost anywhere with a car worth less than $10,000 that burned 1/3 the gas and didn't fetishize obsolete 1940s-era technology. Or at least you could get stuck in the snow for a lot less money];
--Driver completely unable to utilize this all-terrain capability [ed: see above] due to his complete ignorance with regard to the nature of traction and gravity;
--Road rage [ed: completely avoidable had he just taken off walking down the street. In the seven minutes of his tantrum, he easily could have covered a half-mile or more, which gets close to the most common length of a car trip in the US];
--Grown man throwing an obscenity-laden temper tantrum in front of a private residence in clear view and earshot of children [ed: errrrr...glass houses for me].
Yes, it's quite satisfying to see someone's faith in their lavish purchase get completely shattered, though it's horrifying to consider this represents the state of mind of many of the drivers with whom you "share" the road."

Giving school kids fruits and vegetables and restricting their access to bug juice may make them live longer, healthier lives. Go figure. But previous reservations about unpublished conference presentations apply. 

Letting a kid stare blankly at a piece of glass with moving colors and pictures on it for three hours a day is associated with increased fat mass and increased insulin resistance. Good to know. But the fact that 2-3 hours of screen time was in most markers better than 1-2 hours makes me suspicious of any neat, tidy linear relationship between screen time and bad metabolic markers.

In the spirit of people giving up on weight loss, overweight moms may underestimate the weight of their own kids.

A man lived alone for 27 years in the Maine backwoods. "...he did not follow any formal religion; he was not protesting modern society; he produced no artwork or philosophical treatise. He never took a photograph or wrote a sentence; not a single person knew where he was. His back was fully turned to the world. There was no clear reason for what he chose to do." This is not a recommended life strategy. Side note: this story was written by Michael Finkel, known to me as the Jonah Hill character in True Story.

Climate change is already affecting our health, says a consortium of eleven medical societies. Popular Science has a take. Among their findings and vulnerable groups:

• Extreme heat is adversely affecting people with chronic conditions, outdoor workers, student athletes, and people lacking air conditioning
• Air pollution from increased smog, wildfires, and pollen is detrimental to people with asthma and chronic lung conditions
• Increased geographic range of disease-carrying ticks and mosquitoes threatens anyone who spends time outdoors
• Contaminated food and water puts children, seniors, the poor, and people with weakened immune systems at risk

Linkfest March 15, 2017

Watch a professional cyclist's carbon wheel melt before your very eyes:

Some people think going gluten-free may be risky for diabetes. Hmmm. Gluten-free diets are, for the most part, a waste of time and effort unless you have celiac disease. And whole grain intake is generally associated with a decreased risk of diabetes, which is consistent with the alleged findings of this study. And this paper (not yet published) comes from Harvard, which gives it a certain cachet, but I'm always skeptical of big, splashy pronouncements like this when they're made ahead of publication. Too many of these studies end up having fatal flaws.

Bikes now officially outnumber cars in Copenhagen. "When Copenhagen first began manually counting cars and bikes in 1970, there were 351,133 cars and 100,071 bikes on the roads—a ratio of about 3.5 to 1. That's important, because it means not only are more people riding—about 150 percent more over 46 years—but also, fewer people are driving."

How the world's heaviest man lost it all. "The only thing that gave him comfort in life was food. It was a drug of abuse, freely available, heavily marketed."

Is loneliness the biggest threat to middle-aged men? Well, Vivek Murthy is definitely qualified to say so, and I think we're self-isolating ourselves with suburban homes and gadgets, but "biggest" is a stretch when we still have tobacco and obesity/diabetes to contend with...

Big pharma is very nervous about possible Trump FDA deregulation. This one cuts both ways. On one hand, I'm afraid that ineffective drugs are going to start coming to market if deregulation goes too far. On the other hand, any deregulation that is opposed by big pharma is inherently attractive.

The ADA 2017 Standards of Care in Diabetes are out. "To help providers identify those patients who would benefit from prevention efforts, new text was added emphasizing the importance of screening for prediabetes using an assessment tool or informal assessment of risk factors and performing a diagnostic test when appropriate." It's a start.

Link-o-rama - March 10, 2017

"Someone in Kansas Created a Protected Bike Lane Using Toilet Plungers—and It's Amazing"

"The true paleo diet is eating whatever’s out there in the environment." Based on DNA in dental plaque, it looks like Neanderthals ate whatever they could get their hands on, not just organic, grass-fed beef and free-range chicken. Huh.

Florence Williams on the Outside Podcast talking about her new book "The Nature Fix," which I'm reading right. this. minute.

The bacterium Akkermansia muciniphila appears to protect against obesity and diabetes in mice. Google is already crawling with ways to buy it, natch. *shakes head*

Link dump - March 8, 2017

Fewer and fewer Americans report trying to lose weight. We may be settling into our role as the one of the fattest countries on earth (we're coming for you, Tonga...). I can't help but think this is because of the many, many, many shitty options that people have had pushed on them that didn't work. Now they've given up. *sigh*

The search for the perfect artificial sweetener continues: 

"Let us pause here to acknowledge the sugar-frosted codependent embrace of Big Food and the American consumer. You could rightly fault consumers for their insistence on an oxymoronic product. But who has been indulging their fantasies for decades now, promising sweet, satisfying taste and no calories? Big Food, of course. Now customers are upping the stakes—and it’s not at all clear that companies can pass the test."

In what seems like a just reversal of a law that had the unintended consequence of highlighting the law of unintended consequences, after 60 years, street hockey will once again be legal in Hamilton, Ontario, under the following conditions:

• The roadway has a speed limit of 40 km/h or less and is a local road.
• Play happens in a place that is "safe and suitable."
• People play no earlier than 9 a.m. and no later than 8 p.m.
• No one plays during periods of limited visibility from fog, snow or rain.
• Play is stopped for any vehicles. ("Car!")

Having robot minions control the lights for them may be turning kids into a bunch of lazy, entitled monsters.

No one can get you to take your medicines but you. Three reminder devices to take your medications were no better than no notification or device in a randomized controlled trial. 

Go. To. Bed. People who get out of bed in the morning tend to eat better and earlier in the day than night owls. Original paper here.

"We found that night owls had postponed timing of food intake, and less favorable eating patterns with higher intakes of sucrose, fat and saturated fat in the evening hours than early birds," said Maukonen, a doctoral candidate in the department of public health solutions.