Fitness versus Health: Marathons Test Not Just Endurance but Logic Too

Safer on the sidelines?

The mortality toll of the 2011 Philadelphia Marathon was two runners out of approximately 25,000, a death rate that proponents of the event might represent as less hazardous than the risk of commuting the distance by car. And probably much safer than couch-bound obesity. Even when we take into account the many people who require first aid for dehydration or suffer orthopedic injuries, the hazards of marathon participation might strike many as relatively low. Life is risky business, after all, and testing human limits -- for pleasure or heroism -- often comes at a price.

Nonetheless, it is curious to observe how sanguine health experts and the public have become about tests of endurance that can result in needless death, and how little discussion we hear in the aftermath about the wisdom or health value of marathon participation. That’s because marathons -- once considered an “extreme sport” for the very few -- are now an icon of our fitness culture, attracting virtual hordes of runners in cities across the country, more and more of whom run the full distance each year.

Marathons are a spectator sport and a badge of fitness honor -- not to mention a source of mood elevation for those addicted to long-distance running. And for the cities that host them, they are also very much a business that creates dollars, press, and caché. When endurance events like marathons and triathlons are promoted by health celebrities and fitness missionaries like CNN’s Sanjay Gupta, they gain more credibility and many more converts.

A Survey of Battlefields in the War on Cancer: Oncologists Reporting from the Front Lines

In 2008, we launched an oncology market surveillance program, “Oncologists Look at Oncology: Prognosis for U.S. Cancer Care.” We were moved to do this by what we were hearing from oncologists as we conducted in-depth interviews with them on behalf of our clients. Our clients in the field, who range from small startups to leading “Big Pharma” companies, shepherd innovative molecules from the bench to the clinic and, if successful, to the commercial marketplace. But over 35 years after the “War on Cancer” was famously declared by President Nixon in 1971, what we were hearing from oncologists on the front lines of cancer care was a sense of frustration, even despair.

A significant part of oncologists’ frustration at the time was financial. In 2006, Medicare and Medicaid reimbursement to physicians for in-office intravenous cancer medications was cut dramatically. Private practice oncologists had been earning 50 percent or more of their total personal income from profits on IV medication -- profits earned directly from reimbursement paid by public and private payers. The industry published fictional “average wholesale prices” (AWP) that set the reimbursement physicians would receive, but physicians were able to purchase drugs at prices substantially below AWP. Centers for Medicare and Medicaid Services’ updated reimbursement policy based on actual average selling prices rationalized reimbursement but changed the game for oncologists.

But loss of personal income wasn’t the only thing that seemed to have disheartened oncologists. They told us that they were sending more patients to hospitals for drug administration when coverage was uncertain -- even though patients generally feel more comfortable receiving treatment in familiar, less institutional treatment settings -- because private practices could no longer absorb unreimbursed drug costs. They told us that they were unable to treat patients with the best available care because of patients’ inability to afford requisite out-of-pocket co-payments. They told us that they did not see how providers or patients or payers could keep pace with the escalating costs of new cancer therapies. They told us that their colleagues were retiring and their children were pursuing specialties other than oncology because both financial compensation and lifestyle were better in procedure-oriented fields.

So What if Statins Increase Diabetes? The Real Risk May be Patient Non-Adherence

Just when we thought we had clarity on statin safety …

Last week’s leading health headline was a startling new finding that statin use increases the risk for diabetes mellitus (DM) in post-menopausal women by 50 percent, from six percent to nine percent.

While the data source -- the Women’s Health Initiative -- is an observational rather than a prospective study, the finding persists in a variety of patient subgroups, and even after the authors adjusted for baseline patient characteristics. This makes it unlikely that the increase in DM rate is due to women’s pre-statin risks of developing DM. Since diabetes is probably the single most important cardiac risk factor -- often considered the equivalent of a first MI in certain predictive models -- this news was both unsettling and perplexing. How might physicians and their patients interpret and act on this new information?

We were curious, so last week we conducted a small survey of full-time, office-based U.S. primary care physicians (PCPs) from the Epocrates physician panel* to test our hunches. Seven out of 10 PCPs had heard the recent mass media news coverage and, as a point of interest, two-thirds of them found the coverage “sensational” rather than “balanced/informative” -- despite the fact that clinicians interviewed on NBC Nightly News emphasized that they expected to keep their patients on statins.

Certainly, the news got patients’ attention. As of our survey date, at least one-third of PCP offices had received inquiries from statin patients. Balanced coverage or not, this sort of news event raises alarms, and it’s impossible for patients to draw implications on their own. What should patients, in fact, make of it?

The Obesity Epidemic: When Biology and Culture Conspire Against Us

What We Eat or What We Are?

Tara Parker-Pope’s recent cover story in The New York Times Magazine, “The Fat Trap: Do You Have to be Superhuman to Lose Weight?” describes what is fast becoming canon: that modern culture has unmasked in our evolutionary biology a genetic propensity to defend against scarcity and starvation by retaining excess fat.

Research that documents weight plateaus for dieters, and biological differences between obese subjects and others is allowing us to assemble a picture of the human animal as metabolically hard-wired to conserve or regain weight -- especially after it has been reprogrammed by periods of obesity. Research also lends strong support to genetic differences in the degree to which individuals may be prone to obesity based on innate metabolism, food addictions, or other epigenetic factors.

Many frustrated dieters will find redemption in that thesis -- as, clearly, does Parker-Pope, whose article is unusually solipsistic for a card-carrying science writer. It is really a lamentation … which just goes to show how intractable and all-consuming this problem truly is for those of us who live in societies of plenty.

Dim Prospects for Cure

It turns out that when culture and biology team up, they have the potential to do great mischief together. Modern obesity and modern terrorism both demonstrate how aspects of our basic nature can be potentiated by forces of culture -- including both the Big Mac and the Internet -- to produce negative outcomes.

Plan B and Public Health: Morning-After Problems We Can’t Easily Fix

Today I signed a petition to protest Kathleen Sebelius’ decision to override the recommendations of the FDA and the American Academy of Pediatrics by banning OTC availability of Teva’s Plan B morning-after contraceptive. I say that without intent to be provocative. I simply want to acknowledge right up front that I have no moral compunction about morning-after contraception -- although I tend, dispositionally, to prefer a pound of prevention to even an ounce of cure -- and I certainly don’t believe in subjugating science to religious principles. I was surprised at the Administration’s decision because it most assuredly wasn’t in the best interest of public health -- but neither do I know how to chalk up the political wins and losses on this for Obama, who was clearly willing to ignite a controlled burn on his left in order to avoid a firestorm on his right.

The petition I signed enjoined the President “not to put politics above science” -- a credo that sounds like the right slogan for the professional (and personal) world I inhabit. Still, I can’t help but note the irony that since all regulation of public health is inherently political, this distinction is forced and artificial. The FDA came down on what I happen to think is the right side of this issue -- public health and equal protection for those young teens who have, as a practical matter, limited access to all health resources. But the FDA, like all agencies charged with health policy oversight, is an instrument of politics. Public health is just a euphemism for politics. In fact, the whole public health sphere is becoming a house built by government and merely furnished by science.

Earlier Warnings of Cancer Drug Shortages? Alarm Bells Should Have Sounded 50 Years Ago

Right now in the US, over 40 million people are 65 years of age or older. And today -- right now -- we cannot meet the cancer drug demands of this age group. We cannot meet the demand for the wave of very expensive, new branded medications because the cost of these agents prohibits use for many patients. We cannot meet the demand for much cheaper generic cancer medications because -- among other reasons, some of which I addressed in a previous post about generic oncology drug shortages -- manufacturers do not get the financial returns to remain committed to continued supply.

To try to begin to remedy generic drug shortages that have already delayed care for many patients -- indeed, may already have led to preventable deaths -- President Obama signed an executive order earlier this week, directing the Food and Drug Administration to take action to reduce prescription drug shortages. The order instructs the FDA to do three things: broaden reporting of potential shortages of certain prescription drugs; speed reviews of applications to begin or alter production of these drugs; and provide more information to the Justice Department about possible instances of collusion or price gouging.

Soda and Teen Violence: Hazards of Correlational Analysis Can Put Truth in Harm’s Way

Statistical Ammo for the Twinkie Offense: Guns Don’t Kill People, Soda Kills People?

No one with an interest in public health and a zest for social engineering can go wrong by criticizing soda. That particular cup runneth over with empty calories and plausible links to obesity, as well as tooth decay. The carbonated beverage industry is fighting a pitched battle in municipalities across the US to avoid punitive taxation meant to price soda beyond the reach of citizens who seem most at risk of making poor nutritional choices -- choices that ultimately all of us must pay for. No matter what you think of coercive taxation, it’s really hard to defend soda.

Now, though, thanks to research published by two Harvard-trained researchers, Sara Solnick of University of Vermont and David Hemenway of the Harvard School of Public Health, soda has come under another sort of fire.

An analysis performed on the Boston Youth Survey database shows a significant correlation between soda consumption and violence in teens, including a propensity to carry guns and exhibit violent behavior with partners. The paper, which appeared in the Journal of Injury Prevention, got a two-day flurry of press attention because it has a provocative thesis that keyed off the famous “Twinkie Defense.” It gives everyone even more reason to worry about what dangers may lurk in our refrigerators.

Or does it?