Measles Makes a Comeback

The rash caused by measles. Credit: CDC/ Heinz F. Eichenwald, MD

The rash caused by measles.
Credit: CDC/ Heinz F. Eichenwald, MD

I haven’t written about measles in over two years, but unfortunately it’s in the news again.

Measles is a very contagious viral illness that causes a high fever, rash, cough, and a runny nose. Complications include pneumonia, brain inflammation and death. Prior to 1963 there were hundreds of thousands of measles cases in the US annually, causing hundreds of deaths. In 1963 the measles vaccine was introduced, leading to an immediate decrease of measles cases in this country.

In 2000 measles was declared eliminated from the US. That means that for at least 12 months there was no person-to-person transmission of measles in the US, and any cases in the US were acquired by travelers abroad. But since then, instead of progressive global elimination of measles, we’ve had several setbacks.

In 2012 I wrote that there were 222 cases of measles in 2011, the highest number since 1996. This year that number doesn’t seem so bad. From January to October 2014 there have been 603 cases in 22 states, including California. There were 20 outbreaks during that time, meaning episodes in which person-to-person transmission is occurring in the US. The majority of the cases were in unvaccinated people.

In January to April of this year there were 58 confirmed measles cases in California, including 22 in Orange County and 10 in Los Angeles County. Of them, the vast majority were linked to recent travel abroad. Most of the patients were either unvaccinated or had no vaccination documentation available.

The problem is that vaccination has been a victim of its own success. Before 1963 everyone knew lots of people who had measles, and everyone heard of some people who had terrible complications. The case for vaccination was obvious and universally understood. But with nearly universal vaccination, public understanding of the risk of measles has waned and increasing numbers of parents are choosing not to vaccinate their kids. Add to that a scurrilous and fraudulent campaign to link vaccines with autism (a link that has been debunked repeatedly) and you have the perfect milieu for reversing decades of life-saving progress.

These numbers have much to teach about how vaccines work and how they don’t work.

First, though most of this year’s measles cases were unvaccinated, a minority of the cases were people who had documented vaccinations. That means that vaccines, like any other preventive medicines, aren’t perfect. Some vaccinated people will not develop protective immunity and will remain susceptible. In addition, some kids can’t be vaccinated for medical reasons. That means that even in an ideal world in which everyone who can be vaccinated is vaccinated, a small fraction of the population remains susceptible to infection.

So how was transmission ever eliminated?

It’s the number of susceptible people, or rather their fraction of the population, that matters. Below some critical number, each susceptible person comes into contact with people who are all immune, making person-to-person transmission very unlikely. But above that critical threshold there are enough susceptible people to sustain a chain reaction of infection.

The scary conclusion is that I can’t be sure I’ve protected myself by being vaccinated. I’m protected when most people around me are vaccinated, and I contribute to their protection by being vaccinated myself. If parents’ refusal to vaccinate their kids only endangered them, we might only raise our eyebrows in disapproval. But their refusal endangers our kids too.

Learn more:

The Measles Outbreak Coming Near You (Wall Street Journal)
Wealthy L.A. Schools’ Vaccination Rates Are as Low as South Sudan’s (The Atlantic)
O.C. measles outbreak spurs officials to call for immunizations (Los Angeles Times)
Measles (Centers for Disease Control and Prevention)
Notes from the Field: Measles — California, January 1–April 18, 2014 (Morbidity and Mortality Weekly Report)

Some of my previous posts about measles:

Measles Cases in 2011 Highest in Fifteen Years (2012)
Study Linking Vaccines to Autism not Just Wrong, Intentionally Fraudulent (2011)
U.S. Measles Cases at Highest Numbers Since 2001 (2008)

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Thank You Very Much

Image credit: Jim/Wikimedia, Creative Commons license

Image credit: Jim/Wikimedia, Creative Commons license

Tomorrow I expect to sit with my extended family at my sister’s house and consume copious quantities of yummy food. After that, my and her kids will destroy her house in cute ways that will delight the grandparents. Good times.

That in itself is a reason for gratitude. Given the fact that most humans who have ever lived spent every winter nearly starving to death, the abundance of food and material comfort at our disposal is nothing short of miraculous. And the fact that we’re all healthy enough to get together to celebrate is a true blessing.

But I would be remiss if I headed off to celebrate without thanking you.

To my readers: I’m grateful for all your feedback, for pointing me to interesting stories, and for forwarding my posts on social media. It’s largely because of you that my posts have appeared on KevinMD, American College of Physicians Internist blog, The Jewish Journal, and other publications. I know my blogging has been very intermittent this year. Patient care will always come first, but I promise to keep trying to inform you.

To my patients: I’m so thankful to you for the trust you place in me. Some of you have had serious illnesses this year and it’s been an honor and a privilege to guide you through such trying times. It’s a blessing to simply make a living, but I have the double blessing of getting paid to do what I love. I owe that to all of you. And because so many of you mentioned me to your colleagues and loved ones, this year is my best so far. Thank you very much. I promise to do my best to keep you healthy.

As is my tradition, I hereby lift my patients’ dietary restrictions for one day. Of course, I can’t suspend the laws of biology. If you take your dietary indiscretion too far, I’ll probably hear about it from your local emergency department. I hope you are able to gather with loved ones and energetically attempt to enumerate your countless blessings.

Happy Thanksgiving!

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A Second Vaccine against Pneumonia Recommended for Seniors

Streptococcus pneumonia bacteria grown from a patient’s blood culture. Credit: CDC/Dr. Mike Miller

Streptococcus pneumonia bacteria grown from a patient’s blood culture.
Credit: CDC/Dr. Mike Miller

If you’re over 65, there’s a new vaccine you should know about.

But before I explain the vaccine, let me introduce you to the bacterium that the vaccine protects you from. The little blue ovals in the above picture are Streptococcus pneumoniae bacteria. You might have guessed by its name that S. pneumoniae is a leading cause of pneumonia, and you’d be right. Pneumonia is an infection of the lungs, usually manifested by fever, productive cough, and shortness of breath. Pneumonia can be caused by bacteria, viruses, and fungi, but S. pneumoniae is such a common cause of pneumonia that it’s nicknamed the pneumococcus – the coccus (little round bacterium) that causes pneumonia.

The Centers for Disease Control and Prevention (CDC) estimate that 900,000 people in the U.S. contract pneumococcal pneumonia every year, and tens of thousands of them die. Pneumonia is usually treated with antibiotics, but some strains of the pneumococcus have developed resistance to some drugs. If that wasn’t bad enough, S. pneumoniae can also cause bloodstream infections and meningitis, which are even more life-threatening than pneumonia.

Given the severity of pneumococcal illness in people over 65, prevention in this age group has been critical. For over 30 years a pneumococcal vaccine called Pneumovax 23 has been recommended for everyone 65 and over. (The generic name for Pneumovax 23 is PPSV23, 23-valent pneumococcal polysaccharide vaccine. You don’t need to know that for the test. I’m just mentioning it here because you’ll see that name in other articles. Oh, and there is no test.) Pneumovax 23 protects against 23 different strains of S. pneumoniae but the immune response it stimulates in patients is just meh. That’s good enough to protect against bloodstream infections and meningitis, so it still saves many lives, but the evidence that it prevents pneumonia isn’t very strong.

A newer vaccine against the pneumococcus appeared in 2010. It’s called Prevnar 13 (PCV13, 13-valent pneumococcal conjugate vaccine). It has been used since that time in vaccinating children. It only covers 13 strains of pneumococcus but it stimulates a much stronger immune response than Pneumovax 23. Interestingly, there is some evidence that immunizing children against the pneumococcus has led to fewer pneumococcal illnesses in older people since there are fewer sick kids around to infect them. This is another bit of evidence of a phenomenon called herd immunity – immunizing some members of a “herd” protects the rest of them just because there are fewer vulnerable members to transmit the disease.

Recently Prevnar has been tested in and approved for use in seniors. A recent study showed definitively that it helps protect from bloodstream infections, meningitis, and pneumonia caused by the pneumococcus. Last month the CDC recommended Prevnar in everyone 65 and older.

Because Pneumovax 23 covers more strains, seniors should now receive both vaccines, not just the new one, but because the two vaccines protect against some of the same strains, they can’t be given at the same time. Here’s the recommended timing.

  • People 65 and over who haven’t received either vaccine should first receive Prevnar 13 followed 6 to 12 months later by Pneumovax 23.
  • People 65 and over who have already received Pneumovax 23 since they turned 65 should receive Prevnar 13 at least a year after receiving Pneumovax 23.
  • People 65 and over who have already received Pneumovax 23 before turning 65 should receive Prevnar 13 at least a year after their most recent Pneumovax dose, and then should receive another dose of Pneumovax 6 to 12 months after the Prevnar but not earlier than 5 years after the last Pneumovax dose.

Got that? If not, this handy box illustrates the options nicely. The good news is that you can get the flu vaccine at the same time as either pneumococcal vaccine, so you’ve got that going for you, which is nice.

So if you’re 65 or older make sure that you get both Pneumovax and Prevnar in whichever order is appropriate for you. And if you’re younger, make sure your parents and aunts and uncles get the news. Because you don’t want the above picture to be the blood culture of someone you love.

Learn more:

Some Good News on Pneumonia (New York Times, The New Old Age blog)
New Advice for Vaccines to Stave Off Pneumonia (Wall Street Journal)
Pneumococcal Vaccination (Centers for Disease Control and Prevention)
Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP) (Morbidity and Mortality Weekly Report)

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Sorting Out the Different Flu Vaccines

A sailor receives a flu shot. Credit: US Navy

A sailor receives a flu shot. Credit: US Navy

The best way to avoid the flu is spending the months from fall until spring in a solitary bunker, communicating with other people only electronically. The second best way is getting the flu vaccine. The Centers for Disease Control and Prevention (CDC) recommends the flu vaccine for everyone over 6 months who doesn’t have a specific contraindication to it.

Because of the increasing number of different flu vaccines that are now available, this post highlights the three most commonly used flu vaccines, their indications and side effects.

Inactivated Standard-Dose Injectable Vaccine
This is the standard flu shot. It is approved for adults of any age and for children 6 months or older. It is recommended for pregnant women and for people with chronic illnesses, both of whom are at increased risk of serious complications from the flu. It is more effective in adults than the intranasal live-attenuated vaccine.

Side effects from the flu shot are very rare except for soreness and redness at the injection site. The vaccine contains no live virus, so the common misconception that the flu shot can cause flu-like symptoms is just that.

Intranasal Live-Attenuated Influenza Vaccine (FluMist)
This vaccine is a nasal spray. It is approved for healthy, non-pregnant people 2 to 49 years of age. It’s more effective than the inactivated vaccine in children 6 years old or younger. Because it contains a live virus, it should not be taken by pregnant women, patients with weakened immune systems, people with respiratory illnesses, or caregivers of severely immunocompromised patients.

FluMist can cause runny nose, nasal congestion, and sore throat.

Inactivated High-Dose Vaccine (Fluzone High-Dose)
Older people are at highest risk for complications for the flu, so they have potentially the most to benefit from vaccination. But ironically older people have immune systems that have the weakest responses to vaccines. For this reason, a vaccine with a higher dose was produced. Fluzone High-Dose has four times as much antigen from each flu strain as the regular vaccine. It’s basically just like getting four standard flu shots but in the same injected volume as one shot. It is slightly more effective in preventing flu than the standard vaccine. In a randomized trial trial 1.4% of older adults who received the high-dose vaccine later developed flu compared to 1.9% of those who received the standard-dose vaccine. That means that for every 200 older adults who take the high-dose vaccine instead of the standard-dose, one case of flu is prevented. Fluzone High-Dose vaccine is approved for adults 65 years and older. This group of people can also opt for the standard vaccine.

Fluzone High-Dose causes more injection-site reactions than the conventional vaccine but no increase in serious adverse effects.

The CDC influenza vaccination page has a lot more information about each vaccine and more specific contraindications.

So figure out which vaccine is right for you and get it. Our office only carries the inactivated standard-dose shot, but the others are available at many pharmacies. After protecting yourself you can come out of your bunker, or invite friends over. I’ll bring snacks.

Learn more:

Vaccination: Who Should Do It, Who Should Not and Who Should Take Precautions (Centers for Disease Control and Prevention)
Google Flu Trends for Los Angeles
Efficacy of High-Dose versus Standard-Dose Influenza Vaccine in Older Adults (New England Journal of Medicine, by subscription only)
Influenza Vaccine for 2014-2015 (The Medical Letter, by subscription only)

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Why Ebola is not a Major Threat in the US

Colorized electron micrograph of Ebola virus particle. Credit: CDC/Cynthia Goldsmith

Colorized electron micrograph of Ebola virus particle. Credit: CDC/Cynthia Goldsmith

I have written twice this year (links below) about the increasingly severe Ebola outbreak in West Africa. The news in West Africa is still mostly bad. Over 7,000 have become ill and over 3,300 have died. This is by far the worst Ebola outbreak ever.

This week marked another first, the first Ebola patient diagnosed in the US. This news is likely making many of my regular readers wonder “Should I freak out?” This is a reasonable question, and I will attempt to answer it. But first, let’s go over how this nasty microbe spreads.

Ebola is caused by a virus that is transmitted through contact with the bodily fluids of someone who is sick. It is not airborne; that is, it is not spread by respiratory droplets (coughing, sneezing). After being infected with the Ebola virus, a patient develops symptoms 2 to 21 days later. The patient is only contagious once symptoms appear, not before. Symptoms of Ebola include fever, headache, muscle aches, diarrhea and vomiting.

On Sept. 15 Thomas Eric Duncan, a man living in Liberia, was helping a neighbor who had become ill. (The neighbor later died.) On Sept. 19, while Mr. Duncan was feeling well, he boarded a plane and flew from Liberia through Brussels and Washington. He landed in Texas on Sept. 20 and visited family in Dallas. As is now standard practice for all passengers leaving Liberia, his temperature was checked before boarding his flight and was normal.

On Wednesday Sept. 24 Mr. Duncan began feeling ill. On Sept. 26 he presented to the Emergency Department at Texas Health Presbyterian Hospital. He told a nurse he had been in Liberia. The nurse used a checklist to screen for possible Ebola patients. Embarrassingly, that information didn’t get transmitted to the rest of the team caring for Mr. Duncan. He was evaluated and discharged with a prescription for antibiotics. Oops. Major, potentially consequential oops.

On Sept. 28 Mr. Duncan became more ill and was taken by ambulance to the same hospital. At that point, things unfolded as they should. He was quickly identified as a potential Ebola patient and isolated. On Sept. 30 tests confirmed that Thomas Eric Duncan is the first patient to be diagnosed with Ebola in the US. He remains hospitalized under isolation and is in serious condition.

Since then Centers for Disease Control (CDC) and state health officials have carefully tracked Mr. Duncan’s movements since he became ill. Remember, the disease is not transmissible until symptoms develop. So, as a CDC official said, there is “zero risk of transmission on the flight”. Four people at the Dallas apartment where he stayed are under quarantine and are being evaluated daily for symptoms. So far, all of them are still well. 12 to 18 people had direct contact with the patient and are also being followed by health officials but are not quarantined. A broader list of about 100 people who may have had very brief contact with Mr. Duncan was also interviewed by health officials to narrow the list to those who might have been exposed to Ebola and require monitoring.

So, dear reader, this is why you shouldn’t freak out. The conditions that have permitted Ebola to spread like wildfire in Africa simply don’t exist here.

What’s the worst that could (likely) happen? A few of the people under quarantine might get sick. That would be terrible. (Some of them are kids.) But the CDC would be on them like, um…, well, like health officials on an Ebola patient. They would be immediately hospitalized and isolated. It’s conceivable, but unlikely, that a couple of the 12 to 18 less-close contacts also become ill, but they would get the same treatment. The point is if Mr. Duncan infected anyone, those patients won’t have a chance to infect anyone else. That’s good workaday epidemic control and it’s one of the many things that African health officials don’t have the resources for.

There are a few other important differences between the conditions here and in Africa that bear on this outbreak. The first is that a very large number of the victims in Africa are healthcare workers. That’s because of the lack of even the most basic equipment for personnel protection, like latex gloves and disposable gowns. Another difference is that in Africa there is deep mistrust of public health officials and many families hide sick relatives and don’t seek care. In the US the response from the public is likely to be the opposite. If even three or four more patients are identified, the public is likely to overreact. Every fever, runny nose, or pessimistic thought in Dallas is likely to be reported to a physician. The problem will not be in quickly identifying all the Ebola cases. The problem will be that the healthcare system will be flooded with run of the mill flu symptoms. Don’t have a heart attack that day.

Traditional burial practices in Africa which involve direct contact with the deceased have also contributed to the spread of the disease, and obviously would not be allowed here.

So, spare a kind thought for Mr. Duncan. The Ebola case mortality in Africa is about 50%, but I hope with excellent care his chances are much better than that. I also hope that if any of his family fall ill they also recover.

West Africa will continue to require enormous resources to control the current outbreak. And infected people, despite the best screening methods, will continue to travel to the developed world and then learn that they are sick. But a few simple questions, some gloves and gowns, and meticulous tracking of contacts will always prevent a sustained outbreak here.

Learn more:

Five Things About Ebola in the U.S. (Wall Street Journal, a terrific brief summary of the facts)
Up to 100 possibly exposed to U.S. Ebola patient; four isolated (Reuters)
As Ebola confirmed in U.S., CDC vows: ‘We’re stopping it in its tracks’ (Washington Post)
Ebola Virus Disease (Centers for Disease Control and Prevention)

My previous posts about Ebola:

Ebola Outbreak in West Africa Worries Health Officials (April)
Largest Ebola Outbreak in History Continues to Spread (July)

Tangential Miscellany

Saturday is Yom Kippur so some of us are planning to fast. It’s also going to be very hot in Los Angeles, which means some of us are going to get dehydrated, faint, and end the day in the emergency department getting intravenous fluids. If you are planning to fast and you’re not-so-young, or if you take prescription medications, please ask your doctor if fasting is safe for you. Also ask which medications should be continued even if you’re fasting.

Have a safe Yom Kippur and a healthy and sweet 5775.

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All Ashkenazi Jewish Women Should be Tested for BRCA

A woman receives a mammogram. Image credit: National Cancer Institute / Wikimedia

A woman receives a mammogram. Image credit: National Cancer Institute / Wikimedia

Mutations in two genes called BRCA1 and BRCA2 greatly increase the risk of breast and ovarian cancer. Last year I wrote about Angelina Jolie’s discovery that she carries a harmful BRCA1 mutation and her decision to have preventive double mastectomy.

In the general population mutations in these genes are quite rare, but among Ashkenazi Jews these mutations are much more prevalent. One in 40 Ashkenazi Jews carries a mutation in BRCA1 or BRCA2. In the Ashkenazi population one in 9 cases of breast cancer and 2 in 5 cases of ovarian cancer involve mutations in a BRCA gene.

Identifying women with BRCA mutations who are at high risk of breast and ovarian cancer isn’t just an exercise in predicting trouble. Preventive action can be taken. As Angelina Jolie’s story teaches us, preventive surgery that removes the breasts and ovaries greatly decreases the risk. Mastectomy, of course, is difficult physically and psychologically. For some women at very high risk, intensive screening with mammograms and breast MRI offers some level of protection without resorting to surgery.

Thus far genetic testing for these mutations has only been recommended for Ashkenazi women with a strong family history of breast or ovarian cancer. That’s because BRCA mutation carriers with a family history of breast or ovarian cancer were the only group studied and found to have increased cancer risk.

But if the BRCA mutations themselves cause breast and ovarian cancer, why should family history matter? Why not test everyone who might have these mutations? The answer is that the risk of cancer in BRCA mutation carriers without a family history of cancer has never been measured. Without knowing that, it is possible that the mutation carriers who have a family history of cancer have an increased risk because of some other shared genes that have yet to be identified or because of some shared exposure to cancer-causing agents in the environment. That is, without knowing the risk of BRCA mutation carriers who do not have a family history of cancer, we can’t be sure if the BRCA mutations are the cause of increased risk, or simply a marker for some other cause that is yet unknown.

A study carried out in Israel and published this month in the Proceedings of the National Academy of Sciences sought to answer this question in an ingenious way. The study enrolled about 8,000 Israeli Ashkenazi men without a history of cancer and tested them for BRCA mutations. 175 of them were found to carry harmful BRCA mutations. The first degree female relatives of these 175 men (their mothers, sisters and daughters) were invited to undergo BRCA testing. This identified 211 female BRCA mutation carriers, many of whom had no family history of breast cancer. By studying the medical histories of the identified female mutation carriers, their risk of ovarian and breast cancer was calculated.

The results showed that a woman with a BRCA1 mutation has an 83% risk of developing breast or ovarian cancer by age 80. BRCA2 mutation carriers have a 76% risk of breast or ovarian cancer by age 80. These numbers are very similar to those from studies that only counted women with strong family histories of cancer. That means that a family history is not necessary to identify women who benefit from screening, and suggests that all Ashkenazi Jewish women should be tested for BRCA mutations.

National groups that evaluate scientific data and make testing recommendations like the American Cancer Society and the US Preventive Services Task Force haven’t had a chance to digest the news yet. They still recommend BRCA testing only for women with strong family histories of breast and ovarian cancer.

A medical geneticist I spoke with said that BRCA testing costs about $400 and is generally not covered by insurance. If you’d like to pursue testing, the first step is asking your doctor to refer you to a medical geneticist for pre-testing counseling.

Population screening for specific genetic diseases, like Tay-Sachs, has proven in the past to make enormous reductions in the societal burden of disease. Screening all Ashkenazi Jewish women for BRCA holds out the promise of similar gains against breast and ovarian cancer.

Learn more:

Study of Jewish Women Shows Link to Cancer Without Family History (New York Times)
Israeli research team: Screen all Ashkenazi-Jewish women for BRCA mutations (The Jerusalem Post)
Population-based screening for breast and ovarian cancer risk due to BRCA1 and BRCA2 (Proceedings of the National Academy of Sciences, abstract free, full article by subscription)
Understanding Angelina (My post from 2013 explaining the BRCA testing recommendations at that time)

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A Comparison of Low Carb and Low Fat Diets

Image credit: Wikimedia commons, public domainThe joys of September! Parents gleefully shove their reluctant children onto school buses, the palm trees in Los Angeles don’t change color, and everyone realizes that they gained 20 pounds during their summer vacation. It’s time to get serious again about losing weight.

But how should you eat to best help you shed the extra pounds? Many people are passionate about their favorite diet, but there is very little data comparing different diets to each other. Some swear by low carbohydrate diets (like Atkins), while others insist that low fat diets (like Weight Watchers and others) yield more weight loss and achieve healthier cholesterol numbers.

This week, a study published in Annals of Internal Medicine attempted to shed some light on this question. The study enrolled 148 men and women who were obese (BMI 30 to 45) but didn’t have diabetes or cardiovascular disease. The participants were randomized into two groups. One group was counseled to eat a low carbohydrate diet, with less than 40 grams of carbohydrates per day. The second group was counseled to eat a low fat diet, with less than 30% of total calories from fat, and less than 7% from saturated fat. Neither group was counseled about limiting total calories or about exercise. Both groups received ongoing periodic dietary counseling throughout the study.

The subjects were followed for a year and had periodic assessments of their weight, diet, cholesterol, blood pressure, and other blood tests measuring cardiovascular risks.

At the end of the study the group eating a low fat diet lost an average of 4 lbs. while the group eating a low carbohydrate diet lost an average of 12 lbs. Even more impressive was that the low-fat group lost lean body mass (muscle weight) and gained fat weight, while the low-carbohydrate group lost fat weight and gained muscle. This is especially surprising since average caloric intake and physical activity was similar between groups. One frequent criticism of low carbohydrate diets – that it results in an increase of LDL (bad cholesterol) – was dispelled. Total cholesterol and LDL levels remained similar between groups, but the low-carbohydrate group had bigger increases of HDL (good cholesterol).

This all suggests that a low carbohydrate diet leads to more weight loss than a low fat diet while improving body fat composition and some cholesterol measures. For those who are losing weight on a low carbohydrate diet but were worried that the excess fat intake was increasing their cardiovascular risk, this is good news.

Though the results were trumpeted as a major vindication for low carbohydrate diets, I interpret the results differently. Sure, the low carbohydrate group fared better than the low fat group, but what I find striking is how disappointingly modest the results in both groups were. The participants had a BMI of 30 to 45 which means that at minimum they were 35 lbs. overweight, some much more. An average weight loss of 12 lbs. is a laudable step in the right direction but is a small fraction of the weight that should be lost. Considering the fact that this weight loss took 12 months and that all longer term studies suggest that some of this lost weight will be regained, the results seem quite discouraging.

So I conclude from this study that any diet that helps you eat less and that you can maintain indefinitely will help you lose weight but that for meaningful weight loss you have to make a more radical change in your diet than the groups in this week’s study. If you feel full and not deprived on a low carbohydrate diet, then do it and stick to it. But you should probably have even less carbohydrates than 40 gm per day until you reach your target weight. This study at least reassures you that your cholesterol and body fat composition won’t get worse. If you do best with a low fat diet, consider a diet that is radically low in fat, like a plant-based vegan diet without processed foods. My patients who have stuck with either strategy have done well. This study is also a reminder that without exercise, changing what you eat will only achieve modest results. Frequent exercise can accelerate weight loss while maintaining muscle mass.

And for people who are over 100 lbs. overweight, especially those with diabetes, studies increasingly suggest that weight loss surgery has healthier outcomes than diet and exercise alone.

So let’s all make a plan and get started. Thanksgiving is just around the corner.

Learn more:

A Call for a Low-Carb Diet That Embraces Fat (New York Times)
Cutting Back On Carbs, Not Fat, May Lead To More Weight Loss (NPR)
Effects of Low-Carbohydrate and Low-Fat Diets: A Randomized Trial (Annals of Internal Medicine)

Some of my past posts on diet and weight loss:

Why Losing Weight Is So Hard
Startling Scientific Finding: Dieting Leads to Weight Loss
Scientifically Proven Weight Loss Method: Eat Less

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Raining on the Ice Bucket Parade

Raising awareness, lowering temperature.

Photo credit: flickr/slgckgc Creative Commons License

Amyotrophic lateral sclerosis (ALS, sometimes called Lou Gehrig’s disease) is a truly horrible illness. It is a progressive fatal neurodegenerative disorder that leads to worsening muscle weakness.

Weakness in the limbs initially makes handwriting sloppy and makes it hard to button clothes and eventually causes paralysis. Patients also develop weakness in the muscles that control swallowing and speech, eventually requiring them to use feeding tubes and computer text-to-speech software. Eventually the muscles that control breathing are affected. Half of ALS patients die within 3 years from the time that weakness is first noticed, and only about 5% survive more than 10 years. About 5,600 people are diagnosed with ALS in the US every year, so about 18,000 Americans are living with ALS at any time.

In a small fraction of patients the disease is familial. In most patients the cause is unknown. The only effective treatment so far is riluzole, a medication that prolongs survival by only several months. Besides the catastrophic consequences to the patient, ALS frequently places overwhelming pragmatic and psychological burdens on family members and caregivers. If I had ALS I would gladly trade it for colon cancer or lung cancer, but patients don’t get to choose.

Unless you live in a cave in Waziristan or get all of your news from this newsletter (which would be a lot of pressure for me) you’ve already seen myriad well-meaning folks douse themselves in ice water to raise money for the ALS Association (ASLA). The ice bucket challenge is the perfect social contagion – entertaining to watch, supportive of a good cause, and using peer pressure to infect others. Since late July the ASLA has raised over $70 million – about three times what it made last year – and there’s no sign that the donations are slowing down any time soon.

There are so many positive aspects of this phenomenon. First of all, it’s voluntary (as opposed to, say, the government taking your money to fund obesity awareness while also taking your money to subsidize sugar). It’s fun. And it’s a rare example of peer-pressure used for a good cause. Usually when tens of thousands of people convince each other to do the same thing, it’s moronic if not outright destructive. This will also inspire many other charities to use viral social media fund-raising campaigns. And did I mention that ALS is a really dreadful disease?

Still, my regular readers know that I’m here to be your skeptical stick-in-the-mud, to give the cold facts an impartial look, and to pick nits. Some writers have raised very reasonable objections to the ice bucket challenge. One objection is that given how rare ALS is, we really should be spending our money elsewhere. The linked article has a graphic showing different diseases listed both by the number of deaths they cause and the amount of funds donated to combat them. Compared in terms of dollars donated per death caused, ALS was already far ahead of much more common killers like diabetes and heart disease.

Another objection is that ALSA is a research organization. So the money will be used to unravel the complex genetic and molecular mechanisms behind the disease and search for new treatments, an effort that is unlikely to yield results for many years. In the long term, that investment might yield priceless results, but it won’t help today’s patients or their families, some of whom could use financial help to buy the motorized scooters, computerized speech aides, and other technology that ALS patients need. The current amount raised could give more than $3,000 of aid to each patient living with ALS.

Of course, some of the criticisms are foolish. Some celebrities have refused to participate on the grounds that ALSA funds research on animals. I’m not aware of any diseases that have been cured without animal research. Fortunately, not too many people listen to these beautiful ignoramuses. Research scientists should sneak up on them and dump ice water on their heads.

But the best criticism of the ice bucket challenge is that it’s a terrible reason to donate, and it’s a terrible way to think of your philanthropic spending. Your dollars achieve the most benefit when you pick a charity that can make the biggest difference for the most number of patients, and when you give repeatedly over time, not just a one-time gift when everyone else is giving too.

So whether you give to ALSA or not, pick a disease to attack with your dollars, make a recurrent annual event on your calendar, and commit to an annual donation. (My wife and I give to the Juvenile Diabetes Research Foundation, largely because my nephew has type 1 diabetes. 30,000 people in the US are diagnosed with type 1 diabetes annually, and about 3 million Americans are currently living with it.) Let other people soak themselves with ice water. And in five years when the American Heart Association comes up with the live-chicken-in-your-pants challenge you can ignore it and continue the rational charitable giving you’ve already started.

Learn more:

Why the Ice Bucket Challenge is bad for you (Maclean’s)
The truth about the Ice Bucket Challenge: Viral memes shouldn’t dictate our charitable giving (Vox)
The Ice Bucket Challenge Isn’t Going Away, But giving money to disease-specific charities is still a bad idea (Slate)
A different #icebucketchallenge: How will the ALS Association spend all that money? (Fortune)
ALS Association (Learn more about ALS, donate)
Amyotrophic Lateral Sclerosis (Medscape review, written for health professionals)

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Posted in Cancer, Diabetes, Public Service | Comments Off

Suicide Contagion in the Age of Social Media

Robin Williams in 2004. Photo credit: Darsie / Wikimedia

Robin Williams in 2004.
Photo credit: Darsie / Wikimedia

In every life we have some trouble
When you worry you make it double
Don’t worry. Be happy.

It will soon pass, whatever it is.
Don’t worry. Be happy.
— Bobby McFerrin

Much has already been written in reaction to Robin Williams’s untimely death, about his incandescent talent, his prolific career, his decency and kindness, his addiction and his mental illness. His death robbed his fans of many more years of his genius and, of course, inflicted permanent grief on his loved ones.

In Johann Goethe’s 1774 novel The Sorrows of Young Werther the protagonist shoots and kills himself after the woman he loves marries another man. The novel became very popular. In the following years many young men in Europe committed suicide by dressing precisely as Werther is described in the novel and shooting themselves. The concept of suicide contagion was first described at that time, the idea that the romantic or idealized description of a suicide could trigger suicide in a susceptible person.

In the 1980s the media in Vienna was abuzz with extensive and dramatic coverage of the deaths of people who jumped in front of subway trains. In 1987 an educational campaign alerted reporters to the possible phenomenon of suicide contagion. The reporters were asked to use more neutral, less dramatic language, and to focus more on the victims’ lives rather than on the details of their deaths. In the subsequent six months, subway suicides and non-fatal suicide attempts dropped by more than 80%, and the total number of suicides in Vienna also decreased.

No one suggests that these stories cause suicide in mentally healthy readers. The victims of suicide contagion are clearly depressed and may already be suicidal. The theory is that stories that make suicide seem very prevalent, heroic or romantic give permission to suicidal readers to act on their impulse.

The magnitude and specific mechanism for this effect is, of course, difficult to study. Randomized studies obviously can’t be done, and some researchers argue that the evidence for suicide contagion is overblown. Nevertheless, mental health professionals and public health officials have compiled recommendations for journalists covering stories of suicide, especially of celebrities. The press has largely followed these recommendations.

Enter social media. The wonderful thing about social media is that it allows anyone to broadcast their ideas to countless others. That’s also the terrible thing about social media. Social media has reminded us of all the negative consequences of free speech, from false rumors, to hate speech, to cyberbullying (most recently of Robin Williams’s daughter). And because the public hasn’t been educated to consider suicide contagion, we inadvertently spread potentially dangerous messages.

A tweet about Williams’s death that I’m sure was well-intentioned and seems sympathetic and sweet, nevertheless would never have made it past a professional reporter or editor writing about suicide. That’s because it makes suicide seem like a poignant escape, a freeing act, an option. The tweet has been retweeted hundreds of thousands of times and likely seen by millions.

What can be done about it? If the public is going to take up broadcasting then we’ll have to try educating the public about the responsibilities of broadcasting. In the meantime I hope that susceptible individuals will shield themselves from triggering messages and get the help they need. I have to imagine that Mr. Williams would have wanted that too.

Get help:

National Suicide Prevention Lifeline

Learn more:

What happens when a suicide is highly publicized in the wrong way: The suicide contagion effect (Washington Post)
The Science Behind Suicide Contagion (New York Times)
Suicide contagion and social media: The dangers of sharing ‘Genie, you’re free’ (Washington Post)
Recommendations for Reporting on Suicide
Cyberbullying pushes Zelda Williams to leave social media (Colorado 9 News)
Suicide Rate Among Baby Boomers Increases Sharply (My post in 2013)
Don’t Worry Be Happy (the video to Bobby McFerrin’s song featuring Robin Williams)

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Largest Ebola Outbreak in History Continues to Spread

Doctors without Borders staff carry body of a patient killed by Ebola in Guinea. AFP/Getty Images

Doctors without Borders staff carry body of a patient killed by Ebola in Guinea.
AFP/Getty Images

Given the myriad horrors happening around the world this week you could be excused if West Africa has fallen off of your radar, but from a health perspective, it deserves some attention.

I wrote in April about an Ebola outbreak in southeastern Guinea that had spread to Liberia and Sierra Leone. (Browse that first post for a history of Ebola, its symptoms, and how it’s transmitted.) By April the outbreak had already become the most geographically widespread Ebola outbreak in history, and the first in West Africa. By that time it had reached the capital of Guinea and had infected over 130 people and killed 88.

As of now, the outbreak remains to be contained, and by any measure is now the worst outbreak ever. Over 1,000 have been infected, causing over 600 deaths. The outbreak has also reached the capital of Sierra Leone. Most worrisome is that new cases are still developing, with 67 new cases reported from July 15 to 17.

Emblematic of the struggles that local health officials have faced in containing this infection is the news that the lead physician treating Ebola patients in Sierra Leone has himself become infected. At least eight nurses in the same hospital have also contracted Ebola. This large number of infected healthcare workers hints at poor adherence to infection prevention guidelines or perhaps a simple lack of isolation supplies such as gloves and masks.

Officials are also battling public mistrust and false rumors about the cause and transmission of Ebola. Many locals also adhere to traditional funeral rites that involve contact with the deceased, increasing the likelihood of infection. A patient in the capital of Sierra Leone was forcibly removed from the hospital by her family and remains unaccounted for. Most recently, a possible Ebola case surfaced in Nigeria. If confirmed this would add a fourth country to this outbreak’s toll.

The World Health Organization’s recent update on the outbreak was quite frank about the shortcomings of the current efforts. It criticized

“low coverage of contact tracing; persisting denial and resistance in the community; weak data management; inadequate infection prevention and control practices, especially in peripheral health facilities; and weak leadership and coordination at sub-national levels.”

My last post worried about an Ebola patient getting off a plane in a large European or American city. I no longer have that concern. I think a country with an advanced healthcare system and an informed and cooperative public would quickly extinguish an Ebola outbreak. But the ensuing panic in which every fever is a potential Ebola case would cause much disruption.

I know you share my hope that the health workers toiling in West Africa gain the upper hand and contain this outbreak soon. Then we could go back to only worrying about all the other horrors in the world.

Learn more:

Worst Ebola outbreak ever gets worse: top Ebola doctor now infected (Vox)
A Doctor Leading The Fight Against Ebola Has Caught The Virus (NPR)
Ebola virus disease, West Africa – update (World Health Organization Global Alert and Response)
First Ebola victim in Sierra Leone capital on the run (Chicago Tribune)
Ebola Outbreak in West Africa Worries Health Officials (My post in April about the current outbreak)

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