Processed meats – cancer risk or hype

Bacon is perhaps the archetypical of processed meats – whether typical US or Canadian – it is one of the most identified foods by sight or smell.  Recently, the World Health Organization (WHO) classified  processed meats as a cancer risk, equating it to smoking.  How did they come to this decision, and can we infer the same risk about all meat – processed or not?

What did the WHO say?

The WHO evaluated data from about 800 studies of meat intake and cancer.  About 14 of them were designed well enough to analyze the information.  There were another 15 studies that had strong design to help with the decision-making.  Based on these 29 studies, they found evidence that processed meat increased cancer risk – specifically colon cancer by about 17%.  The data for red meat in general was not strong enough to make an association.

How should we interpret the WHO statement?

The association of processed meats and GI tract cancer has been known for quite some time.  In cultures where these foods are consumed regularly, stomach cancer has had an increased rate, leading to screening programs.  The statement from the WHO adds strength to the association, and should encourage people who have multiple risks for colon cancer to consider their diet as a controllable  risk factor.

What does this mean for most people?

The risks for colon cancer are age, smoking, a low fiber diet, family history and now processed meats.  Just like most health decisions we make, our diets should be modified based on our risks.  Moderation, or occasional consumption of processed meats is a better choice than daily consumption.  Of course, getting a colonoscopy based on your doctor’s recommendation further minimizes the risk of developing colon cancer!

Life is full of choices – moderation and a varied diet seems to be one of the better ones.  In the words of Joe Jackson, “Everything gives you cancer”

The path to wellness begins with a proper diagnosis.


Annual Physical Exam vs Personal Health Assessment

I read a piece in the New York Times this week questioning the usefulness of a yearly checkup with your doctor.  It cited a study from 2012 that said that people who went for an annual exam did not live longer, avoid the hospital more or visit the doctor less.  A similarly themed Op-Ed piece was written by Ezekiel Emanuel earlier this year.  With all due respect to Dr. Emanuel and the New York Times, I will disagree, although with a caveat.
The usefulness of anything depends on how you define it and the what you seek to accomplish.  A checkup that ticks off boxes on a form for an insurance discount – maybe checking blood pressure, weight, blood sugar and cholesterol may identify some people with a health issue.  A fuller exam that looks at when recommended screening exams and vaccines were last done may increase health care usage, but no one argues that a colonoscopy at the right time in one’s life can be life saving and cost-effective.  Medicare covers an annual wellness exam, designed to identify those things that cost medicare money and increase health expenses – dementia, falls and depression.  It also requires a discussion about advanced directives – what a person does or doesn’t want done if they get too sick to make decisions for themselves.  It does not cover lab work, blood pressure checks or other “problems”.  In fact, there is no “laying of hands” at all.
The argument often cited for the yearly exam is relationship building.  If you see your physician when you are well, it is a chance to know what your baseline is, and later you are not trying to establish a relationship in a crisis.  There are pros and cons to this argument – in a mobile society, when you are young, will you have the same doctor when you get ill?  Or do you view your relationship as an insurance policy?  You have the relationship, and hope not to use it.  If there wasn’t precedence for this, wouldn’t we only buy auto insurance after the accident?  Or do you view your physician as a trusted advisor, investing in your health like you might your financial portfolio, with regular review to try to optimize things?

So what do I think of an Annual Exam?

The issue with studies on physical exams are multiple – inconsistent definitions, goals and outcomes make it hard to compare results from various studies.  Besides the studies the NY Times quoted, there are several studies that show recommended screening occurs more in people who come for annual physicals, and that there are health benefits – such as identification of high blood pressure – which has no symptoms and won’t be found until it is too late.
I believe in a yearly checkup.  However, I think the definition needs to change, and it has a very specific goal.  Personal Health Risk Assessment.  All the studies are based on large populations, and when I am with a patient, the most important thing is that person across from me.  We can use population data for a discussion, but what really matters is your risk.  So I like to use the opportunity of an annual exam to go through a person’s history, family history, social history and medical concerns.  Using that information, we can use population studies and decide what studies are appropriate for you!  We can look for the things you are at highest risk for and are most concerned about.  We can decide on a risk reduction plan once we have testing data back.  Can I guarantee you will be healthier for it? No, life does not come with guarantees.  We will be able to say that we identified your risks and did our best to reduce them.  We come away with information and recommendations that are specific to you.  I know your health risks, fears and concerns, and can provide advice that addresses them.
Will you live longer for our time together?  I don’t know.  Can you live better for it – absolutely!
 The path to wellness begins with a proper diagnosis

Got Milk? Too much of a good thing?

The USDA recommends 3 cups of milk or dairy a day.  This is mostly to promote bone health.  However, it has also been linked to increased cancer risk in some studies, others have supported health benefits.  A recent study tried to sort out these conflicting results by separating milk from other dairy products and looking at death rates, heart disease, cancer rates and fractures.
What they found was surprising – adults who drank 3 or more glasses of milk a day died sooner, had more fractures as well as heart disease and cancer.  Those with similar dairy intake, but from fermented dairy like yogurt, cheese, sour milk, etc. had a lower incidence of death and disease.  The difference?  Lactose content.

What is lactose?

Lactose is a sugar found in milk.  When digested, it is broken down into glucose and galactose.  Galactose has been linked to oxidation and inflammation – triggers for disease.  The study authors hypothesized that the difference in lactose, therefore galactose intake with milk versus other dairy products is the cause of the difference if death and disease

What did they do?

The researches used 2 health registries of residents in Sweden where records are centralized, totaling over 61,000 women and 45,000 men and sent them questionnaires that looked at milk and dairy intake.  They then followed their records from the early 1990’s until now, looking at death and disease rates.  What they found was that women who drank 3 or more glasses of milk daily were:
  • 1.9x more likely to die
  • 1.4x more likely to get cancer
  • 1.6x more likely to fracture a hip
In men, the effects were less pronounced:
  • 1.1x more likely to die, mostly from cardiovascular disease
  • no increase in fractures
They also messed marks of inflammation and oxidation in the blood of participants and found higher levels of both in those with higher milk intake.

So what does this mean?

There are some interesting associations based on this study.
  • ingestion of milk, with it’s higher lactose content, may be linked to increase risk of disease
  • ingestion of low lactose dairy products (yogurt, cheese) is associated with a decrease of disease
  • moderate intake of milk is not associated with increased disease risk

There are some limits to this study

  • the data is based on 1 or 2 food surveys, and subject to people’s memory and answers
  • the population studied was very uniform – 2 or 3 counties in Sweden – which may limit generalizing to the population at large
  • All subjects were over 39 years old so no conclusions can be made about children and young adults
  • Lactose free milk was not evaluated

What can we take away from this?

  • High amounts of lactose may contribute to disease based on its breakdown into oxidation and inflammation promoting compounds
  • Dairy foods with low lactose contents are associated with lower death rates and illness
  • Moderation again seem to be the word of the day – it is possible to have too much of a good thing!

The path to wellness begins with a proper diagnosis

Ebola in the US – what’s next!?

Last month, the first Ebola patient was brought to the US – a physician infected in Africa and brought back to the US for treatment.  I reviewed Ebola and that case in a earlier post on 8/2/14. That was a controlled transfer, just as the 2 other known cases transported to the US for treatment were. On September 30th, the first case of newly diagnosed Ebola in the US occurred, in a person who had recently traveled from West Africa to Dallas, Texas.

Once in the US, he went to an Emergency Room for fever.  He was sent home with antibiotics. He returned 2 days later when his symptoms had progressed and his travel history was noted. He was quarantined, tested and diagnosed with Ebola.  Why he was discharged after the first visit has been blamed on a computer error and then on poor communication between the intake nurse and the doctor. Since I wasn’t there I can only hypothesize that the truth is somewhere between.

Since being admitted to the hospital, his immediate contacts have been isolated and a HazMat team is cleaning the apartment where they stayed.  The CDC is monitoring about 50 more people he may have had contact with and so far, no one has developed fever – the first sign of Ebola.

What does this mean for the US now?

Ebola is a virus, causing fever, body aches, headache and sore throat. Unlike most viruses, it can also cause internal bleeding. You need to have symptoms to be contagious, and the incubation period – the time from exposure to symptoms is 2 to 21 days. Treatment is mostly supportive – meaning fluids and oxygen, although experimental treatments are in use as well.  It is likely that the death rate, nearly 50% in West Africa, would be much lower in the US due to better facilities, quarantine and access to care.

Ebola is spread by fluid contact – meaning you need to directly come into contact with secretions from an infected person – similar to HIV or Hepatitis.  It is not an airborne virus – meaning a cough or sneeze won’t spread it.  It also does not live long on surfaces. Therefore, if none of this person’s contacts develops symptoms, then the current US outbreak will be over.

That said, it is likely that another traveler will bring the virus to the US. Modern air travel makes this more likely, even with screening at both the departing and arriving airports.  Vigilance in the doctor’s office and Emergency Department will be needed to quickly identify potential cases – and most importantly, a travel history!

For updates from the CDC

The path to wellness begins with a proper diagnosis 


Personalized Medicine – Back to the Future

Almost every day I get asked a similar question.  “Should I get…”  we fill in the blank with a test – mammogram, stress test, PSA, colonoscopy are common ones.  People are concerned about having a disease and want to know if they can do anything about it.  They are worried and a little scared of what they may find out.  In addition, people are presented with conflicting information – the cancer society recommends women get mammograms beginning at age 40, an advisory committee called the US Preventive Services Task Force (USPSTF) says 50.  The USPSTF says not to check PSA in men, the cancer groups disagree.  There are ads for home DNA tests, full body scans and “executive physicals” that claim to identify disease.  There are media stories of being able to use all this technology to tailor treatment to a persons genetic code – ushering in the age of “Personalized Medicine.”  

It is against this backdrop and expectation that people ask their doctors to be able to predict the future, or look at their blood tests and reassure them that they are safe.  When people purchase these tests or ask me about ordering a test, almost all are thinking that a normal result will reassure them they are ok – not about what a positive test means – or worse – an indeterminate test.

The result is we now have the ability to use technology to see what is normal or not – but our ability to find abnormalities is much greater than our ability to assign meaning to it.  Is that nodule on your full body scan something dangerous or is it an abnormality that likely has no clinical meaning or impact on health – what we call an “incidentaloma?”  What has happened as our ability to detect has exceeded our ability to interpret is the development of guidelines.

These guidelines evaluate a technology or test and give a recommendation on its use.  The recommendation is usually based on a review of published evidence or a review of selected evidence.  The review of evidence averages out differences in the population in an attempt to give a blanket recommendation.  These generalizations are then applied to individuals and often viewed as hard and fast rules instead of suggestions.  This non-discriminate application of guidelines is the exact opposite of what science is trying to accomplish with technology – resulting in depersonalized medicine.  

It is ironic that with all the technology we are developing to personalize care we have devalued the very thing that would allow its proper implementation – the doctor-patient relationship.  By coupling technology with a doctor’s knowledge of both an illness and the personal history of the patient in front of them an intelligent plan of how to apply technology can be developed.  Prior authorizations, approval requests and denials by insurance companies interfere with a doctor’s ability to do so.  These obstacles add more to the cost of care than the very tests a physician may be trying to order!  

I have spent the majority of my career advocating for the intelligent use of information technology and Electronic Health Records to enhance the care of the patient in front of the doctor.  Guidelines based on the “average person” can be applied to large populations with ease.  However, when you are discussing disease risks and testing with the individual sitting across from you, it becomes less clear-cut that they are the “average person” the guideline applies to.

So while a patient’s DNA may lead to personalized treatments to diagnose and cure illnesses the ability to deliver personalized medicine already exists – when a doctor and a patient take their history and intelligently apply technology to it – resulting in the best care for that person.

The path to wellness begins with a proper diagnosis

Misdiagnosis – A Second Opinion

Earlier this week, I saw a segment on the Nightly News claiming 1 in 20 people have a misdiagnosis – based on a new study that had come out that day.  That error rate translates into 12 million Americans per year.  As a physician I find that number startling.  As a physician who specializes in making the proper diagnosis, and who advocates that you can’t be well without a proper diagnosis, I wanted to delve deeper into this report.  If accurate, I am making 1 or 2 mistakes a day!

What was the study about?

So how did they make the claim that 1 in 20 patients have a misdiagnosis?  How was a misdiagnosis defined?

The study looked at 3 earlier studies and combined the results.  One was a study in a primary care setting that defined a potential error as an unscheduled hospitalization or return visit within 14 days of the initial appointment.  Then they looked at the records of those cases to decide if a misdiagnosis occurred – defined as the information to make a correct diagnosis existed at the time of the first visit.

The other 2 studies looked at delay of diagnosis for colon cancer and lung cancer.  They defined a misdiagnosis as lack of follow-up of a “red flag” – an abnormality or symptom that should trigger further evaluation.

What did they find?

In the primary care study, they found 177 errors in 1343 records.  In the colon cancer study, they found 26 errors in 291,773 records.  Finally, in the lung cancer study, they found 127 errors in 587 records.  These results were combined and applied to the US population to come up with the number of 1 in 20 mistakes or 5% of the US population having a misdiagnosis – based on 330 errors found in 293,703 actual reviews.

What does this mean?

No profession is perfect – we are all human – so errors are a matter of consequence – if I was a baseball player who had a .950 batting average, I’d be playing for the Yankees.  Errors happen in medicine, just as in any profession.   It is less critical if you are told you have allergies when you have a cold – both are treated similarly and not life threatening.  However, being told your chest pain is heartburn when you are having a heart attack can have serious consequences.

A misdiagnosis is a serious issue.  Trying to define the rate and circumstances where a misdiagnosis occurs should be studied more, and ways of improving the practice of medicine explored.  I do feel the statistical manipulations in this study and generalizing their results to the entire US population oversimplified this issue.

I reviewed the thought process of a physician in an earlier post.  It involves re-evaluating a person’s symptoms as more information comes in.  Being willing to reconsider a diagnosis is key to being a good doctor – and avoiding a misdiagnosis.

I hope this review of a headline helps put it in perspective.  I plan to do this regularly – a second opinion of health news.  So, if you see or read a story you’d like to learn more about, let me know – I’ll give you A Second Opinion.

The path to wellness begins with a proper diagnosis