Water

ecowater.com“Cross the meadow and the stream and listen as the peaceful water brings peace upon your soul.” ~ Maximillian Degenerez

Recently I decided to get a new scale for the bathroom, and being easily impressed by technology, I selected one with several assessments aside from weight. This included measures for muscle weight, bone weight, BMI, and, interestingly enough, a percentage of bodyweight comprised of water. Mine generally runs between 49.8 and 51%, which is low, as adult males should have around 60% (55% for women).

Water, as any 8th grader will explain, is of utmost importance to living things. Depending on species, some animals owe 90% of their body weight to water. The human brain is comprised of about 70% water, and the lungs somewhere around 80%. That’s a lot of water. At 190 pounds with water comprising about 50% of my body weight, 95 pounds of me is water. At 8.34 pounds per gallon, on an average day, I contain over 11 gallons of water! No wonder I have to go to the bathroom at 2 AM! Every day.

As I calculated my water weight, I thought about another water-related issue; how many people lack access to clean water. As an epidemiologist, I am trained and educated to prevent illness or disease, and to consider the environmental as well as biological, psychological, and cultural contributors to those diseases and illnesses. Environmental factors are responsible for a majority of infectious disease, and a good deal of the chronic ones as well.

For example, we know that polluted drinking and cooking water is responsible for hundreds of thousands of deaths world-wide from diseases like cholera, and that clean drinking water goes hand-in-hand with adequate sanitation. We also know that about 85% of the world’s population lives in the driest half of the planet, and about 783 million people do not have access to clean drinkable water. Nearly 2.4 billion people, or one in three, lack access to adequate sanitation; as a result around 7 million people die every year from disasters that effect water access and water-related diseases including Trachoma, Amebic dysentery, Cholera, Giardiasis, Typhoid, Hepatitis A and E, Lassa fever, Guinea worm, and Hook worm. It might come as a surprise that a substance so fundamental to life on Earth would be so squandered, misused, and wasted.

Before you think that this is a problem limited to far-flung places like Africa or Southeast Asia, even a nation as undeniably wealthy as the United States has not always considered water cleanliness, or even water conservation, as being anything so important as commercial profit. From Texas to Tennessee, public water sources n recent years have been found to have as high as 30 times the federal limit of lead. About 4 million Americans get water from small water source suppliers who did not bother with the required tests, and did not conduct the tests properly, in direct violation of federal safe drinking water laws. These tests are necessary because without them, regulators of the water utilities do not know if the water is clean, and the people end up drinking unsafe or polluted water. A recent investigation found that over 2,000 communities the US skipped the required and mandated lead testing on more than one occasion. Hundreds of these repeatedly failed to properly test for lead for five or more years.

We should not be that surprise by these findings. Placing profit ahead of people has a long and proud tradition in America, going back to the 18th century, and this greed has had a direct impact on the health of Americans and their drinking water, then and now.

Back in 1799, Alexander Hamilton and his associates in the Bank of New York and New York Branch of the First Bank of the United States monopolized the banking industry. Several other groups had attempted to break Hamilton’s stranglehold on banking, but being so well politically connected, the Bank of New York had little trouble squeezing out competition. Much of the city was clustered together in overcrowded neighborhoods, and Manhattan was no exception. The residents of Manhattan were clustered on the southern end of the island, and the drinking water was said to have been “horrid, smelly, and filled with effluence.” The people clamored for clean, or at least cleaner drinking water. Something must be done.

Following an epidemic of yellow fever that swept the city, a group of investors calling themselves the Manhattan Company formed with the magnanimous purpose of providing clean water to lower Manhattan, to end the suffering of the people who had little or no access to clean water. Aaron Burr (Who would later duel with, and shoot, Alexander Hamilton) founded the company, and Burr’s brother-in-law, Dr. Browne, suggested the ills suffered by the residents of Manhattan were caused by polluted drinking water (on this he was correct), and that residents that were clustered around lower Manhattan could be supplied with fresh water piped in from the then pristine Bronx River.

While the city had planned on designing, building, and maintaining the water system, Burr and his associates campaigned for the privatization of the project, suggesting that a private company could do the job better and cheaper. The charter for the Manhattan Company to build and maintain the water system was granted; thanks to Burr’s influence, the charter stated that any surplus capital not used in the water system could be used for “banking transactions.”

While the original plan would cost upwards of 2 millions dollars, and would have provided a significant population with clean drinking water, it seems clear that the company’s true focus from the beginning was in becoming part of the banking industry in New York. Although the original construction plans called for clay pipe, to bring the water from the Bronx River located miles way, the company used cheap materials such as hollow logs, and piped water from dug wells and cisterns erected in nearby buildings in the congested areas of Manhattan where sewage was allowed to mix with drinking water. The Bronx River impoundment project was at first delayed, then ignored, and eventually forgotten.

“What made New York a prosperous port – its deep saltwater rivers – made its drinking water lousy. By the middle of the eighteenth century, Manhattan’s water was already infamous: there was too little of it and what little there was tasted terrible.”

~ Jill Lepore

While the Manhattan Company had originally raised over 2.2 million dollars to construct the water delivery system, only about one hundred thousand dollars would be spent on the project. The rest of the funds were used to start the Manhattan Company Bank. In 1808 the Manhattan Company sold its waterworks to the city for 1.9 million dollars and turned completely to banking. To maintain the illusion it identified as a water company as late as 1899. True to form, the Manhattan Company maintained a Water Committee which yearly attested that, true to its founding charter, no requests for water service had been denied. Considering the quality of the water, this seems to have been an accurate assessment. Within the first few years, The Manhattan Company Bank made loans to Burr and other insiders for over $60,000. Meanwhile the city’s water supplied continued to grow worse. Eventually, a real water system was designed and implemented, but before several cholera epidemics took thousands of lives.

The Bank that had started under the guise of providing clean water to citizens of Manhattan would eventually merge with Chase National Bank in 1955 to become Chase Manhattan. Then in 1996, Chase Manhattan was acquired by Chemical Bank, who retained the Chase name, to form what was then the largest bank holding company in the United States, before acquiring J.P. Morgan & Co. in 2000 to form JPMorgan Chase & Co.

Just think, it all started with the need for clean water, the promise to improve the health f the citizens, and the greed that so often seems to permeate from such things.

Today we know how critical clean drinking water is to health. Keeping the body fully hydrated is essential for heart health; when the body becomes dehydrated, the blood thickens causing resistance to blood flow. This results in elevated blood pressure. Dehydration can also lead to a rise in blood cholesterol as the body attempts to prevent water loss from the cells. When you combine high cholesterol and high blood pressure, there is a significantly elevated risk of coronary heart disease, according to the American Heart Association.

Dehydration can also lead to an increased risk of obesity, a condition that is associated with type 2 diabetes. When combined with high blood pressure and high cholesterol, a condition known as Metabolic Syndrome can occur. Dehydration can cause issues with the kidneys, infections of the bladder, and kidney stones.

But these conditions can be avoided by drinking two 8-ounce glasses of water before breakfast, lunch, and dinner, according to a recent study published in the Journal of the American Dietetic Association. Not only does proper hydration keep you healthier, it can help keep weight off for at least a year. In the end, regularly drinking adequate amounts of water speeds up our metabolism and makes us feel more “full” while promoting good physical, mental, and emotional health. That is of course, provided we have access to it, and today, even in America, millions of families do not.

Because of political corruption, corporate greed, or shortsighted practices, tens of millions of American citizens lack clean drinking water. Like Samuel Taylor Coleridge’s Ancient Mariner, many have “water, water everywhere, but not a drop to drink.”

Prisoners of Childhood

child-abuse

While I try to respond to inquiries from readers, recent accounts in the press have prompted this month’s post. It should be mentioned that the development of chronic conditions and the association with child abuse was the topic of my dissertation. That work reflects in this month’s post.

Childhood should be carefree, playing in the sun; not living a nightmare in the darkness of the soul. ~Dave Pelzer, A Child Called “It”

 Virtually everyone is familiar with the term Posttraumatic Stress Disorder, or PTSD. And while PTSD has been recognized for many decades, it has been known historically by different names including Battle Fatigue, Soldier’s Heart, and Shellshock. Whatever the name, it is Psychological Trauma. While there are some agreed-upon definitions of posttraumatic stress disorder, the bottom line, at least from a physiological and neurological standpoint, PTSD results when an event or series of events have completely overwhelmed the person’s stress adaptation system.

The Stress Response System

What exactly this stress adaptation system is and how it works has only recently been discovered. In 1976, an endocrinologist named Hans Selye proposed a neurophysiological model for understanding what he termed the mind/body connection. He suggested that stress reactions were based on perception and cognition, showing that a person’s perception had a direct effect on their biological systems through a psychological stress response. Dr. Selye came to recognize this response in his patients: those who suffered from higher rates of disease, ranging from infections to cancers, reported having experienced psychological trauma.

A Product of Nature

The stress response system evolved for one purpose: surviving an attack. Often know as the fight or flight response, researchers have now added a third state, known as freeze, as some mammals tend to simply stay still to avoid a threat. The fight/flight/freeze response evolved among mammals to help them survive threats through a complex system of endocrine glands, hormones, and neurochemicals known as the Hypothalamic-Pituitary-Adrenal, or HPA system.

The HPA works through the perception of danger. Being attacked, or seeing another attacked, or perceiving oneself in mortal danger of attack or death, can stimulate the HPA system to prepare the body fight, flee, or freeze in help it to survive. The fight/flight/freeze response is governed by the HPA and prepares the body to meet the threat through the manipulation of glucocorticoids, primarily cortisol, corticotrophin-releasing hormone (CRH) and arginine-vasopressin (AVP). The HPA response causes significant changes in major organ systems as a response to the threat. Digestion slows, blood flow is reduced to the skin (to reduce blood loss by cuts, bites, scrapes) and the blood flow to the arms, legs, shoulders, brain, eyes, ears and nose increases (allowing the brain to think faster, preparing the muscles to run or fight, increasing the hearing to detect threat sounds, and dilating the pupils to focus). The body will begin to sweat to avoid overheating during fight or flight (giving off a particular ‘stress odor’ or diaphoresis, which is detectable by humans and other mammals, for example dogs). The mouth dries as saliva and gastric juice production decreases, as does blood flow to the digestive system.

The HPA system works very well to survive threats, and has worked this way for many hundreds of thousands of years. But it’s not foolproof. Sometimes the threat is not real, but the system switches on just the same. If a person (or another mammal) experiences a severe trauma, the system may not turn off at all. Because the body cannot return to its unstressed or homeostatic state, the long-term effects of the flight/fight/freeze response begin to take their toll.

Chronic Stress

Medically speaking, stress results when an organism fails to return to homeostasis. Homeostasis refers to the normal state of the organism before the threat. While our hunter-gatherer ancestors faced threats from predators on a daily basis, and most of us face nothing more threatening than a bad driver, the system that helped them survive remains largely unchanged. While occasional stress may actually be beneficial as it allows us to perform, or to push ourselves to reach goals, provided that stress is short term, the body can return to it’s normal state. For our ancestors, once the threat was dealt with, they could return to the homeostatic or pre-stressed state. Short-term stress is not damaging, however long term or chronic stress is a significant problem.

Chronic stress has deleterious consequences and harmful effects. This is due to how the system works, what it has evolved to do, and why it is a short-term adaptive process. When activated long term, even at relatively low levels, the results are often a compromised immune function, weight gain, developmental impairment, cardiovascular disease, dyslipidemia and insomnia. Chronic stress has also been associated with Metabolic Syndrome and Arteriosclerosis.

Chronic Stress and your Organ Systems

Long-term stress affects the body in several ways, and more than a few medical conditions can be traced to overstressed organ systems. Chronic stress can cause major skin problems including acne, psoriasis, eczema, and dermatitis. It can also make your skin more sensitive and more reactive to sunlight. A person suffering from chronic stress will often experience migraines or cluster headaches due to the build up of tension in the neck and shoulders. Chronic stress can cause anxiety and depression, and new evidence links stress to some forms of dementia and memory loss. Because stress increases blood pressure, there is a long-established link between long-term stress and heart disease. Prolonged stress also reeks havoc in maintaining blood sugar levels which can have direct implications in how the heart functions. Stress can also result in heart arrhythmias, and stress has long been known to cause inflammatory responses in a number of organ systems. Stressed directly affects how well our gut functions. When stressed our stomachs stop processing nutrients as effectively and decreased nutrient absorption and oxygenation can decrease by 75% in the intestines resulting in significantly reduced metabolism and decreased enzymatic output.

Immune and Metabolic Impact of Stress

During the stress response, the pancreas produces more than the required amount of insulin to allow the muscles to convert all available glucose to energy. However, when consistently elevated as in the case of chronic stress, the increased insulin begins to cause damage to arteries and other organs. The immune system is severely impacted by the stress response, and chronic stress greatly impacts the immune system’s ability to defend against foreign bodies like bacteria, viruses, or cancer cells. The elevation of corticosteroids released during stress negatively affects the immune system by impacting the number of leukocytes available in the blood, making us far more susceptible to infections. New research is currently being done which may show a link between long-term chronic stress and inflammatory diseases such as multiple sclerosis, type-1 diabetes, rheumatoid arthritis, lupus, Crohn’s kidney disease, chronic fatigue syndrome, kidney disease, ulcerative colitis fibromyalgia, and a host of other inflammatory response disorders. Chronic stress is also involved in the neurobiology of mood disorders and functional illnesses, including anxiety disorder, bipolar disorder, insomnia, posttraumatic stress disorder, borderline personality disorder, ADHD, major depressive disorder, and emotional burnout. There is also new research into the long-term effects of PTSD from child abuse.

PTSD, Child Abuse, and Chronic Stress

Memories instilled in children, particularly around physical, psychological, or sexual abuse, are often multi-schematic, meaning they are stored in different parts of the brain as emotional stimuli, visual stimuli, physical stimuli, and auditory stimuli. For this reason, a smell, a picture, anything that stimulates the sensory system may trigger the fight/flight/freeze response, and one reason why childhood memories are lasting. While physical injuries may heal over time, at least in some degree, psychological scars do not. Psychological trauma from child abuse is at epidemic levels in the United States, according to the Centers for Disease Control and Prevention (CDC). In 2012 alone, nearly 700,000 children were victims of abuse, and the National Children’s Alliance reported that abuse was suspected in an additional 3.8 million incidents involving children under the age of 18 years. Perhaps most shocking is that children between birth and one year of age suffered the highest rate of abuse. According to the CDC, the direct and indirect costs of treating child abuse in the United States are nearly $125 billion annually.

Often the results of child abuse, whether it is physical, emotional, or sexual abuse may not manifest for years. A group of researchers investigated whether or not a history of assault and childhood could be associated with chronic health conditions in later years. The team used data from a large study that involved over 6000 middle-aged Americans, finding a significant association between abuse in childhood and the diagnosis of hypertension. The team concluded that, although the abuse had taken place decades earlier, the negative impacts on psychological and physiological health remained long after the event or events. Perhaps it is not surprising that psychological disorders were also found among the same child abuse survivors including depression and anxiety. However it is hypertension that has been termed the silent killer, but the real culprit is stress. While there are often few symptoms of hypertension if accompanied by other conditions, like dyslipidemia, cardiovascular disease, and atherosclerosis, the resulting cluster of conditions called Metabolic Syndrome. In this study, several of the preconditions of Metabolic Syndrome were found to be associated with a history of posttraumatic stress in childhood at least within these study participants.

 

How Cronyism, Nepotism, and Unqualified Providers are depriving you of the best in Health Care

nepotism

Currently, there is a bill before Congress called the Access to Quality Diabetes Education Act of 2015 (HR 1726, S 1345) which is to amend title XVIII (Medicare) of the Social Security Act to recognize only state-licensed or -registered certified diabetes educators or state-licensed or -registered healthcare professionals who specialize in teaching individuals with diabetes to develop the necessary skills and knowledge to manage the individual’s diabetic condition and are certified as a diabetes educator by a recognized certifying body. However, many currently working as diabetes or nutritional educators would not qualify for this license or registration as they lack both the educational background and the experiential training.

While many see this as simply more regulation, there is another way of examining the issue. Shouldn’t someone suffering from metabolic syndrome, type- two diabetes, or a similar metabolic condition expect that the person they are seeing has a minimal education and professional background? This certainly does not seem to be too much to ask. Unless of course, the person in this position lacks the education or training, or possibly both, to work in this capacity. This seems to be an issue with many, and that is because of nepotism or cronyism which has placed an unqualified provider in the position they are neither educated nor trained to fill.

Cronyism, hiring your friends or favorite staff to fulfill positions based on your liking of them rather than education or experience, and nepotism, the hiring of family members for the same reasons create unqualified providers that deprive people of the best health care possible. But don’t just take my word for it.

Jone L. Pearce, from the Paul Meringue School of Business at the University of California at Irvine, wrote that cronyism and nepotism are bad for everyone, and provides the research to back it up. According to the author, there is substantial quantitative research on nepotism and cronyism in the workplace as well as negative impacts on overall performance.

Max Weber (1864-1920) conducted observational research of German organizations, finding bureaucracies were nepotism and cronyism were constrained by minimal requirements provided superior functioning when compared with those organizations that were based upon, and allowed, nepotism and cronyism among other favorite leveraging. But this was nearly 100 years ago, so why hasn’t business learned the lesson?

While it probably does not surprise anyone that the owner of the local market employs his teenage son, and perhaps some of his friends, as bagboys or check out clerks, it should come as a surprise when persons in positions of authority that directly impact medical treatment, medical research, or healthcare, should have obtained those positions through a combination of higher education and experience. But even in the hallowed halls of medicine, we find nepotism and cronyism. The difference is that while you probably don’t care if your canned goods are placed in the same bag, you would probably be concerned that the person in charge of some aspects of your health care was placed in that position through means other than education and training. And you should.

For those of us who pay for our health care coverage, as well as those who have earned health care through a lifetime of work, when we go to a hospital, a clinic, or medical Center, we take it for granted that the people who sit in the offices that dictate our healthcare are qualified to perform the job. But this may not be accurate.

Favoritism, whether nepotism or cronyism not only diminishes our healthcare, it also decreases the performance of those healthcare professionals who have legitimately earned, through years of education and training, positions of leadership in hospitals and medical centers. When organizations place untrained in positions based on personal relationship or other favoritism, it not only decreases the effectiveness of that office and the staff but also negatively affects employee attitudes and perceptions. The last people we want distrustful of the medical establishment are those we rely on to deliver that medicine to us.

And rest assured, those working under these leaders who gained their position through means other than education and experience do not go unnoticed by their fellows or their staff. Realizing that the person you work for lacks both education and experience, and yet has control over your unit or department, is frustrating and undermining. Often the result is that coworkers, staff, and eventually employers are more just satisfied and less committed to supporting these supervisors and directors. And although the outcomes are frequently a reduction in employee satisfaction, a reduction in patient care and patient satisfaction, and an overall decrease in the personal appraisal of the hospital or clinic, I can point to more than a few situations in my state where this is a current issue.

In the end, cronyism and nepotism place loyalty and obligation not to the hospital, clinic or medical center itself, but instead to friends or family, those who secure the position. Cronyism is damaging to healthcare delivery because it supports the placement of unqualified people in positions of decisions regarding healthcare, medical research, or patient care. Decades of research in political science, economics, and even anthropology, have demonstrated that nepotism and cronyism are bad for organizational performance, and often spell disaster for both the manager as well as the staff.

You say Potato, I say.. Sponge Cake?

medical

Since starting this blog a few years back, I have had some interesting feedback on the diagnostics and research of the odd ailments and conditions, and yet, I’ve gotten more than a few questions that really defied an easy answer. Not surprisingly, these were not health or medically related. Here is a short post that I’ve compiled based on two such questions.

Question one: “What is a Clinical Epidemiologist?”

Question two: “Do you work with bugs or skin?”

Let me try to address these questions and clear up any confusion concerning epidemiology, entomology, and dermatology.

Epidemiology

A clinical epidemiologist is a medical professional who studies diseases and the way they spread. Primarily, they use research to improve clinical and patient-oriented healthcare. Some clinical epidemiologist work in labs, or in a forensic capacity conducting investigations of disease outbreaks. Whether they work in a hospital setting, a research laboratory, or in the field, ultimately, the focus is on reducing the occurrence of negative health issues.

Some of the duties that a clinical epidemiologist would perform include overseeing research on various diseases or outbreaks (like Ebola or influenza), compiling data for publication, developing procedures or policies related to disease control in medical facilities or research laboratories, consulting with healthcare facilities, nursing homes, or hospitals to minimize infectious disease issues, help develop educational resources to minimize the spread of diseases (hand washing, wearing a seatbelt, etc.), consulting with public health department on infectious and chronic disease issues, designing and developing research studies, interpret and analyze medical data for other researchers, investigate the results of medications on patients to better understand safety and effectiveness, and working in the field to locate the source of disease outbreaks from viruses (Ebola), bacteria (Pestis), vibrio (Cholera), or zoonotic (parasites).

A clinical epidemiologist may choose to work in a field that is more specialized, for example, environmental health (pollution or environmental toxins), chronic conditions (cancer, metabolic syndrome, obesity..my speciality), infectious conditions (Viruses, Bacteria, Vibrio, or Zoonotic). Beyond these specialties, clinical epidemiologists spend a good deal of time consulting and conferring with other medical professionals including physicians, public health officials, researchers, and health administrators. Many also work in research facilities or universities, and the Centers for Disease Control and Prevention (CDC), the Federal Emergency Management Association (FEMA), the Food and Drug Administration (FDA) and other government agencies employ a large number of clinical epidemiologists.

Entomology

An entomologist is a natural scientist that studies insects. Entomologists study the classification, life cycle, distribution, physiology, behavior, and ecology and population dynamics of insects. Many work in agricultural and urban environments. Everything we know about pollinators like bees, we own to entomologists. They also enforce quarantines and regulations on certain imports, performing insect survey work, and consult on pest management. The greatest numbers of entomologists are employed in some aspect of economic or applied entomology that deals with the control of harmful insects, this includes methods of controlling insects like mosquitos while protecting beneficial insects like bees.

Perhaps the greatest entomologist of all time is Edward O. Wilson, who has written many books, among them some of my personal favorites Sociobiology: The New Synthesis (1975), On Human Nature (1978), and The Ants(1980). His most thoughtful work to date, Consilience (1998) asked some fundamental questions about science. According to Wilson, all knowledge, from the humanities to the natural sciences, can be unified. Along the lines of field epidemiology, a relatively new area of research is called medical entomology, and works with public health professionals, epidemiologists, and other medical professionals in the areas of disease prevention.

Dermatology

A dermatologist is a medical doctor that specializes in treating diseases and conditions of the skin, hair, nails, and the mucous membranes (lining inside the mouth, nose, and eyelids). Dermatologists treat over 3,000 different diseases, including skin cancer, eczema, acne, psoriasis, infections, and some autoimmune disorders.

So, in conclusion, I do work with bugs (sort of) but only those very few that cause diseases. Other than knowing that the skin is the largest organ of the body, I know next to nothing about dermatology.

I hope this clears up any confusion.

Two Kirks, One Ship

james_kirks_evil_counterpart

I recall as a child watching an episode of Star Trek where a malfunction in the transporter created two Captain Kirks. Although I was very young at the time, I recall wondering, if the transporter disassembled and then reassembled matter how could there be two full-sized Captain Kirks? Wouldn’t the best possible outcome be two 50% sized Captains Kirk? Okay, so I was a bit of a science nerd as a kid. Of course, we soon learned that these Kirk’s were not the same. One was the normal Kirk, the other, evil. Even these exact duplicates were not the same, although even then it was puzzling as to why all the evil aspects of a person would be confined to the duplicate.

In reality, how do we know which Kirk was the original? It seemed puzzling, at least to me. And as it turns out, this puzzle was not limited to viewers of Star Trek.

In ancient Greece, the man said to have founded the city of Athens was the legendary king named Theseus. Athens at the time was dependent upon the strength of its ships, and as you might have guessed, Theseus was a great naval tactician who fought, and won, a great many sea battles. As a result, and perhaps to capture the magic, the people honored the memory of their king by putting his great ship, afterwards known as the “Ship of Theseus” on display as a memorial. The ship, we are told, was there for hundreds of years.

As time passed, the wooden ship began to deteriorate. Although Athens is in a very weather-stable area, rain and sun, and the progression of time began to weaken the planks and the substructure, at which time, workers would replace bits and pieces. Now, over a few hundred years, most of this ship of Theseus had to be replaced in order to keep it looking original. The question is, at what point does the ship stop being the Ship of Theseus, and start being just some other ship that was, more or less, LIKE the ship of Theseus?

While the Ship of Theseus probably never actually existed, nevertheless, it has become a philosophical puzzle for thousands of years: the problem of identity. In looking at both Kirk and the ship, what can we truly know about a thing? How do these things change? If the thing changes, can we even agree on what exactly has changed? (After all, the two Kirks looked identical, acted identical, until the one started being evil).

Concerning the ship, how many planks or other bits can be replaced before we no longer have the same ship? Let us suppose, for the same of discussion, that the ship was comprised of 400 pieces or bits. We can agree that replacing one or two bits would make little difference. What if, over time and due to weathering, and other forces, we needed to replace all the deck boards? Is this still the Ship of Theseus? How about after the people had to replace a third of all the bits and pieces? How about half? Lets say that after 400 years, and the ship was so deteriorated over time that, by now, all but the keel had been replaced? Can we say this is still the Ship of Theseus? Would it even matter?

The truth is simply that there is no agreed upon, objective answer. Either to the two Captains Kirk, or to the question of the “Ship of Theseus.” So at this point you may be thinking, okay, this was an interesting thought experiment, but isn’t this a medical blog? And you would be correct, however, there is always method in the madness, or in this case, this digression.

By the time that you reach the age of 68 to 70 years, every single cell in your body will have died and been replaced. You are simply not the same person you were 50 years ago, or even 10 years ago. Like Kirk’s doppelgänger, or the ship replaced over hundreds of year’s bits at a time, you are no longer the original. This is simply a part of aging. But that begs the question, why do we age? Why can’t we, like Captain Kirk, simply replicate our cells in the same condition as the original?

Each time our cells replicate there must also be copies made of our DNA, a complex molecule that is essential for cellular function and reproduction. One theory is that eventually, all this replicating of cells will eventually lead to catastrophic errors that cause cellular death. This is the reason given that our skin begins to lose its elasticity, our muscles begin to atrophy, and our organ systems begin to fail. Maintenance of our biological tissues includes maintenance of the structural integrity of our DNA, critical for cell survival, and just as important, accurate transcription to the daughter cells that replace the original cells.

The concern lay in an enzyme called DNA polymerase alpha. This enzyme constructs DNA molecules by assembling nucleotides. It is essential to the replication of DNA. Generally, these enzymes work in pairs, in order to create two identical DNA strands from each single original DNA molecule. However, if there are any errors in the information transferred during DNA synthesis, it is copied to the new cell’s DNA, another way to look at it, instead of an old cell with original DNA and a new cell with copied DNA, when each double stranded DNA is copied you end up with two double strands, each containing one template strand and one transcribed strand.

When the cells divide, it leads to two 1/2 new cells. Should the original cell have errors, they would be in either or both of the new daughter cells. Alterations in the fidelity of DNA polymerase alpha could result in a progressive degradation in the information transfer during DNA synthesis, eventually affecting a range of cellular components.

Like School children playing telephone, once an error creeps into the story, that error is passed along, and entirely new errors are added to the story based on the original error. The result, much as it was in grammar school, we end up with a message (transcribed in our DNA) that makes no sense at all. When this happens, the daughter cell ceases to function correctly. Eventually this leads to error catastrophe, where the new cell is replicated with such dysfunction that it is essentially useless. At this point, the cell may initiate a process of self-destruction known as apoptosis, or it may be signaled to self-destruct by neighboring cells (Apoptosis is one area of cell death being looked it for certain diseases). Interestingly, cancer cells seem to maintain these DNA errors, yet avoiding apoptosis. No one really understands why, at least right now (Another area of research is looking at errors in the replication of telomeres, but that’s a different post).

In the end, we are all very much like the great ship. We are replaced, bit-by-bit, until the inevitable decay overcomes the ability to replace the parts. If only we could replicate ourselves like Captain Kirk. Of course we would run the risk of stepping off the transporter pad evil.

 

 

 

 

How Leptin, Ghrelin, and other Hormones can Thwart your best efforts to get “thin.”

leptin-1

In 1950, researchers at Maine’s Jackson Labs produced a strain of Mice labeled OB/OB, or Obese/Obese, as both parents carried a recessive mutation that was expressed in Obesity. This recessive mutation was found to cause the mice to become three times as large as normal mice, and their appetites were ravenous. They were inactive and suffered from some chronic conditions including obesity, constant appetite, a diabetes-like syndrome of hyperglycemia, glucose intolerance, elevated plasma insulin, subfertility, impaired wound healing and an increase in hormone production from both pituitary and adrenal glands. They were found to have slowed metabolic processes and lower than normal body temperature. The obesity is characterized by an increase in both the number and the size of adipocytes (fat cells). The excess in weight and excess fat continued even after restricted diet that was sufficient for normal weight maintenance in normal mice.

Dr. Jeffery Friedman, a molecular geneticist at the Rockefeller University, became curious as to why the defect in just one gene (of the approximately 25,000 genes) would have such dramatic effects on the mice’s weight, appetite, and behavior. He began searching for the gene he suspected was causing this obesity in mice in the late 1980’s using a recently discovered methodology called positional cloning. Positional cloning has become the process of choice when searching to identify genetic mutations that underlay pathology using Mendelian inheritance. After eight years of searching, Friedman was able to identify and cloned the OB gene in mice. He found the corresponding gene in humans, and by 1995 had managed to purify the product expressed by the OB gene; a hormone he called Leptin.

Friedman discovered that through leptin, and the regulation of food intake and metabolism, fat functioned as an endocrine organ. Therefore obesity can be best understood as a problem of biology. Leptin is a 16-kDa polypeptide that is primarily produced in white adipose tissues and secreted into the blood stream. Like many hormones in the mammalian body, leptin acts to maintain homeostasis. How fat controls the physiology and metabolism is through secretion of leptin into the bloodstream where it acts on parts of the brain through influencing the neurotransmitters used to communicate, including melanocortin peptides that allow the brain to regulate food intake and energy expenditure. When fat is reduced, the levels of leptin in the bloodstream diminish, stimulating appetite and suppressing metabolism until the fat mass has been restored. Conversely, when fat mass increases, leptin levels also increase thus suppressing appetite until the weight is brought back to homeostatic level. This system maintains control of adipose mass and is extremely difficult to circumvent.

Because leptin modulates the amount of adipose tissue in the body, it acts on specific receptors in the hypothalamus to inhibit appetite through both counteractive and stimulatory mechanisms through interaction with other hormones such as ghrelin (that tells your body you are full), and neuropeptide Y as well as the effects of a cannabinoid neurotransmitter called anandamide which stimulates appetite. Leptin also promotes the synthesis of an appetite suppressant called α-melanocyte-stimulating hormone. When the fullness hormone ghrelin is suppressed, the stimulation of neuropeptide Y and anandamide, the result is an almost addictive desire to eat. Researchers are finding that as fat mass decreases, the level of plasma leptin falls, thus stimulating appetite until the fat mass is recovered. There is also a decrease in body temperature; energy expenditure (metabolism) is also suppressed.

Leptin also plays an important role in regulating and modulating the onset of puberty. For example, girls from undernourished societies and underweight women take longer to reach puberty than heavier girls. In fact, girls who are too thin often fail to ovulate during menstrual cycles. Reproductive growth and fat stores are therefore vital in the regulation of reproduction. In the athletic field, dancers and other energy-intense training young women sometimes cease menstruating due to a lack of adequate adipose tissue.

As it turns out, Leptin is so central to the treatment of obesity that it has begun to be developed as a therapy for some forms of obesity including life-threatening metabolic disorders such as lipodystrophy (a medical condition characterized by abnormal or degenerative conditions of the body’s adipose tissue), some forms of diabetes, and hypothalamic amenorrhea (caused when the hypothalamus gland slows or stops releasing gonadotropin-releasing hormone). Dr. Friedman’s landmark research has created a flood of research in laboratories around the globe, resulting in tens of thousands of research articles.

Made by the body’s fat cells, leptin is now understood to be the critical hormone of a very complex endocrine system that not only maintains the body’s weight; it exerts controlling effects on other hormones that control glucose metabolism and insulin sensitivity, and even immune function. In fact, the neuroendocrine system itself is greatly influenced by leptin. Dr. Friedman came to understand that the OB mutated mice completely lacked the gene for leptin; they ate until they became obese, simply because their brains went into a permanent starvation mode. And when given leptin supplements, these OB mice ate less. They lost weight and became more active. It was also found that they responded better to insulin, a significant factor in Type II Diabetes and Metabolic Syndrome. Mouse models are used to better understand disease states because the genetic, biological and behavior characteristics closely resemble those of humans, and many symptoms of human conditions can be replicated in mice. It should come as no surprise that in humans would leptin mutations who are also unable to produce leptin are massively obese and suffer from some chronic conditions that drastically improve with leptin therapy.

When our bodies are functioning properly, excess fat cells will produce leptin, which in turn triggers the hypothalamus to lower the appetite response. This allows the body to utilize the fat stores to feed us. Unfortunately, when someone suffers obesity, they will have too much leptin in the blood. This can result in leptin insensitivity and lead to leptin resistance. Because the person feels hungry despite not utilizing stored energy, they keep eating, and the fat cells produce more leptin to signal the hypothalamus to send the satiation signal, leading to increased leptin levels and more leptin insensitivity.

This does not mean that all persons suffering from obesity have similar mutations. In fact, some studies have shown that only a small subset of people with obesity was able to lose weight with leptin therapy. Most humans, like most mice, produce ample amounts of leptin, but their bodies simply were resistant. One possible means of reducing this leptin resistance is through combination therapy with other hormones, in articular, Amylin.

Amylin is a peptide hormone that is co-secreted along with insulin from the pancreatic β-cell and has been found to be deficient in patients with Type-II Diabetes. By combining leptin with amylin, at least in clinical studies with obese patients, a reduction of 13% bodyweight has resolved. If you are struggling with obesity or weight, these hormones can affect your overall health as well as your scale. Excess body fat causes problems with hormonal secretion, neurochemistry, and even immune function. While leptin has been called the starvation hormone, this is not accurate; a better term might be the satiation hormone as leptin inhibits hunger, regulates energy balance, and prevents the body from triggering hunger responses when energy is not needed.

Low levels of leptin are rare but do occur. There are a very few people who suffer from a genetic condition called congenital leptin deficiency. This condition prevents the body from producing leptin. Without leptin, the body is confused and thinks it has too little body fat, signaling the brain to consume resulting in an intense, uncontrolled hunger. This often manifests in childhood obesity and delayed puberty. The treatment for leptin deficiency is currently leptin injections. However, significant research is now taking place.

 

 

Pluralism, the Profit-driven Healthcare Market, and Health.

With the new incoming president and administration, many are clamoring for an end to the affordable care act. If they’re honest, politicians would admit that the act was neither affordable, nor really focused on health care so much as pork projects, and was not so much an act as a law designed to force the sale of a service. Currently Americans spend over 17% of our nation’s wealth on medical care, the vast majority of it focused on treating existing conditions, with very little spent on preventing those same conditions. Not that we would listen anyway. We are not really big on prevention, as that would require us to modify our behaviors.  Meanwhile, most public health organizations are forced to beg money to keep even their basic prevention programs afloat, while fast-food (an oxymoron if there ever was one), and junk-food sales have reached an all-time high. Sounds more than a bit self-defeating doesn’t it?

Our nation currently ranks number one in healthcare costs per person and America tops everyone in cost of care relative to gross to GDP. The U.S. scores poorly on many fronts, ranked 11th out of 11 in the Commonwealth Fund (2014) while outspending all other first-world nations in terms of the amount it spends on healthcare. You would think that for this enormous cost, we would be receiving the best health care in the world. Not if we use life quality, infant mortality, longevity, and general health as measures.

If we take even a tertiary look at the three highest rated nations for healthcare in the world (according to the World Health Organization), at least currently, we can formulate some idea of how we might go about replicating these top healthcare systems, rather easily and relatively cheaply, at least compared to what we have now.

What we need then, or so it would seem, are some examples to use from among the top healthcare nations, a “Best of the Best.” According to many researchers, the top ten healthcare nations are, in order, #10-Sweden, #9-Switzerland, #8-South Korea, #7-Australia, #6-Italy, #5-Spain, #4-Israel. All share similarities, for example a focus on prevention, public health, and patient responsibility. But let’s just look at the top three.

#3. The Japanese health system is based upon universal healthcare, which is backed by mandatory participation through payroll taxes by both employer and employee. These are income based for self-employed. Add to this long-term care insurance required to be carried by citizens over 40. Japan has controlled cost by setting flat rates for everything from checkups to surgery to medications. This has the obvious effect of removing competition among insurance companies. And while most hospitals are privately owned, as in the United States, there are smart regulations to ensure they are focused primarily on egalitarianism.

#2. Singapore has an even better health care system, largely funded by individual contributions and based on preventative medicine, public health, and individual responsibility. Individuals are required to contribute a percentage of their salary based on age, although the government does provide a safety net to cover expenses beyond those that the individual person may be able to afford. While private healthcare plays a significant role in the Singapore system, it is secondary to public health and public hospitals which employ the vast majority of doctors and other health professionals.

#1. Hong Kong, at least currently, has the best health care in the world as well as arguably the free-est economy. Hong Kong manages this by offering universal health care, which includes significant government participation. Hong Kong’s health secretary calls public health the cornerstone of their system, and public hospitals account for 90% of all inpatient procedures. There are private hospitals in Hong Kong; however, these are generally used by the wealthy.

Currently at least, the U.S. does provide the best medical training in the world; however, our healthcare, although the most costly. is far from the best. For population health, infant mortality, maternal health, longevity, and chronic disease, we are somewhere near 20th place. What can we do to improve healthcare in America?  That’s a bit complicated and will take some explaining. Warning: Personal Opinions ahead. 

Step 1: Provide Basic Health Maintenance to all Americans.

The adage “An ounce of prevention is worth a pound of cure” is no truer than in health care. Public Health and Preventative Medicine has lengthened the lifespan by decades, reduced fatalities in traffic accidents and accidental poisoning, and in combating environmental disease. Yet the funding for preventive medicine and public health is infinitesimal compared to the overall healthcare budget. While Preventive Medicine has been a specialty for over half a century, it comprises only 0.8% of the physician workforce. There is an inadequate focus on prevention in medical school curriculum, and physician training in preventive medicine as a specialty is an economic catastrophe due to the lack of funding. When you combine this with the profit-driven treatment ideology of American medicine, and the very small amount of financing the US Federal Government Health Resources Service Administration funds for preventive medicine training programs, we end up with a treatment, rather than prevention, focus. Treatment focused medicine is very advantageous for hospital administrators, highly profitable for pharmaceutical companies, yet less so for the folks who actually treat the illnesses, and of course, often financially devastating for those unlucky enough to find themselves on the receiving end. If we know that prevention is the best method to reduce healthcare costs, morbidity and mortality, why not create a single payer basic coverage for Americans? It has worked in every other first world nation, why not here? (To guarantee success, do not repeat what bureaucracy and administration-heavy ideologies have done to the American Public Education system).

Step 2. End malpractice insurance requirements and introduce Tort Reform.

The claims have been that without the right to file suit, patients are vulnerable to bad doctors and bad procedures. Yet the cost of frivolous suits, often paid rather than fighting due to the cost of lengthy legal battles, and the resulting increase in medical care due to high premiums for liability insurance have a detrimental effect on health care providers. Combine this with the realization that America is a very litigious society, and you have a recipe for costly healthcare. There can be no question that malpractice lawsuits have drained the system for decades. Americans once accepted that there are certain involved risks in every serious medical procedure, and when things went wrong they did not immediately look for an attorney and someone to blame. This is especially ridiculous in a culture that places so little emphasis on preventative medicine and public health. We eat what we want with little regard to how healthy it is, we are sedentary, and the majority of us do not get regular exercise. And should we have complications from open-heart surgery due to life choices, we immediately look for someone to blame. Make no mistake; things do go wrong in some medical procedures, these are called risky for very good reasons. Yet today’s OB/GYN’s are paying $100,000 per year for insurance, often to protect themselves from grieving parents and emotional juries seeking to hold them responsible for outcomes that no one could possibly have prevented. I am not suggesting that people with a legitimate right to sue a physician for screwing up badly should be eliminated, only that some system of reform is desperately needed. Going hand-in-hand with legal reform, the need for huge malpractice coverage drives up the cost of healthcare.

Here’s an idea: during the 1980’s, one could purchase “Accidental Death” insurance before flying on a commercial airline. Why not make this a part of medical care? No need for costly malpractice insurance for the annual check up; however, if you have to undergo a risky procedure or an operation, why not purchase coverage for that event only? The policy would be temporary and would cover the outcomes of the procedure only. There is little need for the average family practitioner that seldom wields a scalpel or ventures near an operating theater to pay out tens of thousands of dollars for liability insurance. Of course, the insurance companies are quite happy to take the money.

Step 3. Make people responsible for their own preventative health.

Benefits of a healthy diet and even a modicum of exercise result in a moderate reduction in the risk of stroke, cardiovascular disease, diabetes, certain cancers, and coronary artery disease. These five maladies alone account for 74 percent of the total fatalities attributable to the U.S.’s top 10 leading causes of death according to a report by the Centers for Disease Control and Prevention. Going along with providing basic coverage for things like childhood vaccines, wellness checkups, and annual physicals, making people responsible for their own behavior may have fallen out of favor in America today, but it makes sense, both physiologically and financially. If patients refuse to take responsibility for their healthcare, for example, refusing to participate in prevention or wellness check ups, they could be dropped from the program, thus providing significant motivation to maintain their own health. Ultimately, you and you alone are responsible for your health care. We must remember that here in the U.S., hospitals are duty-bound to treat emergency cases, and government spending pays for a surprisingly large share of visits to medical practitioner and treatments through a patchwork of public programs. These include Medicare for the old, Medicaid for the poor, and still other programs for kids. This being said, there are no incentives to try to remain healthy, no responsibility expected from patients, and any suggestion on diet or behavioral changes are often met with derision.

Step 4. Put Healthcare experts in charge of healthcare.

As Americans we rail against the administrative heavy bureaucracy of politics, and rightly so, but why then do we accept it in healthcare? Currently the experts state that physicians account for roughly 8 to 9% of healthcare costs, yet ultimately they shoulder the responsibility of accurate diagnosis and treatment. The same bureaucratic take-over that has diminished public schools in America (when districts once got by with two principles and a superintendent for 1,000 students, the same student population today may have two superintendents, three assistant superintendents, four principles, and four assistant principals as well as two educational directors, for example), is currently running wild in American medicine. A recent study for the State of California broke down the Healthcare Dollar this way: 31 cents went to hospitals, 22 cents to physicians, nurses, and treatment staff, a dime went to pay for prescription drugs, another 10 cents to dental care, 9 cents to nursing homes, 7 cents to administrative costs and 10 cents to items like medical equipment and hospital construction. The two biggest gainers were prescription drugs (up 15 percent) and administration (up 16 percent).

Step 5. Introduce product competition.

This goes hand-in-hand with making patients responsible for their own healthcare. Instead of requiring standard co-pays, make patients responsible for seeking the most cost-effective treatment. Changing from a copay system, for example $25.00 regardless of the doctor you visit to a percentage, for example 20%, would reduce healthcare costs. If a visit to Dr. A were billed at $200, the patient would pay $40.00. However, if Dr. B offers the same service at $125, the fee would be $25.00. This is how many patients purchase prescription medications; why not create a completion among service providers to reduce costs? Currently, if the doctor you see charges $300 per visit, and you pay a copay of $20.00 regardless, why do you care how much they charge? Lets introduce some competition. While even the best (so-called Cadillac) insurance policies have huge deductibles, few can escape the often crushing weight of medical related bills due a combination of bureaucracy, risk-averse medical practices based on the fear of a litigious culture, and a refusal of average people to take responsibility for their own health.

So how come we cannot just model a healthcare system after, say Japan or Denmark?

Well, it’s not that easy. A big part of it is cultural. Take teen pregnancy for example. Americans have the highest rate in the world, and in our culture we have decided to reward it (and even have reality television shows about it); in other cultures, for example Japan or Hong Kong, it’s seen as something to be avoided at all cost. In Denmark and Norway, people do not have to be forced to practice preventative medicine; they seek the information. Finally, bad behavior and the negative health impact that goes along with it is often rewarded or at the least, excused in our culture. So long as American medicine remains a profit-driven rather than care-led culture, where trivial health-related lawsuits are put before vindictive, emotional juries, and where public health and prevention are not incentivized, we will continue to have emergency departments clogged with chronic conditions, mental illness, and preventable illness. Through a combination of under insurance for most, over insurance for a few, and a disregard for public health and prevention by most, the citizens of the U.S. will continue to suffer the highest healthcare costs in the developed world, combined with some of the worst health outcomes, particularly if you are poor, female, or a child.

In the end, simply doing things the same way and hoping for improvement is ineffective at best, and dangerous at worse. Let’s get medical experts back in charge of medicine, reign in profit-crazed insurance companies, and our litigious population, and accept that maybe, just maybe, we are responsible for how crappy, sick, and unhappy we are.