Those of you who have read my blog regularly know that I think that alcohol is a valuable medicine that lowers the heart-attack risk. This whole subject was recently reviewed in the Journal of the American Medical Association in the May 26, 2010 issue (vol. 303, # 20, pp. 2065-2073). It is a fairly comprehensive review, with an extensive list of references. Before summarizing the review, I should like to iterate my opinions:
(1) We should lower the legal drinking age to 16. The age was forcibly raised to 21 by the U.S. Gov't, who threatened to reduce federal aid for highway construction to any state (e.g. New York) that did not raise the age to 21. The result is that many adolescents do their first serious drinking at college, away from parental supervision, and without the necessity of coming home to their parents in a somewhat sober condition. The system is even worse at state colleges. My daughter went to a state college, which was kept rigorously dry, even in the fraternity houses. The only result is that the students went off-campus to drink, and drove back to their dorms drunk. I hardly think that this is an improvement.
(2) If the greatest fear is that of teen-age drunken driving, then why not make it legal for teenagers who do NOT have a driving license to drink?
(3) My oldest grand-nephew just finished a 3 year tour in the Marines. He is allowed to drive a tank, operate a 50. caliber machine gun, a SAW, and kill our enemies, but was not even allowed to drink 3.2 beer on his base. There is something wrong with this picture if we trust him to kill responsibly, but not to drink responsibly.
The JAMA article made the following points, all of which were referenced to published articles. I should add that we still do not know the direct mechanism by which alcohol exerts its beneficial effects.
(1) Alcohol increases the "good' cholesterol HDL-C, in a dose-dependent effect.
(2) Alcohol decreases the level of fibrinogen, a clotting factor.
(3) Alcohol increases insulin sensitivity, and decreases the generation of glucose by the liver, so its ingestion opposes diabetes by two different mechanisms.
(4) Alcohol prolongs bleeding time.
(5) There is also an inverse relationship between alcohol intake and risk for stroke.
(6) All alcoholic beverages appear to be equipotent, and seem to benefit men more than women, provided that the alcohol is ingested on a regular basis.
(7) Alcohol does contain calories, and also increases a woman's risk for breast cancer (but the latest Danish study showed that pregnant women can imbibe a drink a day without harm to the fetus).
Overall, since cardiac disease causes the most deaths in the US, and since regular alcohol use can reduce the risk of coronary artery disease by as much as 30%, I think that doctors should consider recommending this as a daily medicine to men, and perhaps thrice weekly to women.
Thursday, May 27, 2010
Sunday, April 25, 2010
When is a Low Salt Diet Beneficial (if ever)
I was upset, both from a medical and a mathematical point of view, after I read the paper published in "Annals of Internal Medicine" by Crystal Smith-Spangler and others: "Population Strategies to Decrease Sodium Intake",Ann.Int.Med. 2010;152:481-487, the lead article in the Annals volume published on April 20 of this year. I have been a reviewer for Annals for over 10 years. I can assure you that I would have rejected this article immediately. I never had an article I rejected overridden by the editor-in-chief, but sometimes the article in question would be published in a journal with less strict criteria.
I object to this paper on epidemiological grounds, on mathematical grounds, and on moral grounds as well.I think we all agree that blood pressure is a monotonically increasing function of the amount of daily NaCl consumption. We also note that increased blood pressure puts one at risk for strokes (CVA's) as well as heart attacks (MI's). The question of course is twofold: does lowering blood pressure reduce the risk or rate of CVA's and MI's? And furthermore, by how much can we reduce blood pressure "the silent killer, by decreasing the salt in the diet.
I will pass over the fact that some heart failure patients on NY Class III or IV worsen their faliure when their salt intake is lessened. I will also ignore the fact that there is no city-wide Institutional Review Board to evaluate the safety of this intervention in various groups of patients, and, of course, the "patients" in an entire city or country are not all consulting adults. So we are treating/testing a group of involuntary "volunteers".
Since correlation is NOT causation, we first have to see if lowering dietary salt lowers cardiovascular events (presumably by lowering blood pressure). Giving a patient a diuretic makes his kidneys excrete extra salt, so a daily water pill mimics a low salt diet somewhat. The result of diuretic treatment to lower blood pressure was that the incidence of CVA's was reduced. but not that of MI's.
To add further spice to the stories, the authors claimed that a 9.7% reduction in salt intake, as achieved by the British Government, would attain a 1.25mm (i.e. 1%) reduction in systolic blood pressure, and this would prevent 513,885 strokes and 480,358 heart attacks.
This not only looks too good to be true, it is too good to be true. The intra-observer error/statistical deviation in measuring blood pressure is+/- 2 mm.The interobserver error is worse, and is +/- 3 to 4 mm. Hg. (Not unlike the radiologist ' mammogram report that says they miss 10% of cancers). This would be similar to my claiming that since the measured speed of light is 186,272 miles/second, and I measured it to be 186,273 +/- 2 miles/sec., it is time to change the accepted value of the speed of light.
This is also like the situation where the government, seeing that pumping auto brakes helps to reduce the skidding of a car insisted on installing an automatic pumping system on the brakes, the ABS. You got a car insurance reduction for doing this,but it did not decrease the number of accidents after a skid, and now it is no longer mandatory. I also am skipping over the fact that the NTSB knew that if they required air bags to explode/expand rapidly enough to protect you even when you were not belted in, then children in the front seat might be hurt. They deliberately did not mention this fact to Congress, in fear that the air bag law might not be pass. They just admitted the week of May 16 that the air bags cause more damage to front-seat passengers and drivers who are belted-in rather than those who are not. Why believe ANY government reports or recommendations unless you can study the basic data from which the recommendations were derived?
I object to this paper on epidemiological grounds, on mathematical grounds, and on moral grounds as well.I think we all agree that blood pressure is a monotonically increasing function of the amount of daily NaCl consumption. We also note that increased blood pressure puts one at risk for strokes (CVA's) as well as heart attacks (MI's). The question of course is twofold: does lowering blood pressure reduce the risk or rate of CVA's and MI's? And furthermore, by how much can we reduce blood pressure "the silent killer, by decreasing the salt in the diet.
I will pass over the fact that some heart failure patients on NY Class III or IV worsen their faliure when their salt intake is lessened. I will also ignore the fact that there is no city-wide Institutional Review Board to evaluate the safety of this intervention in various groups of patients, and, of course, the "patients" in an entire city or country are not all consulting adults. So we are treating/testing a group of involuntary "volunteers".
Since correlation is NOT causation, we first have to see if lowering dietary salt lowers cardiovascular events (presumably by lowering blood pressure). Giving a patient a diuretic makes his kidneys excrete extra salt, so a daily water pill mimics a low salt diet somewhat. The result of diuretic treatment to lower blood pressure was that the incidence of CVA's was reduced. but not that of MI's.
To add further spice to the stories, the authors claimed that a 9.7% reduction in salt intake, as achieved by the British Government, would attain a 1.25mm (i.e. 1%) reduction in systolic blood pressure, and this would prevent 513,885 strokes and 480,358 heart attacks.
This not only looks too good to be true, it is too good to be true. The intra-observer error/statistical deviation in measuring blood pressure is+/- 2 mm.The interobserver error is worse, and is +/- 3 to 4 mm. Hg. (Not unlike the radiologist ' mammogram report that says they miss 10% of cancers). This would be similar to my claiming that since the measured speed of light is 186,272 miles/second, and I measured it to be 186,273 +/- 2 miles/sec., it is time to change the accepted value of the speed of light.
This is also like the situation where the government, seeing that pumping auto brakes helps to reduce the skidding of a car insisted on installing an automatic pumping system on the brakes, the ABS. You got a car insurance reduction for doing this,but it did not decrease the number of accidents after a skid, and now it is no longer mandatory. I also am skipping over the fact that the NTSB knew that if they required air bags to explode/expand rapidly enough to protect you even when you were not belted in, then children in the front seat might be hurt. They deliberately did not mention this fact to Congress, in fear that the air bag law might not be pass. They just admitted the week of May 16 that the air bags cause more damage to front-seat passengers and drivers who are belted-in rather than those who are not. Why believe ANY government reports or recommendations unless you can study the basic data from which the recommendations were derived?
Apropos of poor math training, tonight we attempted to give our waitress the check with a coupon good for an $25 discount, and asked her to divide the bill into 2/3 and 1/3 with tax and tip. It took her only 20 minutes (!). Hooray for the new math.
What I am saying again is that correlation is not causation, and we can only hope that the low salt diet will be of benefit to some patients, and not too harmful to others.
BTW, if you have a blood pressure problem, please make sure your doctor measures the blood pressure in both arms.
What I am saying again is that correlation is not causation, and we can only hope that the low salt diet will be of benefit to some patients, and not too harmful to others.
BTW, if you have a blood pressure problem, please make sure your doctor measures the blood pressure in both arms.
Saturday, April 17, 2010
Obamacare, Medical Economics, Gov't Guidelines
This blog is an attempt by a family physician to evaluate "Obamacare" from the perspective of a patient, since the bill will affect them the most. To begin with, the same arguments made today against "Obamacare" were made 35 years ago against Medicare, and by the same groups. Almost all of my MCR patients today are more than satisfied with the system, and their children are even more so, since they can spend their money on their children's college education instead of on their parents' medical bills.
The first modern government to start government medical insurance as well as social security and workmen's compensation was that of Prussia under Otto von Bismarck in 1887 (cf. "Blood and Iron"), because he felt that a socially secure worker was a better worker. The first state government to mandate health care was Massachusetts. I don't yet know how it is working out, except that there is always a dearth of primary care physicians, since diagnosis and thinking through are not well-compensated. I think that it is wonderful that the parents' coverage of their children will be extended to age 26, since fewer newly-minted college graduates are getting immediate jobs.
Initially, the plan will cost more than is predicted, because fewer people will die. This was discovered when MCR covered dialysis in all ESRD patients. Without dialysis, many patients died of their renal disease. With dialysis, many lived longer lives, and therefore cost the system more.
I also envision that with state-controlled insurance, you won't have to go scurrying to find a new internist, gynecologist and pediatrician just because your employer changed medical insurance companies.
The one economic calculation that is never done, however, is how much living people contribute to government finances. If you dropped dead from a heart atack now, then that is the end. If they call 911, do CRP, rush you to the hospital and do emergency CABG surgery, the economists say that you cost the system $30,00 in medical expenses. No one adds that now you will work and pay taxes for another 20 years, and yourtaxes will amount to much more than $30,000.
Medical economics is also unpredictable: I bought a lot of Pfizer and Merck stock years ago, because they had the largest and most aggressive sales force. I reasoned that the more drugs people bought, the longer they lived, and the longer they lived, the more drugs they bought, so drug stocks should rise forever. When the drug stocks flattened out for 2 years, I realized that the market made no sense to me, and got totally out.
We will also spend less on acute medical care if everyone has his/her own doctor, because workups of medical problems in the emergency room is enormously expensive, while your family doctor who knows you can diagnose your problem with much fewer tests (e.g. he will not order a CT scan of yuor brain for ordinary dizziness).
BTW, the best way to diminish medical malpractice suits is to eliminate contingency fees. This law could be passed by any state legislature. At the same time, perhaps we should eliminate medical class action suits as well. Dow went bankrupt because a Texas jury was convinced of the "fact" that leaking silicone breast implants caused chemical lupus in susceptible females. Of course the fact that an article in NEJM demonstrated 2 years later that the association was not one of cause-and-effect did nothing to reverse Dow's financial position.
We should be very cautious about following any government guidelines for medical treatment. As I have stated before, it is very unlikely that a panel of 20 physicians agree 100% on anything, but unlike the arguments about global warming, we never get to see a minority report. The "normal" value of glucose and of cholesterol keep on being lowered, although statins seem to benefit everyone regardless of their cholesterol level, and intense control of diabetes seems to benefit few, if any (but if you are over the limit it does raise your life insurance premium). The suggestion that mammograms do not benefit women in their 40's was met with a storm of protest. A Nobel prize in medicine was given to the doctor who "proved" that pre-frontal lobotomies cured schizophrenia.The drug Singulair came out 2 months after the guidelines for asthma treatment were published. The only pro/con discussion about benefits or lack thereof of lowering salt in the diet was published in Lancet more than 10 years ago. The government knows that moderate use of alcohol reduces heart attack risk, but they still don't recommend starting. No patient is "average", and every patient is "special", best known by his family doctor, and we are spending too much time excplaining to insurance companies and Medicare Part D that in this particular patient the generic drug does not work as well as the brand name does.
The overall economic picture is that medical care saves lives, technology works but gets increasingly more expensive, and we wil end up rationing by time, availability, or money
The first modern government to start government medical insurance as well as social security and workmen's compensation was that of Prussia under Otto von Bismarck in 1887 (cf. "Blood and Iron"), because he felt that a socially secure worker was a better worker. The first state government to mandate health care was Massachusetts. I don't yet know how it is working out, except that there is always a dearth of primary care physicians, since diagnosis and thinking through are not well-compensated. I think that it is wonderful that the parents' coverage of their children will be extended to age 26, since fewer newly-minted college graduates are getting immediate jobs.
Initially, the plan will cost more than is predicted, because fewer people will die. This was discovered when MCR covered dialysis in all ESRD patients. Without dialysis, many patients died of their renal disease. With dialysis, many lived longer lives, and therefore cost the system more.
I also envision that with state-controlled insurance, you won't have to go scurrying to find a new internist, gynecologist and pediatrician just because your employer changed medical insurance companies.
The one economic calculation that is never done, however, is how much living people contribute to government finances. If you dropped dead from a heart atack now, then that is the end. If they call 911, do CRP, rush you to the hospital and do emergency CABG surgery, the economists say that you cost the system $30,00 in medical expenses. No one adds that now you will work and pay taxes for another 20 years, and yourtaxes will amount to much more than $30,000.
Medical economics is also unpredictable: I bought a lot of Pfizer and Merck stock years ago, because they had the largest and most aggressive sales force. I reasoned that the more drugs people bought, the longer they lived, and the longer they lived, the more drugs they bought, so drug stocks should rise forever. When the drug stocks flattened out for 2 years, I realized that the market made no sense to me, and got totally out.
We will also spend less on acute medical care if everyone has his/her own doctor, because workups of medical problems in the emergency room is enormously expensive, while your family doctor who knows you can diagnose your problem with much fewer tests (e.g. he will not order a CT scan of yuor brain for ordinary dizziness).
BTW, the best way to diminish medical malpractice suits is to eliminate contingency fees. This law could be passed by any state legislature. At the same time, perhaps we should eliminate medical class action suits as well. Dow went bankrupt because a Texas jury was convinced of the "fact" that leaking silicone breast implants caused chemical lupus in susceptible females. Of course the fact that an article in NEJM demonstrated 2 years later that the association was not one of cause-and-effect did nothing to reverse Dow's financial position.
We should be very cautious about following any government guidelines for medical treatment. As I have stated before, it is very unlikely that a panel of 20 physicians agree 100% on anything, but unlike the arguments about global warming, we never get to see a minority report. The "normal" value of glucose and of cholesterol keep on being lowered, although statins seem to benefit everyone regardless of their cholesterol level, and intense control of diabetes seems to benefit few, if any (but if you are over the limit it does raise your life insurance premium). The suggestion that mammograms do not benefit women in their 40's was met with a storm of protest. A Nobel prize in medicine was given to the doctor who "proved" that pre-frontal lobotomies cured schizophrenia.The drug Singulair came out 2 months after the guidelines for asthma treatment were published. The only pro/con discussion about benefits or lack thereof of lowering salt in the diet was published in Lancet more than 10 years ago. The government knows that moderate use of alcohol reduces heart attack risk, but they still don't recommend starting. No patient is "average", and every patient is "special", best known by his family doctor, and we are spending too much time excplaining to insurance companies and Medicare Part D that in this particular patient the generic drug does not work as well as the brand name does.
The overall economic picture is that medical care saves lives, technology works but gets increasingly more expensive, and we wil end up rationing by time, availability, or money
Monday, March 8, 2010
Prostate, Prostate CA, BPH, and economics
There has been much written in the news lately about the prostate: prostate cancer, new guidelines for Dx. and Rx., robotic prostate surgery, and a recent article in Archives of Internal Medicine (vol 170, #5, 3/8/10, pp 451-452)by Dr. M. Barry.
Just as an aside, "regular" prostate surgery is generally done in less than 2 hours, and robotic surgery generally takes longer than 3 hours. If you undergo more than 2.5 hours Operating room time,the risk of complications rises sharply.
What it all boils down to is that THERE IS NO INCONTROVERTIBLE EVIDENCE THAT TREATING PROSTATE CANCER SAVES LIVES.This does not mean that every male with prostate cancer will die from the cancer, but only that no treatment has been shown to cure it. The only study that has not been done is to do quadrant biopsies on all males annually, beginning at age 40, and treating all cancers with a Gleason score of 3 or less. Once prostate cancer is diagnosed (prompted by a rectal exam or an elevated PSA) surveys have shown that your family doctor will often recommend watchful waiting, your urologist will most likely recommend surgery, and a radiation oncologist will most likely recommend radiation. Since there is no evidence that treatment saves lives, it is difficult to justify an annual PSA test, unless the patient agrees to treatment. And, based upon my office experience, his wife will never agree to watchful waiting, so send the lab results to his office.
Once the CA is treated, many men have a few months of urinary incontinence, and/or erectile dysfunction. This may last for 2 years, or be permanent. If the ED seems to be permanent, the most satisfying treatment seems to be to transplant the 12th rib to the center of the penis, so that the "erection" is permanent.
Since the prostate grows without limit, all men will eventually have symptoms of BPH, evidenced by having to get up at night to urinate, or reduction in urinary stream force,etc. The prescribed treatment is with selective alpha-blockers, and/or reductase inhibitors (Proscar, etc.)The newest selective alpha-blocker, which has the least effect on the ciliary artery and therefore is the safest vis-a-vis future cataract surgery, is Rapaflo, (silodosin) 4mg or 8mg at bedtime. Only the combination of a reductase inhibitor plus an alpha-blocker has been shown to reduce the future need for a TURP to open up the prostatic urethra. However, since the old TURP involved inserting a rotatable knife thru the penis and up to the prostate, much like a Roto-rooter operation, and the procedure is now relatively bloodless and pain-free when done with the "green light" laser, not all men opt for the two drugs, especially since Proscar and its relatives diminish the amount of seminal fluid that is ejaculated. One should also remember that alpha blockers can increase the amount of retrograde ejaculation, i.e. backwards into the bladder, rather than forward and out of the urethra.
As for economics, why do you think surgeons recommend surgery and radiators recommend radiation? This leads into the larger question of economics. It is somewhat paradoxical that in today's times, microeconomics would suggest that you save your money, while macroeconomics wants you to help America spend its way out of the recession.
As a former mathematical and experimental physicist, I have looked into the mathematics, models and predictions of all branches of economics, and they all have the same fallacy: They assume that humans are always rational, and never panic sell or binge buy. This is clearly not the case (cf. "The Madness of Crowds"), but since arbitrary,"irrational" behavior cannot be mathematically modeled, calculated or predicted, it is excluded from ALL economic mathematics and their models. When the Black-Scholes "Theorem" was used to model the portfolio of Long Term Capital Funding, it was implicit in their model that no major country would fail to support its own currency. No allowance was made for this occurrence because (a) its happening was abrupt and unpredictable, and (b) the results depended on which country forfeited its currency. Therefore, when Russia defaulted on the ruble, LTCF would have gone bankrupt to the tune of $4B, but the U.S. Gov't bailed them out.
I won't even go into the required nonlinearity of any market model,that is caused by feedback. What we are dealing with here is the drunkard looking under the lamppost for his lost auto keys because the light is better there, rather than in the dark up the block where he actually dropped them. (And no, I lost no money in the market plunge.) People feel more comfortable with a "prediction" created by mathematics, even though GIGO is operating on a huge scale. Now in physics, if the result of an experiment differs from that predicted by our model of the world, we change our model. But economists cannot change their models, because catastrophe theory is too difficult to be mathematically tractable enough to use for predictions (see Rene Thom's work on this problem).
There are and seemingly will always be market crashes, because it is impossible to predict their occurrence or their nature (?something similar to earthquake prediction). No matter what the model, it basically assumes that the past can be used to model the future. How a tulip bulb crash can model Penn Central or the crash of 1873 is not clear to me. It is the question of predicting individual economic behavior vs. mass economic behavior. We have the same problem in medicine. I have no problem recommending that 1,000,000 women have annual mammograms beginning at age ??, but I have 25 female patients over the age of 85 who have never had mammograms or breast cancer, and so far they are right, too.
Just as an aside, "regular" prostate surgery is generally done in less than 2 hours, and robotic surgery generally takes longer than 3 hours. If you undergo more than 2.5 hours Operating room time,the risk of complications rises sharply.
What it all boils down to is that THERE IS NO INCONTROVERTIBLE EVIDENCE THAT TREATING PROSTATE CANCER SAVES LIVES.This does not mean that every male with prostate cancer will die from the cancer, but only that no treatment has been shown to cure it. The only study that has not been done is to do quadrant biopsies on all males annually, beginning at age 40, and treating all cancers with a Gleason score of 3 or less. Once prostate cancer is diagnosed (prompted by a rectal exam or an elevated PSA) surveys have shown that your family doctor will often recommend watchful waiting, your urologist will most likely recommend surgery, and a radiation oncologist will most likely recommend radiation. Since there is no evidence that treatment saves lives, it is difficult to justify an annual PSA test, unless the patient agrees to treatment. And, based upon my office experience, his wife will never agree to watchful waiting, so send the lab results to his office.
Once the CA is treated, many men have a few months of urinary incontinence, and/or erectile dysfunction. This may last for 2 years, or be permanent. If the ED seems to be permanent, the most satisfying treatment seems to be to transplant the 12th rib to the center of the penis, so that the "erection" is permanent.
Since the prostate grows without limit, all men will eventually have symptoms of BPH, evidenced by having to get up at night to urinate, or reduction in urinary stream force,etc. The prescribed treatment is with selective alpha-blockers, and/or reductase inhibitors (Proscar, etc.)The newest selective alpha-blocker, which has the least effect on the ciliary artery and therefore is the safest vis-a-vis future cataract surgery, is Rapaflo, (silodosin) 4mg or 8mg at bedtime. Only the combination of a reductase inhibitor plus an alpha-blocker has been shown to reduce the future need for a TURP to open up the prostatic urethra. However, since the old TURP involved inserting a rotatable knife thru the penis and up to the prostate, much like a Roto-rooter operation, and the procedure is now relatively bloodless and pain-free when done with the "green light" laser, not all men opt for the two drugs, especially since Proscar and its relatives diminish the amount of seminal fluid that is ejaculated. One should also remember that alpha blockers can increase the amount of retrograde ejaculation, i.e. backwards into the bladder, rather than forward and out of the urethra.
As for economics, why do you think surgeons recommend surgery and radiators recommend radiation? This leads into the larger question of economics. It is somewhat paradoxical that in today's times, microeconomics would suggest that you save your money, while macroeconomics wants you to help America spend its way out of the recession.
As a former mathematical and experimental physicist, I have looked into the mathematics, models and predictions of all branches of economics, and they all have the same fallacy: They assume that humans are always rational, and never panic sell or binge buy. This is clearly not the case (cf. "The Madness of Crowds"), but since arbitrary,"irrational" behavior cannot be mathematically modeled, calculated or predicted, it is excluded from ALL economic mathematics and their models. When the Black-Scholes "Theorem" was used to model the portfolio of Long Term Capital Funding, it was implicit in their model that no major country would fail to support its own currency. No allowance was made for this occurrence because (a) its happening was abrupt and unpredictable, and (b) the results depended on which country forfeited its currency. Therefore, when Russia defaulted on the ruble, LTCF would have gone bankrupt to the tune of $4B, but the U.S. Gov't bailed them out.
I won't even go into the required nonlinearity of any market model,that is caused by feedback. What we are dealing with here is the drunkard looking under the lamppost for his lost auto keys because the light is better there, rather than in the dark up the block where he actually dropped them. (And no, I lost no money in the market plunge.) People feel more comfortable with a "prediction" created by mathematics, even though GIGO is operating on a huge scale. Now in physics, if the result of an experiment differs from that predicted by our model of the world, we change our model. But economists cannot change their models, because catastrophe theory is too difficult to be mathematically tractable enough to use for predictions (see Rene Thom's work on this problem).
There are and seemingly will always be market crashes, because it is impossible to predict their occurrence or their nature (?something similar to earthquake prediction). No matter what the model, it basically assumes that the past can be used to model the future. How a tulip bulb crash can model Penn Central or the crash of 1873 is not clear to me. It is the question of predicting individual economic behavior vs. mass economic behavior. We have the same problem in medicine. I have no problem recommending that 1,000,000 women have annual mammograms beginning at age ??, but I have 25 female patients over the age of 85 who have never had mammograms or breast cancer, and so far they are right, too.
Tuesday, February 16, 2010
Weight Loss, Nutrition, Low Salt, Low Sugar
This blog was stimulated by the recent surge to have government endorse/require lower salt in the diet. There is, of course, no direct evidence that a low salt diet prolongs life. In the recommendations, lowering salt in the diet is taken as a surrogate for lowering blood pressure. It is assumed that lowering the amount of salt in the diet by 3 grams/day will lower systolic blood pressure between 3.5 and 5.5 mm; no estimate is given for the effect on diastolic blood pressure (is there any?). It is claimed that this will reduce death by heart attacks and other problems.
High blood pressure is a demonstrated risk (i.e. there a correlation, but an 0.80 correlation is a 0.8x0.8 or 64% estimate) for strokes, hypertensive heart disease, and abdominal aortic aneurysms (the latter in male smokers). However, every study of lowering blood pressure (usually by diuretics) only shows a reduction in the risk of strokes; there is NO demonstrated reduction in mortality or hypertensive heart disease. I should also mention that reduction of blood pressure by beta-blockers alone has shown no reduction in any risk of stroke or heart attack. In addition, there has been no prospective study to see if lowering the amount of salt in the diet has any injurious effect, and a lot of medicine is counter-intuitive. I recall a study that lowering the salt in the diet INcreases the risk for heart failure, but who really knows?
A related dietary question deals with lowering the amount of sugar in the diet (?by taxing sodas). I pause here to remind my lay readers that just because diabetes is evidenced by elevated blood sugar, this does NOT mean that increasing the amount of sugar in your diet causes diabetes, assuming you gain no weight. And we will also ignore the white lab rat study that shows that if we keep lab rats 30% below their IBW (and who determines the Ideal Body Weight for a lab rat?) they live longer. The flip side is the recent studies that demonstrate that overweight adult humans (BMI 26-29) have an increased chance of surviving a heart attack.
Now let us assume that we wish to lose weight. What is the most efficient and surest way to do this? (Remember that when you lose weight as an adult, your fat cells shrink, and get smaller and have a smaller net surface area for metabolism.) Of course, the obvious method is to eat less. No one was overweight in a concentration camp. The lap-band surgery shrinks the functioning volume of your stomach, so you can't ingest many calories, and again you lose weight, and usually cure your diabetes as well. Anorectics have absolutely no problem in losing weight. In another vein,liposuction sucks the fat cells away from your body,and these cells can never increase in size again.
But the brain demands homeostasis, and strives to keep your body parameters as constant as possible. Most people's weight varies very little from year to year. All nutritionists agree that 3500 calories = 1 pound. If you divide 3500 by 350 days, you find that you have to micromanage your food intake to plus or minus 10 calories a day to keep your weight constant for the year. Not even the most dedicated fanatic can do this. Obviously, the brain has a mechanism to raise or lower your metabolism to keep your weight constant, sort of a feedback mechanism, which has nothing to do with leptin. This metabolic/mass inertia is what makes it equally difficult to gain or lose a lot of weight. In fact studies have shown that when you gain weight, your metabolism increases, and when you lose weight, your metabolism decreases, in a true negative feedback manner, which is why most dieters hit intermittent weight plateaus.
In order to lose weight, you must feel good about yourself, and be relatively happy and free from anger. Food was the first pleasure, given to you by your mother. It is very difficult to deny yourself this pleasure if you are not "in a good place". If you are mentally at peace, then you can walk around hungry without feeling (emotionally) deprived. You can be satisfied by the flavor of half a chocolate chip cookie rather than a whole box of Mallomars. So losing weight is not a matter of pure will-power, but rather a matter of not being too out of rhythm with the world and ego-dystonic. This is not to say that all overweight people are neurotic. Many are very happy with themselves, and see no need to change their body habitus. Your self-image is everything to you, and this is what we all rely on and judge ourselves by. This is why I don't think special diets are the answer. We all eat the way we like, and no one does Weight Watchers forever. The answer is always portion control. Why torture yourself by eating foods you don't like , instead of simply eating less of the foods you do like?
Let me close by saying eating "healthy" food is less important than eating less and losing weight. We know very little about nutrition. When I went to school as a child, the food pyramid was the exact inversion of what it is now. We don't even know (i.e. have good evidence) if the biggest meal of the day should be breakfast, lunch, or dinner. Should we have one large meal a day or six small ones. For every study, there is a counter-study. Do lefties live longer than righties? Do short people live longer than tall people? Why does overall health correlate so strongly with economic position in life? Maybe we all would be healthier if everyone were a millionaire? Any time any person or authority tries to tell you that something is "good" for you, or "good for your health" always ask the same question we asked reflexively in physics and on hospital rounds: "Do you have a published article to support that opinion?".
High blood pressure is a demonstrated risk (i.e. there a correlation, but an 0.80 correlation is a 0.8x0.8 or 64% estimate) for strokes, hypertensive heart disease, and abdominal aortic aneurysms (the latter in male smokers). However, every study of lowering blood pressure (usually by diuretics) only shows a reduction in the risk of strokes; there is NO demonstrated reduction in mortality or hypertensive heart disease. I should also mention that reduction of blood pressure by beta-blockers alone has shown no reduction in any risk of stroke or heart attack. In addition, there has been no prospective study to see if lowering the amount of salt in the diet has any injurious effect, and a lot of medicine is counter-intuitive. I recall a study that lowering the salt in the diet INcreases the risk for heart failure, but who really knows?
A related dietary question deals with lowering the amount of sugar in the diet (?by taxing sodas). I pause here to remind my lay readers that just because diabetes is evidenced by elevated blood sugar, this does NOT mean that increasing the amount of sugar in your diet causes diabetes, assuming you gain no weight. And we will also ignore the white lab rat study that shows that if we keep lab rats 30% below their IBW (and who determines the Ideal Body Weight for a lab rat?) they live longer. The flip side is the recent studies that demonstrate that overweight adult humans (BMI 26-29) have an increased chance of surviving a heart attack.
Now let us assume that we wish to lose weight. What is the most efficient and surest way to do this? (Remember that when you lose weight as an adult, your fat cells shrink, and get smaller and have a smaller net surface area for metabolism.) Of course, the obvious method is to eat less. No one was overweight in a concentration camp. The lap-band surgery shrinks the functioning volume of your stomach, so you can't ingest many calories, and again you lose weight, and usually cure your diabetes as well. Anorectics have absolutely no problem in losing weight. In another vein,liposuction sucks the fat cells away from your body,and these cells can never increase in size again.
But the brain demands homeostasis, and strives to keep your body parameters as constant as possible. Most people's weight varies very little from year to year. All nutritionists agree that 3500 calories = 1 pound. If you divide 3500 by 350 days, you find that you have to micromanage your food intake to plus or minus 10 calories a day to keep your weight constant for the year. Not even the most dedicated fanatic can do this. Obviously, the brain has a mechanism to raise or lower your metabolism to keep your weight constant, sort of a feedback mechanism, which has nothing to do with leptin. This metabolic/mass inertia is what makes it equally difficult to gain or lose a lot of weight. In fact studies have shown that when you gain weight, your metabolism increases, and when you lose weight, your metabolism decreases, in a true negative feedback manner, which is why most dieters hit intermittent weight plateaus.
In order to lose weight, you must feel good about yourself, and be relatively happy and free from anger. Food was the first pleasure, given to you by your mother. It is very difficult to deny yourself this pleasure if you are not "in a good place". If you are mentally at peace, then you can walk around hungry without feeling (emotionally) deprived. You can be satisfied by the flavor of half a chocolate chip cookie rather than a whole box of Mallomars. So losing weight is not a matter of pure will-power, but rather a matter of not being too out of rhythm with the world and ego-dystonic. This is not to say that all overweight people are neurotic. Many are very happy with themselves, and see no need to change their body habitus. Your self-image is everything to you, and this is what we all rely on and judge ourselves by. This is why I don't think special diets are the answer. We all eat the way we like, and no one does Weight Watchers forever. The answer is always portion control. Why torture yourself by eating foods you don't like , instead of simply eating less of the foods you do like?
Let me close by saying eating "healthy" food is less important than eating less and losing weight. We know very little about nutrition. When I went to school as a child, the food pyramid was the exact inversion of what it is now. We don't even know (i.e. have good evidence) if the biggest meal of the day should be breakfast, lunch, or dinner. Should we have one large meal a day or six small ones. For every study, there is a counter-study. Do lefties live longer than righties? Do short people live longer than tall people? Why does overall health correlate so strongly with economic position in life? Maybe we all would be healthier if everyone were a millionaire? Any time any person or authority tries to tell you that something is "good" for you, or "good for your health" always ask the same question we asked reflexively in physics and on hospital rounds: "Do you have a published article to support that opinion?".
Saturday, February 6, 2010
Electronic Medical Records
There have been many articles published about the benefits of electronic medical records. The US gov't has appropriated millions of dollars to aid in their development and adoption. The claim is that the adoption of such systems will save money by reducing the number of duplicated tests and also reduce patient mortality and morbidity because fewer errors will be made.
I will leave aside the question of the possible (unproven as yet) benefits of computer-generated hospital records and notes. I will note,however, that computerized hospital notes and orders use up more of a doctor's time, and that is the one dimension we already have too little of. It used to take me 5 minutes to admit a patient with pen and paper. Now it takes at least 25 minutes on a computer, in part because of "mission creep". By mission creep I allude for instance to the U.S. Census, which is mandated by the U.S. Constitution to do a head count every 10 years to re-apportion U.S. Congressional districts among the states, but now also requires you to tell the government how many bathrooms, bedrooms, and telephones you have, among other details. And when the computer crashes, all the residents are helpless.
I admit to two hospitals. In one of them, I cannot even admit a patient unless I answer the question: should the patient I am admitting have a flu and pneumonia vaccine at discharge (and there is no place to indicate that the patient refuses). In the other hospital (and only God knows why) they ask for the birth date of the admitting doctor. This information can't possibly help the patient, but someone wants the information. They even set up the answer matrix so that 00-00-0000 does not work.So now most of the doctors were born on 11-11-1911, because that is the easiest number to write that the computer will accept.
I am also concerned because not once in the past 5 years has a nurse called me from the ward to ask if my drug order was correct. The order goes by the computer to the pharmacy dept., who delivers it pre-labeled to the floor. The nurses seem to think that a computer-generated label must be correct, and besides, the pharmacy filled it. Of course the pharmacologist does not know the patient nearly as well as the nurse does, but it is efficient! I don't even want to discuss my reaction when I ask an intern for a patient's Hct. , and I am told that it isn't in the computer yet. It never occurs to them that the number is generated by the hematology laboratory, and you can call them up for the result.
Now let's look at electronic medical records, and their benefit for the patient. When I started practice, I used to give all my patients a photo-reduced copy of their EKG to keep with them , because when a patient hits the ER with chest pain, the doctor certainly wants to know what the previous EKG looked like. I found that fewer than 10% of patients carried the copy with them, so I stopped this practice.
Now a doctor's medical record system is supposed to be compliant with and interactive with the hospital system. This requires you to be HIPAA compliant which means the changing of your hospital password every 90 days, or else you cannot log on to the hospital computer. How in the world can two hospital computers exchange data? I can't imagine changing your password every 90 days for every hospital in the US, and the SmartCard still requires a password.
I also know that every doctor wants to review Xrays and MRI results personally before surgery, etc. So even if I have a transmitted electronic report about the result of an MRI, I would want to repeat it if the patient's treatment depended on it. This also holds true for cardiac echoes, stress tests, cardiac angiograms,etc. If you were a patient, wouldn't you want your doctor to personally review a study before operating? You also would not trust the result of a technically difficult lab test (e.g. N-terminal parathyroid hormone) unless you had total faith in the lab, and therefore you would probably repeat the test. And if different labs with different techniques have different normal ranges, this complicates matters still further. Similarly, where cancer is concerned, the pathologist and oncologist will want to review the biopsy slides personally, rather than rely on a written report.
All the above can be summarized by saying that no doctor would depend on a written report alone, but would want to see the actual data. If details are needed in the ER about a patient, then the ER doctor will probably communicate with the family doctor for information that is not in the computer system (e.g. the patient uses cocaine, is bisexual, etc.) because no computer system is totally secure. There is always critical data about a patient that is known very well by the family doctor but never makes it into the chart because of its sensitive nature. I would never write down in an office chart that a patient hates his wife or is having an affair if I know the wife has legal access to the chart, or vice versa. I am not being paranoid about the non-security of data in the hospital system, because in the last 2 years I have received communications from 3 Veteran's Hospitals that their information systems have been hacked.
I yield to no one in agreeing that computers are terrific for transferring information. What concerns me is the uncritical acceptance of information on a computer, and where the paper backup is when the system crashes. When patient lives are at stake, there must be accessible backup. As I recall, a few months ago LAX had to divert planes for 3 hours because of a malfunction in the computer program that linked their radar systems. There have also been recent articles on radiation overdoses received by patients because the technicians did not understand the intricacies of computer-operated radiation beams. And with a typical automobile having 30 computers with thousands of lines of code, it's a miracle that there aren't more recalls.
Let me close with the following anecdote (and I repeat that I am not a Luddite, and was an early fan of Wylbur): "Ladies and Gentlemen, welcome to the first fully automatic transcontinental airplane ride that is fully operated by onboard computers. We have 3 computers, and therefore double redundancy for safety. This system has been tested thousands of times. Relax as we take off, and be assured that absolutely nothing can go wrong, go wrong, go wrong, go wrong, go wrong,....."
I will leave aside the question of the possible (unproven as yet) benefits of computer-generated hospital records and notes. I will note,however, that computerized hospital notes and orders use up more of a doctor's time, and that is the one dimension we already have too little of. It used to take me 5 minutes to admit a patient with pen and paper. Now it takes at least 25 minutes on a computer, in part because of "mission creep". By mission creep I allude for instance to the U.S. Census, which is mandated by the U.S. Constitution to do a head count every 10 years to re-apportion U.S. Congressional districts among the states, but now also requires you to tell the government how many bathrooms, bedrooms, and telephones you have, among other details. And when the computer crashes, all the residents are helpless.
I admit to two hospitals. In one of them, I cannot even admit a patient unless I answer the question: should the patient I am admitting have a flu and pneumonia vaccine at discharge (and there is no place to indicate that the patient refuses). In the other hospital (and only God knows why) they ask for the birth date of the admitting doctor. This information can't possibly help the patient, but someone wants the information. They even set up the answer matrix so that 00-00-0000 does not work.So now most of the doctors were born on 11-11-1911, because that is the easiest number to write that the computer will accept.
I am also concerned because not once in the past 5 years has a nurse called me from the ward to ask if my drug order was correct. The order goes by the computer to the pharmacy dept., who delivers it pre-labeled to the floor. The nurses seem to think that a computer-generated label must be correct, and besides, the pharmacy filled it. Of course the pharmacologist does not know the patient nearly as well as the nurse does, but it is efficient! I don't even want to discuss my reaction when I ask an intern for a patient's Hct. , and I am told that it isn't in the computer yet. It never occurs to them that the number is generated by the hematology laboratory, and you can call them up for the result.
Now let's look at electronic medical records, and their benefit for the patient. When I started practice, I used to give all my patients a photo-reduced copy of their EKG to keep with them , because when a patient hits the ER with chest pain, the doctor certainly wants to know what the previous EKG looked like. I found that fewer than 10% of patients carried the copy with them, so I stopped this practice.
Now a doctor's medical record system is supposed to be compliant with and interactive with the hospital system. This requires you to be HIPAA compliant which means the changing of your hospital password every 90 days, or else you cannot log on to the hospital computer. How in the world can two hospital computers exchange data? I can't imagine changing your password every 90 days for every hospital in the US, and the SmartCard still requires a password.
I also know that every doctor wants to review Xrays and MRI results personally before surgery, etc. So even if I have a transmitted electronic report about the result of an MRI, I would want to repeat it if the patient's treatment depended on it. This also holds true for cardiac echoes, stress tests, cardiac angiograms,etc. If you were a patient, wouldn't you want your doctor to personally review a study before operating? You also would not trust the result of a technically difficult lab test (e.g. N-terminal parathyroid hormone) unless you had total faith in the lab, and therefore you would probably repeat the test. And if different labs with different techniques have different normal ranges, this complicates matters still further. Similarly, where cancer is concerned, the pathologist and oncologist will want to review the biopsy slides personally, rather than rely on a written report.
All the above can be summarized by saying that no doctor would depend on a written report alone, but would want to see the actual data. If details are needed in the ER about a patient, then the ER doctor will probably communicate with the family doctor for information that is not in the computer system (e.g. the patient uses cocaine, is bisexual, etc.) because no computer system is totally secure. There is always critical data about a patient that is known very well by the family doctor but never makes it into the chart because of its sensitive nature. I would never write down in an office chart that a patient hates his wife or is having an affair if I know the wife has legal access to the chart, or vice versa. I am not being paranoid about the non-security of data in the hospital system, because in the last 2 years I have received communications from 3 Veteran's Hospitals that their information systems have been hacked.
I yield to no one in agreeing that computers are terrific for transferring information. What concerns me is the uncritical acceptance of information on a computer, and where the paper backup is when the system crashes. When patient lives are at stake, there must be accessible backup. As I recall, a few months ago LAX had to divert planes for 3 hours because of a malfunction in the computer program that linked their radar systems. There have also been recent articles on radiation overdoses received by patients because the technicians did not understand the intricacies of computer-operated radiation beams. And with a typical automobile having 30 computers with thousands of lines of code, it's a miracle that there aren't more recalls.
Let me close with the following anecdote (and I repeat that I am not a Luddite, and was an early fan of Wylbur): "Ladies and Gentlemen, welcome to the first fully automatic transcontinental airplane ride that is fully operated by onboard computers. We have 3 computers, and therefore double redundancy for safety. This system has been tested thousands of times. Relax as we take off, and be assured that absolutely nothing can go wrong, go wrong, go wrong, go wrong, go wrong,....."
Friday, January 22, 2010
Cholesterol, Statins, Zetia,Niacin, ASCVD, and MI's
This blog was stimulated by several recent articles and studies about statins, zetia, Niacin, ASCVD, and MI's. We must not lose sight of the fact that virtually all researchers have concluded that an MI is triggered by the rupture of an atheromatous plaque in a coronary artery, although the actual rupture has not, I think, ever been seen dynamically. Nevertheless, when a coronary artery is found clotted off at autopsy, and the clot is adjacent to and newer than the plaque, and the surrounding tissue is necrosed, then the conclusion is probably correct.
The first fact to notice at such an autopsy is that the atheromatous-clotted artery, as a rule, has a larger diameter anatomically before and after the clot than does another coronary artery. In other words, the probability of a rupture-to-clot process does not seem to depend vitally on the pre-clot diameter, although there is, of course, some influence. Just recall how many times an artery with 97%-99% stenosis is not occluded, but is stented instead.
So we then come to the question: what causes (or prevents) the plaque in a coronary artery from rupturing, clotting off the artery, and causing an MI? Clearly there must be some degree of inflammation which sets the plaque up to be susceptible to the shearing force of coronary blood flow. So we can have some equation that the probability of clot formation varies as (C)x(probability of plaque)x(?thickness of plaque)x(probability of rupture), where C is a factor to indicate that an MI has occurred before; if C=1 we are dealing with primary prevention, and if C is greater than one, we are dealing with secondary prevention.
Since we have plenty of data on secondary prevention, I am going to concentrate on primary prevention. Now CRP, a measure of inflammation, has been variously correlated with the risk of MI as has 81 mg/day of ASA, with no clear-cut primary prevention shown by either lowering CRP or by daily ASA. But in experimental physics we have a saying: If you are arguing about the significance of data, then the data is not significant, similar to the last data point in a particle physics experiment.
We do know that diabetes, cigarette smoking and hypertension are synergistic with cholesterol levels in causing a plaque as well as a clot. This shows at least two mechanisms at work, since it is difficult to imagine that hypertension increases local plaque inflammation. Similarly Zetia, which lowers cholesterol, does not seem to increase coronary artery diameter, but these studies did not look at MI or CVA as an endpoint, so we don't know if Zetia affects plaque inflammation and rupture. A curious observation is that if your "native" cholesterol is 200, your risk of an MI is greater than if Crestor was used to lower your native cholesterol from 240 to 200. This clearly indicates to me that statins have an additional preventive effect, probably lowering inflammation of the plaque, over and above lowering cholesterol and/or reducing the size of the plaque. Similarly Niacin, which raises HDL, has a beneficial effect beyond its size effect, and probably lowers inflammation as well. And patients (usually female) with cholesterols over 300 and 85+ years old without and ASCVD are outside our explanations and models.
But to me, the most amazing drug is C2H5OH, or ethanol. In matched pairs, people who drink "moderately" (= 1 drink/day for men, and one every other day for women) have a lower heart attack rate and LARGER DIAMETER CORONARY ARTERIES AT AUTOPSY than do non-drinkers. This result holds for numerous studies with whiskey, beer, slivovitz (plum brandy), scotch, etc,in homogeneous populations (e.g.native-born Japanese males in Hawaii) and seems to be a pure alcohol effect. We have known this since 1974 (see article in JAMA). No one knows the mechanism by which this occurs, but I assume constant research is going on. Since young people already have atheromatous plaques, then if we want to reduce heart disease in our older population, it seems to me we should encourage a glass of wine with dinner starting with high school seniors. There is no argument in the literature about this effect, as there is about lowering CRP, adding ASA, or lowering salt in the diet.
With regard to lowering salt in the diet, there were two long articles (one pro and one con) about this subject published years ago in Lancet. The con argument was that just as eating sugar will not make you a diabetic, so will eating salt (with normal kidney function) not give you hypertension. I have a more fundamental ethical objection to imposing salt reduction. In hospitals and research clinics, when an experiment is performed on human subjects, it must be passed by the Institutional Review Board, and each subject must be warned of possible negative side effects and given a chance to withdraw. No such board will review the law if low salt diets are mandated, and I am concerned that 10 years down the road we may learn that we have done irreversible harm to the subjects, our fellow citizens, or to the children in school cafeterias.
The first fact to notice at such an autopsy is that the atheromatous-clotted artery, as a rule, has a larger diameter anatomically before and after the clot than does another coronary artery. In other words, the probability of a rupture-to-clot process does not seem to depend vitally on the pre-clot diameter, although there is, of course, some influence. Just recall how many times an artery with 97%-99% stenosis is not occluded, but is stented instead.
So we then come to the question: what causes (or prevents) the plaque in a coronary artery from rupturing, clotting off the artery, and causing an MI? Clearly there must be some degree of inflammation which sets the plaque up to be susceptible to the shearing force of coronary blood flow. So we can have some equation that the probability of clot formation varies as (C)x(probability of plaque)x(?thickness of plaque)x(probability of rupture), where C is a factor to indicate that an MI has occurred before; if C=1 we are dealing with primary prevention, and if C is greater than one, we are dealing with secondary prevention.
Since we have plenty of data on secondary prevention, I am going to concentrate on primary prevention. Now CRP, a measure of inflammation, has been variously correlated with the risk of MI as has 81 mg/day of ASA, with no clear-cut primary prevention shown by either lowering CRP or by daily ASA. But in experimental physics we have a saying: If you are arguing about the significance of data, then the data is not significant, similar to the last data point in a particle physics experiment.
We do know that diabetes, cigarette smoking and hypertension are synergistic with cholesterol levels in causing a plaque as well as a clot. This shows at least two mechanisms at work, since it is difficult to imagine that hypertension increases local plaque inflammation. Similarly Zetia, which lowers cholesterol, does not seem to increase coronary artery diameter, but these studies did not look at MI or CVA as an endpoint, so we don't know if Zetia affects plaque inflammation and rupture. A curious observation is that if your "native" cholesterol is 200, your risk of an MI is greater than if Crestor was used to lower your native cholesterol from 240 to 200. This clearly indicates to me that statins have an additional preventive effect, probably lowering inflammation of the plaque, over and above lowering cholesterol and/or reducing the size of the plaque. Similarly Niacin, which raises HDL, has a beneficial effect beyond its size effect, and probably lowers inflammation as well. And patients (usually female) with cholesterols over 300 and 85+ years old without and ASCVD are outside our explanations and models.
But to me, the most amazing drug is C2H5OH, or ethanol. In matched pairs, people who drink "moderately" (= 1 drink/day for men, and one every other day for women) have a lower heart attack rate and LARGER DIAMETER CORONARY ARTERIES AT AUTOPSY than do non-drinkers. This result holds for numerous studies with whiskey, beer, slivovitz (plum brandy), scotch, etc,in homogeneous populations (e.g.native-born Japanese males in Hawaii) and seems to be a pure alcohol effect. We have known this since 1974 (see article in JAMA). No one knows the mechanism by which this occurs, but I assume constant research is going on. Since young people already have atheromatous plaques, then if we want to reduce heart disease in our older population, it seems to me we should encourage a glass of wine with dinner starting with high school seniors. There is no argument in the literature about this effect, as there is about lowering CRP, adding ASA, or lowering salt in the diet.
With regard to lowering salt in the diet, there were two long articles (one pro and one con) about this subject published years ago in Lancet. The con argument was that just as eating sugar will not make you a diabetic, so will eating salt (with normal kidney function) not give you hypertension. I have a more fundamental ethical objection to imposing salt reduction. In hospitals and research clinics, when an experiment is performed on human subjects, it must be passed by the Institutional Review Board, and each subject must be warned of possible negative side effects and given a chance to withdraw. No such board will review the law if low salt diets are mandated, and I am concerned that 10 years down the road we may learn that we have done irreversible harm to the subjects, our fellow citizens, or to the children in school cafeterias.
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