Older Bolder Life

Stronger | Leaner | Sharper | Longer - From Older Bolder Fitness

medical policy

Monday Must Read: The Great Barrington Declaration

By

If you haven’t yet, you need to take a few minutes this morning and read The Great Barrington Declaration.

At a point in time where much of the very good, very solid science about COVID-19 is being buried by the media and various social media agents and search algorithms, this thoughtfully crafted, plain-spoken piece offering scientifically grounded and common-sense calls to further action, authored by an impeccably credentialed and well respected group of scientists, deserves thoughtful consideration.

I’ll hold off on elaboration this morning so as not to cloud their message; more to come.

Inquiring Minds Want to Know: Older Bolder Links, Reads, Recipes, and More 21 September 2019

By

The panacea of human aging: impacts of calorie restriction and exercise – a very interesting perspective with some profound implications that should be easily attainable for the masses.

An MCT-based (20 g of MCTs) ketogenic “formula” improved cognition in a small group of patients with mild to moderate Alzheimer’s.

Alzheimer’s memory loss improved with TEMT – transcranial electromagnetic treatment.

Commentary on the importance of birth year for the incidence of dementia.

In Britain, people over 55 are far happier than those under 35.

Sure seems to be a flurry of commentary defending statins of late – here’s one noting that despite statin-related myalgia, statin users didn’t have significant impacts in aerobic capacity or maximal fat oxidation. I will still venture the myalgia impacted group was less active overall due to their pain levels…

A peek behind the medical policy and funding curtain: nearly 2/3’s of the costs of managing cervical radiculopathy prior to surgery are related to diagnostic testing. Impressive, and a perfect example of how pricing/costs of medical intervention in America simply isn’t sustainable…

A layman’s look at why more men under 40 are having MIs.

A stunning contrast in American death rates, even if there’s some educated guesswork involved.

If you’re overweight, it’s more likely your dog will be too.

There’s been a bit of a flurry over discovery of this Hungarian hominid pelvis – here’s an example from American news.

Food, Glorious Food

Food is more than the sum of its parts. (Pithy, pointed, and true.)

Vid to watch: Low carb diets and mortality in NHANES.

Our Recipes from the Week

Slow roasted gochujang chicken thighs and more
Charred scallion dressing
Garlic bomb cauliflower rice

Two Prime Examples of A Traditional Medical Swing and A Miss: Practice Guidelines for T2DM and Obesity

By

As a former clinical physician I’ve always been fascinated by the promulgation of clinical guidelines, ostensibly crafted by leading minds in a given field convening to articulate treatment and diagnostic pathways to follow based on, what we’d all presume to be at least, the latest and greatest empirical evidence.

The overwhelming challenge is of course that human pathophysiology varies widely from person to person, given their unique genetics, history, constellation of conditions, nutrition, and even behavior. One-size-fits-all guidelines are often somewhat muddled in real-world application, and can lead to inappropriate, sub-optimal, or even harmful treatments being offered.

I personally know physicians who would be offended at the paragraph above, yet examples are stunningly commonplace of clinical guidelines run amuck today. For example, I have an 86-year old family member who’s currently being pressed to take statins for an incorrectly interpreted lipid panel, with her internist refusing to pursue the most specific testing, reporting it’s not allowed in his employer’s guideline directives.

For further example, here are two clinical guidelines released in the past few weeks that miss the mark impressively.

From Canada, T2 Diabetes Clinical Practice Guidelines for Physicians

From the Canadian Family Physician, Diabetes Canada 2018 Clinical Practice Guidelines, was published in January, detailing an intensive and comprehensive, pharmacologically-focused treatment pathway with stunningly little discussion of dietary guidelines focused on rational management of carbohydrate intake.

The article was presented on MedScape here (free account required); as always the comments were illustrative (and saddening), with one RN insisting that T2DM is best managed by increasing complex carbohydrates and limiting protein, a stunningly incorrect approach. Critically these articles referenced failed to address diet/nutrition in any detail, which has been increasingly shown to be impressively effective in management of T2DM.

Obesity Management in Primary Care

The second example is this: European Practical and Patient-Centred Guidelines for Adult Obesity in Primary Care.

The recommendations are multi-faceted and listed in some detail; they to their credit suggest pursuit of a “typical balanced Mediterranean style diet”, though suggest that at least of quarter of caloric intake come from starchy foods including cereals, legumes, and grains, with robust consumption of fruits as well, despite ample evidence suggesting these very foods can be obesogenic for many.

Of particular interest are the recommendations regarding targeted weight loss objectives (5-10% weight reduction), which while helpful would be woefully inadequate for many, and the responses on the Medscape summary of the guidelines, including one physician claiming the obesity epidemic to be unstoppable/untreatable.

The Take Home: Don’t Be Distracted By One Size Fits All Guidelines

Two Points of Interest. First, one-size-fits-all clinical guidelines, whether written by the AMA (or some other bastion of traditional medicine) or your favorite alternative health guru, need to be interpreted for you personally with great care.

Some recommendations you’ll come across, like the two examples above, have such glaring foundational flaws (missing fundamental nutrition and diet principles), one doesn’t have to venture too far out on the proverbial limb to suggest genuine harm is being done to many as they’re overmedicated, passing time waiting for complications of their lifestyle ‘diseases’ and treatments to manifest.

Some recommendations you’ll come across, and I’m thinking social media driven “advice” here, touting magical ingredients, supplements, workouts, etc, are not only anecdotal, but occasionally frankly duplicitous, evening bordering on the absurd. The keto world on social media is a hotbed of “experts” right now, prompting Mark Sisson to even refer to folks doing “caricature keto” in this post covering The Curious Phenomenon of Keto Crotch.

You physiology is unique to you; pay attention to what your body is telling you, and find supporting team members, including a good physician(s) when needed, who are willing to do the same.

And secondly, when anyone offers you recommendations based upon their guidelines, it’s absolutely fair game to apply several common sense tests: Do the recommendations make sense? Do the recommendations start with the least risky intervention or activity? What potential risks (or comorbidities) are involved?

An easy example – it’s my opinion that treating T2DM with pharmacological agents without a well-thought out, well-designed interval in a low carb (or VLC) diet trial is, given the information available today, clearly inappropriate. Another easy example is the liberal use of statins in clinical practice today, without adequate trials of dietary modification, particularly given statins’ long list of problems/side effects and questioned efficacy in reducing all-cause mortality in populations without proven heart disease, the risks very well may outweigh the benefits (more on statins to come another day).

Fascinating Supplement Read for the Week: Supplements and CVD

By

Christopher Labos, a cardiologist practicing in Quebec penned an interesting piece on Medscape two weeks ago yesterday titled Supplements and CVD: Why Negative Data Don’t Dampen Sales. You’ll need a free Medscape account to read the article; if you don’t have access, I’d encourage you to register and read this one.

Any article that begins with the opening sentence “Vitamins and supplements do not prevent cardiovascular disease (CVD)” promises to cast supplements in a very negative light, and he paints with a very broad brush here appearing to lump “vitamins and supplements” into one ineffective heap.

The author does provide superficial summary data from several studies, though his interpretation of several is later challenged and corrected by multiple commenters, and he goes on to castigate the physicians and patients who persist in ignoring his cited data denigrating supplement use.

I don’t have time to delve into nitpicky particulars today, but three points come to mind about the article…

Three Quick Points About the Article

One, if you’re interested at all in the rational utilization of supplements, take 10 minutes, read the article AND the comments. You’ll note that opinions expressed by a number of health professionals in the comments vary widely (an understatement), and an impressive subset of physicians and allied health providers commenting disagree vehemently with the article’s premise.

Two, several commenters hit upon a key principal often neglected (or ignored) in the institutional practice of allopathic medicine today – the fact that supplement (or treatment) decisions need to be ultimately framed by an individual’s physiology (and metabolic state in this discussion of supplementation), and not necessarily by the sweeping generalizations of often very narrowly focused (i.e., looking a single vitamin, mineral, or cofactor) empirical studies.

Three, for those who face an uphill battle with their personal physician(s) with regard to supplement utilization, understand that you’re not alone. The reasons for the disconnect are multiple, and both the article and commentary suggest that physicians and the rest of us are heavily influenced by a number of biases we carry (including financial ones).

A Deeper Dive on Supplements Coming Shortly…

I have to admit, I’m fascinated by the supplement world, and come at it from the position of a longterm skeptic, no doubt due to my traditional medical training and practice, though personally use and recommend supplements routinely today. More to come…

Medical Policy: A Slippery Slope if There Ever Was One – “Rational” Elder Assisted Suicide

By

On a site dedicated to exploring health and wellness, it might at first glance seem a bit odd to find a link to a source talking about elder assisted suicide.

[As a quick aside, let me make my personal position crystal clear on the topic – I am against all forms and every practice of assisted suicide on moral grounds. Clearly adherents and supporters of the practice can put forth, at least on some level, cogent arguments, however, particularly in the context of the “elderly” as discussed in the links below, I find even the discussion abhorrent.]

That said, one of our goals here is to present occasional medical policy topics that have practical and current standing; given as to how media outlets such as the New Year Times have recently called attention to the issue, and physician friends have continued to report discussions along this line by entities ranging from local medical ethics committees to national professional association level, policy-articulating boards, I felt it reasonable to throw this out there.

Several months ago I was actually sent this link – Promoting ‘Rational’ Elder Suicide – by a physician friend; this friend (who shall remain nameless for obvious reasons) holds an appointment in a prominent American School of Medicine, heads his specialty department, and has served several stints on medical ethics boards for local centers as well as an ethics task force for his specialty nationally. He also happens to hold a JD in addition to his medical degree; of note, he never actually practiced law.

In his email he lamented that, for a variety of reasons, in his opinion we’re going to see a “significant push toward acceptance of assisted suicide for a an ever-enlarging spectrum of issues, including its routine use in the elderly who have outlived their resources, have diminished functional capacity and ability to meaningfully and consistently contribute to the greater society as a whole.”

Sober food for thought, and yet another reason to optimize one’s health and maximize one’s functional capacity for the long haul.

And back to more uplifting regular programming tomorrow…

Interesting Read: A Brief History of American Medical Insurance

By

From time to time I’ll be sharing thoughts on medical policy and the medical insurance arena, both areas that anyone (certainly those of us, say, over 30) who wish to maximize wellness, function, and our longevity should, at least from a respectful distance, cast a wary eye toward.

There’s a lot to talk about in these areas, and of course the intricate realities of medical policy and the insurance world are at times deviously complex, maddeningly opaque, and almost always costly (both in human and financial terms) when you have an up-close and personal encounter with either, though particularly medical insurance.

To that end, I recently came across this (relatively) short read – A Brief History of American Medical Insurance – via an unlikely source, Hillsdale College’s Imprimis. Mr. Gordon doesn’t get everything right, though he’s much closer in presenting reality than most these days. Worth a read…

Much more to come in these two topic areas, with an eye to practical application for we consumers of health care.

Image via Imprimis.