Sunday, February 27, 2022

Jane Brody, Dietary fat and carbohydrate, Vitamin D and really assessing the evidence

I admit that, as I write this, it is hard to think of anything else as important when Vladimir Putin has invaded Ukraine in an action that, in addition to its obvious direct impact on that country, had led to as great a threat to nuclear war and human extinction as we have seen in two generations. That a deranged power-mad autocrat can do this is even more terrifying when we look at the number of psycho autocrats that have gained power in the world, including recently (and hopefully not in the future) in the US. But I am not going to write about it, for three reasons:

--It is not the topic of this blog, which is Medicine and Social Justice

--There remain a lot of things that urgently need discussion in regard to American healthcare, mired as it is not only in the evils of for-profit capitalism but incredible inefficiency and incompetence, and

--These issues actually matter on a day-to-day, week-to-week, year-to-year basis for the American people.

First, I will start a good thing, or at least a mixed one. The less-good part is that Jane Brody, the health columnist in the New York Times, has written her last column. The good part is lauding her for the incredible contributions she has made to our understanding of the issues of our health over the decades (since 1976) that she has been writing it. We all have (or should have) learned much from her, about diet, and exercise, and dealing with illness and even death. In her last column she points out some areas where her advice has been incorrect, based on the science of the time, when new evidence has disproven it. I believe that an ability to acknowledge that you were wrong, whether because (as usually true for her) the scientific knowledge has changed, or because you wanted to believe something and so were previously unwilling to actually examine the evidence adequately. A particular area of health that she has been associated with is diet (she has written several cookbooks), and this is the area in which her admission of error is most incomplete and thus disappointing. While she notes that ‘One of the most significant shifts has concerned dietary fats,’ her emphasis is on how the recommendations in the ‘70s to shift away from animal fats missed the dangers of vegetable-based trans fats. She cautiously says ‘But time will tell whether specific dietary fats, or the much vaunted Mediterranean diet currently embraced by many doctors, will fall prey to future findings.’ 

But that’s it. There is no mention whatever of the problems with carbohydrates in the diet, particularly simple carbohydrates like sugars, on people’s health. This is a major lapse. Without getting into a discussion about the benefits of a very-low-overall carbohydrate diet (e.g., Atkins, paleo, etc.), there can be no question that large amounts of sugar (and possibly even small amounts of sugar) in the diet is deleterious, non-nutritious, and causes not only obesity but a great many other health problems, and that no reasonable diet today can fail to feature this fact. Moreover, it completely avoids the evidence that the campaign against dietary fat, carried on by organizations such as the American Dietetic Association (now the Academy of Dietetic and Nutrition, AND) and many others, for decades was funded by the sugar industry and the manufacturers of high-sugar foods such as soda pop (addressed in several blog posts, including Gangster capitalism and our health: In the US and in the World Jan1, 2019, The AAFP, Coca-Cola, and Ethics: Serving the public interest? Aug 20, 2010, and others). The lack of any mention of this in Ms. Brody’s column is concerning; does she still believe that fat is a bigger dietary problem that sugar? This is not an academic question; go to your grocery store and look at the labels on “low fat” or “fat free” products and see what is in them. My personal favorite is “fat-free half-and-half”, which is almost an oxymoron because fat is the basis of half-and-half: half whole milk (4% fat) and half cream (about 20%) for a total of about 12%. How can half-and-half be fat free? Read the label! It is full of sugars. Indeed, almost all foods with such labels are high in calories an high in carbohydrates, especially sugar (commonly in the form of ‘high-fructose corn syrup’).

Another undying health claim, promoted by some doctors and many non-medical professionals and non-scientists for several decades is vitamin D (not an issue which Ms. Brody, in this final column, addresses). Fifteen years ago, endocrinologists were promoting vitamin D deficiency as a major endemic problem, claiming deficiency at blood levels then (and now) considered normal. While most have backed away from the idea that it is a panacea, some have not and fed an ongoing commitment to taking more of this vitamin, an idea that flourishes on, of course, the Internet. With the onset of the COVID-19 pandemic, enthusiasts have found this to be the newest “indication” for it (Vitamin D, false nostrums, and conspiracy theories: The world has enough real problems, Jan 28, 2021). In an excellent – and brief and easy to read --Commentary on Medscape® (Feb 17, 2022), John Mandrola asks ‘Why Is Vitamin D Hype So Impervious to Evidence?’. His emphasis is on critical appraisal of the scientific research, on the quality, breadth, and significance of the studies done. He emphasizes that there are many, many randomized controlled trials that do not show that taking Vitamin D decreases the risk of any condition (other than true vitamin D deficiency, which occurs at quite low levels.) Among the many important points he makes is that association (many people with chronic disease have lower vitamin D levels) does not show causation (it was the low vitamin D levels that caused the disease), because often ill-health causes the lower levels, and still less that administration of vitamin D will cure it. Indeed, he discusses the many large, well-designed studies that prove that it does not.

So why is this issue so impervious to evidence? The answer, it appears, is rooted more in psychology than science, in how people choose to believe what they believe and seek out evidence that supports it (if, indeed, they seek evidence at all). There are always experts who espouse their (and almost any) position. Even when they are a small minority, there are 330 million Americans and 8 billion people in the world, so a small minority can be a lot of people. Almost all people (scientists are a very small minority) do not have the training or the skill to read and assess the scientific literature, and it is uncommon that they even try. Instead, they seek (or have sent to them) articles by people that seem to be reputable that support their position. Mandrola focuses also on how even scientific papers engage in “spin”, pointing out how often they emphasize minor, secondary, and non-significant results even when the main point that they were trying to prove (that vitamin D cures or prevents something) is not shown by their research. Indeed, such minor things are pounced on by a public that wants to see what isn’t there; he gives this example:

the authors of the VITAL trial, which found that vitamin D supplements had no effect on the primary endpoint of invasive cancer or cardiovascular disease, published a secondary analysis of the trial looking at a different endpoint: a composite incidence of metastatic and fatal invasive total cancer. They reported a 0.4% lower rate for the vitamin D group, a difference that barely made statistical significance at a P value of .04. 

But everyone [he says; I think he means physicians and scientists] knows the dangers of reanalyzing data with a new endpoint after you have seen the data. What's more, even if this were a reasonable post hoc analysis, the results are neither clinically meaningful nor statistically robust.  Yet the fatally flawed paper has been viewed 60,000 times and picked up by 48 news outlets. [emphasis mine].

Think about that. It is not what is proven to be true that gets the most coverage, it is what is most provocative. And clearly, this is not just about vitamin D. COVID and the COVID vaccines are common and prevalent examples of people choosing to believe something and then picking and choosing research that supports it; they even call this “doing their own research”. Some of this is the result of religious-like devotion to a position or point of view, some is purposely malicious, some is conspiracy theory, and some is honestly being overwhelmed by data that they do not understand. But it sure can be very dangerous. You deciding that COVID is not a risk anymore (if ever) and you don’t need to be vaccinated and don’t need to wear a mask is dangerous to me!

If over 95% of climate scientists agree that human activity, especially the burning of fossil fuels, is the cause of global warming, but many people do not believe it, why would we think the kinds of foods we eat, the benefits (or not) of taking high doses of a vitamin, the risk of a pandemic virus, the benefit of vaccination, would not be controversial? I would like to agree with Dr. Mandrola that there is hope, but I am sometimes not sure.

In the meantime, get vaccinated, eat very little sugar, and do not overdose on vitamin D, which can absolutely happen.


Monday, February 7, 2022

Direct Contracting Entities: Scamming Medicare and you and bad for your health!

On October 25, 2021 I wrote about ‘Medicare Advantage, Direct Contracting Entities, and other scams to transfer your money to insurance companies’. In the interim, it has become clear that the impact, and even existence, of DCEs is not well known among Medicare recipients, physicians, members of Congress, and many policy analysts. Indeed, it involves a lot more than insurance companies, particularly “private equity” (a newish term for “venture capitalists” including hedge funds, that maybe sounds better). While DCEs are still an ‘experimental’ program by the Centers for Medicare and Medicaid Innovation (CMMI) it is significant that the Biden administration has continued this Trump-initiated policy. As, presumably, part of its experimental nature, it has not had much publicity; few Medicare recipients know about it and it is just getting known to Congress, particularly with Senate Finance Committee hearings on February 2, 2022. It is probably worth calling attention to again, even if this piece repeats some of what I wrote in October.

Medicare was established in 1965, and the first two cards were issued, by President Johnson, at the Truman Library in Independence, MO to Harry and Bess Truman, in recognition of Truman’s efforts to pass national health insurance during his presidency. It meant that for the first time in American history, older adults would not suffer and die just because they could not afford medical care. It remains, along with Social Security, the most popular program in the US, in every poll, by almost everyone (except of course the rich elites, who believe the best programs are the ones that funnel money directly into their pockets, but more on that later).

Medicare has been a rousing success, but there are two problems. The real and serious problem, as seen from the point of view of Medicare recipients, or for that matter anyone who claims to be a decent non-narcissistic human being, is that it does not comprehensively over health care costs. For starters, there are several important health conditions it does not cover, including vision, hearing, and long-term care. Also, even for the conditions (most hospitalizations and office visits) it does cover, it does not cover the entire cost. Generally, for hospitalization, it covers 80% of the Medicare-approved fee (which is always less than hospital charges, but which is in fact all the hospital can charge Medicare patients). This puts patients on the hook for the other 20%, which as anyone who has been hospitalized knows can be a lot of money.

The other problem, perceived as egregious by the small but powerful group of very wealthy investors (not regular people at all) is the same as with all effective government programs: it doesn’t put money in their pockets. Medicare is funded by different sources; Part A is for hospitalization and comes from the Medicare tax on your paycheck. Part B is for outpatient care and is funded from general revenue funds, plus a monthly charge to Medicare recipients (a minimum of about $135 now, which can go quite a bit higher for high-income people and be waived for low income). Part D is the drug plan that each recipient is required to buy. We’ll talk about Part C later.

Medicare, as a public (government) program that is in the business of paying for health care rather than generating shareholder profit operates very efficiently, with about a 2% overhead for administrative costs. As a taxpayer, I’d think this is good. But for the small number of powerful wealthy investors (for short, let’s call them GNPs, for Greedy Narcissistic Pukes) it represents an opportunity; if they could control it they could reap profit from it!

So, of course, while the fact that it is not making rich people even richer is not a problem for most of us, the problem we have is the solution that the government has come up with in service to the GNPs. It has been regularly altering Medicare to help them make money from it. First Congress created Medicare Part C, or Medicare Advantage (MA), which, if you choose it, basically enrolls you in an HMO. You get everything paid for plus other stuff that traditional Medicare (TM) doesn’t cover, like hearing and dental and maybe gym memberships. This is good for you provided you don’t get sick. If you do, you don’t have the choice of virtually all doctors and hospitals that you do with TM, just those “in network” (an even greater problem if you don’t spend all your time in the same area, since those networks are geographic). Also, since, if you are sick, those MA programs would just as soon you left went to TM so  they don’t have to pay your bills, and they have a variety of tricks to encourage you to do so. MA may be good for basically healthy seniors, unless they travel, until they’re not healthy. MA plans also don’t pay for long-term care – that’s expensive and would cost too much; gym memberships are cheap. And they can – and do -- pocket overhead and profits of up to 15%. (The insurance term is that their “medical loss ratio” -- the amount that they have to spend on actually providing medical care – has to be 85%, while in TM with its 2% overhead, it is effectively 98%.) Medicare Part D, the required drug coverage was another gift, this time to big pharmacies and pharmacy benefit managers (PBMs) who make big profit from them.

But wait! A lot of people were and are still choosing TM, and not all of them are the high-cost really sick people that the MA plans don’t want! While the insurance companies and GNPs are glad that they are in TM when they are sick and costly, there are still a lot of them who we could make money on. How can we do that? Well, let’s get the Center for Medicare and Medicaid Innovation (CMMI), which is supposed to come up with innovative programs that improve quality and save the government money, to implement an “innovation” that lets us pocket money from even those who chose TM! Cool! So they did, without even having to have Congress approved it. These are called Direct Contracting Entities (DCEs). If your primary care clinician is affiliated with a DCE, the DCE collects all your money from Medicare, and – this is a really good part – they only have a medical loss ratio requirement of 60%, so they can keep 40% if they can deny you enough care! A better deal (for them!) than even Medicare Advantage! And since most primary care physicians are now employees or part of large groups, the DCEs can just contract with the group, not with each physician. And even better, the DCEs, the majority of which are now owned by “private equity” (a particularly noxious form of GNP), can just buy the primary care groups! Voilà! The group is now owned by the DCE, your doctor is part of it, and you are part of it and being hosed. Your only recourse is to change your primary care doctor. Which you may not want to because you may like and trust your doctor…

Of course, the two problems I mentioned are mirror images of each other. Medicare does not pay for all your care because Congresspeople and Wise Policy Analysts say that would be bad because it would cost too much. They see it as much better to spend lots of money on further enriching the insurance companies, PBNs, DCEs, and other GNPs. Why? Because they contribute a lot of money to Congress, and because many congresspeople are heavily invested in these; often they are also GNPs, either before entering Congress or as a result of it (how they get so rich on a Congressional salary is another story).

By the way, in case I haven’t been clear in what I think, these are all both bad and evil programs, taking money that should be spent on your healthcare. They are healthcare examples of the impact of “gangster capitalism”, or in another term I’ve heard, Götterdämmerung capitalism, which describes our current situation where the GNPs would rather destroy the world that stop acquiring all its wealth. And if they are willing to destroy the world, how much weight do you think your health and life have? These programs are not developed by accident; they are purposely designed to take what you have (as in the cost of health insurance premiums) or have previously been recognized as social benefits (as Medicare) and transfer them to the richest people in society.

The only – maybe, hopefully -- good news is that Congress has recently started holding hearings on DCEs, recently by the Senate Finance Committee, with outstanding testimony by many experts including Dr. Susan Rogers, current president of Physicians for a National Health Program (PNHP), whose website has lots of good information on DCEs. At the end of the hearing, Sen. Elizabeth Warren (D, MA) urged the Biden administration in the strongest terms to have CMMI end this “innovative experiment” (or perhaps you prefer grift or scam). Maybe they will.

Let your Congresspeople know what you think. And everyone else.

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