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.

 

Nursing homes, assisted living, and home care: Can we have reliable quality?

Getting older is unavoidable (until the end); I myself have been doing it all my life. When I was a child and getting older (being a teenager! Or an adult!), it was an entirely positive aspiration. Now, not so much. We know that we will die, and as we grow old, if we are lucky enough to not die young, we know that are going to meet that end sooner rather than later.

As I have grown past “Medicare age”, I have personally experienced many of the issues that I have worked through with patients over the decades, and am also experiencing (vicariously, but closer) the travails of my much-older parent. While not everything that happens with aging is negative (retirement, not going to work every day, is a major positive, provided you can afford it!), the body and the mind can’t do what they once did and often really start to fall apart. Those of us who are lucky enough to avoid dementia, from Alzheimer’s disease or another cause, still find ourselves with memory lapses. And hopefully, we can continue to find ourselves, and our keys, and remember the word or name that we know so well but just is evading us, or the reason we came into this room. A colleague of mine calls this “benign senile forgetfulness”, and I guess it is benign, as long as it doesn’t progress too fast.

Aging is a process of the body falling apart. Different pieces fall apart in different people at different rates, and some folks overall do better for longer than others, but there is an inexorable downward progression. There are things that we can do to help, to slow it, to lessen the risks we face (see, for example, Jane Brody’s article on How to Prevent Falls); among the most important is continued physical activity, as vigorous as we are able to do. I tell people, with a straight face because I am serious, that when I was young I worked out to get fitter and stronger, but now I work out to just fall apart a little more slowly.

As we age we are more likely to acquire disease. These include both the diseases associated with aging (although they can occur younger ages) like Alzheimer’s and arthritis, as well as almost all other diseases that become more common and often more serious: heart disease, most cancers, diabetes, stroke, high blood pressure, influenza, etc. The real question becomes when and even whether to treat them. In youth and well into (and past) middle age we are conditioned to think of illness as curable, or at least significantly treatable. This attitude is enabled by the medical profession, that can do so much more than it used to be able to, and the health care industry, which makes money on it. And we tend to take these views into older age, even when the treatment is worse than the disease, as it often is, or there is no demonstrated benefit, and sometimes definite evidence of harm, both in treatment and even in “preventive” screening (see the CDC and USPSTF recommendations for age-appropriate screening).

Aging and its accompanying diseases and infirmities may require a change in our living situation. Options can include living with family members, or having a health aide (living in or commuting, see below), or a variety of institutional settings ranging from “independent living” (your own place, but some easily accessible help, such as available meals and nurse visits), to “assisted living” (regular meals, more nursing and cleaning help, more protected environment) to full-on nursing home (skilled) care. Given the variety of options, both in terms of “level” of care and in terms of quality and cost of provider, we should be able to depend on licensing, legal standards, and ratings. Unfortunately, we are not always able to do so.

“Care Suffers as More Nursing Homes Feed Money Into Corporate Webs”, in the NY Times on January 2, 2018, documents just what the title says. Most nursing homes are owned by for-profit companies, often very large regional or national corporations, and thus there can be cuts in the quality of care (the service ostensibly being rendered) in order to increase profits. Or, looking at it the other way, every dollar spent on actually delivering care is a dollar lost to profit. The insurance industry has a cute term for this, “medical loss ratio”, which is the money lost to the bottom line by paying health insurance claims. In addition, nursing homes contract “out” for many services (food, cleaning, etc.), and management of the homes, and rent for the buildings. The companies that they contract with are often owned by the same people, but through this trick these costs now become fixed expenses, not covered by regulations governing the nursing home itself. Voilà! Instant profit!

Similar problems abound in other levels of care. “U.S. Pays Billions for ‘Assisted Living,’ but What Does It Get?”, NY Times February 3, 2018, documents the low quality of care often provided to people in assisted living for whom Medicaid is paying as much as $30,000 a year (for assisted living, mind you, not even for skilled nursing services). Part of the problem in this case is that, because Medicaid is a joint state-federal program, they operate “…under a patchwork of vague standards and limited supervision by federal and state authorities.” And, again the people being cared for are the ones who suffer.

So there is good reason to be concerned about these institutions. What about home care? At least that is in your own house, right? On January 31, 2018, the Times had two articles about it. One was from Britain, although it is actually describing institutions, “home care” settings that are like small private assisted living facilities. “Britain Was a Pioneer in Outsourcing Services. Now, the Model Is ‘Broken,” discusses serious adverse health outcomes for people in “home care” there. This could be seen as a ‘gotcha’ for those of us who advocate a national health system, which Britain has, but there are some important caveats. One, of course, is that these are not “home care” in the US sense, and a second is that the fault is clearly not with having a national health system, but rather the efforts to privatize aspects of it (“outsourcing”) which has failed because – surprise – these private sector companies make more profit if they provide cheaper, read “worse”, care! The less national, government involvement, the worse the care.

The other important point is to remember the difference between how much money is spent and how it is distributed. The US spends a lot of money, but it is incredibly unequally distributed among the population. Britain distributes it much more equitably, but has (particularly under Tory governments) underfunded it, including the efforts to privatize aspects of it described in this article. Now, if the US distributed its health care funds in a manner similar to the British NHS, it could spend a lot less and the people would get a lot more!

The other article, from the US, is about what we truly understand to be home care, but its focus is not on the quality of care for patients but the difficulties confronted by the home care workers. Titled “For Health Care Workers, the Worst Commutes in New York City,” it specifically addresses the commutes (from poorer neighborhoods where the mostly-minority mostly-female home care workers live to where they work). But these workers are also poorly paid and lack benefits, often including paid time off, and ironic but true, health coverage! They are, of course, employed by for-profit companies. We depend on these people to care for our parents, or us, but like many involved in the doing-actually-important-things-that-make-a-real-difference-in-people’s-lives industries (e.g., teaching, social work, etc.) they are underpaid and undervalued in comparison to those in the let’s-make-a-lot-of-money-for-ourselves-and-the-heck-with-them industries.

Those who advocate a for-profit capitalist market as the solution to all problems, and particularly the privatization of currently government-run activities, claim that the private sector can operate more efficiently and more cost-effectively, and provide better service than a government bureaucracy. This claim usually turns out to be untrue. Such companies, particularly when gifted with government contracts, are better at making profit, especially by keeping down workers’ wages and cutting back services. When we talk about the care of our seniors, our parents, ourselves, the tradeoff between adequate care and profit is not one any of us would want to make; we want the best quality of care, period. So whether this is compromised by inadequate funding, as in the case of British home care, or (almost worse) adequate funding but excessive profit-taking by the private sector, it is unacceptable.

There is an answer. Have the structure of our society reflect the things that most people actually value. Have a well-funded national health system or a well-regulated private one, that ensures quality of care for its clients and living wages for its workers. The elimination of excessive profits (or all profit in a government-run system) would make it not only better, but still cheaper than the way we do it now, where the “care” is the “medical loss” to profit.