Vaccination

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In regards to public health, survival, and longevity we would be hard pressed to not consider modern vaccination as one of the top 2 or 3 developments in the history of mankind.

The History of Vaccine Development and Implementation

If you like history and science then you will be inspired by the story of Jonas Salk and the development of the flu vaccine and later the Polio vaccine.

Enjoy the book: Splendid Solution: Jonas Salk and the Conquest of Polio

 

Prior to effective vaccines:

Diphtheria killed 10,000 people per year in the 1920’s.

Polio afflicted 50,000 children per summer in 1940’s-50’s

Measles infected 500,000 people per year in U.S.

1918 Spanish flu killed up to 50 million people worldwide.

1957 70,000 deaths in the U.S. from H2N2 Asian flu

1964 Rubella kills thousands of children in the U.S.

Key events in history of vaccine development:

1796, Europe, Edward Jenner experimented with inoculation with cattle version of smallpox and then learned it protected against Smallpox.  This was the birth of the vaccine era.

100 years past, 1877 Pasteur formulated the germ theory and did experiments with weakened germs to prevent rabies.  He developed inactivated rabies vaccine in 1884.

By mid century Jonas Salk and Albert Sabin developed the Polio vaccines still used today to rid the civilized world of polio.

Timeline of vaccine development:

1914 Rabies and Typhoid vaccines licensed in the U.S.

1915 Pertussis vaccine was introduced.

1930 Scientists learned to culture viruses in labs, paving way for vaccines for viruses.

1938 FDR founds the March of Dimes to develop treatment and prevention strategies for polio.

1942 Influenza A/B was developed by the Armed Forces Epidemiological Board, Jonas Salk.

1945 Inactivated flu virus licensed in the U.S., Jonas Salk

1947 DTaP was licensed in U.S. for children

1949 Last case of smallpox in the U.S., another 20 years before disease was irradiated in world.

1952 57,628 cases of polio in the U.S.

1955 Inactivated polio vaccine licensed in U.S., Jonas Salk

1961 Oral Polio vaccine was licensed by Sabin.

1962 JFK signs mass immunization assistance program

1963 First live virus Measles vaccine was developed.

1966 National Measles campaign decreases incidence to 10% of pre vaccine era.

1967 global smallpox eradication campaign

1971 U.S. stops Smallpox vaccine program

1973 Measles and Mumps vaccine licensed.

1974 Meningococcal vaccine licensed

1977 Pneumococcal vaccine developed for 14 strains of the 88 known to cause disease.

1977-Small Pox was eradicated from the world.

1979 las case of wild polio in U.S., unvaccinated religious group.

1981 first hepatitis B vaccine

1985 HiB vaccine for meningitis licensed.

1991 last case of polio in western hemisphere

1995 first childhood immunization schedule was developed by AAP, AAFP

1995 hepatitis A vaccine licensed.

1998 Rotavirus vaccine licensed.

2006 Zostavax for Shingles was licensed.

2009 Gardisil licensed to prevent genital warts and cervical cancer, nearly 100% effective for cancer prevention.

2010 Gates Foundation pledges $10B for Vaccine Decade.

How Vaccines Work

When we become infected with live germs our immune system reacts using B cells, T cells and Macrophages.  As a result of the reaction the invading germs can be killed or contained and our body retains memory T cells to immediately fight the same or similar germs in the future.  This whole process of fighting a new infection can take several weeks for the immunity to ramp a response, it is during this time that susceptible victims may die or need antimicrobial medications to assist their body in curing the illness.

Vaccines are made of weakened germs, or fragments of germs, or killed germs to induce our immunity.  As the body’s immune system reacts to the germ like particles in the vaccine, antibodies are created.  These antibodies then provide subsequent protection for months or years or even a life time.  If a our body is exposed to a live germ, for which we have received immunization, then our memory T Cells and B cells and antibodies are loaded and ready to react to the live germs and the host may have a more minor illness or not even become ill at all.

There are several types of vaccines depending on the germs being targeted.  Some have live but weakened viruses, like MMR and Varicella.  Some vaccines have only killed germ fragments and some cause immunity to toxins that germs produce inside a victim.  Often, many doses and boosters are necessary to provide adequate immunity in a recipient of the vaccine.

Link to the CDC: How Vaccines Work

Vaccine Recommendations and Schedules

Summary:

9 child and adolescent vaccines to be given

Annual flu shots

DTaP every 10 years

Shingles shot at age 50-60

Pneumonia shots (2) at age 65, or earlier for special populations

Travel Vaccines for special circumstances: Yellow Fever, Rabies, Typhoid, hepatitis and Malaria antibiotics.

Resources:

Travel Vaccine: http://wwwnc.cdc.gov/travel/destinations/listResources:

CDC Vaccines and Immunizations: http://www.cdc.gov/vaccines/recs/immuniz-records.htm

Vaccine Controversies

Vaccines can absolutely be revolutionary and dramatic in their affects on human disease.  A successful vaccination program can literally eliminate or dramatically diminish the incidence of an infectious disease in a society.  I have seen the virtual elimination of several disease just in my career due to the development and deployment of vaccination.  In medical school, while doing pediatrics rotation, we had a child with Haemophilus meningitis.  Our teacher told us, you won’t see that anymore, there is a new vaccine being implemented to eliminate it.  He was right, I’ve never seen, nor heard of a patient with this deadly disease in my career.  I’ve seen Rotavirus go from being one of our most common pediatric admitting diagnosis to now being virtually unheard of.  I’ve had a few patients with post polio syndrome, and will never see another new case in my lifetime.

That doesn’t mean that side effects don’t occur.  I’ve seen a healthy adult get a rare side effect called Guillain Barre Syndrome from flu vaccine.  We had given him vaccine one day, the next day he had trouble walking into my office, I saw him outside my window.  That night in the hospital after many normal tests and scans to rule out stroke and tumors and ruptured discs I knew he had GBS.  We had to transport him to UNMC for lifesaving plasmaphoresis.  He needed months of rehab to recover.  Gillian Beret is more common with an actual live case of influenza than it is with vaccine.

Researchers have falsified data and performed retrospective pseudoscientific and unsound investigations into a link between vaccine and Autism.  They have been discredited and have personally profited as professional witnesses and proponents of chelation therapies that they developed and profited from.  No properly done scientific investigation has shown a link between vaccine and Autism.  This fear mongering is blamed for scaring thousands of parents into denying MMR vaccine to their children resulting in more that 10,000 deaths from Measles in the world.  The incident has been called the “most damaging medical hoax in the last 100 years.”  The preservative has since been removed from the MMR vaccine, but is used in trace amounts in flu shots.

link to Thiomersal controversy:

Thiomersal controversy

Vaccination and the Law

State Laws

State laws establish vaccination requirements for school children. These laws often apply not only to children attending public schools but also to those attending private schools and day care facilities. All states provide medical exemptions, and some state laws also offer exemptions for religious and/or philosophical reasons. State laws also establish mechanisms for enforcement of school vaccination requirements and exemptions.-CDC website

Nebraska vaccine requirements

Vaccine Laws in Nebraska

 

 Vaccine Costs

 

A rough calculation of the cost of vaccine and administration.

Ages 2,4,6 months: $490 per visit

Ages 12,15 mos.: $350 total, another $90 at age 2 for hep A.

Kindergarten shots: $290

plus annual flu: 60/year=$720

7th-12th grade: 20+177×3+112×2, plus annual flu ($60)=$1195

Total cost to immunize through age 18 = $4115 

Note: almost all costs are covered by insurance with no copay or deductible.

Link to vaccine costs

Vaccination Rates

MMR compliance for kindergartner age is 94%.

Adolescents: Meningococcal, HPV and dTaP:

HPV: 36% female, 13% male

dTap: 87%

Meningitis: 79%

Access to Vaccines

VFC

The Vaccines For Children (VFC) program is a federally funded program that provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay. CDC buys vaccines at a discount and distributes them to grantees—i.e., state health departments and certain local and territorial public health agencies—which in turn distribute them at no charge to those private physicians’ offices and public health clinics registered as VFC providers.-CDC

Private Insurance

BCBS website indicated “No charge for preventive services/screening/immunizations.”  Meaning that deductibles and copays should be zero.  Check with your insurance company to confirm.

 

Vaccination for impoverished nations

World Wide

If developing countries vaccination rates could be brought up to 90% compliance it is estimated that 2 million children’s lives could be saved each year.

Bill and Melinda Gates Foundation:

$44B endowment, $27 B from Gates.  Warren Buffet has donated billions of dollars and pledged even more with conditions.

$10B has been spent or pledged to vaccinate the world.

Conclusions:

God has blessed mankind with many remarkable scientists and doctors throughout our history.  Please take advantage of the incredible blessing of vaccination for yourself and your family.  Vaccines are incredibly safe, relatively cheap, and very effective at preventing devastating diseases that plagued our ancestors.  There is no more natural way to prevent infectious diseases than to use vaccines to educate your bodies natural immune system to help keep you and your family healthy.

References:

WHO

CDC

Health Care Policies of the Candidates for President of the United States

 

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Current Health Care Policy

Obama Care, the Patient Protection (protection from getting health care) and Affordable (joke) Care Act

  1. Introduction:
  • ACA is legislation passed on March 23, 2010, designed to fundamentally change the way American healthcare is designed and implemented.
  • It aims to overhaul expansion of coverage, workforce reform, cost control, insurance reform, quality reform, and increase focus on wellness and prevention.
  1. Why did we need PPACA?

Healthcare statistics

      1. Costs of Healthcare today:
        • American healthcare is twice as expensive as the average industrialized country.
        • $2.6 Trillion spent on healthcare in the U.S. annually, 17% GDP
        • $8500 per capita in U.S., in 2012 
          • (China spends $7/capita, India $36)
        • We pay double to triple the costs of other industrialized countries
        • Estimated costs to go to 25% GDP by 2025
        • Medical costs are the #1 cause of bankruptcy in the U.S.
        • Insurance premiums are up 400% in 10 years, wages are up 34%.
        • Starbucks pays more for it’s healthcare than it pays for coffee.
        • An MRI of the brain costs $105 in Japan, $4500 in North Platte.
        • Instead of spending our money on screening, prevention and chronic disease management we spend on procedures, tests, and treatments
        • Medicare population will double in the next 15 years.
      2. Quality of the U.S. Healthcare system
        • Of the 11 industrialized nations, the U.S. ranks 11th in life expectancy.
          • some African countries life expectancy is 43 years
        • We rank 19th out of 19 in mortality amenable to medical care.
        • We have fragmented, non integrated, unaccountable healthcare system
        • As the number of primary care doctors goes up in a community then costs come down, quality and satisfaction are improved. It’s a linear relationship.-1   
        • tests and procedures do not equate to better health
  1. Healthcare philosophy and behavior
      • The fundamental questions is: Is healthcare a right of all citizens or a privilege that has to be paid for?
  • “The U.S. healthcare system is absorbed in treating disease rather than preventing it.”-
  • 40% of deaths are related to obesity, diet, nutrition, lack of exercise, smoking and excessive alcohol, not wearing seat belts, etc.-1
  • There are only two factors shown to decrease healthcare costs; access to insurance and a relationship with a personal, primary care physician.-1
  1. In summary: Good and Bad of ACA

The Bad:

  • High deductible insurance plans, higher premiums demanded by private insurance industry to “cover the cost of the sickly new patients signing up for insurance.”
  • Record profits are being realized by private insurance companies.
  • Subsidized premiums for 70% of Americans
  • Expansion of Medicaid to cover indigents

The Good:

  • Innovative cost and quality programs to increase the value (quality/cost) of health care.
  • It has momentum, in it’s 6th year, billions of dollars and untold hours and energy spent already to implement and innovate changes in US healthcare
  • kids on parents policy up to age 26
  • No pre-existing health conditions can disqualify you from coverage.
  • Motivating doctors and hospitals to improve quality, and measure results.
    • if a patient get’s an avoidable complication in a hospital, it may not be covered by Medicare.
    • If a Medicare patient is readmitted to the hospital in less than 30  days, Medicare will not  cover the cost of the readmission.
      • this has led to innovation to prevent readmissions, whereas before it was a financial windfall for a hospital system to have readmissions, more fees!
  1. Definitions of Health Industry Terms

Medical Industrial Complex– the conglomerate of parties involved in health care that fight change and reform tooth and nail: Hospitals, Insurance companies, Pharmaceutical Manufactures, Medical device manufacturers, Physician Groups like the AMA and other specialty groups.

Universal Health Care

Health insurance for all citizens of all ages provided from a government entity paid for by taxes.  Like we all have police protection, fire protections, military protections from foreign aggressors.

Socialized Medicine

Generally means universal health care for all, paid for by public funds, and employing the health care team to provide that care.  This is what Great Brittan implemented.  Canada has universal care but private health systems to provide that care.

Health Care Systems

Large incorporations of health care assets into a single entity.  A system will include hospitals, urgent cares, ER’s, nursing homes, doctor offices and pharmacies and ancillary services like therapies.  Example: CHI, Mayo, Cleveland Clinic, Banner Health, Kaiser Permanente

Healthcare models in other countries

Single Payer-Private providers

Canada, South Korea, Taiwan

U.S.-Medicare, Medicaid, Indian Health, Military Tricare

Single Payer-Government employed Providers

Brittan, Norway, Spain, Italy

Multipayer-Private providers

Germany, Switzerland, Japan, U.S. (2/3 of our healthcare)

Multipayer- Government  or large system Providers(Kaiser, Mayo, Cleveland Clinic)

U.S. is alone

Positions of our candidates for POTUS

Republicans:

Donald Trump:

  • Repeal ACA.
  • Buy insurance across state lines.
    • (Which is silly to think that will cut costs, there are only 3 major insurance carriers.  Fords are not cheaper in KS or CO than in NE and can be sold anywhere to anyone.)
  • Use HSA to pay for bills not covered by insurance.
    • (I’m not sure Donald Trump worries too much about financial issues that the rest of the American’s are concerned with.)
  • No plans to change Medicare.
    • In regards to Medicaid he says he will make a deal with hospitals.

Ted Cruz:

  • Repeal ACA, the CBO estimates it would cost $350B to repeal ACA over 10 years.
    • he spoke for 21 horus on the floor of the US Senate in 2013, reading Green Eggs and Ham, by Dr. Seuss.  At least his book was written by a doctor.  Had he read “Fractured” by Dr. Ted Epperly we might have all learned something.  He was leading a movement to defund the ACA.
  • Expand health savings accounts to cover deductibles and copays
  • Sell health insurance across state lines.
    • (from all 3 companies)
  • Medicare reform:
    • raise the age of eligibility,
    • tiered options: pay more for more complete coverage.
  • Wants to delink insurance from your job, make it portable.
    • (So if the employer is paying for it, how do you do that if the employee is fired, or quits, or wants to retire?  Answer, either the individual starts paying $1500 per month for $5k deductible insurance or the government pays it.)
  • Repeatedly fear mongers on the campaign using the threat of “rationing” if we have universal health care.
    • (We have rationing now, it’s a daily issue.  It’s in the form of denials by insurance for services your doctor orders, formularies, nursing home refusals to accept patients, high costs of care also rations our choices.  Don’t let politicians scare you with the “R” word, rationing is part of life, being done now.  Rationing can mean making informed decisions about treatments and tests that will not benefit our quality of life and may do harm and cause pain and suffering.)

Marco Rubio:

  • Repeal ACA, replace with tax credits to pay for insurance.
  • Purchase insurance across state lines.
  • Speed up the generic medication process,
    • by this he must mean changing patent laws.
  • Privatize Medicare and supplement the policy with a “base rate” and seniors pay extra for the policy they choose.
    • essentially take our most efficient health care delivery system and throw it back to private insurance industry and then supplement it at a base level and make citizens pay for a better plan if they desire.

John Kasich:

  • PCMH model of innovative care delivery, already part of the ACA.
  • this philosophy is more in line the Primary Care physician groups, like the AAFP
  • many of these concepts are already being implemented in the ACA

Democrats:

Hillary Clinton:

  • Supports ACA.
  • Cap spending out of pocket to $250 per month, lower deductibles and copays.  3 visits per year, no deductible applies.  Currently we have one visit for an annual physical that is free.
  • Tax credit or refund if a family spends more than 5% of it’s income on health care, up to $5,000.
  • Push for price transparency at hospitals and offices so people can shop and increase competition.  This is a good thing, just like retail.
  • import drugs from foreign countries with safety standards similar to the FDA.
  • Cut patents on drugs from 13 years to 7.  Thus more generics.
  • Deal with insurance companies through anti-trust to prevent further consolidations.
  • Strengthen state powers to limit insurance premium increases.
  • Save Medicare money by negotiating drug prices.
  • Cut hospital and doctor fees by lumping reimbursements into one payment based on a diagnosis or symptom, instead of fee for service which pays doctors to order more tests and do more procedures.
    • This is good idea as well, and is being done now with ACA.

Bernie Sanders:

  • Universal health care, the only candidate to promote.  The most radical proposal.
    • Medicare for all.  Funded from tax revenues.
  • Private insurance only for supplemental plans.
  • Import drugs from Canada.
  • Require drug companies to disclose the prices they charge in Europe for the same drugs.
  • The federal government will set the fee schedule for doctors and hospitals.
    • Some doctors and hospitals may not accept the rates, thus opting out and creating a black market or 2 tiered system.
      • This is happening in the U.K. now.
  • “We spend 3 times more on health care than U.K., 50% more than Canada for much worse outcomes.. “(paraphrased) – Bernie Sanders

What the various parties involved are thinking

American Public:

  • Current opinion on Obama Care, Affordable Care Act
  • Most Americans approve of the policies and provisions in the ACA,
    • even though they don’t know that is where the policy came from

Doctors:

  • Some doctors like the status quo, it is working nicely for them.
  • Some want to see innovation and quality improvement initiatives.
  • Doctors are frustrated by payment systems that are essentially a gamble for them based on outcomes of health conditions and costs of care that are not in their direct influence.
    • How can a doctor control the lifestyle of a patient.
    • How can a doctor control costs at a hospital he doesn’t own or manage.

Hospitals:

  • They like the status quo.
  • They are nervous about change because they are slow to adapt.
  • They are spending a lot of time and money to negotiate on their own behalf to maintain a profit and market share.
  • They are stressed by employing expensive doctors, and buying expensive technology and accommodating endless rules and regulations of the federal and state government.
  • The ACA has been an incredible stress to them to change and adapt.

Summary and Opinion:

Current reality

We have nearly the worst healthcare system in the world.  We finish near the bottom in almost every category.  We spend the most of any nation, by a factor of 2 or more.  If we continue the innovations of ACA we will improve the quality of care in the U.S., and decrease it’s cost.  We can have the best health care in the world but it won’t come from doing more of the same policies we have done to date.  You can’t go from worst to first without radical change.  Elections are the opportunity to change the direction of our health care delivery system in the U.S.

Career choices and bankruptcy

Our workers are staying in jobs they don’t like or don’t need, just for the health insurance.  Privately insured individuals, like me, can spend up to $1500 or more for coverage that has $12,000 in deductibles before any payments are made on health care bills.  That is $30,000 out of pocket in any given year.  Medical costs are the number one cause of bankruptcy in the U.S., even among insured individuals.

Retirement and employment for younger workers

If we had universal health care that followed us from birth to death and independent of employment then our economy would change dramatically.  Employers would not have to incur the expense, they would hire more workers.  Workers could be more mobile, even start a small business and not worry about their family being uninsured.  Older workers could retire if they have the ability and not worry about spending $1500 per month for insurance.  This would open up jobs for younger workers that need them.  Medicaid could go away, eliminating the number one cost to every state government in our country, and shrink government. Everyone could afford to go the doctor for necessary preventive care to further decrease costs in the long term.  With one universal payer, i.e. Medicare, doctors and hospitals wouldn’t spend millions of dollars negotiating with middle men, hiring lawyers to negotiate contracts, forming defensive organizations, like ACO’s and PHO’s, to combat insurance companies.  We could make national decisions on what we are willing to spend money on, and what we are not.  We can have one formulary to prescribe medications, putting pressure on the drug companies to develop and price products affordably.  If a medication were not on the formulary, people can purchase it privately at fair, market driven competitive prices.

Universal Health Care

Universal health care doesn’t mean all citizens are going to pay the same for their health care or insurance.  Many candidates are already talking about Medicare reform to include paying for choices in coverage.  We can have an insurance rate tiered to our income, just like our income tax.  Cap it at 10% of income, but then refund some money the next year if we are healthy and meet criteria on costs and health parameters.  Keep the deductibles affordable and limit copays or have escalating copays for each visit after 3 per year.  Encourage and legalize innovation in health care delivery, like telehealth.  Cut doctor’s costs through liability reform, cut licensing and credentials hassles to make physicians and nurses more mobile and flexible so we can go practice anywhere in the country and fill in the underserved areas.  Hospitals spend double the salary for locums workers due to the middlemen involved getting licensure and credentialing. Reform physician Residency training programs to design a health care work force that will meet the needs of our aging nation, not pander to the lifestyle choices of 25 year old medical students whom we have invested a million dollars educating and then let them become sub specialists and fleece us with fee for service health care.

Motivation

Universal health care coverage would have another benefit, motivation  for prevention.  Currently we have one insurance up to age 65 and then are turned over to Medicare.  So, the private insurance industry lacks the motivation to emphasize prevention.  Prevention pays off as we get older, and put on Medicare.  So neglecting prevention when we are on private insurance costs our public insurance, Medicare, billions of dollars to treat diseases that we should have prevented for pennies on the dollar.  It will be easier for a government based Universal health care system to financially reward good health behavior and prevention through our tax system.  If you are working to stay healthy, and your costs are lower, you are meeting health parameters that we establish then your taxes are lower, or you earn an income tax credit.  Private insurance could do it as well but they would have to be forced by law to offer refunds if parameters are met and costs are contained.

Eliminate Middlemen

Universal care would eliminate so many middle men in the industry it would be mind boggling.  Billions of dollars could be saved.  If profit were removed from the health care industry by eliminating private insurance companies, all their agents, the lawyers writing the contracts, the expense to the doctors to negotiate with several different companies, the management of hospitals, the PBM industry that plays with formularies, etc.  Between eliminating all this waste, and incentivizing healthy lifestyles through tax policy we may be able to cut our medical spending in half!  That is $1 trillion in savings per year.  It could almost balance the budget for the federal government.

ACA

If we continue to tweak ACA initiatives to improve quality and decrease cost then we save even more.  With the right leadership we could be on our way to the best health care system in the world, instead of the worst.  Donald Trump is right about one thing, our politicians are bought and paid for by special interests.  No bigger interest group exists than the Medical Industrial Complex.  They fight change by bribing our politicians with campaign support, and likely many other under the table benefits.  We the people can take back our government by getting involved and writing our leaders and holding them accountable.  Many of the representatives blindly take a party line position on reform, not even thinking independently about how to solve these tough issues.

The ACA has brought us a long way down the path of reform.  There is a long way to go from being worst to being first.  Throwing out the ACA and all the innovations that have been implemented would be a crying shame and set us back a decade.  The CBO estimates a cost of $300 billion to repeal the ACA.  Our system is still broken and more reform is necessary.  Let our politicians know that health care reform is important to you and your children and grandchildren.  Tell them you want a leader that will keep innovating, keep changing, and keep improving our health care delivery system.  Don’t be swayed by the drama of Obama hating and fear mongering about repeal.  Realize that 70% of Americans like the provisions in the ACA.

Personal responsibility

If you want to help America be healthier, then take some personal responsibility in the matter of your health.  Adopt healthy lifestyle habits: don’t smoke, eat healthy, exercise, and maintain an ideal body weight, wear a seat belt and a helmet if you ride bicycles or motor cycles.  Forty percent of our health care costs are caused by our bad habits.  Write your representative about your views on health care reform.

References:

WebMD

NY Times

Candidates Web Sites

“Fractured”, Dr. Ted Epperly-1

Obesity

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 Definition

Body Mass Index is a term used to define obesity.  It is ratio of weight to height.  Calculated as Wt.(kg)/Ht.(m^2)

BMI over 25 is overweight, BMI of 30 is obese

Height:                              overweight wt.:                                         obese wt.:

5’4”:                                       145                                                         174

5-6:                                        155                                                         186

5-8:                                        164                                                         197

5-10:                                      174                                                         209

6’:                                          184                                                          221

6-2”:                                       194                                                         233

6-4”:                                       205                                                         246

Body Fat method:

May be used as an addendum, especially for muscular builds from weight training.  Various techniques to measure.

  • Fit women 21-24%
  • Fit men 14-17%, a six pack abdominals is 8%.

Obesity:

  • Women:32%
  • Men:25%

Body Fat charts and pictures, 

http://www.builtlean.com/2012/09/24/body-fat-percentage-men-women/

Prevalence

Adult

  • 1/3 of U.S. adults are obese, 78.6 million people

Childhood

  • 17%, 13 million children and adolescents
  • Increased 3 to 6 fold (600%) since the 1970’s.
    • associated with head of household educational levels and socioeconomic status

by State and Country

  • highest Arkansa, Mississippi, West Virginia
  • Lowest: Colorado, California

by Race

  • Blacks: 48 %
  • Hispanics: 43 %
  • Whites: 33 %
  • Asians: 11 %

by Age

  • highest age 40-59 (39.5%)

Causes:

Genetic

  • drive to eat,
  • sedentary nature,
  • metabolism, minimal differences in most people
  • fat burning capacity or increased tendency to store fat.

Psychological

  • Overeating and eating “comfort foods”
  • can be associated with stress and depression.

Social/Cultural

  • Our social events can be centered around food,
  • often high fat and carbohydrate items
    • When the last time you had your family over to meet at the park or recreation center and go for a walk or swim or bike ride.

Behavioral

  • Habits of eating are developed over time.
  • Family habits from childhood are reflected in adult habits.
  • Lack of education on nutritional principles can be perpetuated in families.
  • Lack of motivation for long term health consequences of our behavior and lifestyle

Associated Medical Conditions:

  • Diabestes
  • Heart and VascularDisease
    • Coronary Artery Disease, Atrial Fibrillation, Congestive Heart Failure, Stroke, Hypertension, blood clots
  • Obstructive Sleep Apnea
  • Cancer
    • virtually every organ and type of cancer is associated with obesity
      • obesity can increase breast cancer risk by 30%
  • Arthritis
    • every pound of body weight contributes 7 psi to joint surface pressure
    • an extra 50 pounds contributes 350 psi on back and hips and knees
  • Infertility
    • Polycystic Ovarian Syndrome
    • increased incidence of labor and delivery consequences, like c/sections
  • Hormones
    • low testosterone
    • elevated estrogens in men and women
      • “man boobs” and female hormone related cancers
  • Psychological health
    • depression
  • Sleep pathology, Obstructive Sleep Apnea

Costs:

  • 190 Billion Dollars annually in the U.S. in direct and indirect costs are related to obesity
  • 21% of all health care spending in the U.S.
  • Obese individuals have medical costs estimated to be 30% greater than normal weight peers
    • $3,000 per obese individual per year

Treatments:

Lifestyle

  • Losing weight is not achieved by going on a diet or starting a fitness program.
  • Losing and maintaining a healthy weight requires a lifestyle change.
  • Lifestyle is defined by components involving nutrition, activity level, hobbies, and habits.

Nutritional Principles:

  • 3 meals and 3 snacks, with good eating habits:
    • eat slowly, put fork down after each bite
    • put your food on a plate, don’t graze around a buffet
    • environment:
      • don’t eat in front of TV, it’s distracting and leads to overeating.
      • drink plenty of water with your meal, have a glass of water before the meal
  • low added sugars (10% of calories from added sugars)
  • low in saturated fats(10% of calories),
  • Mediterranean dietary principles
    • fish, lean meats, legumes, fruits, vegetables, nuts, whole grain breads, plant based fats- canola and olive oil).
  • See the new guidelines: http://health.gov/dietaryguidelines/

Exercise: 

  • 30 min/day most days of the week,
  • 2 resistance weight training sessions per week.

        Adults exercise recommendations:

  • 150 minutes per week of moderate aerobics and 2 or more sessions of resistance weight training for all major muscle groups.

        Children exercise recommendations:

  • 60 minutes of physical activity every day, including at least 3 sessions of muscle building activities and 3 sessions of more intense aerobic activity like running.

Worksite Physical Activity

  • park and walk,
  • take the stairs,
  • stand up at work station,
  • use breaks to walk,
  • short walk after lunch.
  • Wellness programs:
    • motivate employees to attain health goals,
    • pay for fitness memberships,
    • give discounts on health insurance,
    • office contests to promote healthy goals.
    • Work station design:
      • stand up desks.
      • treadmill desks.

Medications:

  • Meds can reduce weight by 10-20% while taking.
  • May not result in persistent weight loss if stopped unless significant lifestyle changes are adopted.

Available Medications: 24 drugs on the market for obesity

Phentermine, generic

  • formerly part of infamous Phen/Phen combination
  • stimulant, acts to inhibit apetite

Orlistat, called Xenical

  • blocks absorption of some of the fats we eat
  • GI side effects are poorly tolerated

SGLT-2 inhibitors (Farxiga, Invoking, Jardiance)

  • Diabetes drugs, very expensive

GLP-1 agonists (Byetta, Victoza, Bydureon, Tanzeum, Trulicity)

  • Diabetes meds, very expensive, injections

Buproprion/Naloxone, called called Contrave

  • can be poorly tolerated with GI side effects

Topiramate/Phentermine, called Qsymia

  • can be poorly tolerated

Lorcaserin, called Belviq

  • 5 HT 2 serotoninergic receptor agonist

Surgery for obesity:

Restrictive procedures, shrink the stomach capacity:

  • Gastric Band
  • Gastric Sleeve
    • most popular modern procedure

Malabsorption surgeries, to prevent the digestion of calories:

  • Gastric Bypass
    • may have increased mortality and complications in some centers

Results of surgical procedures :

  • surgery can reduce all cause mortality by 50% in 5-7 years
  • surgery can reduce incidence of diabetes by 80% in 5 years

Summary/Call to action:

     Obesity is a common American malady.  Obesity has dramatic and expensive adverse affects on our health.  There are several successful strategies and treatments for obesity.  There is plenty of research showing the positive affects of losing weight.  Set a goal for your weight, develop a strategy to achieve your goal.  Measure your progress.  If not achieving your goals then seek help from friends, family, obesity support groups, or see your doctor for assistance in achieving this important goal.

References:

USPSTF

Up To Date

AAFP

CDC, http://www.cdc.gov/healthyweight/index.html

Telehealth: Access to Healthcare Using New Technology

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The advent of technologies for face to face video conferencing have led to exciting new possibilities to revolutionize medical care.  With apparent shortages of physicians predicted in the future, our patients need another method of obtaining necessary healthcare.  The trend to high deductible, high copay insurance plans have left many patients reluctant to seek care in expensive traditional settings like ER’s, Urgent Cares, and doctors offices.  Now, for $40-$50, patients can see their doctor for minor medical conditions, or chronic medical disease management through telehealth.  Convenient, cost effective medical care delivered to their own homes or offices without traveling or waiting in a office, ER or UC.  Many companies and the health care industry in general are adapting and reacting to this new technology.  Many insurance plans now cover telehealth visits for nominal $10-$15 copays, saving patients hundreds of dollars.  Employers appreciate the cost savings to their insurance plans and patients appreciate the low cost, and convenience of telehealth.

You can schedule a Telehealth appointment with me if you are in Nebraska, where I am licensed.  I am usually only available on the site by appointment so you must call my office number, or email my office to schedule the visit so I can be logged in and waiting to see you.  You must select me from the available physicians after you have logged in and registered.  You must download the App from your App store or register on line at Amwell.com to use your desktop or laptop computer.

Steps:

  1. Be located in Nebraska, where I am licensed.
  2. Install the Amwell App on your phone or iPad through your App store.
  3. Input you medical, insurance, and demographic information on their secure site.
  4. or Register for Amwell on their website, Amwell site
  5. Notify my scheduler that you would like a Telehealth visit, call (308)534-8383 or email us at statesfamilypractice@yahoo.com
  6. Log in to the Amwell site or App at the scheduled time and select me as your provider.

History of Telehealth:

Q: How long has this type of service been available and who’s using it?

  • Rural community hospitals and mental health facilities have been using telehealth for years to expand access to specialists and psychiatrists in underserved areas.  Care had to be received at a medical office though.
  • The government’s VA system has been using telehealth to care for veterans, again they must be at a facility.
    • Recently they have introduced in home services.
    • Called Banner iCare, must have at least 5 chronic conditions.
    • They have shown 45% reduction in hospitalizations, 32% reduction in care costs.
  • In Alaska it was estimated that telehealth saved the state $8.5 M in one year in Medicaid related travel expenses.

Q: What type of care can be obtained?

  • Primary care mostly but consultation with specialists are becoming available.
  • Psychological services like counseling
  • Dietary and Nutritional services with a dietician
  • Health coaching is available as well.

Current State of Telehealth:

Q: How does it work?  How does a patient seek medical care using telehealth?

  • The newest innovations are called mhealth, for mobile health.
    • These products utilize smartphones and tablets, as well as desktop and laptop comuters.
    • Patients download an  App, then register and log on.
      • Input their health history: medical conditions, medications, allergies, pharmacy and current symptoms.
      • They can input their vital signs.
      • Then they activate a visit and the doctor is usually available in in 1-2 minutes unless with another patient.

Q: How does it work from the doctors side of the visit?

Doctors are credentialed with the various products and trained to use them.  If a doctor makes himself available to see telehealth patients he is notified when a patient requests a visit.  The doctor then utilizes the physician App and initiates a visit with patient after reviewing the health information input by the patient.  The doctor can see and talk to the patient and then come to a diagnosis and treatment plan.  The App then can be used to send in a prescription and document and bill the visit.  Patient follow up can be accomplished through the App for quality control.

Q: What kind of gadgets are required?

  • Really not much, commonly available devices.
    • Computer, iPad, smartphones
  • Kiosks are available in malls and pharmacies, like a phone booth
    • High Def video, BP cuffs, thermometers, ear scopes, heart monitors, glucometers.
  • Devices are being developed to measure patient data and transmit it to the provider.
    • even EKG’s at home and wearables (smart watches)

Q: Which insurance companies in NE cover telehealth?

  • I found that BCBS of NE covers telehealth.
    • using Amwell product
  • Aetna/Coventry did not.
  • My daughter’s company in Lincoln is now offering telehealth services, Cigna?
    • through MD Live.
  • Medicare and Medicaid still have some restrictions but these are rapidly changing.
  • CMS just released, last week, a statement of “Next Generation ACO model” which will reportedly cover telehealth services to medicare and medicaid patients.
    • ACO product, like SERPA ACO here in Nebraska.

Q: What type of visits are possible in telehealth?

  • Respiratory infections
  • Injuries
  • rashes
  • fevers
  • chronic medical condition management
    • Diabetes
    • Hypertension
    • Obesity
  • NOT: pain pills, or chest pain in older adults, emergencies.

Q: Who are the big players in developing the technologies?

  • American Well, Amwell https://amwell.com
    • this is the product I use.
    • many brand names of products offered under various titles through insurance companies and major employers.
  • Dr On Demand www.doctorondemand.com
  • MD Live https://www.mdlive.com
  • SnapMD
    • lets a provider or network set up their own branded product, can interface with existing EHR
  • John Sculley, former CEO of Apple is involved in the industry as a capital venturist.

Future of Telehealth:

Q: What are the projections for growth in the industry?

  • In 2013 there were 250,000 patient visits.
  • By 2018 it is projected to be 3.2 million.
  • Amwell’s study:
    • 64% of Americans are willing to use video conferencing for health care.
      • Average wait time nationally to see doctor, 18.5 days.  Telehealth < 3 minutes
    • 57% of doctors are willing to use telehealth to care of patients.

Q: What web sites or Apps are available today to allow people to utilize telehealth?

  • Amwell, this is the site I utilize.

  • MD Live
  • Dr On Demand
  • May be coming to your doctor’s office in the future through a self branded product.

Conclusion:

We are seeing a paradigm shift in health care delivery.  Keep an open mind about changes in medical care.  Ask your doctor’s office if they are planning to implement telehealth services.   Check with your insurer or employer to see if telehealth is a covered benefit or plans to become one.  Download an App and become familiar with it.  Then, if the need arises for convenient, cost effective access to medical care you may just find yourself using this new technology.

Sleep

Newborn baby and puppy

two Sleeping newborn babies with a dachshund puppy.

Definitions, Sleep Physiology, Sleep Disorders, Insomnia, Sleep Hygiene, Sleep Testing, Therapies for Insomnia

Introduction

Definition of sleep:
Sleep is an immediately reversible unconsciousness. Sleeping individuals can respond to exogenous (burglar alarm) and endogenous stimuli (you can scratch an itch without waking).
in contrast to a coma or anesthesia, or hybernation

Physiology of sleep:
The brain doesn’t rest. It’s engaged in 2 distinct stages of sleep. REM and non-REM. Deep sleep occurs in non-REM. Deep sleep has 4 stages. REM is when dreaming occurs, about 20-25% of night. REM and non-REM alternate through the night, in cycles of 60-90 minutes.

Definition of Sleep Disorder or insomnia:
Difficulty falling asleep, staying asleep or getting back to sleep resulting in impairment such as fatigue occurring at least 3 days per week.

Prevalence of sleep disorders:
Insomnia affects up to 30%-50% of adults.

What factors affect our sleep?

Sleep hygiene

  • environment, schedule, TV in bedroom, computers in evening
  • emotions
    • drama and stress in evening
    • bereavement
    • disorganization (mind racing due to subconscious mind)
      • use a calendar
      • make to-do lists and project lists
  • diet
    • eating within 2-3 hours of bedtime
  • obesity
    • causes OSA, sleep apnea
  • meds and drugs
    • cold medicine, stimulants, steroids, antidepressants, diuretics
    • substance withdrawal
    • sleeping pills, sedatives, alcohol, pain meds
    • caffeinealcohol
      • within 4 hours of bedtime
      • within 4-6 hours of bedtime
    • Alcohol worsens sleep.
      • Distorts the REM, non-REM cycle,
      • worsens snoring and apnea and increases early morning awakenings.
    • smoking and chewing tobacco
  • exercise
    • too close to bedtime
  • naps
    • long naps in closer to bedtime
  • environment,
  • schedules.
    • swing shifts
    • travel/ jet lag
  • Medical conditions
    • Overactive Bladder Syndrome
    • IBD, Inflammatory Bowel Disease (Colitis, Crohn’s)
    • prostate disease (BPH, enlargement)
    • cancer
  • psychiatric conditions
  • pain

What testing is available to measure sleep physiology?

Polysomnography-a sleep lab study

  • Study brain waves, eye movement, oxygen, limb movements, chest movements, snoring, and body position
  • cost about $2,000

Home Testing:

  • Nocturnal oximeters
  • Home Sleep Studies
  • Wearables:
    • Apple watches
      • smart watches
    • brain wave monitors
      • sync to smart phone and record stages of sleep and wakefulness
      • provide tips and tricks and hygiene advice.
      • ZEO brand home sleep system is what I have.

What are some of the consequences of sleep disorders?

  • Strokes
  • Heart disease
  • Hypertension
  • Mood disorders
    • behavioral disorders
    • Depression
    • Anxiety
  • Motor Vehicle Accidents-more car accidents are associated with sleep disorders than alcohol.
  • Obesity
    • sleep deprivation causes stress hormones which stimulate appetite.
  • Fatigue and malaise

What can be done for people with sleep disorders?

Multifaceted approach:

  • Gather information
    • Keep a sleep diary,
  • Rule out OSA, RLS (Restless Limb Syndrome) with sleep study or oximeter
  • CPAP, APAP and biPAP devices
    • Positive Airway Pressure devices (ventilator type devices)
      with or without oxygen added
    • Dental devices
    • oxygen
  • See your doctor for medical evaluation
    • rule out depression
    • thyroid disease
    • diabetes
    • medication side effects.
  • Assess environment and lifestyle
    • sleep environment,
    • schedule,
    • stress,
    • habits (alcohol, smoking,exercise)
      • evening habits
        • relaxing bedtime routine
        • no late, prolonged napping
          • short afternoon naps are good for your
          • avoid evening naps longer than 30 minutes
        • avoid alcohol,
        • quit smoking and chewing tobacco,
        • computers and TV
          • “blue light” distorts your Circadian Rhythm
        • get a routine
    • Work on sleep hygiene
      • bedtime
        • same each night
      • environment
        • cool, dark, quiet
      • get out of bed if not asleep in 15 minutes
        • pursue a quiet activity until sleepy
    • Cognitive behavioral therapy with relaxation training.
    • Lastly consider medications
      • Sleeping medications can be addictive,
      • tolerance can develop,
      • side effects are common and can be serious.
      • not recommended for more than few weeks
      • OK for travel, “stress”, or bereavement

 

Conclusion:

Sleep disorders are very common. Prioritize your sleep, it is vital to being healthy and feeling your best. Shoot for 7 hours of good sleep. Schedule and plan your sleep time. Don’t be afraid to take a short nap, 20-30 minutes during the day to catch up on your sleep. Work on your sleep hygiene, and see your doctor if you think you have a sleep disorder.

References:

  • AAFP Home Study
  • American Family Physician journal