Links for Tuesday, November 21, 2017: more on the new HTN guideline, Gymnastics coaches throwing robot shade, the last iron lungs, Germany bans smartwatches, and Raymond Chandler hated US healthcare

Thoughtful post on the new HTN guideline by Dr. Allen Brett

Representative quote: "Consider, for example, a healthy white 65-year-old male nonsmoker with a BP of 130/80 mm Hg, total cholesterol level of 160 mg/dL, HDL cholesterol of 60 mg/dL, LDL cholesterol of 80 mg/dL, and fasting blood glucose of 80 mg/dL — all favorable numbers. The calculator estimates his 10-year CV risk to be 10.1%, making him eligible for BP-lowering medication under the new guideline. To my knowledge, no compelling evidence exists to support drug therapy for this person."

A gymnastics coach says the Boston Dynamics robot flip was a 3.5/5.0

'In a back salto, says Mazloum, “you want to be able to go as high as you can, and you want to be able to land as close to where you take off as possible.” To do that, the gymnast has to squat, throw her arms up by her ears so her body is a straight line (in gymnast-speak, opening the shoulder angle and the hip), then contract into a “closed” position again. By these standards, Atlas’ trick is “not the cleanest flip,” explains Mazloum.

Here’s Mazloum’s critique: Atlas didn’t quite get to that open position, “so it didn’t really get the full vertical that we look for. That’s why it went backwards a little bit.”'

The last of the iron lungs

Get your kids vaccinated for polio, folks.

Germany has banned smartwatches for kids

If I understand this correctly, it is not because smartwatches cause kids to be distracted monsters (although I don't doubt that that statement is at least a little bit true). The decision stems from the capability of bad guys to hack in and monitor the location of little Dick and Jane:

You have to wonder who thought attaching a low-cost, internet-enabled microphone and a GPS tracker to a kid would be a good idea in the first place. Almost none of the companies offering these “toys” implement reasonable security standards, nor do they typically promise that the data they collect—from your children—won’t be used be used for marketing purposes. If there ever was a time to actually sit down and read the terms and conditions, this was it.
Get your shit together, parents.

Asking parents to destroy them might be a bit of an overreaction, though.

Raymond Chandler paints a dark picture of American healthcare in a newly-discovered story

The title, "It’s All Right – He Only Died," sounds like the title of a video residencies would show interns to convince them that quality improvement and patient safety are part of their job.

The doctor who turned away the patient, Chandler writes, had “disgrace[d] himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long-acquired skill might help or save”.


You can't use drugs to "prevent" diabetes

Big, big disclosure here: I am a paid consultant for a CDC grant that aims in part to increase use of the Diabetes Prevention Program. So there. Read on.

Good to see you again, Mrs. D. You mind if I call you Mrs. D? Thanks. Reminds me of "Mrs. C" on Happy Days. You know, she was the only one with the cojones to call the Fonz "Arthur." So you can see the resemblance.

I'm glad you asked about the recent study that showed a medicine called "liraglutide" (brand names Victoza or Saxenda) "prevented" diabetes. You're a smart person, so you read some of the fine print in the study, and you know that ~2200 patients, most of them obese, were randomly given a daily shot of placebo or a daily shot of liraglutide, a chemical that mimics a gut hormone to trick the pancreas into producing more insulin. Liraglutide has the side effect of making people feel fuller sooner after eating. Doctors call this "early satiety." The tricky vocabulary's how we make so much money.

All of the patients had elevated blood sugars, but not so elevated that they could be labeled "diabetic." They were "pre-diabetic" in the current nomenclature, just like you. It means the same thing as "impaired fasting glucose" or "impaired glucose tolerance." The study set out to prove that liraglutide could "prevent" the onset of diabetes. Now you're probably wondering: If I'm taking a diabetes drug, what's the point of having "prevented" diabetes?

And you're on to something, Mrs. D. This is an absurd question at face value, but it keeps getting tested, mostly by drug companies. Not surprisingly, in most cases people getting the diabetes drug were less likely than those getting a placebo pill or shot to have their blood sugars rise high enough to be diagnosed with diabetes.

I'm about to get really, really snarky, Mrs. D, but before I do, it's important that I make this point: the prevention of diabetes is actually a HUGE deal, and not only because diabetes remains the number one cause of blindness, kidney dialysis, and foot amputation in the United States. It is astonishingly expensive. Of the $3.2 trillion (!) that Americans spend on health care annually, diabetes directly accounts for $101.4 billion, making it officially the most expensive disease in America. If you can prevent people from advancing from the just-a-little-abnormal-sugars "pre-diabetes" to old-fashioned diabetes, you save about $12,000 per year in expenses. Now, that's insurance company money, but we all pay for it in premiums.

This is where your insurance premiums are going.

This is where your insurance premiums are going.

And as I've pointed out before, a big chunk of that extra spending isn't insurance money at all; it's coming out of your pocket in the form of co-pays and whatnot. And it's not much better for the Medicare crowd, who we all pay for in taxes:

So let's perform a quick thought experiment. You came to see me because you weren't feeling your best, and I checked a blood sugar on a hunch, and it's slightly elevated at 106 mg/dl. That's in that pre-diabetic range I've been talking about.


Now, we've got some options here. But let's say I tell you that the best way to keep yourself from becoming diabetic is to inject yourself with 10 units of insulin every night before bed. That way, your blood sugars will go back to normal, and we can both wash our hands of the whole issue. Great, right? We've prevented a case of diabetes! Your blood sugars are normal, after all.


Of course we haven't prevented a case of diabetes! We've just put you on a diabetes drug that has (predictably) lowered your blood glucose levels. The entire assertion that we've prevented anything is as laughable as the assertion that we could "prevent" a diagnosis of hypertension by putting you on blood pressure medications.

To make the situation even more ridiculous with liraglutide, it costs a fortune: over $3,000 a month for the 3 mg dose! If you wanna know where that extra $12k a year is going, I think we're hot on the trail. Think what else we could do with that amount of money. And if you for some reason think the idea of "preventing" diabetes by taking a diabetes drug isn't patently absurd, it works only modestly better than metformin, a drug that can easily be obtained for $3-4 per month.

But the final insult, Mrs. D, is that liraglutide worked barely better in its study than a program called the "Diabetes Prevention Program," or "DPP." In the liraglutide study, roughly 2% of people receiving the drug went on to have blood sugars high enough to be diabetic in three years, versus 6% of people getting placebo, for what we call an 80% "relative risk reduction." (Drug companies love using relative risk because it makes the numbers sound so much more impressive) In the original version of the Diabetes Prevention Program, 4.8% of people getting counseling on diet and lifestyle by a coach went on to be diabetic, versus 11% getting placebo, for a 58% relative risk reduction. The numbers for both groups in the DPP were higher, which I blame on an older participant population.

The cost of the Diabetes Prevention Program? $429 per year. So you might not be surprised to know that in 2016, when CMS was debating whether to allow Medicare to cover the DPP, the Pharmaceutical Research and Manufacturers of America (PhRMA) fought against it, saying that twenty years of evidence was only "preliminary." They do. Not. Care. About your health or the seemingly inevitable transformation of America into a single, enormous insurance company that also happens to field a Navy. And we should all remember that back when insulin was discovered, the University of Toronto held the patent for insulin to keep any single company from exploiting the drug for unreasonable profit. How times have changed.

Okay. Deep, cleansing breaths. I'm calming down. Liraglutide is a good medicine for diabetes. It helps keep sugars down, it helps with weight loss, and it may even help prevent heart attacks. In diabetics, that is. But you're not diabetic, and you don't have to become diabetic, and all drugs come with a cost, financially and otherwise. I think we can agree that diabetes is expensive enough; we shouldn't use drugs to "prevent" it that are even more expensive than the disease itself.

So, Mrs. D. You'd be a great candidate for the DPP. But even if you weren't, do you know what the DPP asks of its participants? 150 minutes a week of physical activity and some dietary modifications to allow you to lose around 7% of your body weight. Let's think about what that might look like. The average bike commute in this country is around 19 minutes one-way. Do that five days a week, and you're at 190 minutes already! And that doesn't even count trips to the grocery store! And if you stop drinking insect bait and cut out the foods that aren't really foods:

If you cut those out from your diet and start eating most of your food from the produce aisle or from the canned fruits and vegetables aisle, don't you think that 7% weight loss sounds pretty modest? I bet you'd blow it out of the water. 

And besides, do you really want to cross that grim threshold from "person" to "patient?" Because the first time you put the needle of that Saxenda pen into your skin, that's what you'll have done. You'll have moved the wrong direction on the Double Arrow Metabolism Wellness Index. You'll have gone from a person with agency, someone who takes medicines to feel better or live longer, to someone who has yielded control to a chemical--a $30,000 a year chemical--to do something you could have done better yourself. You'll have succumbed to a philosophy of better living through chemistry.

Maybe Du Pont doesn't deserve this.

Maybe Du Pont doesn't deserve this.

Or do you want to be the person who SAVES thousands of dollars per year by ditching the fancy gas-powered wheelchair so you can propel yourself through space with your own legs and feet and by eating real foods you made with your own hands and eating them when you want, the way you want, and in the quantities you want? Do you want to live by a philosophy of self-determination, where you know that every healthy, happy day you live from now on was of your own making? 

If that life is what you want, then don't try to prevent diabetes with drugs. It can't be done.