Monthly Archives: November 2013

facts & data points, healthy habits, nutrition, policy, research methodology

A behavioural economist’s view on obesity…

This is a typically obtuse, academic view of obesity, breathlessly attempting to cite the immense complexity of the disease, capping it with a plea for more research dollars, or at least a reallocation of research dollars.

There are a couple of interesting snippets:

  • pets are also getting obese – 58.3% of cats were obese in 2012
  • lab animals too are getting obese – 11.8% per decade from 1982 to 2003
  • is this due to antibiotic-mediated changes to gut bacteria that not just change how we digest, but also how we behave?
  • socially mediated effects?

So surprising that a behavioral economist’s view could be so dismal.

 

Source: http://www.nytimes.com/2013/11/10/business/the-co-villains-behind-obesitys-rise.html?_r=2&

The Co-Villains Behind Obesity’s Rise

Waltraud Grubitzsch/European Pressphoto Agency

Researchers have compared tissue samples from obese mice with those of normal mice to try to determine which behavioral or biological factors might cause humans to gain weight. Here, a 2012 experiment in Leipzig, Germany.

By SENDHIL MULLAINATHAN
Published: November 9, 2013

Why is obesity soaring? The answer seems pretty clear. In 1955, a standard soda at McDonald’s was only seven ounces. Today, a medium is three times as large, and even a child’s-size version is 12 ounces. It’s a widely held view that obesity is a consequence of our behaviors, and that behavioral economics thus plays a central role in understanding it — with markets, preferences and choices taking center stage. As a behavioral economist, I subscribed to that view — until recently, when I began to question my thinking.

For many health problems, of course, behavior plays some role but biology is often a major villain. “Biology” here is my catchall term for the myriad bodily mechanics that are only weakly connected to our choices. A few studies have led me to wonder whether the same is true with obesity. Have I been the proverbial owner of a (behavioral) hammer, looking for (behavioral) nails everywhere? Have I failed to appreciate the role of biology?

A first warning sign comes from looking at other animals. Our pets have been getting fatter along with us. In 2012, some 58.3 percent of cats were, literally, fat cats. That is taken from a survey by the Association for Pet Obesity Prevention. (The very existence of this organization is telling.) Pet obesity, however, can easily be tied to human behavior: a culture that eats more probably feeds its animals more, too.

And yet, a study by a group of biostatisticians in the Proceedings of the Royal Society challenges this interpretation. They collected data from animals raised in captivity: macaques, marmosets, chimpanzees, vervets, lab rats and mice. The data came from labs and centers and spanned several decades. These captive animals are also becoming fatter: weight gain for female lab mice, for example, came out to 11.8 percent a decade from 1982 to 2003.

But this weight gain is harder to explain. Captive animals are fed carefully controlled diets, which the researchers argue have not changed for decades. Animal obesity cannot be explained through eating behavior alone. We must look to some other — biological — driver.

Fittingly, the study is titled “Canaries in the Coal Mine.” Could our inability to explain animal obesity with behavior be a warning sign? Perhaps we are also overlooking biological drivers for human obesity. But what might these culprits be?

A particularly interesting candidate resides in your gut. Your digestive system is actually a complex ecosystem, playing host to hundreds of species of bacteria that do things as diverse as fermenting undigestedcarbohydrates and providing vitamins. They also regulate how much fat your body stores.

Not everyone, however, has the same gut bacteria. And, interestingly, the composition of this bacteria correlates with obesity. Of course, this relationship could be simple: the obese eat differently, and therefore they have different bacteria.

But a recent study in the journal Science showed that cause and effect could go the other way as well. Researchers harvested bacteria from pairs of human twins, where one twin was obese and the other was not. Then they transplanted these bacteria into mice. The mice who received bacteria from the obese twin gained weight, while the others did not. The mice did not eat more: Their metabolism changed so that they put on more weight even with the same caloric input.

What, then, determines your gut bacteria? It could be antibiotics or environmental toxins or how processed your food is. Another possibility is raised by a study in The New England Journal of Medicine that shows that obesity seems to “spread” across social networks, with people infecting their friends and neighbors. I had always assumed that was because birds of a feather flock together — and that is surely part of the explanation. But because gut bacteria can also spread among people in close proximity, perhaps the obesity epidemic really is, well, an epidemic?

I’m not arguing that behavior does not matter. Biology and behavior often interact; the spread of flu depends on whether we wash our hands. Similarly, the bacteria study found that the “obese gut bacteria” had an impact only when the mice were fed diets heavy in saturated fats.

Perhaps most interestingly, changing biology may even be changing cravings. Some biologists have hypothesized that our gut bacteria actually drive cravings for certain unhealthy foods. A focus on biology doesn’t mean a reduced emphasis on behavior, just a richer understanding of it.

These and other studies raise important possibilities, which deserve more research and attention. At the very least, we should invest as many obesity research dollars in uncovering and understanding these biological channels as we do in understanding behavioral channels. And this is a behavioral economist talking!

After all, this could radically change the way we think about policies to curb obesity. As one newspaper editorial pronounced:

“A little town in Sweden has put a local tax on fat men. It is declared that ‘the fat man stands accused by the very fact of his too solid flesh’ (vide “Hamlet”) ‘of gluttony and laziness.’ Millions of fat men throughout the world may rise up and denounce as liars the town councillor who drew up this cruel indictment and those who voted for it, but the gentler way of reproving them would be to point out the tritely recognised danger of generalisation in almost any statement of supposed fact. Not all fat men are lazy and gluttonous. Obesity is in many a congenital habit of body; in others a disease.”

That editorial was written in 1923, for the paper known as The Paris Herald. Maybe the writer was on to something.

SENDHIL MULLAINATHAN is a professor of economics at Harvard.

This article has been revised to reflect the following correction:

Correction: November 17, 2013

Because of an editing error, the Economic View column last Sunday, about possible causes of obesity, misstated the source of bacteria that were transplanted into mice as part of an obesity study. The bacteria came from human twins, not from other mice.

 

A version of this article appears in print on November 10, 2013, on page BU6 of the New York edition with the headline: The Co-Villains Behind Obesity’s Rise.
complex adaptive systems, data saving lives, facts & data points, healthcare, policy, rapid learning health systems

Preventing medical error

  • diagnostic errors are the most preventable medical mistakes
  • Automation is part of the solution – sifting through medical records to look for potential bad calls, or to prompt doctors to follow up on red-flag test results.
  • Another component is devices and tests that help doctors identify diseases and conditions more accurately
  • online services that give doctors suggestions when they aren’t sure what they’re dealing with
  • changing medical culture is another approach

Source: http://online.wsj.com/news/articles/SB10001424052702304402104579151232421802264

The Biggest Mistake Doctors Make

Misdiagnoses are harmful and costly. But they’re often preventable

A patient with abdominal pain dies from a ruptured appendix after a doctor fails to do a complete physical exam. A biopsy comes back positive for prostate cancer, but no one follows up when the lab result gets misplaced. A child’s fever and rash are diagnosed as a viral illness, but they turn out to be a much more serious case of bacterial meningitis.

Such devastating errors lead to permanent damage or death for as many as 160,000 patients each year, according to researchers at Johns Hopkins University. Not only are diagnostic problems more common than other medical mistakes—and more likely to harm patients—but they’re also the leading cause of malpractice claims, accounting for 35% of nearly $39 billion in payouts in the U.S. from 1986 to 2010, measured in 2011 dollars, according to Johns Hopkins.

The good news is that diagnostic errors are more likely to be preventable than other medical mistakes. And now health-care providers are turning to a number of innovative strategies to fix the complex web of errors, biases and oversights that stymie the quest for the right diagnosis.

Part of the solution is automation—using computers to sift through medical records to look for potential bad calls, or to prompt doctors to follow up on red-flag test results. Another component is devices and tests that help doctors identify diseases and conditions more accurately, and online services that give doctors suggestions when they aren’t sure what they’re dealing with.

twisted_stethescope

Finally, there’s a push to change the very culture of medicine. Doctors are being trained not to latch onto one diagnosis and stick with it no matter what. Instead, they’re being taught to keep an open mind when confronted with conflicting evidence and opinion.

“Diagnostic error is probably the biggest patient-safety issue we face in health care, and it is finally getting on the radar of the patient quality and safety movement,” says Mark Graber, a longtime Veterans Administration physician and a fellow at the nonprofit research group RTI International.

Big Efforts Under Way

The effort will get a big boost under the new health-care law, which requires multiple providers to coordinate care—and help prevent key information like test results from slipping through the cracks and make sure that patients follow through with referrals to specialists.

There are other large-scale efforts in the works. The Institute of Medicine, a federal advisory body, has agreed to undertake a $1 million study of the impact of diagnostic errors on health care in the U.S.

In addition, the Society to Improve Diagnosis in Medicine, which Dr. Graber founded two years ago, is working with health-care accreditation groups and safety organizations to develop methods to identify and measure diagnostic errors, which often aren’t revealed unless there is a lawsuit. In addition, it’s developing a medical-school curriculum to help trainees improve diagnostic skills and assess their competency.

 

Robert Wachter, associate chairman of the department of medicine at the University of California, San Francisco, says defining and measuring diagnostic errors is an important step. “Right now, none of the incentives for improvement in health care are based on whether the doctor made the correct diagnosis,” Dr. Wachter says. But equally important, he adds, “we need to nurture bottom-up innovation.”

That’s already happening. Large health-care systems are mining their electronic records for missed signals. At the Southern California Permanente Medical Group, part of managed-care giant Kaiser Permanente, a “Safety Net” program periodically surveys its database of 3.6 million members to catch lab results and other data that might fall through the cracks.

In one of the first uses of the system, a case manager reviewed 8,076 patients with abnormal PSA test results for prostate cancer, and more than 2,200 patients had follow-up biopsies. From 2006 to 2009, 745 cancers were diagnosed among those patients—and Kaiser had no malpractice claims related to missed PSA tests.

The program is also being used to find patients with undiagnosed kidney disease, which is often found via an abnormal test result for creatinine, which should be repeated within 90 days. From 2007 to 2012, the system found 7,218 lab orders placed for patients with an abnormal test that had not been repeated. Of those, 3,465 were repeated within 90 days of a notice to patients that they needed a repeat test, and 1,768 showed abnormal results. The majority, 1,624, turned out to be new cases of the disease.

Michael Kanter, regional medical director of quality and clinical analysis, says the system enables clinicians to go back “as far as is feasible to find all of the errors that we can and fix them.”

Because the disease is slow moving, Dr. Kanter says, people with a five-year-old undiagnosed case may not have been harmed. Likewise, with many early prostate cancers, “in many of these cases it doesn’t mean harm would have reached the patient,” he says. “But we don’t want patients not to have the information they should have had through some kind of lapse in the system.”

Dealing With the Flood

Electronic records aren’t a panacea, of course, and can even lead to information overload. In a survey of Veterans Administration primary-care practitioners reported last March in JAMA Internal Medicine, more than two-thirds reported receiving more patient-care-related alerts than they could effectively manage—making it possible for them to miss abnormal test results.

Some researchers suggest the best solution isn’t to flood doctors with information but to provide a second set of eyes to find things they may have missed.

The focus now is preventing dangerous delays in follow-ups of abnormal test results. In a pilot program, researchers at the Houston VA developed “trigger” queries—a set of rules—to electronically identify medical records of patients with potential delays in prostate and colorectal cancer evaluation and diagnosis. Records included charts that had no documented follow-up for abnormal findings suspicious for cancer after a certain period, according to the research team’s leader, Hardeep Singh, chief of health policy and quality at Michael E. DeBakey VA Medical Center in Houston and an assistant professor of medicine at Baylor College of Medicine.

The queries were run on nearly 600,000 records of patients seen at one VA facility in 2009 and 2010. Dr. Singh says the use of triggers, which helped find abnormal PSA tests and positive fecal occult blood tests, could detect an estimated 1,048 instances of delayed or missed follow-up of abnormal findings annually and 47 high-grade cancers.

The VA has funded a randomized trial to test whether an automated surveillance system of triggers can improve timely diagnosis and follow-up for five common cancers.

“This program is like finding needles in a haystack, and we use information technology to make the haystack smaller and smaller so it’s easier to find the needles,” Dr. Singh says.

More health-care systems are also turning to electronic decision-support programs that help doctors rank possible diagnoses by likelihood based on symptoms and notes in the medical record. In a study of one such system, called Isabel, researchers led by Dr. Graber found that it provided the correct diagnosis 96% of the time when key clinical features from 50 challenging cases reported in the New England Journal of Medicine were entered into the system. The American Board of Internal Medicine is studying how Isabel could be linked to assessments of physician skill and knowledge.

Another system, DXplain, developed at Massachusetts General Hospital in Boston, was shown in a study last year to significantly improve diagnostic accuracy among first-year medical residents.

Edward Hoffer, associate clinical professor at Harvard and senior computer scientist at Mass General who leads the DXplain program, says the aim now is to have DXplain “push” diagnostic suggestions to physicians through an electronic-medical-records system rather than requiring doctors to initiate a query, which some are still reluctant to do. “We have to focus our attention on dealing with situations where doctors think they know what the diagnosis is, but they don’t,” Dr. Hoffer says.

Other Avenues

New devices also hold promise for confirming a diagnosis and avoiding unnecessary tests. A number of companies are rushing to provide aids such as portable diagnostic equipment and lab tests that can analyze tiny samples of blood and other bodily fluids quickly to detect disease.

Consider MelaFind, which came to market in the U.S. in 2011. The device allows dermatologists to noninvasively examine moles as deep as 2.5 millimeters beneath the surface to gauge the level of “disorganization,” an indicator of irregular growth patterns that are a sign of melanoma, among the deadliest cancers.

New York dermatologist Macrene Alexiades-Armenakas says she uses MelaFind to confirm that a mole is to be removed and prioritize the level of disorganization in multiple abnormal moles. In some cases, when another doctor or the patient has been concerned about a mole, MelaFind supported “clinical diagnosis of a benign mole, thereby sparing them a biopsy,” she says.

But such devices will never replace a thorough physical exam with a trained eye and careful follow-up, says Dr. Alexiades-Armenakas: “These diagnostic tools are aids to increase our accuracy and adjuncts to good physical diagnosis, not a substitute.”

Some efforts to cut down on errors take a different route altogether—and try to improve diagnoses by improving communication.

For instance, there’s a push to get patients more engaged in the diagnostic process, by encouraging them to speak up about their symptoms and ask the doctor, “What else could this be?” At Kaiser Permanente, a pilot program provides patients with a pamphlet that encourages them to think about and write down their symptoms and what concerns or fears they have, encouraging them to ask specific questions to be sure they understand their diagnosis and the next steps they must take.

Medical schools, meanwhile, are teaching doctors to be more receptive to patient input and avoid “anchoring,” the habit of focusing on one diagnosis and excluding other possible scenarios, and “premature closure,” not even considering the correct diagnosis as a possibility.

The Critical Thinking program at Dalhousie University in Halifax, Nova Scotia, established last year, aims to help trainees step back and examine how biases may affect their thinking. Developed by Pat Croskerry, a physician known for his research on the role of cognitive error in diagnosis, it uses a list of 50 different types of bias that may lead to diagnostic error.

The program is being integrated throughout four years of the medical school. Students study cases such as a psychiatric patient with shortness of breath who was assumed to be merely having an anxiety attack; doctors overlooked that she was a smoker on birth-control pills, a risk for the blood clot that later traveled to her lung and killed her.

“If we can teach physicians how to think more critically,” Dr. Croskerry says, “they would be more effective in delivering good care and arriving at the right diagnosis.”

Ms. Landro is an assistant managing editor for The Wall Street Journal and writes the paper’s Informed Patient column. She can be reached at laura.landro@wsj.com.

healthy habits, policy

fat getting fatter

  • eat less and exercise more
  • Jim Clifton is Chairman and CEO of Gallup

Source: http://www.linkedin.com/today/post/article/20131122150210-14634910-america-s-biggest-fiscal-problem-the-fat-are-getting-fatter

America’s Biggest Fiscal Problem: The Fat Are Getting Fatter

November 22, 2013

Much of U.S. politics focuses on the fact that the rich are getting richer and the poor, poorer. But does anyone care that the fat are getting fatter?

The U.S. adult obesity rate so far this year is on pace to surpass all annual average obesity rates since Gallup-Healthways began tracking it five years ago.

Health costs are going to bankrupt us. At the current annual 6% growth rate, our total healthcare bill will go from $2.5 trillion per year — which it is now — to almost exactly $4.5 trillion in 10 years. If you add the stubs of the increases over the 10-year period, above the running $2.5 trillion our debt-burdened nation can’t afford, it totals a staggering $10 trillion.

To put this in perspective, the sum of our coming healthcare costs are three times the size of the subprime meltdown that brought America and the world to its knees. While we survived the subprime mess, healthcare costs will honestly break the nation.

Things look even worse when you compare America’s per person healthcare spending to comparable societies. We spend more than $8,000 annually per person, where Canada and Germany each spends roughly $4,500 per person, and the United Kingdom spends about $3,500, according to the Organisation for Economic Co-Operation and Development — and residents of those countries all live longer.

So is our American healthcare system superior? You tell me.

Americans obviously understand that this is a huge problem. Nearly a quarter of us say cost is the most urgent health problem facing the U.S., surpassing healthcare access for the first time since 2006. Obesity remains the No. 1 health condition named.

Keep in mind that all of the hoopla about the Affordable Care Act (ACA), or Obamacare, has little to do with reducing the bloated and growing $2.5 trillion expense. Obamacare attempts to address the insurance issue — who pays for what — but it doesn’t go after the core problem: Americans are too fat and unhealthy, and the vast majority of our health problems arepreventable.

That’s right — the Centers for Disease Control concluded a few years ago that of all of America’s chronic health problems, a whopping 70%, are preventable. And what is the common thread among these chronic diseases, such as diabetes and heart disease? Being obese puts people at higher risk for developing all of them.

Rather than go on and on about whether the ACA website works or not, or who wins and loses politically in 2014 and 2016 because of a disastrous rollout, shouldn’t the media be trumpeting this headline: 70% of Health Problems in America Are Preventable?

I just figured the overall weight of Americans, and it’s right at about 56 billion pounds if I assume 180 pounds per person. As a nation, in my view if we collectively lost about 10 billion pounds of excess weight, we might reduce our healthcare costs by a third. And we wouldn’t need all of these wasted political conversations, because we could balance the budget. Even better, the fix would be free — it wouldn’t require a new law, sequestration, or a shutdown.

That’s because the real fix doesn’t lie within political battles over insurance coverage. It lies within a sudden new culture of American fitness — and that begins with eating less and exercising more.

*****

Jim Clifton is Chairman and CEO of Gallup. He is author of The Coming Jobs War (Gallup Press, 2011).

healthy habits, nutrition

Katz: lifestyle = breakthrough medical cure = lifestyle = medicine

http://www.linkedin.com/today/post/article/20131124153502-23027997-lifestyle-as-medicine-at-a-fork-in-the-road-who-s-got-a-spoon

Lifestyle as Medicine: At a Fork in the Road, Who’s Got a Spoon?

November 24, 2013
 

Hippocrates recognized the power of lifestyle as medicine some 2500 years ago, testimony to his wisdom and prescience. As president-elect of the American College of Lifestyle Medicine, I celebrate the possibility of finding our way back to a future informed by such insight.

But for now, in the immediate aftermath of announcement, and on-going debate about just how many of us should take statins, let’s consider what Big Pharma would have to do to compete on an even playing field with the power of lifestyle.

Imagine, for instance, if the news were to break tomorrow – on the landing page of your favorite site, or front page above the paper crease for you traditionalists, in whatever news source you like best – that there is a new prescription drug. The drug is stunningly effective, and shockingly free of side effects. It is astoundingly safe – safe enough for newborns and octogenarians alike. It is available in bountiful supply, and remarkably inexpensive. In fact, you might be able to get it without spending any extra money at all – maybe even save money by taking it.

And, here’s the punch line. If you take this pill – which everyone else in your family can take along with you – once daily for the rest of your life, it would reduce your risk of EVER getting ANY major chronic disease – heart disease, cancer, stroke, diabetes, dementia, etc. – by 80%.

The only question here is which would be a better idea and the more immediate priority: calling your doctor to get a prescription for this wonder drug, or calling your broker to get some share of stock in the company holding the patent.

But, of course, there is no such drug. There never has been any such drug. And in my opinion, there never will be any such drug. But lifestyle is exactly that medicine, and we have known about it …well, since Hippocrates.

But we know about the power of lifestyle as medicine in the modern age in ways unavailable to Hippocrates. A seminal epidemiologic study published in 1993 in the Journal of the American Medical Association famously pointed out that the leading, actual causes of premature death in the United States are not heart disease, cancer, and so on – but the things that cause heart disease, cancer, and so on. Those factors sum up to a list of ten exposureswe each, overwhelmingly have the capacity to control in our daily lives. That list of ten is, in turn, overwhelmingly dominated by just the first three: tobacco use, dietary pattern, and physical activity pattern. Or, as I like to call them – how we use our feet, our forks, and our fingers.

That initial study spawned a whole branch of the epidemiologic literature, reaffirming over a span of decades now that lifestyle is by far the best medicine ever conceived – or, if neglected, a source of years lost from life, and life lost from years. Study, after study, afterstudy, after study, after study…has shown that feet, forks, and fingers are nothing less than the master levers of medical destiny. Add to these three the management of sleep, stress levels, and loving relationships in our lives, and the control over our medical destinies is astounding.

And, in tandem with the literature showing how these factors overmaster our fate with regard to chronic disease risk, there is a burgeoning literature showing that they have the capacity toalter gene expression, too. The Genomic Age has served up a powerful insight, albeit not the one we were expecting: DNA is not destiny. To a greater extent, dinner is destiny – because dinner, and lifestyle, can alter the behavior of our very genes. The nature/nurture debate is rather an unfortunate distraction, because we can, in fact, nurture nature.

Lifestyle is then, irrefutably, the greatest of all medicine. But as we learned from Mary Poppinsif not elsewhere, there is the separate challenge of getting the medicine to go down. Certainlythe last thing we need in this case is more spoons full of sugar!

Lifestyle is the greatest of all medicine, but it may feel in this morbidigenic, obesigenic world of ours that we can’t get it to go down, because we just don’t have the right spoon. It may feel that we can’t get there from here.

That is, in a word, wrong. We can get there from here.

Doing so begins by embracing the destination – by acknowledging that lifestyle is medicine we all want. Then, we have to acknowledge that we do indeed know just what destination we mean, that we know what healthy living looks like. We do – including diet – and if we could get past the distractions of competing dogma, we would have the destination clearly in our sights. I have written extensively about that destination before, in columns, peer-reviewed papers, and textbooks– so if you want more on the topic, just follow the links.

Finally, once the destination is clear – it’s a matter of following a route that leads there. And so we come to it: a fork in the road, where for far too long, a luminous opportunity for better health, and consequently better lives, has languished. A fork where health could remain alongthe road not taken, or find itself on a path of much lesser resistance. It’s time to choose.

Along one tine of our fork is perpetuation of the status quo, where we lose loved ones we don’t need to lose, long before their time. Or perhaps they lose us. It’s a road where we succumb to unnecessary miseries and lose both years from life, and life from years. And where we bequeath the same and even worse to our children – where they inherit along with our abdication an ever greater burden of chronic disease and premature death, at ever younger age. I think, and hope, this road is readily rejected.

Along another tine is a world that makes health more accessible, a better world. My career is devoted mostly to creating such a world. But it’s a long, slow, arduous process. This tine doesn’t lead to any immediate opportunity for each of us. Along this tine, some of us keep working, while the rest of us just keep on waiting on the world to change. It may happen, but I wouldn’t hold your breath.

And then there is the third tine, which leads promptly and without detour to the skill set we need to be the health we want to see for ourselves. It leads us to be the health we want to see for those we love. And of course, when enough of us have changed ourselves, it leads us tobe the changes we want to see in the world as well.

There is a place, an important place even, for lifestyle IN medicine – where health care professionals offer valuable guidance, and counseling that is both constructive and compassionate. But the power of this cannot compare to that of lifestyle AS medicine, where each of us pulls on the master levers of medical destiny every day. Think about the Blue Zones, those places around the world where people live the longest, healthiest, most vital lives. Those benefits are attributed to how they live and to their culture, not to the counseling they get from doctors. We are in control of how we live, if latently. We are in control of our culture-which begins at the level of household, where family values take hold. The cultivation of vitality could be a family value.

You can prescribe yourself lifestyle as medicine. You are the doctor in this case, for yourself and those you love. But as with all doctoring, it requires a skill set. If you don’t have it, you can get it. And frankly, there is no real alternative. No other medicine can do what lifestyle can do, and no one else can practice lifestyle for you. It’s your life, and only you can live it. If you empower yourself- if you acquire the requisite “skillpower” to take lifestyle as your medicine- it will almost certainly be a better life. Healthy people have more fun.

Lifestyle is the best medicine there is, ever was, and likely ever will be. At a fork in the road forhealth care, our economy, our culture, and what the future holds for our children and grandchildren- each of us holds the spoon that could get this medicine to go down.

entrepreneurship, storytelling

Forbes: Google Authorship

http://www.forbes.com/sites/netapp/2013/10/14/tiny-disruptive-change/

This One Tiny Change Will Deeply Disrupt Your Business

These days, businesses walk a knife-edge of disruption. Radical changes in your working practices will come from the least expected quarters. David Amerlandoutlines one tiny, yet important, change: You may have missed it, but it has a huge disruptive effect…

Your business totally “gets” the idea that search is marketing. So does Google. But Google also understands that search is a service: In order for it to work, it must be as spam-free as possible.

To achieve this, Google launched an identity-verification initiative calledAuthorship. The basic premise is simple enough: Use the Google+ social network platform to enable members to link their profile to content they’ve written, and so claim its authorship. A thumbnail of their image then appears next to the link description when that content appears in search.

Why Should You Care? 
It’s a small, seemingly cosmetic change in Google’s search, but it’s a catalyst for a huge disruption in the traditional employer/employee relationship.

Why has Google made the change? Because the way we relate to content in search is changing. People looking for information care more about the people who wrote it than a mere faceless link.

A thumbnail image personalizes the results, leads to more clicks, and creates a deeper emotional connection with the end user. It may also lead to the creation of a following for the authors: Online fans of their writing may actively look for what they have written.

Google also favors good writers: Its algorithm checks to see who writes what, and silently assigns a reputation score to them, based on the subjects they write about. This is then further adjusted by another algorithm that follows the complex web of interactions between the writers, their content sharing activity, commenting history, and the commenting and sharing histories of others they have online contact with.

It’s All About The People
In the new Web, people now truly matter.

A well-placed blogger with a strong following can help the company website rise in search and increase its visibility in social networks. Company employees interacting with and helping promote a company blog through social media channels can amplify its brand message and reach—not to mention boosting the company website in search.

Because authorship can only be ascribed to a person and not a company, content authored in company time, using company equipment and under company contract can be claimed by the person who wrote it. This is good for the company.

In multi-author websites, the more of the company’s employees write, the better it is for the company. A company that has strong writers benefits the most.

But this picture hides the seeds of disruption within.

Employees Now Hold The Power
Thanks to search’s digital sleight of hand, the balance of power within the enterprise has now changed.

A company that relies on its employees’ digital presence to amplify its own is no longer in the same position to call the shots the way it did last century. This doesn’t mean that employees can’t be told what to do, but it does mean that there’s a marked shift in alignment between company and employee values.

That shift is convincingly bringing both to the same side of the table:

  • It’s in a company’s best interests to have its staff fully informed and engaged in the development and online promotional of its brand.
  • Invested employees are stakeholders and studies show they feel more responsible, are happier, more productive and feel more in control of their working lives than ever before.

But staff turnover is a constant, so this also raises interesting questions about the impact that staff changes will have on a company’s brand:

  • Will staff members with strong, respected online profiles still be expected to maintain online links from their Google accounts to content they authored for the company after they leave?
  • If so, under what conditions?
  • What happens if the relationship between a company and an employee turns sour?

Work Will Never Be The Same Again
Companies are looking to change their business models to better align their interests with a fast moving market driven by its social customers. So they have to tackle change from the inside first.

Altering the traditional, top-down power dynamic of employer/employee to a more equitable one is a great start: Make sure those within the company share its goals and values. Enable employees to work collectively to achieve those goals.

entrepreneurship, musings

Mentally Strong People: The 13 Things They Avoid

A solid list with no surprises.

Source: http://www.forbes.com/sites/cherylsnappconner/2013/11/18/mentally-strong-people-the-13-things-they-avoid/

Mentally Strong People: The 13 Things They Avoid

For all the time executives spend concerned about physical strength and health, when it comes down to it, mental strength can mean even more. Particularly for entrepreneurs, numerous articles talk about critical characteristics of mental strength—tenacity, “grit,” optimism, and an unfailing ability asForbes contributor David Williams says, to “fail up.”

However, we can also define mental strength by identifying the things mentally strong individuals don’t do. Over the weekend, I was impressed by this list compiled by Amy Morin, a psychotherapist and licensed clinical social worker,  that she shared in LifeHack. It impressed me enough I’d also like to share her list here along with my thoughts on how each of these items is particularly applicable to entrepreneurs.

2. Give Away Their Power. Mentally strong people avoid giving others the power to make them feel inferior or bad. They understand they are in control of their actions and emotions. They know their strength is in their ability to manage the way they respond.

3.    Shy Away from Change. Mentally strong people embrace change and they welcome challenge. Their biggest “fear,” if they have one, is not of the unknown, but of becoming complacent and stagnant. An environment of change and even uncertainty can energize a mentally strong person and bring out their best.

4. Waste Energy on Things They Can’t Control. Mentally strong people don’t complain (much) about bad traffic, lost luggage, or especially about other people, as they recognize that all of these factors are generally beyond their control. In a bad situation, they recognize that the one thing they can always control is their own response and attitude, and they use these attributes well.

5. Worry About Pleasing Others. Know any people pleasers? Or, conversely, people who go out of their way to dis-please others as a way of reinforcing an image of strength? Neither position is a good one. A mentally strong person strives to be kind and fair and to please others where appropriate, but is unafraid to speak up. They are able to withstand the possibility that someone will get upset and will navigate the situation, wherever possible, with grace.

6. Fear Taking Calculated Risks. A mentally strong person is willing to take calculated risks. This is a different thing entirely than jumping headlong into foolish risks. But with mental strength, an individual can weigh the risks and benefits thoroughly, and will fully assess the potential downsides and even the worst-case scenarios before they take action.

7. Dwell on the Past. There is strength in acknowledging the past and especially in acknowledging the things learned from past experiences—but a mentally strong person is able to avoid miring their mental energy in past disappointments or in fantasies of the “glory days” gone by. They invest the majority of their energy in creating an optimal present and future.

8. Make the Same Mistakes Over and Over. We all know the definition of insanity, right? It’s when we take the same actions again and again while hoping for a different and better outcome than we’ve gotten before. A mentally strong person accepts full responsibility for past behavior and is willing to learn from mistakes. Research shows that the ability to be self-reflective in an accurate and productive way is one of the greatest strengths of spectacularly successful executives and entrepreneurs.

9. Resent Other People’s Success. It takes strength of character to feel genuine joy and excitement for other people’s success. Mentally strong people have this ability. They don’t become jealous or resentful when others succeed (although they may take close notes on what the individual did well). They are willing to work hard for their own chances at success, without relying on shortcuts.

10. Give Up After Failure. Every failure is a chance to improve. Even the greatest entrepreneurs are willing to admit that their early efforts invariably brought many failures. Mentally strong people are willing to fail again and again, if necessary, as long as the learning experience from every “failure” can bring them closer to their ultimate goals.

11. Fear Alone Time. Mentally strong people enjoy and even treasure the time they spend alone. They use their downtime to reflect, to plan, and to be productive. Most importantly, they don’t depend on others to shore up their happiness and moods. They can be happy with others, and they can also be happy alone.

12. Feel the World Owes Them Anything. Particularly in the current economy, executives and employees at every level are gaining the realization that the world does not owe them a salary, a benefits package and a comfortable life, regardless of their preparation and schooling. Mentally strong people enter the world prepared to work and succeed on their merits, at every stage of the game.

13. Expect Immediate Results. Whether it’s a workout plan, a nutritional regimen, or starting a business, mentally strong people are “in it for the long haul”. They know better than to expect immediate results. They apply their energy and time in measured doses and they celebrate each milestone and increment of success on the way. They have “staying power.” And they understand that genuine changes take time. Do you have mental strength? Are there elements on this list you need more of? With thanks to Amy Morin, I would like to reinforce my own abilities further in each of these areas today. How about you?

Cheryl Snapp Conner is a frequent speaker and author on reputation and thought leadership topics. You can subscribe to her team’s bi-weekly newsletter, The Snappington Post, here.

healthy habits, nutrition

Eggers on fasting…

http://www.medicalobserver.com.au/news/a-fast-approach

A fast approach?

19th Nov 2013

Professor Garry Egger

CAN caloric restriction help individuals live longer?

Or does it just feel like it…

Two themes in nutrition have recently come together. The first, calorie restriction (CR), involves permanently reducing total energy intake by up to 30%.

CR has been shown consistently to increase the longevity of a number of different species of animal, as well as reduce weight.

The second theme, intermittent dieting (ID), or reducing energy intake on some days but not others, has spawned yet another diet craze that is dominating discussion at the dinner parties of middle suburbia.

Being battered and bruised by the numerous false starts in the dieting game, it’s tempting to pass off both of these as fads.

But the interest of some hard-nosed nutrition scientists makes a second look warranted.

Dr Eric Ravussen from the Pennington Institute in Arizona, is a world expert in energy metabolism and obesity.

For some time, he and several postgraduate students (including several Australians) have studied the mechanisms involved in CR.

The two forms of ageing

Speaking at a recent Australian and New Zealand Obesity Society (ANZOS) conference, Dr Ravussen described two forms of ageing: primary ageing, determined by genetics and natural factors; and secondary ageing, which is related to lifestyle and environmental factors.

Together these determine one’s maximum lifespan.

From animal studies it’s known that rats are able to run daily, live longer than those deprived of exercise.

But when a CR diet of about 30% total energy restriction is introduced, they live even longer.

Possible explanations for this are the reduced cellular oxidative stress from food, decreased DNA damage, decreased inflammation and auto-immunity, and increased metabolic efficiency.

For obvious reasons, such a study over a lifetime in humans has not yet been done.

Those that have been carried out opportunistically for short periods (such as during wars and in the human biosphere study) show a negative bounce-back in weight gain and health after the CR period.

Molecular changes

Physiological studies carried out by Dr Ravussen’s group, however, show molecular changes that are reflective of potential longevity advantages.

There’s also no doubt that weight loss follows such a regime — if it can be maintained.

A different way of restricting calories is through intermittent dieting popularised by the 5:2 diet and TV doctor Michael Mosley.

ID involves two days each week of energy restriction of 500 calories for women and 600 for men, with ad-lib intake over the remaining five days.

Exponents claim not just weight loss but reduced chronic disease risk.

And while there are not a lot of data to support the latter, there is good support for the former — strangely even with an increased overall food intake.

Dr Amanda Sainsbury-Salis from Sydney University’s Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders and author of The Don’t Go Hungry Diet, is currently doing the tests in mice.

While the results are not yet published, she does believe there might be something in the 5:2 diet and that the approach could be improved by using different degrees of energy restriction.

So far, studies with humans suggest weight loss may be more (and easier) with an ID plan like this.

A panacea in middle-age?

Given that most people won’t have the opportunity to calorie reduce (at least in a healthy fashion) for life, the question becomes, what advantage is there for someone trying the process in middle life?

There’s little doubt that (short-term) weight loss at least will be an outcome, but adverse effects, according to Dr Ravussen, include cold intolerance, decreased libido, constant hunger and reduced desire to exercise.

Reversion could also lead to increased difficulties with weight.

Based on animal studies, Dr Ravussen has calculated that a 50-year-old human could be expected to live a measly two months longer! So is it really all worth it?

If not weight, then what?

The use of BMI in diagnosis of metabolic disorder has come under question. Weight over height squared measures mass only and doesn’t take account of body fat. This then discriminates against mesomorphic body shapes – like some short male athletes – and the aged, whose height may decrease with age while weight remains stable. On top of this, BMI is not a consistent measure of ill health, as illustrated by the ‘obesity paradox’.

Garvan Institute researcher Dr Dorit Samocha-Bonet has shown that almost 50% of expected risk can be explained by other, easily measurable factors. The cumulative of risk for each is:

HDL cholesterol 26%
HbA1c 35.5%
Systolic blood pressure 43.2%
Triglycerides (Tg) 46.7%

According to Canadian lipidology expert J-P Despres, a Tg of >2.0 and a waist circumference greater than that recommended for ethnic groups (usually around 100cm for men and 90cm for women – called the ‘triglyceride-waist’), adds even more to diagnostic value. It may all make BMI less relevant at the clinical level.

cool, data saving lives, entrepreneurship, healthcare, healthy habits, meaning, nutrition, policy, politics, quantified self, rapid learning health systems, research methodology, storytelling

Chronic Disease Fear Factor Ageing Messaging

Governments won’t be able to afford you if you are over 70 and can’t work
You will need to be productive
The current health market can only extend your life, but not your productive life
The new health system will have to do both if we are to preserve our standard of living
Sure, people will need to die sometime, but it’s the when, how and why they die that needs to evolve
This health system aims to deliver on this
Australia is well positioned to lead the world on this
Excitement

healthy habits, musings, nutrition, policy

Why diets fail…

That diets fail seems to be the only uncontested fact in the world of nutrition.

Why do you suppose that is?

Well the answer is pretty obvious when you think about it. Its because the idea of normal that people revert to after a diet is pathological.

The modern idea of a “normal” diet is actually sick. Too much food. And too much of the wrong, highly processed food.

The public health challenge is to change the idea of normal, because the current idea is killing us.

Eat only twice per day. No refined carbohydrates. Minimal meat consumption.

As Pollan says: Eat food, mainly plants, not too much.

Brilliant!

healthcare, meaning, policy

How Doctors Die: Showing Others the Way

Source: http://www.nytimes.com/2013/11/20/your-money/how-doctors-die.html?from=homepage&_r=0

November 19, 2013  By DAN GORENSTEIN

BRAVE. You hear that word a lot when people are sick. It’s all about the fight, the survival instinct, the courage. But when Dr. Elizabeth D. McKinley’s family and friends talk about bravery, it is not so much about the way Dr. McKinley, a 53-year-old internist from Cleveland, battled breast cancer for 17 years. It is about the courage she has shown in doing something so few of us are able to do: stop fighting.

This spring, after Dr. McKinley’s cancer found its way into her liver and lungs and the tissue surrounding her brain, she was told she had two options.

“You can put chemotherapy directly into your brain, or total brain radiation,” she recalled recently from her home in suburban Cleveland. “I’m looking at these drugs head-on and either one would change me significantly. I didn’t want that.” She also did not want to endure the side effects of radiation.

What Dr. McKinley wanted was time with her husband, a radiologist, and their two college-age children, and another summer to soak her feet in the Atlantic Ocean. But most of all, she wanted “a little more time being me and not being somebody else.” So, she turned down more treatment and began hospice care, the point at which the medical fight to extend life gives way to creating the best quality of life for the time that is left.

Dr. Robert Gilkeson, Dr. McKinley’s husband, remembers his mother-in-law, Alice McKinley, being unable to comprehend her daughter’s decision. “ ‘Isn’t there some treatment we could do here?’ she pleaded with me,” he recalled. “I almost had to bite my tongue, so I didn’t say, ‘Do you have any idea how much disease your daughter has?’ ” Dr. McKinley and her husband were looking at her disease as doctors, who know the limits of medicine; her mother was looking at her daughter’s cancer as a mother, clinging to the promise of medicine as limitless.

When it comes to dying, doctors, of course, are ultimately no different from the rest of us. And their emotional and physical struggles are surely every bit as wrenching. But they have a clear advantage over many of us. They have seen death up close. They understand their choices, and they have access to the best that medicine has to offer.

“You have a lot of knowledge, a lot of awareness of what’s likely to come,” said Dr. J. Andrew Billings from his home in Cambridge, Mass.

Dr. Billings, 68 and semi-retired, is an expert in palliative care, which can include managing pain, emotional support and end-of-life planning. He is also a cancer patient with a life-threatening form of lymphoma. Dr. Billings said that knowledge of what may be ahead can give doctors more control over their quality of life before they die — control that eludes many of us.

Research shows that most Americans do not die well, which is to say they do not die the way they say they want to — at home, surrounded by the people who love them.According to data from Medicare, only a third of patients die this way. More than 50 percent spend their final days in hospitals, often in intensive care units, tethered to machines and feeding tubes, or in nursing homes.

There is no statistical proof that doctors enjoy a better quality of life before death than the rest of us. But research indicates they are better planners. An often-cited study, published in 2003, of physicians who had been medical students at Johns Hopkins University found that they were more likely than the general public to have created advance directives, or living wills, which lay out specific plans for care if a patient is unable to make decisions. Of the 765 doctors studied, 64 percent had advance directives, compared with about 47 percent for American adults over 40.

Patients and families often pay a high price for difficult and unscripted deaths, psychologically and economically. The Dartmouth Atlas Project, which gathers and analyzes health care data, found that 17 percent of Medicare’s $550 billion annual budget is spent on patients’ last six months of life.

“We haven’t bent the cost curve on end-of-life care,” said Dr. David C. Goodman, a senior researcher for the project.

The amount spent in the intensive care unit is climbing. Between 2007 and 2010, Medicare spending on patients in the last two years of life jumped 13 percent, to nearly $70,000 per patient.

The evidence is clear, Dr. Goodman said, that things could change if doctors “respect patient preferences and provide fair information about their prognosis and treatment choices.”

Sometimes that can be easier said than done, even for doctors. One day last month, as he sat through the first of several hours of chemotherapy at the Dana-Farber Cancer Institute in Boston, Dr. Billings said he had looked at statistical survival curves for his form of lymphoma.

“There are some dots that are very, very soon, and there are some dots that are a long ways off, and I hope I’m one of those distant dots,” he said.

Dr. Billings knows how important it is to have that information. As a palliative care doctor, he has spent a lifetime helping people plan their final days. Also, he is married to a prominent palliative care doctor, Dr. Susan D. Block.

“As a doctor you know how to ask for things,” he said. But as a patient, Dr. Billings said he had learned how difficult it can be to push for all the information needed. “It’s hard to ask those questions,” he said. “It’s hard to get answers.”

There is a reason for that. In his book “Death Foretold,” Nicholas A. Christakis, a Yale sociologist, writes that few physicians even offer patients a prognosis, and when they do, they do not do a great job. Predictions, he argues, are often overly optimistic, with doctors being accurate just 20 percent of the time.

But without some basic understanding of the road ahead, Dr. Anthony L. Back, a University of Washington professor and palliative care specialist, said even sophisticated patients could end up where they least want to be: the I.C.U. “They haven’t realized the implications of saying: ‘Yeah, I’ll have that one more treatment. Yeah, I’ll have that chemotherapy,’ ” Dr. Back said.

In Raleigh, N.C., Dr. Kenneth D. Zeitler has practiced oncology for 30 years. The son of a doctor and the father of two doctors, he learned 18 years ago that he had a brain tumor, which was removed. When the tumor recurred in 2004, he took the conservative route and decided against an operation — the risk of paralysis was too great. Dr. Zeitler, his wife and their two children mapped out a clear medical path, or so they thought.

Then in June, he woke up with the left half of his body paralyzed, after a low-risk biopsy caused a hemorrhage in his brain. “As a physician myself, when treating patients, I listened to this inner voice,” he said, but now he was mad at himself. “Instead of just saying ‘No, I won’t do this biopsy,’ I didn’t follow my instincts.”

Dr. Zeitler realized after his biopsy that saying no can mean more than turning down a procedure. It can mean dealing with something much harder: his family’s expectations that he will do whatever it takes to live and remain with them.

As transparent as Dr. Zeitler was with his family about his clinical care, he had walled off his deepest fears about losing pleasure in his daily life. He has since regained most physical functions and says he has had another chance to talk to his family. “As much as they’ll cry about me at every bar mitzvah and every wedding, I don’t want to be there if I’m just completely miserable psychologically and physically,” he said. “I’ve seen that. I don’t need that.”

Dr. Joan Teno, an internist and a professor of medicine at Brown University, says that often, even families like the Zeitlers, avoid the difficult conversations they need to have together and with doctors about the emotional side of dying.

“We pay for another day in I.C.U.,” she said. “But we don’t pay for people to understand what their goals and values are. We don’t pay doctors to help patients think about their goals and values and then develop a plan.”

But the end-of-life choices Americans make are slowly shifting. Medicare figures show that fewer people are dying in the hospital — nearly a 10 percent dip in the last decade — and that there has been a modest increase in hospice care. At the same time, palliative care is being embraced on a broad scale, with most large hospitals offering services.

The Affordable Care Act could accelerate those trends. Ezekiel Emanuel, the former White House health policy adviser, has said he believes that new penalties for hospital readmissions under the law could improve end-of-life care, making it more likely “we make the patient’s passage much more comfortable and out of the hospital.”

Culturally there is movement too. For example, deathoverdinner.org, a website to help people hold end-of-life discussions, was started in August. The project’s founder, Michael Hebb, said more than 1,000 dinner parties had been held, including some at nursing homes.

The front door at Dr. McKinley‘s big house was wide open recently. Friends and caregivers came and went. Her hospice bed sat in the living room. Since she stopped treatment, she was spending her time writing, being with her family, gazing at her plants. Dr. McKinley knew she was going to die, and she knew how she wanted it to go.

“It’s not a decision I would change,” Dr. McKinley said. “If you asked me 700 times I wouldn’t change it, because it is the right one for me.”

Dr. McKinley died Nov. 9, at home, where she wanted to be.