In Defense of Aging

Photo: Karsten Thormaehlen “Happy at Hundred – Portraits of centenarians”

Photo: Karsten Thormaehlen “Happy at Hundred – Portraits of centenarians”

“When nine hundred years old you reach, look as good, you will not.”
Jedi Master Yoda

My patients occasionally ask me “do you have something that will make me younger?” Sometimes they’re just joking and want to complain a bit about some indignity of getting older. But frequently they’re serious and would like me to reverse some ravage of time. What I find fascinating is that they don’t ask “Do you have something for wrinkles?” or “Can I have a medicine for erectile dysfunction?” or “My hot flushes are terrible. Can you do anything for them?” They blame their symptoms on their age and have decided they’ve had enough of aging.

I hope I’m not the first to break this to you, but your age is just the elapsed time since you were born. The only way to be younger is to be born later. If you’re unhappy with when you were born, take it up with your parents. But if you’re unhappy that you’ve gotten old, I’d like to try to change your mind.

Lots of my older patients are nostalgic about their youth. And many are much less healthy than they were a decade or two ago. And seen through the haze of imperfect memory, it’s tempting to romanticize the past. But would any of us really want to relive our youth? Would we give up the wisdom and experience that we’ve amassed over decades in exchange for painless joints? Would we trade the deep committed relationships we have now to fall in love for the first time again? If we could get rid of every one of our chronic illnesses to reenact all the mistakes we made in our twenties, would we?

I hope not.

We live in a youth-obsessed time in a very youth-obsessed place. But like youth itself, this phase must pass. All philosophies that have stood the test of time and all civilizations that have lasted more than a few generations venerate their elders. Movements that celebrate youth are either shallowly materialistic or radical revolutions. Eventually both consumers and hippies grow up and the bubble bursts. Pete Townsend, who wrote the lyrics “Hope I die before I get old”, turned 70 this year, and I hope he has many happy healthy years ahead of him.

In Los Angeles, patients are likely to be exposed to many types of quackery. There’s the chronic Lyme disease quackery, the intravenous vitamins quackery, and the homeopathic herbalist quackery. But the quackery that makes me saddest is anti-aging quackery. It’s just as ineffective as any other form of quackery, but it’s sadder because it’s based on a double lie. It preys on patients’ irrational fear of aging, and rather than convince them otherwise, it sells them hormones and supplements and other nonsense. There’s never been a better time to be old. I’m a pro-aging doctor; if I do my job well my patients get older.

My oldest patient is 101. I saw her this week. She walks without a cane. She’s mentally sharp. She’s happy. Her biggest complaint is that her friends are so much younger than her. She’s never asked me to make her younger.

I wish my Jewish patients and readers a sweet and healthy year. And I hope that all of us, Jew and gentile, get a year older.

“Live long and prosper.”
Vulcan benediction

Learn more:

Some Notes on “Anti-Aging” Programs (Quackwatch)
Meditations (Marcus Aurelius)
On the Shortness of Life (Lucius Annaeus Seneca)

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Frequently Raised Objections to the Flu Shot

Influenza_VaccineLast week our office received our batch of flu shots for the upcoming flu season. Every fall I urge my readers to get a flu shot. If you’d like to know the different kinds of flu vaccines available, and which is right for you, read my post from last year.

This year I’d like to address the most common objections that patients raise when I recommend a flu shot.

The flu shot might make my arm sore.

That’s true.

I’ll get the flu.

That’s not true. The injectable vaccine has no live virus. It might make you achy or have a low grade temperature for a couple of days, but it can’t give you the flu. And you can’t transmit the aches and low grade temperature to anyone else.

I’m young and healthy and nothing terrible would happen if I contracted the flu.

Fair enough. I usually only harangue patients over 65 and those with chronic illnesses about getting a flu shot. But you should know that the CDC recommends the flu shot for everyone over 6 months who doesn’t have a specific contraindication. Even if you get through the flu just fine and aren’t worried about the misery and lost productivity, consider that you might infect someone much frailer than you.

I got a flu shot four years ago and my hair caught on fire, or I got a flu shot four years ago and later that day my boss yelled at me, or I got a flu shot four years ago and right after that came down with syphilis. I haven’t had a flu shot since then.

This is such an old and well known logical flaw that the ancient Romans had a name for it. Something that happens after something else wasn’t necessarily caused by that first thing. That’s why we need randomized trials to figure out the effects of any intervention. I assure you that the flu shot does not lead to more hair catching on fire / bosses yelling at you / syphilis than placebo. (Though I suspect those specific effects weren’t specifically tested in randomized trials, so I guess we should both keep an open mind.) But I also understand that the mind creates nearly unbreakable bonds between perceived causes and perceived effects so my only suggestion would be to try it again and see if you have better luck this time.

You can’t tell me what to do. This isn’t North Korea.

That’s true, assuming you’re an adult. (If you’re a child, what are you doing in my office without your parents? I don’t take care of children. Take it up with your pediatrician. Go on. Scram.) I’ll only give you good advice. You can refuse. But I don’t think they have flu shots in North Korea.

The last time I got a flu shot the area around the flu shot was red and swollen and painful.

Reactions around the injection area can happen. They usually resolve in a few days and they don’t mean that you can’t have a flu shot again. You shouldn’t have a flu shot if you have an allergy to eggs or have had a severe allergic reaction (hives, swelling around your mouth, trouble breathing) to a previous flu shot.

You’re just a shill for Big Pharma which is trying to inject us with chemicals.

Well, I’m not a very well paid shill. I only get money from my patients. I’m a big proponent of evidence-based medicine which is neither for nor against Big Pharma, but rather for whatever medicines have been proven to be safe and effective. I’ve been advocating vaccine use on my blog for years and have yet to receive a promotional fee from any shell corporation, bogus front, or slush fund of Big Pharma. I don’t even know who manufactures flu shots, but whoever they are, they haven’t even bought me a tuna sandwich. This is patently unjust. If any of you have connections to Big Pharma, please put in a good word for me.

And get your flu shots.

Learn more:

Vaccination: Who Should Do It, Who Should Not and Who Should Take Precautions (Centers for Disease Control and Prevention)
Key Facts About Seasonal Flu Vaccine (Centers for Disease Control and Prevention)

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Unvaccinated Boy in Spain Dies of Diphtheria

A child with diphtheria with the characteristic swollen neck.  Image credit: CDC Public Health Image Library #5325

A child with diphtheria with the characteristic swollen neck.
Image credit: CDC Public Health Image Library #5325

I love writing about vaccine-preventable diseases. I’ve written about measles, polio, and whooping cough. That’s because vaccines have become victims of their own success. Less than one hundred years after some of these vaccines were first used, they have led to the disappearance in the developed world of some of the most devastating infectious diseases. This extraordinary success has led to complacency or outright skepticism about vaccines among people whose grandparents knew the horrors of infectious diseases and rightly saw vaccines as godsends.

I’ve never seen a single case of tetanus or polio or measles, and I hope it stays that way. But it’s much more difficult for typical parents who have also never seen a case to understand the misery that these diseases caused not very long ago. Add to that some beautiful but idiotic celebrities who stoke fear about vaccine safety and a fraudulent study linking vaccines to autism and the result is a small but growing cadre of parents who refuse vaccines for their children.

Unfortunately, this summer diphtheria is in the spotlight.

Diphtheria is caused by a bacterium. It is transmitted from person to person through respiratory droplets by coughing and sneezing. A person can also contract diphtheria by handling an object, like a toy, that has been contaminated with the bacteria. It typically causes weakness, sore throat, fever, and enlarged lymph nodes in the neck. Two to three days later a thick coating builds up on the throat or nose, making it hard to breathe or swallow. The bacteria produce a toxin that is absorbed into the blood stream and can damage the heart, kidneys, and nerves. Diphtheria is treatable with antibiotics, but even with treatment 5% to 10% of patients die. Before antibiotics the disease was fatal in up to half of cases.

In 1921 there were 206,000 cases of diphtheria in the US, causing 1,520 deaths. When vaccination began in the 1920s case numbers quickly plummeted and there has not been a death in the US due to diphtheria for many years. There are scattered cases occasionally but between 2004 and 2008 no cases were recorded in the US.

Well, it’s time to celebrate, get complacent, and flirt with dangerous anti-vaccine propaganda!

In June a six year old boy contracted diphtheria in Spain and died. This was not someone who didn’t have access to healthcare. His parents had refused having him vaccinated. He was the first death due to diphtheria in Spain in 29 years. South Africa is currently facing an outbreak that has sickened fifteen and killed four.

Every day we make use of technology that would have been miraculous just a generation ago. It’s hard to remember that. I use Bluetooth to pair my smartphone to my car. I get turn-by-turn spoken directions using maps on Google’s servers. A flock of satellites allow my phone to figure out its location. It’s hard to keep track of the staggering number of technological breakthroughs at my command. It’s easy to believe that this is the natural order of things. It’s almost impossible to remember that the achievements that we rely on daily are the incremental accumulated work of generations, and that they could just as easily be undone.

Vaccine-preventable diseases are making a comeback because we’re forgetting what the world looked like without vaccines. If we don’t remind ourselves from the history books, we’ll be reminded by the news.

Learn more:

Diphtheria reported in Spain, 1st case in three decades (Outbreak News Today)
Boy Dies of Diphtheria in Spain, Parents Rejected Vaccine (AP)
South Africa diphtheria update: 15 cases and four deaths (Outbreak News Today)
About Diphtheria (Centers for Disease Control and Prevention)
Diphtheria vaccination (Centers for Disease Control and Prevention)

Measles Makes a Comeback (my post in 2014)
Polio Outbreak in Syria (my post in 2013)
Study Linking Vaccines to Autism not Just Wrong, Intentionally Fraudulent (my post in 2011 about the retraction of a fraudulent study)
California’s Whooping Cough Epidemic (my post in 2010 about pertussis)

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Best Treatment for Chronic Insomnia is Cognitive Behavioral Therapy

Photo credit: Vic / flickr, Creative Commons License

Photo credit: Vic / flickr, Creative Commons License

I’m having trouble trying to sleep
I’m counting sheep but running out
As time ticks by…
And still I try…
— Brain Stew by Green Day from the album Insomniac

Sleep that knits up the raveled sleave of care,
The death of each day’s life, sore labor’s bath,
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast.
— Shakespeare, Macbeth

Chronic insomnia affects 5% to 15% of Americans. It is far from only a nighttime problem. As all of us know from occasional sleepless nights, the following day is unproductive and sometimes dangerous. Sleep deprived people are more prone to accidents, and are more likely to have depression, anxiety, diabetes and high blood pressure.

It is no surprise then that many patients seek relief from sleep medications. But most medications are only modestly effective. Many medications also slowly decline in efficacy over time, and some have worrisome side-effects.

Cognitive behavioral therapy (CBT) has been known to be effective for chronic insomnia for some time. CBT is a specific kind of psychotherapy that focuses on thinking and on behavior. It is unlike older kinds of psychotherapy (like psychoanalysis) in that it’s much more brief and pragmatic. It has been proven to be effective in many anxiety disorders, and unlike medications, the benefits of CBT have been shown to persist long after the therapy ends. (Four years ago I wrote about the utility of CBT in chronic fatigue syndrome.) CBT for insomnia (CBT-i) usually involves weekly hour-long meetings with a psychologist. The course of therapy can be as brief as 4 to 8 sessions.

This week, Annals of Internal Medicine published a review of prior studies of CBT-i. The study reviewed 20 randomized controlled trials involving over 1,000 participants. CBT-i significantly improved sleep and did not have adverse outcomes. On average, subjects who underwent CBT-i fell asleep 20 minutes faster and spent 30 fewer minutes awake during the night compared with people who didn’t undergo CBT-i. This may not seem like a large benefit, but it is the same magnitude as the benefits seen in trials of sleep medications, and without the side-effects that medications can cause. Like other studies of CBT, this review showed that the benefits of CBT-i persist after the therapy ends. This is another positive comparison with medication. At best, the benefits of sleep medication end as soon as the patient stops taking it. At worst, stopping the medication leads to rebound insomnia making the symptoms worse than before the medication was started.

Much of CBT-i focuses on teaching good sleep hygiene –behaviors that promote healthy sleep. These behaviors include avoiding caffeine in the afternoon, avoiding alcohol at bedtime, and not staying in bed for longer than 20 minutes if you can’t fall asleep. That last bit of advice may seem counterintuitive, but going to another room until you’re feeling sleepy will train you to associate your bed with sleep. For the same reason you should avoid reading, watching TV, or using electronic screens in bed.

A related editorial in Annals of Internal Medicine makes the point that changes in attitude and behavior are necessary to treat other health problems like high blood pressure, obesity, and diabetes. Drug therapy alone is not adequate for these chronic problems. We should not be surprised then that this is also true for chronic insomnia.

So doctors should do a better job of referring patients with chronic insomnia to CBT-i. And patients should realize that there is a safer and more effective option than medication. Of course finding a psychologist who has been trained in CBT isn’t always easy, especially outside of large cities. There is also an online CBT-i program for those who can’t find or can’t afford in-person therapy.

We’ve known for a long time that chronic sleeplessness is a serious problem. But it turns out that before we can fall asleep we first have to knit up the raveled sleeve of care and balm our hurt minds. As of now, the best way we know to do that is CBT-i.

Learn more:

The Evidence Points to a Better Way to Fight Insomnia (NY Times)
To Beat Insomnia, Try Therapy For The Underlying Cause Instead Of Pills (Shots, NPR’s health blog)
Cognitive behavioral therapy offers a drug-free method for managing insomnia (Harvard Health Blog)
Sleep Hygiene (National Sleep Foundation)
SHUTi (an online CBT-i program)
Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis (Annals of Internal Medicine article, abstract available without subscription)
Cognitive Behavioral Therapy for Chronic Insomnia: State of the Science Versus Current Clinical Practices (Annals of Internal Medicine editorial, subscription required)

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Paying Smokers to Quit

Photo credit: Coco champion / Wikimedia, Creative Commons license

Photo credit: Coco champion / Wikimedia, Creative Commons license

Smoking is a major cause of heart attacks, strokes, emphysema, and lung cancer. Smoking rates have steadily declined in the US in the last 50 years, but about a fifth of US adults still smoke. Helping them quit would make a major contribution to their health.

A study in the current issue of the New England Journal of Medicine (NEJM) studied the effectiveness of different incentive programs on smoking cessation. Over 2,500 smokers were randomized into three groups. One group received “usual care”, meaning encouragement to quit smoking and information about quitting programs and nicotine replacement products. Another group was invited to join a “reward program” in which each subject who successfully quit smoking for 6 months received an $800 reward. The third group was invited to join a “deposit program” in which each subject had to pay $150 which would be forfeited if the subject kept smoking. If the subject quit smoking for 6 months, however, she would receive her deposit back and an additional $650.

6% of the usual care group had successfully quit smoking for six months. 90% of those invited to join the reward program enrolled, and 16% of them successfully quit smoking for six months, much more than the usual care group. Of the subjects invited to join the deposit program only 14% accepted. But of those who accepted, over half successfully quit smoking for six months (or 7.6% of those invited). So overall the deposit group did worse than the reward group, because so few people accepted enrollment into the deposit group. Of those who enrolled in both groups, the deposit group did much better. The findings of the study are well summarized in this short video.

This study sits at an intersection between health research and a relatively new field called behavioral economics. Behavioral economics studies the consistent ways that people make irrational decisions. One finding that has been substantiated by many studies in behavioral economics is the phenomenon of loss aversion – people avoid losses more then they seek gains. For example, most of us will work harder or sacrifice more to avoid a $50 loss than to make $50.

A related NEJM editorial makes the point that this study demonstrated loss aversion in two ways. One was that the subjects who agreed to the deposit program were much more likely to quit smoking than those who agreed to the reward program. That means that people were more willing to quit smoking to recoup their own money than to make additional money. The second demonstration of loss aversion is that so few people agreed to enroll in the deposit program.

I’m sure there are practical lessons here both for policy makers and for friends and colleagues of smokers. If I had a close friend who smoked I would suggest that he write a check to a cause or a candidate or a group that he absolutely loathes. He hands the check to me. I promise that if he quits smoking and doesn’t restart in a year I tear up the check, but if he doesn’t then I mail the check. I suspect if the check amount was painful enough, the success rate would be very high.

Learn more:

Healthy, Wealthy (NEJM Quick Take video)
Nudging Smokers (NEJM editorial)
Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation (NEJM article)
Trends in Current Cigarette Smoking Among High School Students and Adults, United States, 1965–2011 (CDC)
Quitters, Inc. (A short story by Stephen King about a very effective program to quit smoking)

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Another Path to Reform

New York taxis -- transportation dinosaurs Photo credit: Wikipedia

New York taxis — transportation dinosaurs
Photo credit: Wikipedia

It’s very hard to find a product or service that is both lousy and unaffordable. Such expensive duds are usually quickly replaced by cheaper and better competitors. Yet prior to the Affordable Care Act, healthcare was becoming more expensive every year while simultaneously becoming less convenient, less personal, and less satisfying. In 2009 I wrote a series of four posts explaining how the healthcare marketplace reached such a sorry state and offering a suggestion for reform.

Since then the Affordable Care Act has passed. For many, insurance has become much more affordable, but whether this translates to better or more affordable care remains to be seen. If it results in many patients receiving affordable insurance that very few physicians accept, then the situation will be a repetition of the Massachusetts experience with universal coverage: Everyone has insurance; no one has a doctor.

At the same time, the intrusive and complex bureaucracy that physicians must navigate to collect insurance payments has vastly expanded. Physicians are now coerced into serving as the workforce for Federal plans to collect healthcare data, cut costs, and make their care increasingly legible to payers but increasingly opaque to patients.

Bear with me for just a few examples. In an ill-advised plan called “meaningful use” physicians receive incentives for submitting complex reports documenting their use of electronic health records (EHRs). The time and effort required to comply with this program has earned it much scorn from physicians. And the incentives will likely distort the true value of EHRs and inflate their costs.

The International Classification of Diseases (ICD) is the coding system used by physicians and billers to report to insurance companies patients’ diagnoses. In October the government will update ICD to its tenth version. ICD-10 will contain radically more complexity than its predecessors. It is widely ridiculed for the detail with which diseases must be reported. (Code V91.07XA is for a “burn due to water-skis on fire.”) The transition to ICD-10 was already postponed once and I predict it will cause much disruption and grief.

My last example is the recently passed Sustainable Growth Rate (SGR) “fix” which gets rid of the annual congressional scramble to increase Medicare reimbursement to physicians by increasing reimbursement in the short term, but tying reimbursement to outcomes measures in the long term. This is sure to become a data collection and reporting hassle that makes doctors long for the simpler days of “meaningful use”.

I honestly believe that there has been more bureaucratic complexity added to the typical physician’s life in the last few years than in the twenty years before that. None of it cares for a single patient.

Two weeks ago my family and I spent 10 days visiting New York City. We had a wonderful time. The services that completely transformed our experience were the ride sharing services of Uber and Lyft. We never used public transportation. We never hailed a taxi. For longer trips (and a family of five) this was likely cheaper than train tickets. For shorter trips it meant not handling cash, never finding bus or subway stops, and never referring to transit schedules.

For years passengers complained about high taxi prices and poor taxi service, and potential competitors complained about the legalized monopolies given to taxi companies by city governments. But rather than bang their heads against these barriers, companies like Uber and Lyft just started giving people rides.

This was an epiphany to me. I had always assumed that fixing the healthcare marketplace would mean political reform – undoing the myriad laws that substituted insurance for healthcare and caused prices to skyrocket, and dismantling the byzantine bureaucracy that physicians must navigate. Now I understand that political reform is both unrealistic and unnecessary.

Doctors and patients aren’t waiting for political reform. More and more doctors are “going off the grid” to provide excellent care unencumbered by insurance regulations. Concierge primary care is just one example. The Surgery Center of Oklahoma lists on its website the prices for every surgery it offers. The prices are all-inclusive. You won’t get a separate bill from the anesthesiologist, the surgeon, and the facility. And they don’t care what insurance you have because they won’t deal with any insurance company. Other innovative companies are using video conferencing technology to connect patients to doctors thousands of miles away. LUX Healthcare Network (with which I’m proud to be associated) is building a multi-specialty concierge physician network.

I argued six years ago that using insurance for routine care is wasteful. I now realize that attempts at universal coverage and the bureaucracy that comes with it – ICD-10, meaningful use – will never be repealed. This bureaucracy will become the taxi monopolies of healthcare – increasingly ignored by both doctors and patients and increasingly irrelevant. The successful enterprises in healthcare will connect doctors and patients and then get out of the way. Like Uber and Lyft they will help patients find the service they want at a price they’re happy to pay, and they will facilitate not regulate the delivery of excellent care.

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On Delivering Bad News

Photo credit: Physicians News Digest

Photo credit: Physicians News Digest

Delivering bad news is part of my job, an important part.

It is fashionable nowadays to speak of the doctor-patient relationship as a partnership. In the sense that both doctor and patient have important roles to play for the patient to get good care, that’s very true. But even in the best of times, it’s a very asymmetric partnership. Even in a run-of-the-mill visit for a sinus infection the patient and the doctor bring very different skills, experiences, and expectations to the encounter.

The more unexpected and unusual the clinical situation is, the greater the asymmetry between doctor and patient. A perfect example is benign positional vertigo, which is common enough that primary care doctors see it all the time, but most patients have never heard about it. The symptoms are scary, but the prognosis is fine. Ninety percent of the time all that is needed is a careful examination and some reassurance. The patient and the doctor come to the encounter with completely opposite attitudes. The patient is terrified by the vertigo and has never heard of anything like this. Is it a stroke? Is it a brain tumor? For the patient, it’s the first time he’s had vertigo. For the doctor, it’s the hundredth case he’s seen. The doctor’s job is just to rule out a couple of rare but serious possibilities and break the good news in a credible but reassuring way.

That’s a picnic compared to delivering catastrophic news. That’s when the ever-present asymmetry between doctor and patient threatens to be a gulf that can not be bridged. The doctor and the patient couldn’t be in more different positions. The doctor has been through this many times before and is not in danger. The patient has never been through this before and has a life-threatening problem. The doctor is thinking of a checklist of tests to consider, specialists to call, treatment options to weigh. The patient is barely processing the bad news.

Much has been written on the art of delivering bad news. There are entire books and classes devoted to the subject. I am certainly a continuing student, not a master, in this field. The key is the understanding that the patient can not bridge the chasm of experience and expectation between him and the doctor; he can’t even meet the doctor half way. He can’t develop the perspective of seeing a dozen patients with the same illness go through treatment. He can’t review the literature about his disease. He will only hear the words “cancer” or “stroke” or “Alzheimer’s” or “ALS” and hear nothing else until the shock wears off. The doctor has to remember that his hundredth time of delivering terrible news is the patient’s first time hearing it.

The surprising thing is the patient’s response. I’ve seen brilliant successful patients retreat behind a fortress of denial, leaving all important decisions to their upset and bewildered family. I’ve seen emotional breakdown, of course. But surprisingly frequently, even when the family expects emotional breakdowns, I’ve seen courage, and calm, and even acceptance.

About ten years ago, a middle-aged man who had been my patient for many years came to see me for some worrisome symptoms. I ordered a test and the following day called him with the results. He had a kind of cancer that usually had a terrible prognosis. A few days later, waiting for a procedure, he said to me “I have no regrets. I love my family. My family loves me. I’ve lived a good life.” He passed away within a month. He was not an old man. He would have been justified in ranting about the decades that were stolen from him. But instead he faced his mortality unflinchingly.

This week I told a sweet older lady that she has a life-threatening illness. Her son held her hand while I rubbed her shoulder. “Might this kill me?” she asked. I told her it might. We’re taking it a day at a time.

The lesson I keep relearning is that delivering bad news is tough. That’s probably a good thing. If it ever gets easy I should retire. The lesson patients keep teaching me is that they’re frequently tougher than anyone expected.

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Consuming Peanuts in Infancy Can Help Prevent Peanut Allergies

Photo: Wikimedia / public domain

Photo: Wikimedia / public domain

Food allergies are commonly misunderstood, so please bear with me while I first explain what food allergies are and are not. Various foods can cause all sorts of unpleasant effects. Most of these are not allergies. Allergies are only reactions caused by a specific antibody (called IgE) that results in hives, trouble breathing, or a life-threatening condition called anaphylaxis. So, if yogurt gives you diarrhea, that’s not an allergy. It might be lactose intolerance. If coffee gives you palpitations, you’re not allergic to coffee; you’re having a side-effect from the caffeine. Ditto chocolate worsening your heartburn; not an allergy.

Of all foods that cause allergic reactions, peanut allergies are the leading cause of anaphylaxis and death, and the prevalence of peanut allergies in the US has grown fivefold in the last 13 years, from 0.4% in 1997 to more than 2% in 2010. This increasing prevalence of a potentially life-threatening allergy has caused some schools to ban peanut products and has caused some airlines to stop offering peanuts in their snacks.

Believing that repeated exposure in infancy of allergy-causing foods leads to allergies, health officials in the UK in 1998 and in the US in 2000 published guidelines recommending the exclusion of foods likely to cause allergies from the diets of infants at high risk of developing allergies. But subsequent studies failed to show that elimination prevented the development of allergies, so the recommendations were withdrawn in 2008. Since then, pediatricians have had no solid evidence on which to base recommendations, until now.

A study in the UK published this week in the New England Journal of Medicine (NEJM) enrolled 640 infants between the ages of 4 and 11 months who were considered to be at high risk for peanut allergy because they had severe eczema or egg allergies, or both. They were all given a skin-prick test to check for peanut sensitivity. The infants that had a severe reaction to the skin-prick test were excluded from the study. Infants who had no reaction or a mild reaction were enrolled and were randomized to two groups.

The parents of children in one group were told that their children should avoid peanut products. The parents of children in the second group were instructed to give their children at least two grams of peanut protein three times a week. (Their first exposure to peanut protein was done under medical supervision.)

The peanut source given to the infants in the study was Bamba, an extremely popular Israeli children’s snack made from puffed corn and peanut butter. If you’ve spent any time in Israel around kids you’ve seen Bamba. Hilariously, the authors admit that “it was not possible to administer a placebo for Bamba because of financial and logistic constraints.” I can imagine the researchers desperately trying to figure out how to make something that looked and tasted like Bamba but without peanuts, and then giving up when they realized that that this would be more expensive and take longer than the rest of the study. The authors tell us that smooth peanut butter was supplied for those infants who didn’t like Bamba, but intensive psychiatric testing would have been more appropriate, because Bamba is delicious.

The children were followed until they were five years old and then given a supervised oral challenge of peanut protein to test them for allergies.

The results were quite dramatic. Among the children who initially had no reaction to the peanut sensitivity skin-prick test, 13.7% (about 1 in 7) of the children who avoided peanuts became allergic, compared to 1.9% (about 1 in 50) of children who consumed peanuts. That means that for every 8 children who consumed peanuts one fewer child developed a peanut allergy.

The results in children who initially had a mild reaction to the skin-prick test were even more impressive. These children were at much higher risk of becoming allergic since their mild skin test result suggests that their immune system had already been partially sensitized to peanut protein. 35.3% (about 1 in 3) of the children who avoided peanuts became allergic, compared to 10.6% (about 1 in 10) of the children who consumed peanuts. That means that for every 4 children with a mildly positive skin test who consumed peanuts, one fewer child became allergic.

Recommendations will likely be updated to account for these findings. First, infants with no eczema or family history of peanut allergies are at low risk of developing allergies and should start eating peanut products as soon as they start eating solid foods. (Don’t feed whole peanuts to infants. They’re a choking hazard. Anyway, Bamba tastes better and now might be one of the most evidence-based snacks.) Infants who are at high risk for peanut allergy because of eczema, an egg allergy, or a family history of peanut allergy should have a skin test to check for sensitivity to peanut. Those who have a negative test can proceed with Bambafication. Those who have a positive test should have their first exposure to peanut product under the supervision of an allergist.

Learn more:

Exposing infants to peanuts causes big reduction in peanut allergy, study shows (The Washington Post)
Feeding Infants Peanut Products Could Prevent Allergies, Study Suggests (Well, New York Times health blog)
About-Face on Preventing Peanut Allergies (Wall Street Journal)
The LEAP Trial (NEJM Quick Take video)
Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy (NEJM article)
Preventing Peanut Allergy through Early Consumption — Ready for Prime Time? (NEJM editorial)

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Marginal Exercise Advice From a Newbie

Albert finishing 10KI have lots of patients who are incredibly fit. I have patients who have run marathons. I have a patient who rides in rodeos. I have patients who have completed Ironman Triathlons. And I have lots of patients for whom exercise has always been a part of their routine, a lifelong habit. Though I hope they still enjoy it, this post isn’t written for them.

This post is for people who don’t exercise, for people who either hate exercise or have never done it with any regularity. This post is for people who haven’t made the leap from exercising zero times a week to exercising a couple of times a week. In short, this post is for people just like me until about a decade ago.

I’m going to try to get you off your couch.

If you’re anything like me you don’t care your biceps or abs look like. You don’t particularly pay attention to your body, and you assume that your body will return the favor. You make a living with your brain, which means that you drive a desk or a laptop all day. As a kid you never fell in love with sports and you were never much of an athlete.

Now, if you have some chronic medical problems, like diabetes, or high blood pressure, or high cholesterol, then your doctor has already harangued you about exercising to get your sugar, blood pressure and cholesterol down. But let’s assume you have the luxury of good health (for now).

I believe that what will get you exercising regularly are the mental benefits of physical activity. If you’re a pointy-headed geek like me you need to know that exercise will help you concentrate better and think more clearly. It will improve your sleep and your energy. If you do cognitive work for a living, the improved efficiency will more than compensate for the time spent exercising.

If you have psychological illnesses, you should know that exercise will lower your anxiety and stabilize your mood. That doesn’t mean it’s a substitute for medications, but it means that it can help the medications work. I’ve had countless patients tell me that they rely on exercise to help lift their depression, blunt their mania, and calm their anxiety. I know myself that there’s no better way to silence pointless ruminations about an unpleasant event than to climb a hill on my bike.

The only challenge is getting started and persevering until exercise becomes a pleasant habit. I promise you that it will happen. To that end, I have two bits of advice. But remember, I’m not a coach or a personal trainer. Most of my posts are full of links to double blind studies and reviews of data. This post is just the musings of a middle-aged guy who grew up not exercising and now actually likes it.

My first bit of advice is to find the cardiovascular exercise you hate least. Walking is a terrific choice. You can do it almost anywhere, and Los Angeles has gorgeous hikes and walks within short drives from almost anywhere. I love biking and swimming because I can do them alone or with friends. I don’t enjoy running (yet) but some patients and colleagues persuaded me to give running a try. I love the efficiency of it; you can put your shoes on, leave your front door, and have a very hard work out in 30 minutes.

My second bit of advice is to do some kind of exercise almost every day. Doctors will tell you to exercise three times a week to get the cardiovascular benefit. But it’s hard to have a three-times-a-week habit. We don’t do things three times a week. It’s much easier psychologically to do something every day, or at least every weekday. Then, it’s just like brushing your teeth or getting dressed or going to the office. It’s routine.

I know you don’t think you have time. I know when you have a stressful week you’ll be very tempted to skip exercise. But I also know that after a month you’ll look forward to it, you’ll feel better after you do it, and you’ll realize that the rest of your day is calmer, more focused and more organized because you force yourself to elevate your heart rate for 30 minutes daily.

Last weekend I ran my first race, a 10K. My time was abysmal, but my goal was only to run the whole thing without walking, and by that measure I succeeded. This is not bragging. Any serious runner has a much faster time on a 10K race than mine. It’s the opposite of bragging. It’s insisting that if I can do it, you can too.

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Expensive Placebos Work Better than Cheap Ones

Credit: Wikimedia, Creative Commons License

Credit: Wikimedia, Creative Commons License

The power of placebos has long been known. People who believe that they are taking an effective drug frequently feel better. In fact, prior to the discovery of penicillin, it is likely that the placebo effect accounted for much of the benefit of medical care.

A study published this week in the journal Neurology makes an interesting connection between the magnitude of the placebo effect and the medication’s perceived price.

The study enrolled 12 patients with moderate to severe Parkinson’s disease. They were told that they were going to be given two new injectable medications for Parkinson’s that increase dopamine levels. They were told that the medications were believed to work equally well, but because of differences in how they are manufactured one medicine costs $100 per dose while the other costs $1,500 per dose.

The patients were randomized as to which medication they received first – the cheap or the expensive one. The patients received objective measurements of their ability to move and other Parkinson’s symptoms before and after the medication dose. The measurements were made by people who didn’t know which medication the patient received. About four hours after the first medication they received the other medication, again with symptom measurement before and after.

What the patients didn’t know is that both injections were just saline, salt water without any active ingredient.

Not surprisingly, the patients improved after both injections. What was surprising was that the “expensive” placebo was much more effective than the “cheap” one. In terms of magnitude of effect, the expensive placebo was about halfway between the cheap placebo and the effect of levodopa, a Parkinson’s medication that actually increases dopamine levels in the brain.

The result would have been less surprising if the patients were told that the more expensive medicine was more effective, but they were told that they were thought to be equally effective and the difference in price was attributed to a difference in manufacturing. Still, apparently, we can’t help but fool ourselves into making “you get what you pay for” into a self-fulfilling prophecy. The patients expected a greater effect from the more expensive medicine and actually had more improvement in their motor function.

This may help explain why we spend so much on things we should know won’t help. It may explain the continued success of the vitamin and supplement industry and the preference of some patients for brand-name rather than generic medications. (Many of my patients boggle when I tell them that my family and I use generic medicines whenever possible.)

Students and fans of behavioral economics likely would have predicted the outcome of this study. Wines with more expensive price tags are known to taste better than the same wine with a cheaper price tag. In fact the whole art of wine tasting seems to evaporate when experts are blinded about what they are tasting. So we should definitely buy cheap wine (and then fool ourselves by putting big price tags on the bottles).

The clinical applications of this study are not obvious. It’s not ethical to deceive patients, so we can’t just start lying and telling them that their medicines are more effective or more expensive than they really are. But we are reminded again of the power of patient expectations. If we can honestly shape expectations, for example by educating patients about the proven benefits of a medicine, perhaps we can ethically allow our patients to benefit from the placebo effect.

And I’m now surer than ever that I’ll be able to cure more of you as soon as I double my fees.

Learn more:

‘Expensive’ placebos work better than ‘cheap’ ones, study finds (Los Angeles Times)
An ‘expensive’ placebo is more effective than a ‘cheap’ one, study shows (Washington Post)
Expensive Drugs Work Better Than Cheap Ones (Well, New York Times health blog)
Placebo effect of medication cost in Parkinson disease (Neurology article, abstract available without subscription)
Do More Expensive Wines Taste Better? (Freakonomics Radio)

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