No, your doctor doesn't know what that medication will cost you, either

In seven years of working on CDC grants focusing on improved care of metabolic diseases like diabetes and high cholesterol, I’ve come to think that two broad factors determine the success or failure of chronic disease management. First, doctors must overcome clinical inertia, the phenomenon in which the doctor and the patient follow the easier path in the encounter and generally leave things as they are rather than stop, start, or adjust therapy when indicated. As many as 85% of visits for high blood pressure are affected by clinical inertia, meaning that medications are not adjusted when the patient’s blood pressure, symptoms, or labs indicate that they should be.

Second, patients who are prescribed therapy must adhere to it. Only about a third of patients two years removed from a diagnosis of heart disease are still taking their cholesterol medications, for example, and only about two-thirds of patients with hypertension take their blood pressure medications on any given day.

One of the most significant predictors of medication adherence is cost. High-deductible plans, the old Medicare “donut hole,” high copays, and expensive branded medications have all been linked to lower adherence rates. One potential solution to this problem is good coaching by the physician and better choice of drugs at the bedside, driven by the physician’s intimate knowledge of medication costs. But do doctors really have a grasp on medication costs? A recent study (paywall) suggests, to no one’s surprise, that they do not.

Investigators sent a survey to 900 outpatient physicians (300 each of primary care, gastroenterology, and rheumatology). A mix of 374 responded. The survey contained a hypothetical vignette in which a patient was prescribed a new drug that cost $1000/month without insurance. A summary of the fictional patient’s private insurance information was provided, including her deductible, coinsurance rate, copay, and out-of-pocket maximum. Doctors were asked to estimate the drug’s out-of-pocket cost at four time points in a theoretical year as the patient’s cost-sharing changed due to other medical expenses.

Overall, 52% of physicians could accurately estimate costs before her deductible was met, 62% accurately used coinsurance information, 61% accurately used copay information, and 57% accurately estimated costs once she met her out-of-pocket maximum. (This performance actually exceeded my expectations. Prior to my exit from daily clinical medicine and entree into the benefits game, I think I would have failed most of these tests.) But only 21% of respondents answered all four questions correctly. The docs’ ability to estimate out-of-pocket costs was not associated with their specialty, attitudes toward cost conversations, or other clinic characteristics.

We need to acknowledge that this is a feature of the system, not a bug. Doctors are not trained to be HR professionals. They’re forced into the role. To quote Malcolm Gladwell:

I don’t understand, given the constraints physicians have in doing their job and the paperwork demanded of them, why people want to be physicians. I think we've made it very, very difficult for them to perform their job. I think that’s a shame. My principal concern is the amount of time and attention spent worrying about the business side. You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.

Many people in the health care industry want the system to stay complex and opaque. That’s why large groups like the AMA and AHA are fighting some of the rules that have come about in the past couple of years. But I hope that your instincts match mine. We have myriad reasons to simplify insurance coverage, but I’ll start with two:

First, by reducing cost and administrative burden, we can make patients more likely to adhere to helpful therapy.

Second, if we can make the system more efficient by eliminating administrative complexity, we can leave doctors, nurses, pharmacists, allied health professionals, mental health professionals, dieticians, and others the brain power to do the work they were trained to do.

We hope you have a happy holiday season!

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Doctors, like orange juice, are better with breakfast

When I was a medical student, I thought I wanted to be a radiologist. I love the science. I like the physics of radiation, and my ego was invested in the idea of being a “doctor’s doctor” that other doctors looked to for wisdom and interpretation of diagnostic testing. Radiology checked all those boxes without the ooey-gooey autopsies and whatnot that are part of the daily routine of pathologists.

Then I did a radiology rotation.

I truly did like the science of x-rays and the conversations with other doctors and all the rest. I discovered one problem, though: I could not stay alert for hours at a time in a dark room looking at films. Come two or three o’clock in the afternoon, I would inevitably start to fade. Once, I even nodded off in the radiology suite. So, with the safety of future patients in mind, I decided to go a decidedly more well-lit and upright route, eventually completing a residency in internal medicine and a fellowship in endocrinology, diabetes, and metabolism. If nothing else, the work in endocrinology was ambulatory. If I’m moving, I can’t fall asleep.

I review my personal history as a wind-up for a research paper in JAMA Health Policy this last week (paywall). Investigators looked at records from primary care practices–these studies always pick on primary care docs–to see how likely a patient was to receive a “statin” medication depending on the time of day of his or her appointment. This is no casual question. Viral pandemics aside, cardiovascular disease remains the leading cause of death in the United States. Appropriate use of statin medications like atorvastatin (Lipitor), rosuvastatin (Crestor), and others dramatically reduce the risk of death from any cause in people at risk for heart disease.

Using United States Preventive Services Task Force (USPSTF) guidelines, which state that we should offer statins to anyone with known vascular disease, anyone with a diagnosis of a genetic problem called “familial hypercholesterolemia,” or anyone with a low-density lipoprotein (LDL) cholesterol level of 190 mg/dL or more (among other diseases like diabetes), the researchers found a disturbing trend. Compared with 8 am appointments, which the investigators used as their reference group, the likelihood of getting a statin was lower at all hours except 9 am. And the likelihood of getting a statin pretty consistently fell as the day went on: 88% at 9 am, 63% at 12 pm, and 69% at 3 pm. Overall, you were only 69% as likely to get an appropriate statin prescription in an afternoon appointment as you were in a morning appointment. Here’s the raw, “unadjusted” data:

JAMA Health Policy

JAMA Health Policy

And yes, radiologists make more mistakes later in their shifts, too. But this phenomenon is not limited to doctors. Judges sentence defendants more harshly just before lunch, when they’re hungry, and sentence more leniently after a break. Car crashes peak between 5 and 7 pm. Students taking standardized tests perform better earlier in the day and recover performance after rest. If you’re like me, you may have found that you do your best creative work earlier in the day, and you’re better off going to meetings or working on a task list later in the day.

The wellness industry has long coached patients to get the earliest available appointment of the day, but our reasoning has had more to do with the fact that if you go earlier in the day, you’re less likely to have to wait. With this data, we have to consider not only the time in the waiting room but the outcome of the visit.

[Disclaimer: the Kansas Business Group on Health has CDC funding to encourage appropriate use of statin medications.]

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

My comments from the Envision Adult Support Group

I had the pleasure of speaking at Envision this morning about diabetes awareness. Here are my comments:

Thank you for having me. This is not my first time speaking at Envision. It’s always a pleasure to be here. There’s an old joke that the moment a speaker steps to the lectern the crowd wonders: will this be a short, informative talk, or are we stepping into a low-key hostage situation? I promise this is not a hostage situation.

This is the story of Victoria. When we tell biographies, one of our first instincts is to say when and where someone was born. “Robert Goddard was born October 5, 1882 in Worcester, Massachusetts.” You know what I’m saying. But here’s the thing: Victoria hasn’t been born yet. Yet we already know some things about her, assuming she’ll be born in the United States. We know she’ll have a lifetime risk of developing diabetes of around 50%. A coin toss. We know she’ll have a lifetime risk of being overweight or obese of at least 70%. Way worse than a coin toss. We know that these risks will be less related to any specific decision Victoria makes than to the environment in which she is conceived, gestated, born, raised, and in which she ultimately works.

But before we get to that, you deserve to know how I make my money. I have a strange career. I’m an endocrinologist by training. That’s a doctor who specializes in metabolism and hormonal disorders. I’m still board-certified, and I still see patients at Guadalupe Clinic. But the much bigger fraction of my career is spent trying to change the way care is delivered. That sounds too simple. You know the frustration of calling for a doctor visit, waiting on hold, getting an appointment months from now, then waiting in the waiting room for a half an hour while you do paperwork, then waiting in the exam room in a paper gown for another twenty minutes, and then never even getting a copy of your labs once you’re done? That’s what I mean. That’s what we’re trying to change. More care can be delivered by non-doctors in non-offices and at the convenience of you, the patient. 

One of the organizations that pays me to try to affect this change is the Centers for Disease Control, the CDC. Specifically, they along with the Kansas Department of Health and Environment pay me to try to encourage more doctors to offer care like the Diabetes Prevention Program or Diabetes Self-Management Education, or the Diabetes Self Management Program, all of which we’re going to talk about today. So be a cautious consumer. As I talk, ask yourself if you think I really believe the things I’m saying, or if I’m just a government stooge repeating words put into my mouth by my benign overlords.

I originally called this talk, “Should I go to diabetes education?” But I’ll talk about more than that.

Let’s get back to Victoria, our future, not-yet-even-a-twinkle-in-her-mom’s-eye. When Victoria grows into adulthood she’ll be told by her doctor that she needs to take in fewer calories and burn more calories in the form of physical activity or exercise. Good advice. We call these the “Big Two”: diet and exercise. And historically we’ve blamed the obesity and diabetes epidemics on decreased physical activity and increased caloric intake. The physics of it just make sense: you can’t make fat out of air. But there’s a big problem with limiting our explanation of her risk to this simple “calories in, calories out” model: the math doesn’t add up. 

Intentional leisure time physical activity--that’s the kind that takes equipment, like shorts or special shoes or a bicycle or a pool--has gone up (way up) since the 1980s. Yet as a nation we’re fatter than ever. Investigators writing on the findings of a 2016 study in Obesity Research & Clinical Practice noted, “A given person, in 2006, eating the same amount of calories, taking in the same quantities of macronutrients like protein and fat, and exercising the same amount as a person of the same age did in 1988 would have a BMI that was about 2.3 points higher…about 10 percent heavier, even if they follow the exact same diet and exercise plans.”

Why is this? Why are we punished for having habits that are objectively better than those of our parents?

Well, it is no one thing. Anyone who tells you that they know the exact problem and have the precise solution is lying or excessively optimistic or both. It’s the combination of a lot of things, and like Victoria’s, our risk is teetering one way or the other long before we’re conceived, let alone born. Let’s go back to pregestational Victoria. 

If Victoria’s mom is anything like most of us, we know a couple things. First, she probably carries a few extra pounds. And we know that those extra pounds carry just the slightest advantage in reproduction. That is, Victoria’s mom is ever so slightly more likely to get pregnant and carry a baby than a woman who is of a normal body weight or who is too thin. So Victoria is simply more likely to be born than someone with a very thin, non-diabetic mom would be.

The second thing we know about Victoria’s mom is that she has probably had some chronic, low-grade lead exposure, especially if she has lived her life in an urban center where dense car traffic spewed leaded exhaust into the air for decades and let it settle into the soil. The higher the lead level in Victoria’s mom’s blood, the higher Victoria’s risk for obesity, even if mom never had enough lead in her blood to be considered “lead poisoned,” and even if Victoria herself never had enough lead in her own blood to be considered dangerous by current standards. 

And birds of a feather, well, you know…flock together. Victoria’s mom is likely to choose a mate whose body in some way matches hers. Or he chooses Victoria’s mom. Either way, since we know that something like two-thirds of body weight is heritable (that is, two-thirds of your risk of being thin or being heavy), having both a mom and a dad who carry extra weight puts even more pressure on Victoria’s future weight.

Since Victoria’s mom and dad have bills to pay, there’s a big chance they put off having a family. That’s the new American way. Not only the American way; the western way. The age at first birth in the United States has gone from 22 to 26 since the 1960s. And every five years parents wait to have a child, the risk of obesity in the child may go up fourteen percent. 

Five years after they marry, Victoria’s mom and dad decide to get pregnant, and they have good luck. But during Victoria’s gestation, her dad encourages her mom to “eat for two.” We now know that increased fat and sugar in mom’s diet can cause “epigenetic effects” in the fetus. Remember the way DNA is put together, with A and T and C and G all writing a code that turns amino acids into proteins? Epigenetic effects aren’t changes in the A-T-C-G order of base pairs in the DNA itself; these are modifications of those base pairs, like sticking an extra branch onto the side of the “A” to keep it from coding quite as efficiently as it should. And we know one of the possible effects of these epigenetic effects may be to make Victoria more prone to weight gain and diabetes.

Finally, Victoria is born. Her mom breastfeeds her, like most moms do now, and which may have some protective effect. But after that Victoria eats what her folks buy for her: a largely government-subsidized diet that is >50% highly processed, has little fiber, and contains >2x the meat needed. We now know that this highly processed food dramatically increases our risk for weight gain and diabetes.

Investigators at the NIH recently paid twenty volunteers (ten men, ten women) to live in a research hospital for a month. They were randomly assigned to eat either an “ultra-processed” diet (think packaged meat, gravy, and potatoes) or an unprocessed diet (like fresh broccoli, cooked rice, and frozen beef) for two weeks. The diets were identical in the number of calories and amount of nutrients like fat, sugar, protein, and fiber. The volunteers were observed closely for food intake, and frequent testing was done to determine how many calories they were burning. After two weeks each person in the study was “crossed over” to the  opposite diet from what they’d started on. That is, the processed diet folks started eating the unprocessed diet, and vice-versa.

What the investigators found was dramatic. In spite of having equal  numbers of calories available to them at every meal and snack, the people eating the processed diet ate about 500 calories per day more  than the people eating the unprocessed diet. This showed up in their weight: the processed dieters weighed, on average, 2 pounds more at the  end of two weeks than they did at the start of the diet. All their extra weight was in the form of fat. And this may not have even done the effect justice: since the processed food had so little fiber, investigators had to sneak fiber into the processed food just to bring the level up to the unprocessed diet’s fiber. Without that, the results probably would have been even more dramatic. 

When young Victoria turns twelve her parents decide to reward her for her good grades with new cell phone. To keep up with the social scene at school she starts sleeping with it, checking social media when she wakes up at night. As a result of this she ends up sleeping less than seven hours per night. This disrupted sleep has a measurable, clinical effect on her appetite, probably because of changes in hormone levels like ghrelin (from the stomach) and leptin (from fat). 

In addition to the effect of abnormal hormones, Victoria is exposed to a lifetime of endocrine disrupting chemicals like those in air pollution, pesticides, flame retardants, and food packaging. Endocrine disruptors are chemicals that mimic or block the effects of naturally occurring hormones. Investigators in 2017 measured the amount of bisphenol A, a chemical you’ve heard of as “BPA,” in the urine of volunteers. They noted that people in the top quartile of BPA excretion, that is, the people who had more BPA in their urine than 75% of their peers, had a mean body mass index (BMI) a full point higher than people with the lowest BPA level. And BPA is one of thousands of potential chemicals we are exposed to now that were not in our environment even a few decades ago. 

While Victoria eats her processed diet and takes in a strange brew of endocrine-disrupting chemicals, she lives and works in a strictly air-conditioned, heated car, office, and home that block any exposure she would normally have to hourly or seasonal temperature excursions. She’s almost never hot and almost never so cold that a cardigan can’t fix it. The effect of this may be to increase hunger. Researchers in the journal Physiology and Behavior noted that people in an office experimentally heated to 81 degrees reported decreased hunger, decreased desire to eat, feeling fuller longer. Not surprisingly, they were thirstier than their cooler peers. 

Because she lives in a cul-de-sacced suburb that is poorly designed for walkability, Victoria does not have the opportunity to walk anywhere. Not to the store, not to work. Her only opportunities for meaningful physical activity come from going to the gym. She cannot spontaneously exercise. The effect of this can be dramatic. In 2014, engineers reported in the Journal of Transportation and Health that going from an intersection density of 81 per square mile to 324 per square mile dropped was associated with a reduction in obesity from 25% to less than 5%. Similarly, going from a community design that made walking difficult to a grid-like walkable layout cut the obesity rate by a third. 

Perhaps in part because of her poor sleep, processed diet, lack of exercise, Victoria becomes depressed and is put on an SSRI medication by her doctor. These medications and many others have the effect of a small but predictable amount of weight gain.

Depressed yet? Don’t be. There’s not a thing on that list that we couldn’t fix if we wanted to. But I’m not here to talk politics or policy. I’m here to talk about things you can do personally to change your risk of weight gain, diabetes, and complications of diabetes. And anyone in the room with type 1 diabetes, which is less affected by weight, don’t go away. A lot of this applies to you, too. 

If you’ve heard me talk before you might be aware of Justin’s Rubric for Quality Health Care. Any potential medical test or treatment should meet one of three standards. Either:

  1. It should make the patient feel better. This includes hundreds of treatments, like using medications and physical therapy for pain, prescribing inhalers for asthma, giving antidepressants and therapy for depression, and replacing knees. It does not, unfortunately, include much of diabetes care. Any person in the room who takes multiple doses of insulin per day and checks her blood sugar even more often than that can attest to this. Or:

  2. If it does not make the patient feel better, the test or treatment should make the patient live longer. This applies to everyday things like checking and treating high blood pressure and high cholesterol (neither one of which make most patients feel any better or worse today) to surgery and chemotherapy for cancers (most of which make patients feel much, much worse at least in the short-term, but prolongs many lives). Or finally:

  3. If a treatment makes no difference in how the patient feels and makes no difference in how long the patient lives, it should at the very least save money. The best example of this may be diabetes screening. As far as we can tell, screening for diabetes does not prolong life, at least not in the two or three trials that have specifically addressed the question. But diabetes screening linked to preventive measures like the Diabetes Prevention Program clearly saves money.

Diabetes was once a syndromic diagnosis, usually diagnosed when someone presented with epic amounts of urine, extreme thirst, unintentional weight loss, and sometimes strange infections. The very words we use to describe this condition give the crudeness of the diagnosis away: diabetes is from a Greek word meaning siphon, “to pass through.” Mellitus is from a Latin root word meaning honeyed or sweet. Because once upon a time, the diagnosis was confirmed by your doctor tasting your urine for sweetness.

But as our ability to test became more sophisticated, we began finding asymptomatic people with elevated blood sugars, and we had to decide who was normal and who was abnormal. It’s a tougher question than you may think, and we may still not know the answer.

So when should Victoria be screened? Or should she be screened at all? Like many questions in medicine, it depends on who you ask. Every test has risks and benefits. In the case of diabetes screening, the risks are small. There is the issue of the needlestick, but beyond that you mainly risk having an abnormal lab value on your chart. The primary benefit is financial. If Victoria is diagnosed with diabetes she can expect to spend $8,000-12,000 dollars more on medical care than the average non-diabetic person, with 12 percent of that coming out of her own pocket. Unfortunately people who are screened for diabetes and catch it early don’t seem to live longer than those who are caught according to symptoms, but they may feel better in the long run. And if we’re lucky enough to catch Victoria’s blood sugars before they rise into the frank diabetes range, we have things we can offer her.

With this in mind The United States Preventive Services Task Force (USPSTF) says that anyone between the ages of 40 and 75 should be screened at least every third year. The American Diabetes Association says that screening should begin at age 45 but expands this to say that anyone as young as age 10 with certain risk factors like family history; Native American, African American, Latino, Asian American, or Pacific Islander heritage; or certain signs of insulin resistance in the skin or reproductive organs should be screened. They’ve developed a tool alongside the American Medical Assocation and the Centers for Disease Control called the Diabetes Risk Test--you can take it yourself at preventdiabeteswichita.com--that asks a few questions (some demographics, your family history, your physical activity, your height and weight) and tells you whether they think you ought to be screened.

Screening generally means a check of Victoria’s first-morning blood sugar after fasting overnight. It can’t be done with a fingerstick, so Victoria has to resist the urge to borrow a machine from her mom. It needs to be done in the lab with blood drawn from a vein.The cutoffs that we set for pre-diabetes and diabetes are, naturally, semi-arbitrary, but they’re ultimately based on the eye. If Victoria’s result is a blood sugar of 126 or above repeatedly, it means she’s diabetic. If you think 126 is kind of a strange number, you’re right. That number is set at the point where she’s more likely to develop diabetic eye disease. So it’s the eyes that make all the difference in how we define diabetes.

If her blood sugar is below 100, she’s normal. But again, if she’s over 40, most people think she should get it repeated at least every third year.

If Victoria’s blood sugar falls into that range of 100 to 125, between “normal” and “diabetic,” her best bet is to seek out the Diabetes Prevention Program, a one-year program designed to help people decrease their risk of going on to develop diabetes. The DPP, as it’s called, is sixteen weekly one hour visits with a health educator followed by eight monthly visits. In those visits you learn problem solving strategies around food choices and physical activity with the support of your coach and a team of other patients. The program has been shown to reduce the risk of going on to develop diabetes by almost sixty percent, roughly twice as effective as metformin, a common diabetes medication. In addition to simply making your numbers look better, the DPP has been shown to improve cholesterol levels, to reduce absenteeism from work, and to increase patients’ sense of well-being. For anyone insured by Medicare, the program is a covered benefit. 

But what about the unlucky folks who go on to have diabetes?

We have a great program available here in town called the diabetes self-management program, or DSMP. It was developed by researchers at Stanford who were interested in making people with chronic diseases feel more in control of their lives and their destinies. It is 2.5 hours a week for six weeks, and it is taught not by a nurse or a doctor, but by a person who has diabetes herself. Investigators have determined that going through a self-management program like this reduces days in the hospital by almost two per year, probably cuts ER visits, cuts the risk of depression, and reduces low blood sugars. Best of all, it is free! If you’re interested, either ask your doctor or go to selfmanageks.org.

Last year investigators looked for randomized trials--that is, studies where patients are randomly assigned one treatment or another--of diabetes education. They included only trials that compared diabetes education with usual care, and they included only trials that lasted at least a year. Ultimately they found 42 trials that met these criteria, enrolling just over 13,000 patients and lasting an average of a year and a half. What they found was striking: diabetes self-management education significantly cut the risk of dying of any cause in type 2 diabetes patients by 26 percent. That is, a patient in the diabetes education arm of one of these studies was 26% less likely to die, by car wreck, chocolate poisoning, diabetic ketoacidosis, or any other cause, than a person receiving usual care.

In spite of this evidence, the utilization of diabetes education is disappointingly low. Only about one in five patients with diabetes ever attend. 

So let’s review, very briefly. Our risk--and Victoria’s--for being overweight or obese or having diabetes begins to accrue long before we’re even conceived and is constantly modified by our environment as we age. But many of the things that affect that risk--the cleanliness of our air, the foods available for us to eat, the design of our streets, and others--are modifiable. If in spite of optimizing all those things you still find yourself with an elevated blood sugar, you have several options.

So if you think you might be at risk for diabetes, get tested. If you’re pre-diabetic, ask for a referral to the diabetes prevention program. If you’re like Victoria, if your diabetes is out of control--if your hemoglobin A1c level is higher than what your doctor would like it to be, or if you have low blood sugars--ask your doctor about getting into a diabetes education program. If your diabetes is well-controlled numbers-wise but you feel out of control, also consider going to the  diabetes self-management program. The risk of the program is vanishingly low, and the potential benefit is large.

Should young, healthy people with type 1 diabetes take statins?

I encountered this question a couple months ago in a consult and intended to blog about it then, but relatively little trial data was available. I would have essentially been giving my own off-the-cuff opinion. That's very unsatisfying to me, and probably to the reader.

As background: we tend to think of type 1 diabetes as more a need for hormone replacement (insulin) than as a disease state requiring the complex management that type 2 diabetes requires. That is to say that type 1 diabetes, for all the unpleasantness it causes for people, is easier on the blood vessels as a general rule than type 2 diabetes. The ADA has a statement in its guideline that "For patients with diabetes aged <40 years with additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity or high-intensity statin and lifestyle therapy." It's a category C recommendation, meaning it's mostly opinion and has a less-than-spectacular evidence base. It also doesn't differentiate between type 1 and type 2 diabetes. Similarly, a joint statement by the ADA and the AHA states that "Adults with T1DM who have abnormal lipids and additional risk factors for CVD (eg, hypertension, obesity, or smoking) who have not developed CVD should be treated with statins." Both statements argue against the routine use of statins in young healthy type 1 diabetics.

But a recent study from the New England Journal helps us with the question of statins in kids, and throws in ACE inhibitors for good measure. Investigators led by M. Loredana Marcovecchio and Scott T. Chiesa randomized 443 kids between 10 and 16 years with type 1 diabetes and urine albumin-to-creatinine ratios in the upper third of "normal" to some combination of ACE inhibitor, statin, and placebo. Creatinine is a consistently excreted product of muscle metabolism that serves as a nice comparator for other things the kidney excretes. So even if you drink a lot of water and dilute the amount of albumin in your urine, we can look at it compared to the similarly diluted creatinine and see if you're excreting too much.

Anyway: the investigators used a 2 x 2 trial design, meaning that there were ultimately four groups: placebo-placebo, placebo-ACEi, placebo-statin, and ACEi-statin. The statin was atorvastatin 10 mg daily, and the ACEi was quinapril 10 mg daily (after titration). They were most interested in the change in albumin excretion (that is, how much protein spilled through the kidneys into the urine). They assessed this according to that same measure, the albumin-to-creatinine ratio in the urine, from three early-morning urine samples obtained every 6 months over about two and a half years. They also looked at secondary outcomes like the new development of microalbuminuria (that is, the new appearance of protein in the urine), worsening of eye disease, changes in kidney function, blood lipid levels, and measures of cardiovascular risk. For the cardiovascular risk, they did ultrasounds of the carotids to measure the thickness of the vessels (carotid intima–media thickness) and measured levels of high-sensitivity C-reactive protein and asymmetric dimethylarginine in the blood. Both of these are generic markers of vascular risk.

After an average of 2.6 years, no benefits were found within the ACEi group, the statin group, or the ACEi+statin group compared to placebo. Unsurprisingly, the ACEi group had a much lower incidence of new microalbuminuria, but "in the context of negative findings for the primary outcome and statistical analysis plan, this lower incidence was not considered significant (hazard ratio, 0.57; 95% confidence interval, 0.35 to 0.94)." Also unsurprisingly, the use of statins resulted in lower cholesterol levels (including, unfortunately, HDL). But neither drug had significant effects on carotid intima–media thickness, C-reactive protein, kidney function, or progression of eye disease.

So we can take away from this small-ish study that, at least in a short amount of time in pretty healthy twelve-year-olds (the subjects were excluded if they had genetically bad lipid levels; the participants' average A1c was ~8.3% and their average blood pressure was 116/65 mmHg), there was no benefit to statins or ace inhibitors. This study will influence my recommendations to patients and other docs in the future. The kicker, naturally, is that many young people with type 1 diabetes have imperfect blood sugar control. What about those who can't get their diabetes controlled? It's a tougher call in that case, and this study didn't address it. 

What's with all the arrows?

You’re back! I guess the random link dumps and talk about what a tightrope we're all on health-wise didn't scare you off. Where to start today's post, then? Let’s start with the name. Why “Double Arrow Metabolism?”

I grew up on a farm in south central Kansas. Our farm raised cattle, at least until I was 13-14 years old or so. According to WikiPedia, branding, in the form of burning a pattern into animals’ hair and skin, has been performed since at least ancient Egyptian times to identify cattle. The Wild West of the 1970s and '80s hadn't changed the practice. Our farm’s brand was the double arrow, two vertical arrows arranged in parallel, each with an arrowhead on each end. You can see it splattered all over this site:

Everything in Kansas leans to the right.

Everything in Kansas leans to the right.

Now, this may be simple coincidence, but as you may recall from post #2, I’m an endocrinologist, a hormone and metabolism specialist. And if there’s a medical specialty that loves arrows, it’s endocrinology:

There was a time when I could draw this from memory. Then I decided that God gave us Google images for a reason. Now that space is taken up by happier memories.

There was a time when I could draw this from memory. Then I decided that God gave us Google images for a reason. Now that space is taken up by happier memories.

Wow! Converting cholesterol to hormones takes a lot of arrows. And chicken wire. Maybe now you can see how, when my world shifted from the windy, sun-drenched agrarian plains of southern Kansas to the fluorescent, air-conditioned, mint-scented hallways of medical academia, sometimes my studies reminded me of home. And not to get sentimental, but that two-headed arrow has always looked like it wanted to move. It reminds me of freedom of movement back and forth between phases or choices. Or, in my case, over the last couple of years, movement away from those fluorescent-lit hallways back to the outdoors and back in contact with people, not just patients.

So: Double Arrow Metabolism.

It’s not particularly catchy. It doesn’t follow the craze of single-word names out there (Spruce) or baby noises (Hulu) or left-out vowels (Scribd, Flickr) or any of the other internet weirdness. It hasn't been tested for SEO or "optimized" (I hate that word) through Google Ad Words. It hasn't been A/B tested.

But it’s honest. And since I’m looking to connect with people and not necessarily just to optimize search engine results, I like the homage to my past. Plus, metabolism is a cheap way to sound smart without using a word people can’t pronounce (if I'm looking to throw out unpronounceable words, I think I've covered that with the diagram above).

I promise that I’ll get back to discussing the path toward medical, financial, and health independence soon. But first a couple of observations: you shouldn't let the process of getting yourself healthier intimidate you. Just as not every new business name has to follow the naming conventions of Silicon Valley, not every healthy person has to be an athletic coastal hipster foodie or a lycra-covered sex kitten. I mean, if that’s what you are, then great. Magazines apparently can’t shoot enough pictures of you:

Backstreet's back, alright!

Backstreet's back, alright!

But you can just as easily be a middle-aged, slightly frumpy guy like me who decided to paddle himself out of the vortex we talked about in post #1. And you can be as happy as that guy is at how it feels to have your feet planted on dry land.

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