Weekend links for Saturday, August 17, 2017: post-apocalyptic Rio, money makes the Mediterranean diet work, DNA testing may not change behavior, and the folly of clean eating

A year later, the Rio Olympic sites are ruin porn. 

Is money the secret to making the Mediterranean diet work? 

To be fair: I don't know a lot about this literature at all, but I suspect that the same claim could be made of many interventions, dietary and otherwise, were the data known. The more money you have, the healthier you are in general. (link via kottke.org)

Knowing our DNA risk doesn't make us change our behaviors.

I need to investigate this further. The thrust of this article--that knowing our risky mutations doesn't make us behave any differently--flies in the face of some data I've presented in the past. 

Have we all fallen for "clean eating?"

I remain convinced that eating food that looks like food, in the Michael Pollan sense, is generally what we should all be doing. Like most ventures that people look to capitalize on, though, it has been taken too far: see the "influencers" in this article that actually make themselves sick with adherence to an irrationally vegetable-based, uncooked diet. (link via longform.org)

Follow-up on medical school rank and narcotic prescriptions

I've had several conversations with fellow docs about the NBER paper from last week showing a relationship between medical school rank and narcotic prescriptions. Naturally, the responses I got were pretty skeptical. A recurrent theme I ran across was that the authors didn't pay enough attention to practice setting. 

1. Higher-ranked medical schools tend to produce more students who eventually land in academia, often at higher-ranked medical schools or residency programs.

2. Because of the culture of those high-performing places, characterized by greater access to subspecialists, a slower pace of practice, the presence of trainees to keep you honest and whatnot, you practice more conservatively and without fear of patients firing you for not giving them narcotic prescriptions.

 3. Perhaps people graduating from lesser-ranked schools end up in private practice, where there is more pressure to write a narcotic prescription to all those patients with back pain, just to keep them from 1) firing you, and 2) telling all their friends and family what a crappy, uncaring doctor you are.

4. So the speculated end result is that people graduating from higher-ranked medical schools end up writing fewer narcotic prescriptions than their peers from lower-ranked schools.

I pointed out to several people that the study took into account specialty and location; the relationship held for people in the same specialty and same county. The investigators pontificated on practice setting (noting that DO graduates often take care of a more rural, white population, for instance). But they didn't control for it. So I held my hands up ¯\_(ツ)_/¯ and moved on with my life.

But then I listened to a segment about it on the Weeds podcast today (start at 1:01:25):

UPDATE: I'm having some trouble embedding the audio, so if you can't get it to play, go here: http://bit.ly/2uLk2lY

Sarah, Ezra, and Matthew made note that the relationship held within the same clinic, so I re-visited the paper. I found this: 

Check the footnote. *slaps forehead*

Check the footnote. *slaps forehead*

So the investigators did account for practice setting, but since it was hidden in a footnote, I missed it. 

The take-home from this paper is still kind of hard to identify. I'm not in favor of necessarily checking the LinkedIn page of every doctor you see to check what med school she went to, but there is clearly some kind of relationship between the culture of medical schools and the prescribing behavior of graduates.

The lower-ranked your doctor's medical school, the more likely he'll write you a narcotic prescription

You read that headline right: investigators in an NBER paper found that docs who went to a lower US News-ranked school are more likely to write narcotic prescriptions, and the ones who write narcotic prescriptions are likely to write for more drugs, depending on the ranking of their school. And lordy, those osteopathic schools:

US News publishes several rankings, in topics from research to primary care to women's health. For this paper, the investigators used the "research" ranking, which is difficult to translate into medical student bedside education. After all, some of my best teachers in med school hadn't published a paper in a decade.

Several other take-home points from this. First, at first glance general practitioners write a ton of narcotic prescriptions; their rate on the y-axis is roughly double the overall physician population's. But when you consider that primary care docs perform well over half of all the visits delivered, that number of narc prescriptions looks less impressive.

Second, the effect size, if you're willing to take a leap and go straight to the idea that the quality of research at your medical school somehow has a causative effect on how many hydrocodone prescriptions you write, is huge. Using Harvard as the index school, the schools in the eighties and nineties have graduating docs writing three times as many prescriptions.

My first thought when I read this was that docs who went to lower-ranked schools may end up on places where they're more compelled to write narcotic prescriptions: places with high poverty, or a large blue-collar workforce, for instance. But the investigators accounted for that, and found that the relationship persisted even within the same county:

I can't help but try to apply this research to myself, even though I'm an endocrinologist and therefore mostly shielded from the narcotic game, and even though I see relatively few patients nowadays. But here we go. I attended the University of Kansas, which is comfortably ensconced in a tie at number 65 on the research list:

Oof. Medical school got a lot more expensive in the last couple decades.

Oof. Medical school got a lot more expensive in the last couple decades.

So where would I live in the narc prescribing graph?

Riiiiiiiiight about there. It's a wonder I'm not a bonafide narcotic prescribing machine. 

Riiiiiiiiight about there. It's a wonder I'm not a bonafide narcotic prescribing machine. 

What's unsaid in this list is that KU has three campuses (two at the time of my training). And it further goes without saying that the training in Wichita, Salina, or Kansas City may have subtle differences that would lead to slightly different physician performance or behavior. Furthermore, it would be interesting to see the research repeated with residency or fellowship training as the independent variable, since those are the years when trainees really fall into a groove of prescribing habits. If I were held to the standard of my internship with a University of Washington program, I'd be compared to the folks at the skinny end of the graph:

Go dawgs.

Go dawgs.

But if my fellowship training at UNC-Chapel Hill were the standard, I'd be in a nice, comfortable happy medium between the narc-crazed sixties and the narc-stingy pre-teens:

The take-home from this isn't that we should all check our doctors' CVs before we go see them, in fear of them hooking us on oxycodone. It's just that schools who inhabit the lower tiers of medical research need to do a better job of teaching narcotic prescribing. 

And obviously, the take-home for patients is to be very, very careful about requesting narcotics for pain. They don't work as well as we think they do, and the potential for harm is huge. 

I found this link, fwiw, via marginalrevolution.com

Hormonal diseases in literature

I have three favorite pieces of endocrinology-themed fiction.

The short story "Baster" by Jeffrey Eugenides, was featured on this week's New Yorker Fiction podcast. It is in his collection of short stories Fresh Complaint, to be released this fall. "Baster" was adapted into the movie The Switch with Jason Bateman and Jennifer Aniston, but only the first half of the movie, where Wally obsesses over Kassie's impending insemination and eventually switches his own specimen for her better-looking donor's, is drawn from the story. The rest of the movie, dealing with Wally's growing affection for his neurotic son and his eventual confession, are new. 

My absolute favorite piece of endocrinology-related fiction is Middlesex, also by Jeffrey Eugenides.

It tells the story of consanguinous parents of a child born with 5-alpha reductase deficiency, a hormonal disorder in which male children do not make enough of the active male hormone dihydrotestosterone.

The red line is the enzyme defect we're talking about here. Image from Wikipedia. 

The red line is the enzyme defect we're talking about here. Image from Wikipedia. 

This causes them to be very feminized at birth, with a micropenis and undescended testicles. They were often raised female before the disorder was well-known. But at the onset of puberty, people with the disorder suddenly and sometimes dramatically get male features. Callie (later Cal) is the narrator, and his gender identity evolves in parallel with the family's experience in immigrating from Asia Minor to Detroit, then to San Francisco. It's fantastic.

Finally, the novel The Amazing Adventures of Kavalier and Klay, by Michael Chabon, has a clever endocrinologic twist at the beginning. 

It starts off with one of the main protagonists, Josef Kavalier, escaping to New York from Prague, Czechoslovakia by being concealed inside the coffin of the Golem of Prague, a clay mannequin, by his magic teacher, Kornblum. The giant clay mannequin is clothed in the suit of a giant obtained from a deceased patient of Josef's endocrinologist father. It's the first of several escapes by Joe in the book (first from Nazi Europe, then from poverty, then from Antarctica, then from loneliness). The book concludes with (spoiler alert) Sammy, his best friend and cousin, escaping from life as a closeted homosexual. Haunting book.

Links for Friday, August 4, 2017: beans over beef and beautiful Tour de France pics

Substituting beans for beef might get the United States to carbon emission goals

Even if we all continued to eat poultry, pork, and fish. Beef is that carbon-heavy. Related: the economic value of giving up meat and see James Hamblin below.

Astonishingly beautiful pictures of the Tour de France from Strava

I literally gasped when I saw this pic of the Col du Galibier. 

I literally gasped when I saw this pic of the Col du Galibier. 

If you're not the listening type, you can read the transcript here. 

Super four-pack of links July 11, 2017: the five percent and healthcare money, video game addiction, exercise to prevent diabetes, activity inequality, and evil coconut oil

Super-user sounds great, right? Who doesn't want to be super at something? Only this video (in Memphis-style) refers to the 5% of Americans that account for ~50% of health care spending in a year.

To paraphrase the end of the video: "There's almost nothing insurance companies won't charge, and Americans won't pay." How do you keep yourself from becoming a super-user? Everything medical is a matter of risk, so don't believe anyone who tells you there's a rock-solid simple way to keep from falling into that 5%, at least temporarily. But overwhelmingly, if you can keep a steady job you don't hate, if you can abstain from smoking, if you can get even a small amount of daily exercise (more is better, obviously), if you can keep your alcohol intake to a minimum, if you can abstain from recreational drugs (this includes marijuana, obviously), and if you can choose to eat mostly plant-based foods in semi-sane quantities, you're gonna stay out of The Five Percent.

Dara Lind and Dylan Matthews join Ezra to talk about the updated travel ban, how Trumpism has translated into policy, and the impact that increasingly awesome video games have had on young men's work habits.


Links!


White Paper: Leisure Luxuries and the Labor Supply of Young Men


Peter Suderman's piece about young men playing video games instead of getting jobs


What does excess immersion into video games mean for young men?

I've tried to set the Weeds audio above to play at about the 46 minute mark. But if that doesn't work, fast forward to the 46 minute mark. Not because the discussion of what "Trumpism" is isn't interesting (it is), but because the discussion that follows helped me think more deeply about the problem of excess immersion into video games that young people, especially young men, are experiencing. I've blogged about this before, and I talked about it at a recent speaking engagement. We seem to be creating a generation of youths who are increasingly isolated in very immersive video games, and then they're growing up into increasingly isolated and lonely people, particularly after age 40. As Ezra Klein says in the piece: if this were a problem of drug abuse, I think we would be acting collectively to do something about it. That's an apt comparison, since game addiction and drug addiction seem to have some physiology in common. But since the solution to technological problems currently seems to be "more technology," we are kinda-sorta just plowing ahead and hoping that video games fix themselves. I'm not optimistic. I think we need to start introducing programs to help kids moderate their exposure to video games and increase their exposure to the world at a young age. Dylan Matthews, who generally defends the idea of video games as a pacifying technology for people who can't or won't work, ends with this quote: "When we're in our eighties, we're all gonna be doing, like, flight simulator stuff. That's, like, how we'll spend--or, VR stuff, at least--that's what retirement's going to look like." Yuck. No. No. No. 

A new meta-analysis shows that African-Americans who exercise may not derive the same protective benefit from type 2 diabetes as other races

(brief Healio write-up here)

 I'm not ready to sign on to this point; race is a very blunt instrument when it comes to genetics. As the cost of gene sequencing falls, I think we'll not only be able to tease out drug effects in people with specific genetic features; we'll be able to more precisely target interventions like physical activity. Maybe certain people in this collection of studies would have benefited more from strength training, while others needed more endurance-oriented activities. Maybe some would have benefited from a specific combination of drug and activity. We don't know the answers to these things now, but we will soon. 

Smartphone data shows that countries with the highest "activity inequality" are more likely to have large obese populations: 

More differences in activity within the population equals more obese people. 

More differences in activity within the population equals more obese people. 

So it isn't a surprise that the same investigators found that the higher the walkability of a city, the lower the "activity inequality":

Texas is not a place with a great deal of walkability. 

Texas is not a place with a great deal of walkability. 

The cynical take on this study is something like, "Of course people who are inactive weigh more!" Fair enough. But the obvious policy implication of the study is that, to affect the activity level of the inhabitants of a city, the built environment must give opportunities for activity.

ADDENDUM (make it a five-pack): How coconut oil got a reputation for being healthy in the first place. I don't love coconut oil, but even if I did, I'd think of it like I think of butter: an ingredient to be used sparingly, mostly for flavor. 

Don't wanna see the sausage links made, July 7, 2017: New endocrine society statement on obesity pathogenesis and the danger (danger!) of placenta capsules (placenta capsules?)

"...obesity is caused by two distinct processes: energy homeostasis and energy imbalance – specifically, energy intake greater than expenditure."

This is an excerpt from the Endocrine Society's new statement on obesity pathogenesis. I'm relieved to see it. In the past couple of years, as investigators have (rightly) cast light on some of the shortcomings of the calorie as a measure of energy consumption or energy expenditure, the internet has drowned in chatter about how obesity isn't a matter of energy in versus energy out. When of course it is. You simply can't make fat out of air or sunshine. At some level, people who carry more weight than they'd like are eating an excess amount energy or expending an insufficient amount of energy or both. The fact that we don't have a perfect way to measure or quantify it doesn't change that fact. So this nugget from the Endocrine Society's press release is welcome, too: 

“Because of the body’s energy balance adjustments, most individuals who successfully lose weight struggle to maintain weight loss over time,” said Michael W. Schwartz, M.D., of the University of Washington in Seattle, Wash., and the chair of the task force that authored the Society’s Scientific Statement. “To effectively treat obesity, we need to better understand the mechanisms that cause this phenomenon, and to devise interventions that specifically address them. Our therapeutic focus has traditionally been on achieving weight reduction. Most patients can do this; what they have the most trouble with is keeping the weight off. Healthcare providers and patients need to view this tendency as the body’s expected response to weight loss, rather than as a sign of a failed treatment regimen or noncompliance with treatment,” Schwartz said."

In case you were wondering, the CDC is warning against the consumption of dried placenta capsules because of a risk of group B streptococcal infection.

Why am I so late getting to this news? Anyway: there goes my best baby shower side-hustle idea...