Could this be Jane Hall be arguing against prevention..?

Haven’t seen this before – a rational argument against prevention based on its difficult to quantify, long-term, positive impacts impacts on life extension. OMG. And while she’s at it, also suggesting that personal responsibility is the issue. Top work. Go Jane.

But systems research from the 1970s shows while that may well be the case, prevention often increases costs because it must be directed toward large groups, if not the whole population, while treatment is targeted at relatively few.

What’s more, not all preventive strategies are cheap, and their success will be reflected in a growing elderly population.

 

http://theconversation.com/commission-of-audit-should-know-costs-but-appreciate-value-21534

Commission of Audit should know costs but appreciate value
Four of the five members of the Commission of Audit during a Senate hearing at Parliament House in January. AAP Image/Lukas Coch

The Senate Select Committee into the Commission of Audit is holding its third Hearing in Canberra today. Witnesses include the Consumers Health Forum and Australian Health and Hospitals Association, so health is clearly the order of the day.

Instituted by the Abbott government soon after it came to power, the Commission is charged with finding savings by eliminating waste and duplication of functions, and the consolidation of Commonwealth agencies. And the Australian National Preventive Health Agency(ANPHA) is widely held to be an easy target for it.

The agency was established as part of the raft of reforms under the 2011 National Health Reform Agreement, to lead in preventive health through surveillance and monitoring, policy advice, national social media campaigns, and by sponsoring research.

Eliminating the ANPHA would, of course, look like a positive contribution to the savings and agency reductions needed to justify the Commission of Audit. But the 40 or so ANPHA staff will not contribute significantly to the Commission’s targeted reduction of 12,000 public servants.

But let’s assume the Commission is less concerned with justifying its own existence and more focussed on the wise investment of government resources (that’s our taxes). In that case, there are a number of issues it should bear in mind.

Neither easy nor quick

The goal for the ANPHA is to reduce the prevalence of preventable disease. According to the Australian Institute for Health and Welfare (AIHW), 32% of the current national burden of disease is due to preventable risk factors. And that’s set to grow with rising national levels of obesity and falling fitness.

One could say preventable disease is a big target, so it shouldn’t be that hard to make an impact. Unfortunately, what’s preventable in theory is not so preventable in practice.

Take one of the top risk factors of preventable disease according to the AIHW – intimate partner violence. It’s one thing to say there’s a significant national burden of injury and disease due to violence in relationships; it’s quite another to actually stop the dominant partner acting violently.

Much the same applies to obesity, lack of physical activity and poor diets. To paraphrase Shakespeare’s Brutus from Julius Caesar (I,ii, 140-141):

the fault lies not in our health system. But in ourselves…

In many areas, Australia has done well in reducing the prevalence of preventable disease and, to some extent, that’s now reflected in our improving life expectancy and expected life years without disease or disability.

Clearly, action on prevention didn’t start in 2011 with the establishment of ANPHA; the 2008 COAG National Partnership Agreement on Preventive Health committed A$872m over six years, which is a pretty serious investment.

The problem is the payoff period for such action is long – it takes a lifetime of good habits to enjoy their health consequences. Investment and performance in one period will influence performance in later periods.

The issue for the Commission, then, is what value has been added by the existence of a national agency, and how can that be judged when it’s barely three years old.

Better than cure?

Recent inquiries and reviews, such as the National Health and Hospitals Reform Commission and the Preventative Health Taskforce have made the case for stronger investment in prevention, as they have in other developed countries, including the United Kingdom and the United States. And in much policy development, there’s an implicit view that “prevention is better and cheaper than cure”.

But systems research from the 1970s shows while that may well be the case, prevention often increases costs because it must be directed toward large groups, if not the whole population, while treatment is targeted at relatively few.

What’s more, not all preventive strategies are cheap, and their success will be reflected in a growing elderly population.

The policy issue then isn’t whether there should be more investment in reducing preventable disease, but which programs are “good buys” when considering both effectiveness and cost. And effectiveness must reflect the very human goals of adding years to life and life to years.

Both the National Health and Hospitals Reform Commission and the Preventative Health Taskforce recommended that preventive strategies be subject to economic evaluation in much the same way that new medical procedures and pharmaceuticals are.

But the evaluation of broad-scale prevention is more challenging than therapeutic interventions. There are significant issues around which benefits to select for evaluation and what value to assign them, and modelling risk factors with multiple effects (on several diseases), as well as modelling the multiple risk factors for many chronic diseases.

So it’s not clear that the guidelines that have served so well for appraising immediate treatment effects will work as well for long-term preventative programs.

Things to keep in mind

The Commission’s terms of reference stress that its role is to find efficiencies and savings that will reduce duplication and improve the budget position. For this, it’s important to remember that Commonwealth doesn’t equal national; this country has six state and two territory governments, as well as the Commonwealth government.

Successful public health campaigns require political agreement, sufficient funding and national campaigns backed by local initiatives and action. The Commission must distinguish complementary efforts from duplication.

The Commission’s terms of reference also mention the need to improve value for money – it would do well to remember that while knowing the cost of agencies and programs is simple, appreciating their value is considerably more complex.

Quantified-self harm..?

OK. This is purely a rant based on a shallow, n=1 observation.

I lost my fitbit down the toilet in December and chose not to replace it.

Since then, I’ve been maintaining my active habits (walking to work, training for a fun run) without the motivational air cover provided by the device.

Since then, I’ve been eating slightly healthier, primarly reducing meat consumption in favour of vegetables, and also increasing the depth and number of fasting days.

As a consequence, I’ve been losing more weight.

The interesting thing is that the only quantified self metric I’ve been looking at has been my weight.

It’s all a bit zero-sum, but I feel that by no longer monitoring my activity, I’m now focusing more on what matters – weight.

This isn’t to poo poo the tracker. I’m confident that it supported the development of activity habit. It’s just that now I’ve covered that, I need to focus on more salient measures.

It makes me think there’s change management a process that’s required to get healthy:

Firstly, get active using whatever motivational means necessary -trackers, fun runs etc.

Second, perhaps simultaneously, concentrate on diet… fasting, nutrition etc.

For further discussion, no doubt…

Open source quantified self data API

http://www.getquant.com/

Not taking sign-ups yet, but looks interesting…

Analyze all your quantified self data in one place.

Plug in any self-tracking data source for beautiful graphs of your body, brain, and behaviour.


Free as in speech

Quant is an open source project.
Our codebase is MIT licensed and publicly available for download. You’re free to host your own version, make modifications, and contribute back to the community.

Automatic or manual

Track personal data from virtually any QS data source. From Fitbit, to Jawbone, Foursquare, and Withings, we’ve built API integrations for everything. Plus, you’ll be able to enter your own data manually if you’d prefer.

Lies, damned lies, and stats

Quant helps you navigate all of the data you’ve collected by allowing you to slice, rearrange, and order by source, date series, weighted averages, and more. The quantified self movement is about more than just making bar charts, after all.

 

Originally found at:

http://www.fastcolabs.com/3026076/could-an-apple-iwatch-bring-the-open-source-movement-mainstream

Could An Apple iWatch Bring The Open Source Movement Mainstream?

With a rumored focus on quantified health metrics, Apple’s new gadget could prompt people to care more about their data.

The latest rumors say the Apple iWatch will be full of sensors for tracking health metrics. With a deep level of awareness about people’s well-being, these new devices and platforms could revolutionize health care. But if iTunes purchases are any indication, it’s likely that data will stay within Apple’s walled garden. Will this make consumers uncomfortable enough that they get wise to the value of the open source movement?

Companies like Quant should hope so. Quant is an open source library that makes it easy to export data from all the different activity tracking devices. The hope is that peoples’ fear of misappropriation will get them to value their data more than they currently do, pressuring device makers to build products that are more accessible.

“The single biggest challenge is inconsistently structured data from each of the providers,” says Joshua Kelly, Quant’s lead developer. “Everyone has implemented a slightly different format for each kind of data. Meshing these together can prove challenging.”

What happens when consumers are generating their hyper-personal data? Who owns it? What happens to the data if the device company gets into financial trouble, shuts down, or just decides to try and sell it? Even the current crop of rather harmless activity trackers have raised privacy concerns. Mother Jonesrecently dug into the different privacy policies of some of the major players in the space such as Fitbit and Nike with somewhat troubling findings, and the Federal Trade Commission is holding a conference on the matter in May 2014.

“Do I sleep better after eating fewer carbs? How does running impact my mood versus lifting weights? I worry that we won’t even be able to ask these types of questions at all if the trend of closed APIs picks up.”

The concern here is the aggregate impact if Apple does switch on health tracking features. In the recent holiday quarter, Apple sold more than 50 million iPhones and there are hundreds of millions of iOS devices already in the wild. If that many people started tracking their daily activity with a sensor-equipped iWatch and the rumored Healthbook app for iOS, the impact on health care in general would be colossal.

“Apple would be an incredible boon to the space if they can provide a hardware platform for others to build on,” says Kelly. “I think everyone is still trying to figure out what the killer device or app will be, and if history is a guide, Apple could definitely be the one to do it.”

 

Nudging for better health conference

Lissanthea Taylor put me onto this conference that she was at:

PDF: Nudging-for-Better-Health-Conference-Flyer

Nudging for Better Health Conference

Nudging for Better Health decorate image

There is growing enthusiasm in government policy circles for promoting strategies designed to encourage and enable individuals to lead healthier lives. Such strategies draw on behavioural research showing individuals do not always act rationally and are susceptible to a range of influences which impact on the decisions they make. The research suggests that people can be nudged towards making decisions which are better for their health but in such a way that it does not unduly restrict their liberty or freedom to act.

This one-day conference will bring together an interdisciplinary group of scholars and commentators to explore the use of nudge strategies to incentivise better health. Recent developments in relation to the use of such strategies in Australia, NZ, the UK and Europe will be examined, as will case studies in specific areas impacting upon individual and collective health and wellbeing. The conference will be of interest to those working or researching in areas involving health and well being, and public health more generally.

Presenters

  • Dr Rory Gallagher & Mr Simon Raadsma, Behavioural Insights Team, NSW Department of Premier and Cabinet
  • Professor Christine Parker, Monash Centre for Regulatory Studies
  • Assoc. Professor Anne-Maree Farrell, Faculty of Law, Monash University
  • Assoc. Professor Duncan Mortimer, Centre for Health Economics, Monash University
  • Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University
  • Dr Liam Smith, Director, BehaviourWorks, Monash Sustainability Institute
  • Ms Jane Martin, Cancer Council Victoria
  • Ms Sondra Davoren, McCabe Centre for Law and Cancer
  • Dr Muireann Quigley, Bristol University, UK
  • Dr Elen Stokes, Cardiff University, UK
  • Dr John Kennelly, University of Auckland, NZ
  • Ms Paula O’Brien, Melbourne Law School

Event details

Date: Monday, 17 February 2014

Time: 9am – 5pm

Venue: Monash University Law Chambers, 555 Lonsdale St Melbourne

Cost: Free

RSVP: Limited places are available. Please rsvp by Monday, 10 February, 2014 via e-mail toMeli.Voursoukis@monash.edu

To improve health care, governments need to use the right data

Terrific Economist snippet…

http://www.economist.com/news/international/21595474-improve-health-care-governments-need-use-right-data-need-know

Measuring health care

Need to know

To improve health care, governments need to use the right data

DECIDING where to seek treatment might seem simple for a German diagnosed with prostate cancer. The five-year survival rate hardly varies from one clinic to the next: all bunch around the national average of 94%. Health-care providers in Germany, and elsewhere, have usually been judged only by broad outcomes such as mortality.

But to patients, good health means more than life or death. Thanks to a study in 2011 by Germany’s biggest insurer, a sufferer now knows that the national average rate of severe erectile dysfunction a year after removal of a cancerous prostate gland is 76%—but at the best clinic, just 17%. For incontinence, the average is 43%; the best, 9%. But such information is the exception in Germany and elsewhere, not the rule.

Doctors and administrators have long argued that tracking patients after treatment would be too difficult and costly, and unfair to providers lumbered with particularly unhealthy patients. But better sharing of medical records and a switch to holding them electronically mean that such arguments are now moot. Risk-adjustment tools cut the chances that providers are judged on the quality of their patients, not their care.

In theory, national health-care systems should find measuring outcomes easier. Britain’s National Health Service (NHS) compiles masses of data. But it stores most data by region or clinic, and rarely tracks individual patients as they progress through treatment. Sweden’s quality registries do better. They analyse long-term outcomes for patients with similar conditions, or who have undergone the same treatment. Some go back to the 1970s and one of the oldest keeps records of hip replacements, letting medics compare the long-term performance of procedures and implants. Sweden now has the world’s lowest failure rate for artificial hips.

Elsewhere, individual hospitals are blazing a trail. Germany’s Martini-Klinik uses records going back a decade to fine-tune its treatment for prostate problems. The Cleveland Clinic, a non-profit outfit specialising in cardiac surgery, publishes a wide range of outcome statistics; it now has America’s lowest mortality rate for cardiac patients. And though American politicians flinch at the phrase “cost-effectiveness”, some of the country’s private health firms have become statistical whizzes. Kaiser Permanente, which operates in nine states and Washington, DC, pools the medical records for all its centres and, according to McKinsey, a consultancy, has improved care and saved $1 billion as a result.

Such approaches are easiest in fields such as prostate care and cardiac surgery, where measures for quality-of-life are clear. But some clinics have started to track less obvious variables too, such as how soon after surgery patients get back to work. This is new ground for doctors, who have long focused on clinical outcomes such as infection and re-admission rates. But by thinking about what matters to patients, providers can improve care and lower costs at the same time.

Leeder on outcomes…

 

The 1 February edition of The Economist, in an article entitled Need to Know (about health outcomes), took up the theme. The article observed that in Germany, its biggest insurer made available data in 2011 about outcomes for all to see.

Among the outcomes, the data showed five-year survival after treatment for prostate cancer was uniform across the nation – 94 per cent. But the data collected by the insurer went further: while the national average for subsequent erectile dysfunction was 76 per cent, at the best-performing clinic it was just 17 per cent. “For incontinence, the average was 43 per cent: the best 9 per cent,” The Economist wrote.

Armed with data such as these, prospective patients can choose where to be treated. The same data form the basis for discussion between those who provide and those who pay for health care.

 

https://ama.com.au/ausmed/case-measuring-outcomes-what-we-do

The case for measuring the outcomes of what we do

18/02/2014

Archie Cochrane, the Scottish medical epidemiologist after whom the Cochrane Collaboration that develops the evidence base for clinical medicine is named, came out of the Spanish Civil War and World War Two sceptical about the outcomes of his medical care.

Cochrane said, “I knew that there was no real evidence that anything we had to offer had any effect on tuberculosis, and I was afraid that I shortened the lives of some of my friends by unnecessary intervention.”

He changed career, moving into public health and conducting epidemiological research into TB and occupational lung diseases. He became especially sceptical about screening and, as Wikipedia puts it, “his ground-breaking paper on validation of medical screening procedures, published jointly with fellow epidemiologist Walter Holland in 1971, became a classic in the field”.

Cochrane recalled in his 1972 book Effectiveness and Efficiency: Random Reflections on Health Services being puzzled by a crematorium attendant he met who was permanently serenely happy. Cochrane asked why: the attendant said that each day he marvelled at seeing “so much go in and so little come out”.  Cochrane suggested that he consider working in the National Health Service.
In Australia we assess how much work we do in hospitals through activity-based funding.  Money flows in direct proportion – so many coronary grafts, so many strokes treated. But little attention, at least in routine care, is paid to what we achieve. There are examples that contradict this general assertion, but mainly it is true.
Recently, the Bureau of Health Information in the NSW Ministry of Health made available statewide mortality data for five conditions treated in NSW public hospitals, taking account of variations in severity. Such data begin to fill the blanks in our knowledge about outcomes, and prompt discussion about why these variations occur.

The 1 February edition of The Economist, in an article entitled Need to Know (about health outcomes), took up the theme. The article observed that in Germany, its biggest insurer made available data in 2011 about outcomes for all to see.

Among the outcomes, the data showed five-year survival after treatment for prostate cancer was uniform across the nation – 94 per cent. But the data collected by the insurer went further: while the national average for subsequent erectile dysfunction was 76 per cent, at the best-performing clinic it was just 17 per cent. “For incontinence, the average was 43 per cent: the best 9 per cent,” The Economist wrote.

Armed with data such as these, prospective patients can choose where to be treated. The same data form the basis for discussion between those who provide and those who pay for health care.

Once, clinical trials of new cancer drugs were concerned principally with the survival of patients treated versus those not treated with new medications. But they now measure more than life expectancy.

For over 25 years mortality data have been supplemented by quality of life assessments.

But the excellence in clinical trial outcome measurement has not spread to routine care.

So much goes in, but what comes out?
In the US, health care expenditure is a huge worry for individual citizens, for Government (which spends as much as a proportion of GDP/GNP as ours does on health), and for industry, which pays for a lot of health insurance for employees. In response, comparative effectiveness research – CER – has recently evolved.

Wikipedia advises that “The Institute of Medicine committee has defined CER as ‘the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition, or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at both the individual and population levels’.”

There are many agencies and individuals now in the US committed to CER, including Dr John Wennberg at the Dartmouth Institute for Health Policy and Clinical Practice.

He and his colleagues have studied variations in medical practice across the US with a view to ironing out the wrinkles caused by inferior care.

They claim that 30 per cent of health care costs could be saved by correcting care that falls below expected outcomes.

Australia has not been entirely idle, and we have led the world in aspects of outcome measurement in relation to drugs.

Since 1953, Australia’s Pharmaceutical Benefits Advisory Committee (PBAC) has constructed the formulary of publicly funded medicines. Since 1990, the PBAC has made cost and effectiveness (outcome) assessment a mandatory prelude to listing. Pricing and other political decisions follow, but the solid outcome data are necessary. Others are now following our example.

When we have a health care system that is fully connected electronically, the task of measuring outcomes and using them to good effect in managing the system will be far easier. Outcome data are critical to achieving real financial efficiency. They can be used to help us stop doing things that achieve nothing, or cause harm, and instead use the resources saved for clinical care with good outcomes.

But assessing outcomes, as the prostate surgery example demonstrates, extends well beyond financial efficiency and, indeed, beyond life expectancy. When we confidently explain what we achieve with what we do – quantity and quality of life gained –  patients are empowered to make choices.

Wearables snapshot…

A market snapshot of wearables… useful for presentations.

Want A Neat Overview Of What’s Going On In Wearables? Point Your Eyes Right Here…

Want A Neat Overview Of What’s Going On In Wearables? Point Your Eyes Right Here…

Posted  by  (@riptari)

Former Groupon Product SVP Jeff Holden Joins Uber As Chief Product Officer

Wearables are so hot right now. Apple iWatch rumours are in rude health. Google isapparently looking (beyond Glass) at picking up and strapping onto its business anotherstartup in the wearables space (guesses for which in the comments pls).

Jawbone, maker of the UP fitness tracker bangle (and apparently not the company in Google’s Glassy sights), is running sweat-free towards an IPO. Action camera maker GoPro — ok, not technically a wearables company but the point of its cameras are that they are, y’know, wearable — has already filed for one. Smartwatch maker Pebble has raised a tonne of money since 2012, first via Kickstarter and then, off the back of its snowballing crowdfunder, from VC checkbooks.

Even though the genuine usefulness of bits of technology that you strap to your person still has a lot of proving to do – vs the intrusion (both visual, with a lot of these early devices being best described as uuuuuuuugggglllyyy; and, more importantly, the sensitive personal data being captured and monetized) – it’s the big huge lucrative potential that’s exciting makers and investors.

Mature Western markets are saturated with smartphones — ergo step forward sensor-stuffed wearables as the next growth engine for device makers. Devices whose literal positioning on our bodies enables them to gather far more intimate data on the lives and (physical) habits of users than previous generations of consumer mobiles. If only we can be persuaded to wear this stuff.

Yesterday analyst Canalys suggested 2014 will be the year for the wearables category becomes a “key consumer technology” — with more than 17 million wearable bands (alone) forecast to ship this year, rising to 23 million by 2015, and more than 45 million by 2017.

So that’s only wearable tech targeting the wrist, such as the Fitbit fitness tracker and Samsung’s Galaxy Gear smartwatch — it does not include devices aiming to squat on other body-parts (such as Google Glass). In short: tech makers gonna put a smart ring on it. Many are already trying.

On the ‘who is already making what’ front, wearable tech research and consulting firm Vandrico has put together this neat overview of the space — tracking the number of devices in existence; areas of market focus; and even which parts of the body are being targeted most.

(The most popular anatomical target for wearables is the wrists, since you’re curious — with 56 devices vying for that small patch of flesh; followed by the head, with 34 devices wanting to cling to it. On the flip side, the least popular body part for wearables thus far is apparently the hand, with just two devices listed, although the data doesn’t delve into the crotch region, so, yeah, there’s there too. Makers apparently not falling over themselves to fashion iCodpieces…).

According to Vandrico, there are some 115 wearables in play already; with an average selling price of $431; and with lifestyle, fitness and medical being the most popular market areas targeted (in that order).

wearables

The researcher has also taken the time to list and profile every single one of the 115 wearables it reckons are currently in play, so you don’t have to — from 3L Labs Footlogger to the ZTE Bluewatch (another mobile maker doing a smartwatch, who knew?).

Or at least all of the wearables its research has turned up. It’s asking for submissions for missing devices so it can keep expanding this database. (I’m going to throw the Fin into the ring on that front.)

Click here to check out — and start quantifying — the data for yourself.

[Image by IntelFreePress via Flickr]

UK government-backed SMS nudges

well, good.

http://www.fastcoexist.com/3026172/how-would-you-feel-about-your-government-texting-you-to-tell-you-to-exercise

How Would You Feel About Your Government Texting You To Tell You To Exercise?

A few overweight residents of this U.K. town are about to find out.

“Maybe walk to the shops or take the stairs more often.” “Aim to eat regular meals and keep a check on snacks and drinks.” “Eat fruit and veg.” These are some of the texts you get when you sign up for a new health program. The sender? The U.K. city of Stoke-on-Trent.

Stoke is starting the controversial project because it reckons that regular reminders are key to changing habits, and because getting people to slim down helps public budgets. “This is all about getting people on board and taking action before they need medical support, which is so expensive and personally upsetting,” a spokesperson told the BBC.

The British public hasn’t been so positive, though. Twitter lit up after the scheme was reported, with many bemoaning the long arm of government and wasted public money. Others said the texts could backfire, giving people a negative self-image (though presumably if they sign up in the first place, they’re not feeling good about themselves).

The program, which runs for 10 weeks, costs $16,000 to taxpayers, including set-up charges. About 500 people will participate voluntarily, all of them above the overweight limit, with a body mass index above 25. Officials say $16,000 is a pittance against the cost of treating obesity-related diseases.

Time will tell if the texts work. Other similar experiments show that it might, if people want to be involved and aren’t forced into anything.

Leeder on Policy and Politics

Brian Head, program leader in policy analysis at the University of Queensland, wrote “Policy decisions emerge from politics, judgement and debate, rather than being deduced from empirical analysis. Policy debate and analysis involves an interplay between facts, norms and desired actions, in which ‘evidence’ is diverse and contestable.”

Policy that works distils evidence from several sources. It includes the kind that supports evidence-based medicine, but there is also the evidence that comes from an assessment of political feasibility and evidence that comes from what we might call experience.

Doctors are often frustrated when the evidence they present, from both basic and clinical science and from professional experience, is trumped by politics. But the nature of a democracy is such that this is to be expected.

In all of these examples, policy served as a vehicle for organising thought and care. It is critical to achieving the best clinical outcomes.

The challenge to our nation is to ensure that our state and federal policies are as sound as we can help make them.

We doctors do not make the policies, but we contribute positively and importantly to them.

https://www.mja.com.au/insight/2014/5/stephen-leeder-policy-pointers

Stephen Leeder: Policy pointers

Stephen Leeder
Monday, 17 February, 2014

Stephen Leeder

THE federal government, less than 6 months old, faces many challenges in health care.

Establishing priorities will be useful if they guide attention and resources towards where they are likely to offer the best yield in promoting health and providing care for sick and injured people, while honouring the principles of efficiency and equity in the way that we do things and to whom we attend.

The MJA has asked six health leaders to suggest policy pointers — matters that, in their opinion, warrant the attention of the new government and about which policy might be developed for effective action.

The first response is by eminent Melbourne health economist and academic Stephen Duckett. Duckett sets out his call for policy under three headings — keeping the Medicare promise, going beyond the provision of services and ensuring good governance. He splits his proposals into what a first-term and second-term government might aspire to do.

His wide experience in health service management makes his recommendations especially pertinent.

Brian Head, program leader in policy analysis at the University of Queensland, wrote “Policy decisions emerge from politics, judgement and debate, rather than being deduced from empirical analysis. Policy debate and analysis involves an interplay between facts, norms and desired actions, in which ‘evidence’ is diverse and contestable.”

Policy that works distils evidence from several sources. It includes the kind that supports evidence-based medicine, but there is also the evidence that comes from an assessment of political feasibility and evidence that comes from what we might call experience.

Doctors are often frustrated when the evidence they present, from both basic and clinical science and from professional experience, is trumped by politics. But the nature of a democracy is such that this is to be expected.

Policy on initial screening for acute life-threatening disease benefits greatly from medical input.

Although, strictly, it is case finding, researchers have evaluated the use of a more sensitive troponin test for more quickly determining the presence of myocardial damage in line with an “accelerated biomarker” strategy for assessing and managing suspected ischaemia and infarction. Their findings validate the use of this strategy, formulated by the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand.

Here, medical evidence informs the policy that governs the interaction between patients and health care provision.

Because enthusiasm frequently runs ahead of utility when it comes to screening, the authors of a Perspectives article advocate for a national framework for newborn bloodspot screening. Such frameworks have proved their worth in other countries, and one is needed here.

In another Perspectives article, the authors welcome progress in the use of cell-free fetal DNA tests of maternal serum for aneuploidy screening (and the extension of related tests to pregnancy outcome prediction) in the first trimester even though these tests have some distance to travel before sensitivity, specificity and predictive value will be clear.

Ah, the delight of reading an article that describes success in closing a gap — any gap! Gaps so often cause lamentation with no design for a bridge.

Researchers and a linked editorial describe a splendid cardiology network in South Australia that supports patients who have had acute myocardial infarction and who live in places remote from major hospitals in receiving appropriate timely and evidence-based care.

The network involves providing advice from metropolitan hospital specialists to rural health practitioners, carefully stratifying patients into three risk categories to determine who needs reperfusion angiography most urgently, and then organising it. The mortality gap between city and rural dwellers was consequently abolished.

Here, policy built the bridge to bring rural outcomes closer to city ones.

In all of these examples, policy served as a vehicle for organising thought and care. It is critical to achieving the best clinical outcomes.

The challenge to our nation is to ensure that our state and federal policies are as sound as we can help make them.

We doctors do not make the policies, but we contribute positively and importantly to them.

 

Professor Stephen Leeder is the editor-in-chief of the MJA and professor of public health and community medicine at the University of Sydney.

This article is reproduced from the MJA.

John Yudkin: the man who tried to warn us about sugar

Terrific article reprinted in the SMH from the Sunday Telegraph, London…

One of the problems with the anti-sugar message – then and now – is how depressing it is. The substance is so much part of our culture, that to be told buying children an ice cream may be tantamount to poisoning them, is most unwelcome. But Yudkin, who grew up in dire poverty in east London and went on to win a scholarship to Cambridge, was no killjoy.

”He didn’t ban sugar from his house, and certainly didn’t deprive his grandchildren of ice cream or cake,” recalls his granddaughter, Ruth, a psychotherapist. ”He was hugely fun-loving and would never have wanted to be deprived of a pleasure, partly, perhaps, because he grew up in poverty and had worked so hard to escape that level of deprivation.”

”My father certainly wasn’t fanatical,” adds Michael. ”If he was invited to tea and offered cake, he’d accept it. But at home, it’s easy to say no to sugar in your tea. He believed if you educated the public to avoid sugar, they’d understand that.”

”It is not just Big Tobacco any more,” Chan said last year. ”Public health must also contend with Big Food, Big Soda and Big Alcohol. All of these industries fear regulation and protect themselves by using the same tactics. They include front groups, lobbies, promises of self-regulation, lawsuits and industry-funded research that confuses the evidence and keeps the public in doubt.”

 

http://www.smh.com.au/lifestyle/diet-and-fitness/john-yudkin-the-man-who-tried-to-warn-us-about-sugar-20140212-32h03.html

John Yudkin: the man who tried to warn us about sugar

Date

Julia Llewellyn Smith

A British professor’s 1972 book about the dangers of sugar is now seen as prophetic. Then why did it lead to the end of his career? 

Sweet beauty: is sugar aging?Not so sweet: sugar. Photo: Lyndall Larkham

A couple of years ago, an out-of-print book published in 1972 by a long-dead British professor suddenly became a collector’s item.

Copies that had been lying dusty on bookshelves were selling for hundreds of pounds, while copies were also being pirated online.

Alongside such rarities as Madonna’s Sex, Stephen King’s Rage (written as Richard Bachman) and Promise Me Tomorrow by Nora Roberts; Pure, White and Deadly by John Yudkin, a book widely derided at the time of publication, was listed as one of the most coveted out-of-print works in the world.

Pure, White and Deadly.Pure, White and Deadly.

How exactly did a long-forgotten book suddenly become so prized? The cause was a ground-breaking lecture called Sugar: the Bitter Truth by Robert Lustig, professor of paediatric endocrinology at the University of California, in which Lustig hailed Yudkin’s work as ”prophetic”.

”Without even knowing it, I was a Yudkin acolyte,” says Lustig, who tracked down the book after a tip from a colleague via an interlibrary loan. ”Everything this man said in 1972 was the God’s honest truth and if you want to read a true prophecy you find this book… I’m telling you every single thing this guy said has come to pass. I’m in awe.”

Posted on YouTube in 2009, Lustig’s 90-minute talk has received more than 4.1 million hits and is credited with kick-starting the anti-sugar movement, a campaign that calls for sugar to be treated as a toxin, like alcohol and tobacco, and for sugar-laden foods to be taxed, labelled with health warnings and banned for anyone under 18.

Lustig is one of a growing number of scientists who don’t just believe sugar makes you fat and rots teeth. They’re convinced it’s the cause of several chronic and very common illnesses, including heart disease, cancer, Alzheimer’s and diabetes. It’s also addictive, since it interferes with our appetites and creates an irresistible urge to eat.

This year, Lustig’s message has gone mainstream; many of the New Year diet books focused not on fat or carbohydrates, but on cutting out sugar and the everyday foods (soups, fruit juices, bread) that contain high levels of sucrose. The anti-sugar camp is not celebrating yet, however. They know what happened to Yudkin and what a ruthless and unscrupulous adversary the sugar industry proved to be.

The tale begins in the Sixties. That decade, nutritionists in university laboratories all over America and Western Europe were scrabbling to work out the reasons for an alarming rise in heart disease levels. By 1970, there were 520 deaths per 100,000 per year in England and Wales caused by coronary heart disease and 700 per 100,000 in America. After a while, a consensus emerged: the culprit was the high level of fat in our diets.

One scientist in particular grabbed the headlines: a nutritionist from the University of Minnesota called Ancel Keys. Keys, famous for inventing the K-ration – 12,000 calories packed in a little box for use by troops during the Second World War – declared fat to be public enemy number one and recommended that anyone who was worried about heart disease should switch to a low-fat ”Mediterranean” diet.

Instead of treating the findings as a threat, the food industry spied an opportunity. Market research showed there was a great deal of public enthusiasm for ”healthy” products and low-fat foods would prove incredibly popular. By the start of the Seventies, supermarket shelves were awash with low-fat yogurts, spreads, and even desserts and biscuits.

But, amid this new craze, one voice stood out in opposition. John Yudkin, founder of the nutrition department at the University of London’s Queen Elizabeth College, had been doing his own experiments and, instead of laying the blame at the door of fat, he claimed there was a much clearer correlation between the rise in heart disease and a rise in the consumption of sugar. Rodents, chickens, rabbits, pigs and students fed sugar and carbohydrates, he said, invariably showed raised blood levels of triglycerides (a technical term for fat), which was then, as now, considered a risk factor for heart disease. Sugar also raised insulin levels, linking it directly to type 2 diabetes.

When he outlined these results in Pure, White and Deadly, in 1972, he questioned whether there was any causal link at all between fat and heart disease. After all, he said, we had been eating substances like butter for centuries, while sugar, had, up until the 1850s, been something of a rare treat for most people. ”If only a small fraction of what we know about the effects of sugar were to be revealed in relation to any other material used as a food additive,” he wrote, ”that material would promptly be banned.”

This was not what the food industry wanted to hear. When devising their low-fat products, manufacturers had needed a fat substitute to stop the food tasting like cardboard, and they had plumped for sugar. The new ”healthy” foods were low-fat but had sugar by the spoonful and Yudkin’s findings threatened to disrupt a very profitable business.

As a result, says Lustig, there was a concerted campaign by the food industry and several scientists to discredit Yudkin’s work. The most vocal critic was Ancel Keys.

Keys loathed Yudkin and, even before Pure, White and Deadly appeared, he published an article, describing Yudkin’s evidence as ”flimsy indeed”.

”Yudkin always maintained his equanimity, but Keys was a real a——-, who stooped to name-calling and character assassination,” says Lustig, speaking from New York, where he’s just recorded yet another television interview.

The British Sugar Bureau put out a press release dismissing Yudkin’s claims as ”emotional assertions” and the World Sugar Research Organisation described his book as ”science fiction”. When Yudkin sued, it printed a mealy-mouthed retraction, concluding: ”Professor Yudkin recognises that we do not agree with [his] views and accepts that we are entitled to express our disagreement.”

Yudkin was ”uninvited” to international conferences. Others he organised were cancelled at the last minute, after pressure from sponsors, including, on one occasion, Coca-Cola. When he did contribute, papers he gave attacking sugar were omitted from publications. The British Nutrition Foundation, one of whose sponsors was Tate & Lyle, never invited anyone from Yudkin’s internationally acclaimed department to sit on its committees. Even Queen Elizabeth College reneged on a promise to allow the professor to use its research facilities when he retired in 1970 (to write Pure, White and Deadly). Only after a letter from Yudkin’s solicitor was he offered a small room in a separate building.

”Can you wonder that one sometimes becomes quite despondent about whether it is worthwhile trying to do scientific research in matters of health?” he wrote. ”The results may be of great importance in helping people to avoid disease, but you then find they are being misled by propaganda designed to support commercial interests in a way you thought only existed in bad B films.”

And this ”propaganda” didn’t just affect Yudkin. By the end of the Seventies, he had been so discredited that few scientists dared publish anything negative about sugar for fear of being similarly attacked. As a result, the low-fat industry, with its products laden with sugar, boomed.

Yudkin’s detractors had one trump card: his evidence often relied on observations, rather than on explanations, of rising obesity, heart disease and diabetes rates. ”He could tell you these things were happening but not why, or at least not in a scientifically acceptable way,” says David Gillespie, author of the bestselling Sweet Poison. ”Three or four of the hormones that would explain his theories had not been discovered.”

”Yudkin knew a lot more data was needed to support his theories, but what’s important about his book is its historical significance,” says Lustig. ”It helps us understand how a concept can be bastardised by dark forces of industry.”

From the Eighties onwards, several discoveries gave new credence to Yudkin’s theories. Researchers found fructose, one of the two main carbohydrates in refined sugar, is primarily metabolised by the liver; while glucose (found in starchy food like bread and potatoes) is metabolised by all cells. This means consuming excessive fructose puts extra strain on the liver, which then converts fructose to fat.

This induces a condition known as insulin resistance, or metabolic syndrome, which doctors now generally acknowledge to be the major risk factor for heart disease, diabetes and obesity, as well as a possible factor for many cancers. Yudkin’s son, Michael, a former professor of biochemistry at Oxford, says his father was never bitter about the way he was treated, but, ”he was hurt personally”.

”More than that,” says Michael, ”he was such an enthusiast of public health, it saddened him to see damage being done to us all, because of vested interests in the food industry.”

One of the problems with the anti-sugar message – then and now – is how depressing it is. The substance is so much part of our culture, that to be told buying children an ice cream may be tantamount to poisoning them, is most unwelcome. But Yudkin, who grew up in dire poverty in east London and went on to win a scholarship to Cambridge, was no killjoy.

”He didn’t ban sugar from his house, and certainly didn’t deprive his grandchildren of ice cream or cake,” recalls his granddaughter, Ruth, a psychotherapist. ”He was hugely fun-loving and would never have wanted to be deprived of a pleasure, partly, perhaps, because he grew up in poverty and had worked so hard to escape that level of deprivation.”

”My father certainly wasn’t fanatical,” adds Michael. ”If he was invited to tea and offered cake, he’d accept it. But at home, it’s easy to say no to sugar in your tea. He believed if you educated the public to avoid sugar, they’d understand that.”

Thanks to Lustig and the rehabilitation of Yudkin’s reputation, Penguin republished Pure, White and Deadly 18 months ago. Obesity rates in the UK are now 10 times what they were when it was first published and the amount of sugar we eat has increased 31.5 per cent since 1990 (thanks to all the ”invisible” sugar in everything from processed food and orange juice to coleslaw and yogurt). The number of diabetics in the world has nearly trebled. The numbers dying of heart disease has decreased, thanks to improved drugs, but the number living with the disease is growing steadily.

As a result, the World Health Organisation is set to recommend a cut in the amount of sugar in our diets from 22 teaspoons per day to almost half that. But its director-general, Margaret Chan, has warned that, while it might be on the back foot at last, the sugar industry remains a formidable adversary, determined to safeguard its market position.

Recently, UK food campaigners have complained that they’re being shunned by ministers who are more than willing to take meetings with representatives from the food industry. ”It is not just Big Tobacco any more,” Chan said last year. ”Public health must also contend with Big Food, Big Soda and Big Alcohol. All of these industries fear regulation and protect themselves by using the same tactics. They include front groups, lobbies, promises of self-regulation, lawsuits and industry-funded research that confuses the evidence and keeps the public in doubt.”

Dr Julian Cooper, head of research at AB Sugar, insists the increase in the incidence of obesity in Britain is a result of, ”a range of complex factors”.

”Reviews of the body of scientific evidence by expert committees have concluded that consuming sugar as part of a balanced diet does not induce lifestyle diseases such as diabetes and heart disease,” he says.If you look up Robert Lustig on Wikipedia, nearly two-thirds of the studies cited there to repudiate Lustig’s views were funded by Coca-Cola.

But Gillespie believes the message is getting through. ”More people are avoiding sugar, and when this happens companies adjust what they’re selling,” he says. It’s just a shame, he adds, that a warning that could have been taken on board 40 years ago went unheeded: ”Science took a disastrous detour in ignoring Yudkin. It was to the detriment of the health of millions.”

Sunday Telegraph, London