Links for Wednesday, September 5, 2018: docs are nervous about weight loss meds, risky low-carb diets, why I'm not a pediatrician, and continuity of care is good

Why don't more docs prescribe weight loss medications?

Speculation: 1) cost (and by extension, prior authorization requests); 2) residual fear from fen-phen, as one of the docs interviewed alluded to. We can surely put this to bed, since the current crop of meds has been on the market much longer than fen-phen had been when its harm was revealed; 3) nihilism. Five percent weight loss is meaningful from a medical perspective, but unless the doc is consciously, prospectively measuring outcomes like blood pressure, lipids, and fasting sugars, it won't knock her socks off. Patients won't be thanking her for getting them ready for bikini season; and 4) the old Risk Evaluation and Mitigation Strategy (REMS) for Qsymia was such a PIA that it scarred some docs to prescribing these meds.

Can we stick a fork in low-carbohydrate diets? (Ba Dum Tss)

What's a 32% increase in mortality among friends? Investigators (in a study that, to my knowledge, has not yet been published, so caveat emptor) found an association between the lowest quartiles of carbohydrate intake and death:

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

Remember: we can't draw causality from this. There is some chance that people who are sick and more likely to die from heart disease, cancer, or stroke are more likely to adopt low-carbohydrate diets. But it doesn't seem likely. The people at highest risk in this study were those over age 55 and "non-obese."

Reason # 1,001 I'm not a pediatrician:

Can. Not. Do. It.

Special shout-out to the 100 cell phone text alerts during the video. 

If lack of continuity is a mark against telemedicine, then it's a mark against the hospitalist model in general

I've had several Impossible Burgers. They're amazing

A few years ago I made a choice to eat very little meat. Everyone who comes to a this dietary decision gets there for one of several reasons. For some, it's a matter of animal welfare. For me, it was the impact of excessive meat intake on my personal health: meat, particularly red meat and processed meat like bacon, has been linked to increased risk of heart disease, cancer, and other diseases. Plus, beef in particular is astonishingly carbon-intensive; were people to forgo only red meat in favor of beans (while, mind you, continuing to eat pork and poultry), the U.S. would come very near Paris Accord carbon emissions goals, all without a change in driving habits or other energy production from fossil fuels, and without a change in efficiency. 

Giving up meat for me was astonishingly easy. I don't miss it. Were you to ask me to give up sweeteners, we'd have a problem. I like desserts more than I should, and despite my frequent screeds against bug juice, I have an occasional caffeine-free Diet Coke. But no meat? No problemo. Part of the reason for this is that we've had a big increase in the availability of meat substitutes in the past decade or so. This doesn't affect me so much as it affects people who eat with me. I can make meals that are almost meat that I can serve to carnivorous friends and family without feeling like I'm depriving them of anything. But hamburgers, the quintessential American food, have been a problem. I've tried multiple veggie patties and black bean patties. They're all mostly okay, but they're no substitute for real meat. You have to have in your mind that you're not eating a hamburger to enjoy them. You tell yourself, "This is a good veggie burger," but you can never convince yourself that you're eating a real-for-real hamburger.

Then I heard about Impossible Foods and their bleeding vegan hamburgers. I was intrigued, but there was no place near home for me to try one. But last summer I was in Houston a week or two before Hurricane Harvey. We found a Hopdoddy just west of Rice Stadium:

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This was directly adjacent to Rice's semi-famous 1/3 mile "Bike Track," whose popularity I assume is at least partly due to the apocalyptic artillery-grade roughness of the surrounding streets. Hopdoddy was pushing the Impossible Burger hard:

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But that didn't mean they didn't have the customary pile o' beef in their kitchen:

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And it didn't mean that when I ordered on the waitress wouldn't say I was "brave." But when it arrived, so far, so good:

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My burger looked like a million bucks. But I didn't get a chance to find out if my burger bled; it was well-done:

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Impossible Burger has the look and feel of beef. It has the mouthfeel of beef. It just does. For all intents and purposes from the consumer end, this is beef. I tried a bite of my son's regular patty for a taste test. I'm a bit of an unreliable witness here; my enthusiasm for meatless foods taints my impression of these things. But honestly, the only difference was that his real burger was saltier. I suspect Impossible keeps the salt content lower to avoid dryness.

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I liked the one I ate so much that I convinced my then-ten year-old daughter, a notorious carnivore, to try one. She will eat veggie patties, begrudgingly, the way somebody who's tasted whole milk will settle for almond milk on her cereal if they don't have a choice. But after tasting mine, she was enthusiastic to get her own. And she's had several since.

The primary ingredients are wheat, coconut oil, potatoes, and heme. Heme is part of the molecule that carries oxygen in your bloodstream: "hemoglobin." Impossible gets its heme in the form of soy "leghemoglobin." Their website says they chose it because of taste and lack of allergenicity. I suppose this means people won't get a rash if they eat it. Not that I knew hemoglobin allergies were a big problem.

If you're the anti-GMO type (I'm most certainly not), beware that Impossible's leghemoglobin is produced by a genetically modified yeast. But it is 100% vegan. It's not gluten-free, which is a bummer for the small fraction of the population with celiac disease. For the remaining 99% of us, it's neither here nor there. Impossible burger patties are kosher.  Halal are anticipated later this year.

My second Impossible Burger was in Washington, D.C., for a work trip. My daughter's, ironically, came with bacon:

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My wife's medium-rare (not ordered that way, but delivered that way) patty gave us a chance to taste the heme without the searing. It definitely loses something. The seared heme is important: 

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I tried to convince my daughter that the tater tots were also "Impossible," but that since they were naturally made of potatoes the impossible factor was figuring out how to make them out of animals. She didn't buy it: 

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Impossible Burgers are now served in more than 1,500 restaurants. Since April, White Castle has been selling Impossible Sliders for just $1.99. After trying Impossible Burgers myself, I'm convinced that meat production in the way we've been practicing it for the past 100 years has an expiration date. We simply won't tolerate the health and environmental consequences of it when we have alternatives that are this good. I'm not here to tell you that Impossible Burgers represent any kind of achievement. Quite the contrary: as good as they are, they're just the beginning. Meatless "meat" is the worst today that it ever will be. It will only get better from here. Next phase vegetarian chicken? Faux eggs? Faux seafood

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”.

 

Should young, healthy people with type 1 diabetes take statins?

I encountered this question a couple months ago in a consult and intended to blog about it then, but relatively little trial data was available. I would have essentially been giving my own off-the-cuff opinion. That's very unsatisfying to me, and probably to the reader.

As background: we tend to think of type 1 diabetes as more a need for hormone replacement (insulin) than as a disease state requiring the complex management that type 2 diabetes requires. That is to say that type 1 diabetes, for all the unpleasantness it causes for people, is easier on the blood vessels as a general rule than type 2 diabetes. The ADA has a statement in its guideline that "For patients with diabetes aged <40 years with additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity or high-intensity statin and lifestyle therapy." It's a category C recommendation, meaning it's mostly opinion and has a less-than-spectacular evidence base. It also doesn't differentiate between type 1 and type 2 diabetes. Similarly, a joint statement by the ADA and the AHA states that "Adults with T1DM who have abnormal lipids and additional risk factors for CVD (eg, hypertension, obesity, or smoking) who have not developed CVD should be treated with statins." Both statements argue against the routine use of statins in young healthy type 1 diabetics.

But a recent study from the New England Journal helps us with the question of statins in kids, and throws in ACE inhibitors for good measure. Investigators led by M. Loredana Marcovecchio and Scott T. Chiesa randomized 443 kids between 10 and 16 years with type 1 diabetes and urine albumin-to-creatinine ratios in the upper third of "normal" to some combination of ACE inhibitor, statin, and placebo. Creatinine is a consistently excreted product of muscle metabolism that serves as a nice comparator for other things the kidney excretes. So even if you drink a lot of water and dilute the amount of albumin in your urine, we can look at it compared to the similarly diluted creatinine and see if you're excreting too much.

Anyway: the investigators used a 2 x 2 trial design, meaning that there were ultimately four groups: placebo-placebo, placebo-ACEi, placebo-statin, and ACEi-statin. The statin was atorvastatin 10 mg daily, and the ACEi was quinapril 10 mg daily (after titration). They were most interested in the change in albumin excretion (that is, how much protein spilled through the kidneys into the urine). They assessed this according to that same measure, the albumin-to-creatinine ratio in the urine, from three early-morning urine samples obtained every 6 months over about two and a half years. They also looked at secondary outcomes like the new development of microalbuminuria (that is, the new appearance of protein in the urine), worsening of eye disease, changes in kidney function, blood lipid levels, and measures of cardiovascular risk. For the cardiovascular risk, they did ultrasounds of the carotids to measure the thickness of the vessels (carotid intima–media thickness) and measured levels of high-sensitivity C-reactive protein and asymmetric dimethylarginine in the blood. Both of these are generic markers of vascular risk.

After an average of 2.6 years, no benefits were found within the ACEi group, the statin group, or the ACEi+statin group compared to placebo. Unsurprisingly, the ACEi group had a much lower incidence of new microalbuminuria, but "in the context of negative findings for the primary outcome and statistical analysis plan, this lower incidence was not considered significant (hazard ratio, 0.57; 95% confidence interval, 0.35 to 0.94)." Also unsurprisingly, the use of statins resulted in lower cholesterol levels (including, unfortunately, HDL). But neither drug had significant effects on carotid intima–media thickness, C-reactive protein, kidney function, or progression of eye disease.

So we can take away from this small-ish study that, at least in a short amount of time in pretty healthy twelve-year-olds (the subjects were excluded if they had genetically bad lipid levels; the participants' average A1c was ~8.3% and their average blood pressure was 116/65 mmHg), there was no benefit to statins or ace inhibitors. This study will influence my recommendations to patients and other docs in the future. The kicker, naturally, is that many young people with type 1 diabetes have imperfect blood sugar control. What about those who can't get their diabetes controlled? It's a tougher call in that case, and this study didn't address it. 

June 6, 2017 link-a-dink

The idea that good diabetes care isn't strictly an obsessive quest for an A1c level of 7% or less is finally hitting the mainstream press. This article also touches on the very real dilemma that doctors and patients face: Do we use old, cheap drugs that are effective at lowering the hemoglobin A1c level, or do we use new, astonishingly expensive drugs that have better evidence of actually reducing death?

Most people will never understand my eating disorder. "I am six feet tall and between 180 and 190 pounds, depending on the month. I am by no means the picture of health or even particularly muscular-looking—not for someone who exercises this much, and definitely not compared to most of the men I see at my gym. Or maybe I am? That's the problem, or one of them: What I see when I look in the mirror doesn't correspond with reality. I see a fat piece of shit, and then I think to myself that it's time to punish my body for letting me down."

Do patients make mistakes during doctor visits because they're put in a position that forces them to rely on intuition and makes them vulnerable to biases? 

RIP Warner Blackburn: sadness at the Dirty Kanza

I finished the Dirty Kanza 200 yesterday, and I plan to write about the experience in detail. But for now, I want to mention Warner Blackburn, a man who died during the 50-mile race. He was given CPR on the course by a friend of mine and taken to the hospital, where he died of an apparent heart attack.

I suppose the most cyclist-y thing to say is that "Warner died doing what he loved" or some such crap. But I don't know that. I don't know that Warner even liked cycling. He left almost no trace on the internet. Maybe he was doing the DK 50 on a bet, or maybe he was trying to support a family member. My wife makes fun of me because I automatically assume that people in cycling and other outdoorsy pursuits are nice, even though I'm not the warmest cuddliest type around. So I'll say this: whether Warner liked cycling, or whether he was trying to support someone else, or whether he was trying to support a cool event for the local community, he went out on a high note. 

FWIW, for anyone thinking of starting exercising after a long period of physical inactivity, please take the Physical Activity Readiness Questionnaire first. It's a little too sensitive, meaning it may flag a few people who aren't that high risk, but if you have a "yes" anywhere on the form, it's worth talking to your doctor about before you go out and hit it too hard.