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Archive for the ‘Preventative Medicine’ Category

Time to heal: Round 2

Posted in Life, medicine, New Zealand, Preventative Medicine, tagged , , , , on November 30, 2018|

Back in 2013 I wrote a post about an accident I had with a horse which resulted in two broken metatarsals (the long bones in your foot). That post was about how healing takes time, and indeed, my foot did heal with time and patience.

Alas, it’s time to remind myself, again, that healing takes time…

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Goofing around on that fateful day…

A few weeks ago I was out mountain biking with a friend. The irony of the story is that while we pushed ourselves to try out some new skills and sessioned a jump for a while, it was the relatively tame trail back to the car that had me hit the dirt. I can’t tell you what happened (I didn’t hit my head, thank goodness, I just have no idea what happened!) but as my hip and fist collided with the packed earth I was acutely aware that I’d broken something in my hand. In fact, my first words were “I’ve broken my hand” (repeated 3-4 times).

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My X-rays from 2013 needed arrows for emphasis. No arrows needed here: Spiral fracture of the 5th metacarpal and fracture at the base of the proximal 4th phalynx.

The doctor who saw me in the local Urgent Care was confident that I could continue working with my injury. Sure- I couldn’t suture or do some specific physical exam maneuvers, but otherwise I shouldn’t be too limited; at least that’s what he thought. Looking back on it, it wasn’t a smart decision to work with a bulky splint on my freshly-broken dominant hand. Yes, my brain was fully functional, but I could only examine patients using one hand, could only type with one hand, and had to use my left hand to use the mouse and navigate my computer (a task that required a surprising amount of focus- I couldn’t “drive” my computer and listen to a patient at the same time). Despite adding in some extra breaks and a brief stint having a nurse work in parallel with me it became obvious that I couldn’t carry on with work as usual.

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When my patients saw me in this they often said “It looks like you need a doctor more than I do!”. Another classic was “You’ve been in the wars!”. 

While I’ve working in the New Zealand medical sector for just over a year, this has been my first experience as a patient.

In my last post I wrote a bit about the healthcare system in New Zealand, but I didn’t mention how it’s all paid for and provided. I am no expert on the NZ health system, and the whole system is certainly more complex that I could (or should) spell out in a blog post, but the core organizations are the DHB (the district health board) which uses government funds to provide health care, ACC (the Accident Compensation Corporation) which is New Zealand’s Universal no-fault accident insurance scheme, and some private coverage (either paid out of pocket by patients or by optional additional health insurance).

ACC

The DHB pays for medical care which is needed as a result of illness while ACC pays for medical care (and more) that is needed as a result of injury. The DHB only covers healthcare for citizens and those with working visas 2-years in duration, so if you are travelling (or working in NZ for less than 2 years) and become unwell you are financially responsible for your own medical expenses. ACC, however, covers everyone in New Zealand. If you are travelling in New Zealand and injure yourself you have access to healthcare through ACC. You may have to pay co-pays (For example $35+ for a GP or urgent care visit, $45 for an X-ray, and $20+ for physio visits), but if you have a massive accident requiring a helicopter ride and a prolonged ICU stay, you won’t get a bill…

ACC doesn’t just cover medical expenses, it also functions as disability insurance. If you can’t go to work due to an injury, they will compensate you at a rate of 80% of your normal income after one week. If you can go back to work part time they will help subsidize your until you are recovered and back to full time work. They have return-to-work programs, and try to get people back into the workforce in whatever capacity and quantity they are able.

ACC helps with other things: if you can’t drive they can provide taxis, if you can’t keep up with your daily tasks they get you in home help, if you need physio and strengthening they subsidize therapies and gym memberships, if you need counseling they cover that.

Essentially, ACC is a massive, national, accident insurance policy that is paid for by levies placed on employers, workers, and vehicles. Does the system have flaws? Certainly, what system doesn’t? There are people who defraud the system, and people will complain about declined coverage, but as a clinician and now a client I am very impressed with the system.

The day after my injury I was seen at urgent care where I paid $120NZD to be seen (this would be much less if I had a 2-year visa and was thus entitled to healthcare in NZ) and $45 for an X-ray. I then had a splint put on and a week later went back in for repeat X-rays, evaluation, and a more permanent splint at no additional cost. I’ve since seen the hand therapist and visited a physio twice because of a pain in my hip that wasn’t settling with time- both with a reasonable co-pay. I worked for a week with my initial injury, but came to realize that I wasn’t able to doctor one handed and in a splint, so after talking with my boss it was decided that I’d be off work while I was in my current splint and limited to the use of my non-dominant hand. ACC promptly recognized my claim and called me to see if I needed help getting to appointments, help around the home, and what was appropriate compensation while I couldn’t work (information based on last year’s tax return). Thinking about what my ACC levy was last year and what it’s likely to be this year I suspect I’ll get about as much out of ACC as I put in. I’d be very happy if I hadn’t had to use their services, but I’m incredibly glad that a national accident insurance exists in NZ*.

I’ve extended my time in New Zealand through March but plan to return to the United States to work and live after that. As I start to mentally prepare myself to return to the US and think about working in a for-profit healthcare system, I find myself already missing the public health system in NZ.

5 years ago, when I broke my foot, even though I had medical insurance I ended up owing over $2000 out of pocket for a single, simple, medical encounter.

For one medical encounter where I was evaluated, X-rayed and given a walking boot and crutches the total bill was well over $5000USD. The old orthopedist who walked in and said “Doctor, heal thyself!” sent a bill for $2479, including global billing codes for evaluation and treatment of 2 fractured metatarsals (at $1027 a pop, or perhaps I should say a hair-line crack), despite needing no treatment other than protection in a medical walking-boot. My foot healed with time, and my hand will heal with time, but it is high-time that the US figures out how to provide affordable healthcare for its people.

(*This also has huge implications in “Treatment Injuries” and physicians are not sued for huge sums as they are in the US in the case of adverse outcomes, but that is more than I care to go into today!)

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My dad writes good get-well cards…

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Time to heal…

Posted in General, Life, Preventative Medicine, tagged , , , on September 22, 2013| 3 Comments »

“Doctor! Heal thyself!”

 

Those were the words of the orthopedist as he entered my room in the Emergency Department.

 

Two weeks ago, while taking a break from working on residency applications, I decided to go ride one of my horses.  Alas, as I was leading him and his pasture-mate to the barn they spooked and one of them literally jumped on my foot.  I’ve been around horses for decades (eek!), and have had my toes crunched many times, but I immediately knew this time was different, not least because he had landed on the side of my foot not my toes.  The pain was instantaneous and overwhelming, I was doubled over and hyperventilating within seconds (at which point I realized that the horses hoof had actually torn my leather boots- let this be a lesson to ALWAYS wear boots around horses, a lesson I’ll admit that I haven’t always followed).  After taking a couple of minutes to catch my breath I hobbled to the barn, optimistically hoping I’d still be able to go for a ride.

 

Once in the barn, with the horses secured, I pulled my boot off and had a quick palpate. One good squeeze and I knew I needed to make a trip to the hospital for some X-rays. *Sigh*  This was NOT how I had planned to spend my evening!

 

A little later, at the community hospital, the X-ray tech snapped a few angles.  I asked if I could see the films before hobbling back the waiting area and immediately spotted two, slim, hypodensities in my 4th and 5th metatarsals.  With an expletive, I pointed to one of the lucencies. The tech tried to reassure me that it wasn’t anything significant: “just an artifact” because there was a similar line in the adjacent bone…

 

After the Physician’s Assistant examined me in fast track, he went to go check out the X-rays.  I asked if I could take another look, admitting that I was a med student (and currently on rotation in this community hospital for my sub-internship!). When he came back to pull the images up on the computer, he let me know that he and the ED doc agreed that I did, indeed, have non-displaced fractures of the 4th and 5th metatarsals.  There wasn’t really much they could do, but the orthopedist was coming into the hospital to see a couple other patients and if I was willing to hang out for half an hour he’d take a look at my images as well.

 

They don't look like much, but those two little lines are really cramping my style!

They don’t look like much, but those two little lines are really cramping my style!

 

Half an hour later, the cheery orthopedist came in, chatted with me about my future plans in medicine, and told me to follow up with him if things got worse instead of better.  I headed home with a walking cast, crutches, and a few Percocet.

 

This was two weeks ago, and while my foot is by no means “fixed” it is certainly getting better.  Hobbling around to take a shower the first morning was rather excruciating, but the walking cast was my saving grace in the hospital and I’ve been able to do more normal activities without the boot with time (though I think I may have pushed my limits last night heading into the city for a book release party and am paying for it today- on that note, definitely check out John Durant’s book The Paleo Manifesto).

 

So why am I writing this, other than catharsis? (It’s perfect fall hiking weather and I’m out of commission- boo.)

 

Healing takes time.

 

With things like a fractured bone people know this, but sometimes we (“we” the public, and “we” the medical community) seem to forget that healing takes time.

 

There’s no denying that I am “into” preventative medicine.  However, as much as we can try and prevent injury and illness- something is bound to happen.  In that vein, I don’t think preventative medicine is only about avoiding problems, but encouraging a physiology where healing is promoted.

 

I’ll admit that I’ve been frustrated at times in the hospital when my stable patients have complained to me on morning pre-rounds that they had a horrible nights sleep because someone was taking vital signs every couple hours, and the phlebotomist came for morning labs before 5.  Vital signs are vital for the management of some patients, but others would benefit much more from a good nights sleep. Of course, making the decision that your patient needs sleep more than monitoring is not an easy one- no one wants to find that their patient is hypotensive on morning rounds and not know when the problem occurred, but for some patients the risk seems quite low.  On my neurology clerkship I remember thinking that what many of our stroke patients needed most was a good night’s sleep.

 

I recently read, at the recommendation of my favorite cardiologist, the book Cutting for Stone.  It is amazing, in many ways. I particularly loved a short passage that talked about the success one person had in improving women’s recovery from fistula surgery.

 

Hema shared with us that she and Shiva had operated on fifteen successive fistula patients with not one recurrence.  ‘I owe this to Shiva,” she said. ‘He convinced me to take more time preparing the women for surgery. So now, we admit the patients and feed them eggs, meat, milk, and vitamins for two weeks…. We work on strengthening their legs, getting them moving.’…

 

‘Can’t get them to walk after surgery if they won’t walk before.’ Shiva said.

 

When I was on my anesthesia clerkship I saw how hard it is to manage a “sick” patient, and how easy it is to intubate and anesthetize a healthy one (a complicated cardiac patient vs a young ortho patient, for example).  On surgery, you see how well some people tolerate surgery and how poorly other do- how some heal quickly while other seem incapable of healing.  One’s underlying “health” certainly affects one’s ability to heal.

 

This is one of the many reasons I like primary care.  A good primary care doc makes everybody else’s job easier.  They can keep their patients healthy and out of the OR and specialist’s office, and if misfortune strikes, a patient in the best of health is almost always set up to fair better (the only example that I can think of where this is not the case is the pandemic flu of 1918, where the robust immune systems of young, healthy, adults was actually their demise).

 

Injury and illness, at some level, are inevitable.  A healthy lifestyle and good genetics can go a long way to keeping you out of the hospital, and they can also go a long way towards helping you heal if you do find yourself in harms way.  As the Dos Equis man might say “Stay healthy my friends.”.

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Mammography- What we know vs. what we think we know

Posted in Disease, Preventative Medicine, tagged , , , , , , , on July 3, 2013| 6 Comments »

In my last post I introduced some of the controversies surrounding breast (and prostate) cancer screening methods.  I’ve been digging into the research on screening mammography for an assignment for the radiology elective I just finished, and realized there is definitely more on this subject that I want to write about.

 

I’ve been focusing my reading on the perceptions (and misconceptions) about mammography, both on the side of physicians and patients (though breast cancer awareness has become such a public issue, I wish there was research looking at general awareness about cancer, not just awareness in women of screening age- but I digress…).

 

So how effective is mammography?

 

Over the years, quite a lot of data has been generated looking at the ability of screening mammography to prevent death from breast cancer.  I’m not going to dig into all the data now, but I want to mention the most recent Cochrane Review (the “Holy Grail” of Evidence Based Medicine (EBM)) and the 2012 New England Journal of Medicine (NEJM) article that I mentioned in my last post.

 

Here is an excerpt from the 2011 Cochrane Review (emphasis mine):

 

…for every 2000 women invited for screening throughout 10 years, one will have her life prolonged and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false positive findings. It is thus not clear whether screening does more good than harm.  [1]

 

And from the NEJM (emphasis mine):

 

Despite substantial increases in the number of cases of early-stage breast cancer detected, screening mammography has only marginally reduced the rate at which women present with advanced cancer. Although it is not certain which women have been affected, the imbalance suggests that there is substantial overdiagnosis, accounting for nearly a third of all newly diagnosed breast cancers, and that screening is having, at best, only a small effect on the rate of death from breast cancer. [2]

 

So the eminent minds in evidence based medicine think that it’s unclear if mammograms do more harm than good?  That certainly isn’t the public message that most of us have heard…

 

Liars, damn liars, and statisticians

 

Part of the difficulty of understanding the benefits (and the risks) of mammography is understanding the statistics.  Unfortunately, despite being taught some basics in medical school, I fear that many med students and physicians aren’t good at interpreting data.  Indeed, a 2009 paper found that the vast majority of ob/gyns couldn’t accurately calculate the positive predictive value of a positive mammogram [3].

 

Even if a physician is statistically literate, data can appear much more or less convincing depending on how it’s presented.  A 2011 article entitled “There is nothing to worry about”: Gynecologists’ counseling on mammography” gives some excellent examples [4]. Working with data published in 1996 from a randomized study conducted in Sweden, they emphasize the difference in absolute risk reduction and relative risk reductions.  In the 1996 study, for every 1000 women that were screened there was a decrease in breast cancer deaths from four to three women in favor of the screened group.  An absolute reduction in breast cancer deaths of 1 woman for 1000 screened does not sound particularly impressive, but the relative statistic of “a 25% decrease in mortality” sounds worthwhile [5]. [It is also worth noting that according to the Cochrane review above, the reduction in breast cancer mortality with screening mammography is actually 1 in 2000, or a 15% decrease in relative mortality or a 0.05% decrease in absolute mortality.]

 

When the data is presented as relative risk reduction and not absolute risk reduction, screening mammography looks a lot more beneficial.  Interestingly, the risks of mammography (those of overdiagnosis and over treatment) are often presented as absolute rather than relative risks, seemingly downplaying the adverse consequences while exaggerating the benefits.

 

It’s not just relative…

 

Other mammography statistics can also be used to skew the perception of benefits.  One statistic that has largely fallen out of favor, because of loud protestation from those calling for a realistic analysis of the benefits of mammography, is “survival statistics”.

 

To understand survival statistics we much first understand “lead time” and “lead time bias”.  Wikipedia does a good job explaining this phenomenon, but for those that don’t want to take the time to click over- I will briefly expand.

 

Imagine a disease that kills a person at 65.  Imagine that the person becomes symptomatic for that disease at 63, but with the use of a screening tool we can detect (but not cure) that disease at 55.  The “diagnosis” is given when the disease is first detected, so the person diagnosed at 63 dies 2 years after diagnosis.  The person whose disease was identified at 55 “survives” for 10 years, which sounds great- except really there is no difference in total life expectancy.  Similarly, if you detect a “disease” that would never kill in the first place you can have stunning survival data…

 

Side note: The cancer that isn’t

 

No one questions that breast cancer kills.  The problem is that “breast cancer” is not a single entity, and some of the things that are classified as breast cancer aren’t even in the same ballpark as the diseases that kill.  Case in point is Ductal Carcinoma in situ (DCIS).  Despite having the word “carcinoma” in its name, calling DCIS “cancer” isn’t really fair, though it can progress to cancer.  Sadly we don’t know when, why, or in whom it will progress to invasive cancer.  However, in the majority of women it just sits there, in situ, and is something the woman dies (or would die, if it were left alone,) with, not from [6].  Including the diagnosis of DCIS in survival statistics further skews an already questionable statistic.

 

Back to stats…
 

Promoting mammography by saying that it increases 5-year survival from 23% to 98% sounds impressive, while the actual reduction in the chance of a woman in her fifties dying from breast cancer over the next ten years only drops from 0.53% to 0.46% with mammography [7].

 

Perception

 

If you’ve made it this far, you (like me) may be becoming underwhelmed with the evidence supporting the regular use of screening mammography (and that’s without starting to consider the financial incentives that might encourage the promotion of early and often mammography…).

 

Unfortunately, if I poll most of my fellow classmates, they will emphatically reply that screening mammography is a good thing. It catches cancers (yes). It saves lives (marginally). It’s highly beneficial (that’s debatable).

 

This sentiment is not unique amongst my classmates.  A recent survey shows that over 80% of responding primary care physicians believe screening mammography to be “very effective” in reducing breast cancer mortality in women aged 50-69 [8]. Another study reported that 54% of responding physicians believe that screening mammography is “very effective” at reducing cancer mortality in women aged 40-49 [9], a population where screening mammography decreases the 10 year risk of dying from breast cancer from 0.35% to 0.3% [7]. In yet another study, none of the 20 gynecologists queried mentioned risks of mammography such as over-diagnosis and over-treatment [4].

 

Sentiments amongst patients are similar. A 2001 study found that only 19% of women surveyed accurately assessed screening efficacy realistically, selecting that screening reduced mortality by about 25% in women over 50 (and again, this number is probably closer to 15% according to the most recent Cochrane report, and is equivalent to 1 less death per 2000 women over ten years).  50% of the women who responded estimate that screening mammography reduced breast cancer mortality by 50-75%.  Not surprisingly, women who believed that screening was effective were more likely to plan to have a mammogram [10].

 

Women’s sentiments towards mammography are shaped by many factors.  Patients, like physicians, are largely influenced by personal experiences.  “Knowing someone who survived” can largely influence personal beliefs, as can the media and statements from celebrities and politicians.  The type of media a woman gets her information from can also largely influence her perspective.  A 2001 paper found that publications aimed towards women with lower education levels published articles that were clearly persuasive or prescriptive for screening mammography, while publications aimed towards more educated women included more balanced and informative messages [11].  Therefore, perhaps it is not surprising that higher levels of education are associated with more realistic expectations of mammography [12].

 

So what’s the Cliff-Notes version

 

Despite what many of us have come to believe, screening mammography is not womankind’s salvation in pink.  Alas, it appears that survival (as in real survival, not a 5 year statistic) is basically unchanged whether women participate in screening mammography or not.  Women that do participate also face the sizable risk of experiencing negative repercussions from mammography: false positives (being told there’s something there when there’s not- this is particularly prevalent in younger populations), over diagnosis, and over treatment.

 

I don’t want to downplay breast cancer.  Breast cancer is real.  Breast cancer is terrible.  Breast cancer kills. But the statistics show that whether women are screened or whether a cancer is caught with diagnostics after a lump is appreciated, population survival is largely unchanged.  Furthermore, women suffer ill consequences from over diagnosis and over treatment from screening mammography.

 

So what should we do?

 

Some of the screening recommendations are heading in the right direction.  While the American College of Gynecologists (ACOG) and the American Cancer Society (ACS) recommend that women initiate annual screenings at the age of 40, the most recent US Preventative Task Force (USPTF) recommendations recommend starting biennial mammograms at 50.

 

Personally, I think the USPTF is heading in the right direction, but I, for one, would like to see a mammography recommendation similar to the recommendations for PSA testing for men given by the American Urology Association as I wrote about in my last post.  We shouldn’t do it in the young (read 40-50), we shouldn’t do it in the old (and instead of “old” we really need to talk about life expectancy), and those patients in the middle need to have a serious talk with their doctor about the risks, benefits, and their personal values.

 

We need personalized medicine.  Instead of a carte blanche recommendation about when to start mammography, we need real discussions about an individual’s risks, their values, and the potential benefits and risks of screening.  Of course- that’s a lot more difficult than handing a prescription for a mammogram to every 40 year old woman who walks through the door, but I think that as doctors, we are up to the challenge. 

 

Of course, doctors aren’t up for the challenge if they’re only given 5 minutes to talk to a patient.  We need to value primary care doctors, and the doctor patient relationship, if we’re going to make strides towards personalized medicine- the question is whether the system is up to that challenge, but that’s a question for another day. 

 

1.            Gotzsche, P.C. and M. Nielsen, Screening for breast cancer with mammography. Cochrane Database Syst Rev, 2011(1).

2.            Bleyer, A. and H.G. Welch, Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med, 2012. 367(21): p. 1998-2005.

3.            Gigerenzer, G., Making sense of health statistics. Bull World Health Organ, 2009. 87(8): p. 567.

4.            Wegwarth, O. and G. Gigerenzer, “There is nothing to worry about”: gynecologists’ counseling on mammography. Patient Educ Couns, 2011. 84(2): p. 251-6.

5.            Nystrom, L., L.G. Larsson, S. Wall, L.E. Rutqvist, I. Andersson, N. Bjurstam, G. Fagerberg, J. Frisell, and L. Tabar, An overview of the Swedish randomised mammography trials: total mortality pattern and the representivity of the study cohorts. J Med Screen, 1996. 3(2): p. 85-7.

6.            Welch, H.G., S. Woloshin, and L.M. Schwartz, The sea of uncertainty surrounding ductal carcinoma in situ–the price of screening mammography. J Natl Cancer Inst, 2008. 100(4): p. 228-9.

7.            Woloshin, S. and L.M. Schwartz, How a charity oversells mammography. BMJ, 2012. 345: p. e5132.

8.            Yasmeen, S., P.S. Romano, D.J. Tancredi, N.H. Saito, J. Rainwater, and R.L. Kravitz, Screening mammography beliefs and recommendations: a web-based survey of primary care physicians. BMC Health Serv Res, 2012. 12: p. 32.

9.            Meissner, H.I., C.N. Klabunde, P.K. Han, V.B. Benard, and N. Breen, Breast cancer screening beliefs, recommendations and practices: primary care physicians in the United States. Cancer, 2011. 117(14): p. 3101-11.

10.            Chamot, E. and T.V. Perneger, Misconceptions about efficacy of mammography screening: a public health dilemma. J Epidemiol Community Health, 2001. 55(11): p. 799-803.

11.            Dobias, K.S., C.A. Moyer, S.E. McAchran, S.J. Katz, and S.S. Sonnad, Mammography messages in popular media: implications for patient expectations and shared clinical decision-making. Health Expect, 2001. 4(2): p. 127-35.

12.            Domenighetti, G., B. D’Avanzo, M. Egger, F. Berrino, T. Perneger, P. Mosconi, and M. Zwahlen, Women’s perception of the benefits of mammography screening: population-based survey in four countries. Int J Epidemiol, 2003. 32(5): p. 816-21.

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Lady parts, man parts- we need a serious talk and some better diagnostics.

Posted in Disease, Preventative Medicine, Science, tagged , , , , , , , , on June 19, 2013| 14 Comments »

I abhor the pinkification of our culture.

 

I have nothing against the color pink (for a brief time in my childhood, after wearing a princess-like peach bridesmaid dress at my aunt’s wedding, peach was actually my favorite color), but I do have a deep dislike of the culture of cancer that has grabbed pink ribbons (or pink cookware, clothes, and even garbage barrels) to raise awareness *cough* money *cough* for foundations that make a big deal out of breast cancer.

 

I don’t want to downplay breast cancer.  According to The American Cancer Society, breast cancer is the most common cancer among American Women after skin cancer.  It is estimated that around 40,000 women will die from breast cancer this year.  But breast cancer awareness is also a BIG money maker- turning over many million dollars per year.

 

I’ve yet to see this movie, but the trailer raises some interesting points.

 

 

All the pinkification and fanfare would be tolerable if the breast cancer awareness campaigning, and most importantly the mammography that it promotes, reduced the toll of breast cancer, but the reality, according to a November 2012 New England Journal of Medicine article [1], is not such a pretty picture.

 

Let’s cover some of the basics…

 

To be an effective screening tool, a modality must detect life-threatening disease at an early treatable stage.  It follows that an effective screening tool then decreases the prevalence of late stage disease.

 

While screening mammograms have certainly led to an increased detection of breast lesions (it has effectively doubled the rate of diagnosis), the reality is that this increase in detection has not led to a significant decrease in advanced disease.  [The NEJM abstract is here, and certainly worth a read]. Furthermore, it appears that increased detection has had, at best, only a small effect on the rate of death from breast cancer.

 

What the NEJM of article doesn’t cover is the psychological toll that the pinkification of our culture has had.  Women feel like they are failing themselves if they don’t start getting annual mammograms at the age of 40.  Teenage girls are being brought up to believe that their breasts are two pre-cancerous lesions… ticking time bombs.

 

Yes- breast cancer kills, but there are also plenty of breast lesions that women have that they would live and die with, not from, if it weren’t for aggressive screening recommendations.  I’m not a psychiatrist (and I’m not going to be), but I do wonder what the increased diagnosis (and then “survival”) of otherwise slow-growing and relatively benign cancers does to the psyche – the survivor effect.  These factors raise a number of concerns, without even bringing up any monetary issues…

 

Apparently the prostate cancer ribbon is blue, but men (and our culture) seem to have avoided a tidal wave of “bluification”.  Perhaps, as the gender that tends to utilize the healthcare system less, [2], men have been seen as a less lucrative target. Nonetheless, prostate cancer has fallen victim to some of the same pitfalls (abuses?) as breast cancer.

 

Prostate cancer is the most common non-skin malignancy and the second leading cause of cancer death in men. Prostate specific antigen [PSA] is a protein that can be detected in the blood, and until fairly recently it had been recommended that men undergo regular PSA testing as a screening for prostate malignancy.

 

The problem with PSA testing however, much like mammography, is that it catches many lesions that a man would die with, not from.  As with mammography, increased detection leads to increased treatment, increased surgery, increased patient stress, and increased financial burden for the patient and the system. And for what?

 

Many of the lesions that PSA screening catches do not negatively impact the life expectancy of the patient.  In fact, a paper published yesterday in the Annals of Internal Medicine [3] shows the opposite- that treating these lesions (instead of observing them), actually leads to a decrease in quality-adjusted life expectancy (and increased medical costs).

 

What does this all mean?  Should we give up on screening tests for the two big sex-specific cancers?

 

No- I’m not a nihilist when it comes to screening, but I do think that screening should be done with full patient awareness of the risks, benefits, and consequences.

 

I think the American Urological Association (AUA) is on the right track, with their 2013 guidelines that greatly limit the recommendations for PSA testing (these came after the 2012 US Preventative Taskforce recommendations, which advised against the use of all PSA screening). While the AUA made general recommendations for some populations that PSA screening is unnecessary (those with a low-risk who are young, those who are old, and those with less than a 10-15 year life expectancy), for a large group the recommendation is that men should talk to their doctors about the relative risks and benefits, and from that discussion make a decision based on their personal values and preferences.

 

Having a patient weigh in with his personal values doesn’t seem like a particularly groundbreaking recommendation, but in many ways it is.  A patient’s medical care should be in his hands as much as possible, and when the risks and benefits of a screening tool are unclear it is appropriate that the patient and doctor discuss the risks and benefits.  Looking back at the data on mammography over the last few years, I think it is only right that doctors start to have similar discussions with women about their personal values and preferences when it comes to mammography. [The elephant in the room, however, is that if screening tests are deemed “optional”, will insurance companies cover them?]

 

So where does that leave us.   

 

Screening MAY catch an early cancer, but it may also catch a lesion that you would die with not from.  It can lead to extensive testing, stress, expenses, and surgery.  I’m not saying we shouldn’t screen, but I’m saying that the medical community (and the organizations that profit from cancer-awareness) need to be honest about the reality of our testing modalities.

 

I also think this is a call to arms for scientists.  The screening tests we have are not meeting our needs.  While the tests above can tell us about potential lesions, they tell us little about the malignancy of the lesions.  We need tests that can more accurately tell us what is going on in our bodies.  Those tests are coming- in the forms of mRNA and protein assays, but until they get here I think we ought to have more informed discussions about what screening tests are really doing today.

 

1.            Bleyer, A. and H.G. Welch, Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med, 2012. 367(21): p. 1998-2005.

2.            Bertakis, K.D., R. Azari, L.J. Helms, E.J. Callahan, and J.A. Robbins, Gender differences in the utilization of health care services. J Fam Pract, 2000. 49(2): p. 147-52.

3.            Hayes, J.A., D.A. Ollendorf, S.D. Pearson, M.J. Barry, P.W. Kantoff, P.A. Lee, and P.M. McMahon, Observation Versus Initial Tretment for Men with Localized, Low-Risk Prostate Cancer: A Cost-effectiveness analysis. Annals of Internal Medicine, 2013. 158(12): p. 853-860.

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These feet were made for walking…

Posted in Anatomy, Evolutionary Medicine, Preventative Medicine, Principle into Practice, tagged , , , , on October 20, 2012| 7 Comments »

Many people get their start in the ancestral health/evolutionary wellness world through food.  Be it “paleo” or “primal” (or perhaps the ever practical advice of Dr. Emily Deans: “Don’t eat like a Jerk”), most people start this journey with food, and then start to apply the evolutionary mindset to other aspects of life. Once the logic of “eating evolutionarily” sets in (and once you realize how good you look and feel while doing it), you might start to apply the evolutionary approach to other aspects of your life.

Once you’ve been at this long enough, you start to think about the evolutionary aspects of everything- food, movement, socialization, sex, sun, stress, and sleep (so many s’s!)- but it seems that the two that most frequently go together are food and feet.  The exact timeframe may vary, but there’s usually not a huge gap between someone adopting a “primal” or “paleo” diet, and someone purchasing their first pair of Vibram Five Fingers– and so your migration to the fringe begins…

The jump from an evolutionary approach to food to barefoot running is an appropriate one.  The evolution of the foot (and our ability to run) is often traced to the human ability to run down prey, and thus the evolutionary argument that meat is an important part of an appropriate human diet. From an evolutionary health perspective, the argument that “these feet were made for moving” (without the help of massive rocker-bottom shoes) just starts to make sense, and might just prevent (or explain) injury.

If you’re not familiar with the arguments for a barefoot approach (or if you are, but haven’t seen this video), I highly recommend the following brief video, made to accompany this paper [1], in the eminent journal Nature*.

It certainly makes sense that a forefoot foot strike pattern inline with our evolutionary “design” might be protective against running-induced injury.  Indeed, a small retrospective study that was published this July showed exactly that.  In cross-country runners, those with a forefoot foot strike had significantly less repetitive stress injuries than their rearfoot-striking counterparts [2].

Embracing the barefoot message does not mean you have to embrace actually going barefoot.  You can see from the VFF link above that there are options for those who want the barefoot experience without the unpleasant effects of doggie-doo.  For those worried about being labeled part of the monkey-foot army, have no fear- there are minimalist options out there that are relatively indistinguishable from *regular* footwear.

In the last few years there’s been an explosion of minimalist or “barefoot” shoes. Those in the market can chose from a number of mainstream or more esoteric brands.  From New Balance Minimus Zeroes and Merrel Gloves to Vivobarefoot and some of the Inov-8 options, there are many options for the barefoot enthusiast to try.

I’ve gone through a number of pairs of VFF at this point, with the rather simple KSOs being my style of choice.  I’ve endured the occasional joshing from friends and entertained many questions from strangers out on trails, and am generally enthusiastic about VFFs, but they’re definitely not a “stealth” minimalist shoe.  On the other hand, the Vivobarefoot sneakers that I wear in the hospital look like totally normal sneakers. [I’ll admit my favorite hospital “outfit” is the 4 S’s- Scrubs, Sneakers, Sweatshirt, and Stethoscope]

I’m not here to write a review of the Vivos I’ve been wearing (though they’ve been great for me). My advice for anyone looking to explore minimalist shoes is to go to a store and try on the different options. I know some people love the Merrel line, but they’re definitely too narrow in the arch area for me (they leave me feeling like I’m in shoes with big arch support).  I want to try the NB Mimimus Zeroes (the newest NB “barefoot” option with no heel drop) before I purchase my next pair of sneakers.

Shopping for a new pair of sneakers is definitely on my mind, as I’ve recently realized that my original pair of Vivos is on the way out. They’re had a good run, but some of the luggs are now totally worn down, and the sole is starting to erode too. I hadn’t noticed in the way they wore, but when I flipped them over I was initially surprised to see where there was wear.

Ever since I was a kid I’ve been “hard” on sneakers. I’ve worn through the soles of many shoes (and stomped down the back of many an unlaced sneaker- much to my parents chagrin). In the past, I’ve always noticed that it was the heels of my sneakers’ soles that went first.  With my Vivobarefoots, the wear is only prominent at the ball of my feet. I dug up an old pair of sneakers (not worn out, as I switched over to minimalist options before these were done) and you can clearly see that the greatest wear is in the heel areas. Yes- there is some wear in the toes, but not much. For contrast, look at my ailing Vivos.

The different wear patterns in my last pair of normal Merrels and my minimalist Vivobarefoots.

For me, this is pretty convincing evidence that minimalist shoes do, in fact, encourage the midfoot strike that is desired by those that go barefoot. That’s not to say that minimalist shoes are a cure-all for heel striking. You can check out this video from the 2011 NYC barefoot run to see the variety of footfall patterns- many of those with minimalist shoes have a different footfall from the truly barefoot, with a couple examples of heel-striking in minimalist shoes… ouch!

Some technical difficulties aside, minimalist shoes are definitely a step in the right direction (pun intended?) for those wishing to get a more “evolutionarily appropriate” footfall, without going truly barefoot (or for those who might like to go barefoot, but are constrained by social norms (or hospital policy!))

Lunch/sun break on a sunny day on my surgery clerkship.

Usual disclaimers apply- minimalist shoes are not for everyone. Getting accustomed to minimalist shoes can take time. Consult a medical professional before starting any exercise regime. Go in search of the Wizard of Oz (NOT DOCTOR OZ!) if you are in need of your own brain.

*For those keen on reading more about evolutionary medicine, Daniel Lieberman published an article on evolutionary medicine and barefoot running in April [3].

1.         Lieberman, D.E., M. Venkadesan, W.A. Werbel, A.I. Daoud, S. D’Andrea, I.S. Davis, R.O. Mang’eni, and Y. Pitsiladis, Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature, 2010. 463(7280): p. 531-5.

2.         Daoud, A.I., G.J. Geissler, F. Wang, J. Saretsky, Y.A. Daoud, and D.E. Lieberman, Foot strike and injury rates in endurance runners: a retrospective study. Med Sci Sports Exerc, 2012. 44(7): p. 1325-34.

3.         Lieberman, D.E., What we can learn about running from barefoot running: an evolutionary medical perspective. Exerc Sport Sci Rev, 2012. 40(2): p. 63-72.

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Thought of the day…

Posted in General, Life, Med school, Preventative Medicine on September 23, 2012| 5 Comments »

(I wrote this a few weeks back as I was just starting the first portion of my internal medicine clerkship. I was obviously rather energized at the time, though my thoughts now remain generally the same. More science-y posts to come, I promise, but for now it’s hard to find time to put together such posts!)

____________________________________

Our current medical system does not fit our current medical condition.

Our health-care system was built on the premise of people being relatively healthy until they became significantly sick.  By those standards, our medical system has been hugely successful. Antibiotics routinely save people who would die without medical intervention. Trauma surgeons routinely put people back together who would have died 100, or even 10 years ago (and put them back together better and faster with improving technology).  Today, conditions that used to be major killers- meningitis, endocarditis, pneumonia- are usually (though not always) successfully treated.  The pediatrics floor of my University’s hospital is frequently almost empty- most serious diseases of childhood are now prevented.

Yet people see our medical system as a failure.

And it is.

Our medical system fails to prevent the preventable.  Rates of diabetes, cardiovascular disease, and “diseases of civilization” are increasing exponentially.  The expense of our medical system is unaffordable. As much as we are able to treat the sick, we often fail the ill.

Different doctors have different views towards medicine. Some are rather paternalistic; some are loud proponents of patient autonomy. For the most part, however, all hospital-based doctors know they can’t keep their patients in the hospital until they are healthy. They treat them, and when they are ready to go home (or to a rehab center or nursing home), they are discharged. The problem is- you can treat an infection or a crisis, but you can’t treat a lifestyle.

When a patient comes in with Acute Coronary Syndrome (ACS- a term that refers to a spectrum of cardiac conditions from unstable angina to a severe myocardial infarction) and four risk factors (let’s say diabetes, hypertension, dyslipidemia and a history of smoking), what is the job of the hospital team?  They CANNOT fix all the underlying factors. Their job is to stabilize the patient, make a diagnosis, and treat their current condition.

Who is “to blame” for this situation?  Is it the patient that lived a lifestyle full of cardiovascular risk factors? Is it the fault of the patient’s family that never taught the patient, as a child, how to cook and care for themselves? Is it the fault of the community for not providing safe playgrounds for the patient when they grew up, leading to a sedentary lifestyle? Is it the fault of the education system, which might have fed this patient disastrous food while preaching the benefits of the food pyramid (if they taught anything nutrition-related at all)?  Is it a lack of physician availability, which leads to ‘dead zones’ where no primary-care physicians can be found, even if you have insurance or can pay for care?  Is it the failure of the patient who took at face value all the ill-guided “health-care” advice they were given (or perhaps, is it their fault for blatantly pursuing a lifestyle that no one would suggest is healthy)?

Our system was built around the premise of people being healthy until they got sick. We currently live in a world where most people are chronically ill.

It’s a fun thought-experiment to imagine what we could do with modern medical tools and technology with the patient base of 100 (or 10000?) years ago.  What would the hospitals look like in a world where patients ate real food, moved, lived, and interacted like humans, but with all the marvels of the modern world?  It’s a pretty dream to dream- especially if you are a physician (or future physician).  Helping people return to health is rewarding. Patching people up to die another day is exhausting, and frequently demoralizing.

Some say the system is broken.  I wouldn’t necessarily disagree, though I’d be apt to argue that we have some pretty amazing skills and tools, but we’re working in a broken world.  No one person can fix this. No one profession can fix this.  What are you doing to make things better?

Imagine there’s no diseases of civilization
It’s easy if you try
No collapsed arches below us
Above us only Vitamin-D producing sky
Imagine all the people living for today

Imagine there’s no diabetes
It isn’t hard to do
Nothing to chronically treat or amputate for
And no exogenous insulin too
Imagine all the people living life in peace

You, you may say
I’m a dreamer, but I’m not the only one
I hope some day you’ll join us
And the world will be as one

 

(Humblest apologies to all John Lennon fans… I couldn’t help myself)

There will always be disease. There will always be trauma. The question is: how do we handle these things, minimizing illness and maximizing the enjoyment of life?

__________

An addendum…

A friend and classmate made a good point over on my facebook page. I’ll paraphrase.

Our hospital’s pediatrics ward is empty because we’re not a peds specialty hospital and all the intense cases get shipped to a hospital with more pediatric specialists or to a children’s hospital.

It’s a good point, but if anything I think it strengthens my argument. We no longer have the bread-and-butter pediatric diseases of yore. Our pediatricians aren’t managing polio, treating a bunch of meningitis, or rehydrating children with rotavirus. On the other hand- the children’s specialty hospitals are now treating things that were previously unseen because children died. Children with rare and complex disorders now survive and are treated at specialty hospitals, while the run-of-the-mill pediatric illnesses fall into distant memory (though Pertussis is making a nasty comeback).

When it comes to pediatrics, we’re making great headway in keeping children healthy (though the rates at which our children are getting “adult” diseases such as Type II Diabetes are terrifying). What we do see, at least at our hospital, is a failure of good pre-natal care, leading to complex and problematic pediatric conditions… Again- it’s the lifestyle stuff that we struggle with!

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The missing element

Posted in General, Med school, Preventative Medicine on May 1, 2012| 1 Comment »

I’m currently on my surgery rotation, which has left me with little time not spent in the hospital, driving to the hospital, or sleeping (in the wee hours of the morning I will be found making coffee and when I get home in the evening I make a good dinner… that about fills you in on my life for the past few weeks and the ensuing month.). Surgery is an exhausting clerkship, and for the most part students are kept pretty busy during the day running around the floors checking up on our patients, tracking down information, seeing consults, or “scrubbing in” in the OR. Sometimes, when I have a chance to slow down (or when scrubbed in on a case where there isn’t a lot to see) I’ll find myself mulling over the system in which I’m working. I’m sure I’ll write about my thoughts and experiences on surgery at some point, but recently I’ve been thinking about medicine in general. I don’t think it’s much of a secret that my real interest is health, which for some reason often seems to be conflated with medicine, though it is increasingly obvious that the later does not always beget the former.

I am, by no means, anti-medicine or anti-medical technology. I am, undyingly, a nerd, and when I see what “we” can do, and how we do it, I am often amazed and in awe. Surgery is full of “I can’t believe we can do this!” moments, and the technology that has been developed, and the knowledge that has been discovered, is truly staggering. Yet sometimes this amazement leaves me feeling hollow. There are procedures, devices, and medicines that cure, reverse, prevent, and heal, but often it seems like we’re doing a lot of work to fix problems that should never happen in the first place. We can do so much, but maybe we shouldn’t have to.

The Fifth Element has been one of my favorite movies for years. I probably haven’t watched it in almost a decade, but I still think of it fondly.  My recent musings on our capabilities (with a certain unease about how frequently and pervasively we feel the need to patch a problem instead of fix or prevent it) has left me thinking of this scene… it is a favorite.

The reality is, the study of disease and the development of techniques and technologies to treat preventable diseases frequently leads to the advancement of science and knowledge. In a way, science and technology ‘wins’ at the expense of the people who suffer from preventable diseases. I’m not a conspiracy theorist- I don’t think this is all a big cynical plot and I don’t think pharmaceutical companies are trying to prolong a problem- they’re simply filling the niche (oh natural selection, you are everywhere) that has been created by the lifestyle that we live.

This thought is a recurring theme as I become more immersed in hospital life, and it is not one I can easily disconnect. When you see a patient in her mid-forties with a list of medication longer than my college transcript (trust me, that’s saying something!), coming in for her fourth surgery (you can take out troublesome body parts like the appendix, gallbladder, and sigmoid (or more) colon, but, inevitably, surgery begets more surgery, and you’ll see someone coming back for a hernia repair at an old incision site or a lysis of adhesions from a prior surgery), you have to wonder- can’t we do better? I don’t necessarily mean “we” the medical community, but more “we the people”. Health is in our hands, and while we have been greatly mislead by (generally) well-meaning government and institutional suggestions, ultimately the pursuit of health is in our hands.

There is a lot of misinformation to overcome and a lot of intricacies that people like to fight about, but for a lot of people health IS simple.  Live like a human.  Eat like one, move like one, sleep like one, and interact like one.  Eat real food, get out and move, spend time with people that fulfill you, feel the sun on your face and get a good night’s sleep… it might just keep you out of hospital (though there’s little hope of that for a 3rd year medical student!).

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On the importance of evolutionary principles in preventative medicine…

Posted in Preventative Medicine on February 29, 2012| 3 Comments »

If I were to ask my fellow med student how natural selection might impact the everyday business of medicine on the floors, I’d probably get a few puzzled looks.  The last time most of my classmates saw the word ‘evolution’ in an academic setting was probably in a basic biology class, which for some might have been as far back as High School.  Med students are quick on the uptake, however, and anyone who has spent any length of time on the floors (or listening to over-hyped news anchors on the 5 o’clock news) has heard of the growing number of antibiotic-resistant bacteria we’re breeding in the hospitals.  There we have it- evolution in action!  Push a little further and someone might remember that being heterozygous for sickle-cell offers some benefit when infected with malaria, so we see sickle-cell disease most frequently in those of sub-Saharan decent.  After that- crickets…

For those of us that spend a bit (ok a lot) more time than most musing about how natural selection applies to everything (it does- I’ll write about that sometime soon), it’s sometimes hard to explain to others why thinking about human health from an evolutionary perspective is the smartest place to start.  After a while it just seems obvious.  When you’ve spent enough time talking to those who also embrace an evolutionary approach to health, you start to banter about the details while forgetting that there are many people out there who haven’t yet seen the big picture.

The big picture- for those that missed it- is that our hunter-gatherer ancestors evolved to fit a very different environment from the one we live in today.  The details of how our ancestors lived are being hashed out by archeologists and anthropologists, but it is obvious to everyone that the modern culture in which most of us live is very different from that which our great-grandparents lived in, let alone the one our pre-agrarian ancestors enjoyed.  Others have spent a lot of time and effort exploring the different aspects of life from an evolutionary perspective- nutrition, exercise, sleep, social interactions- they all matter.  I don’t want to rehash these subjects on a broad-basis here as I think others have already done that job very well.  With time, I will explore some aspects of these elements, but for those that are looking for more on these general topics now, I would suggest the following links.

In the paleo-sphere, there is the occasional dust-up about how useful it is to ponder ‘What would Grok do?’.  Just because our ancestors did something does not mean it is something that we need to do now.  Equally, just because something is modern or a product of civilization does not mean it should be eschewed.  What an evolutionary based perspective on health offers is a paradigm which we can hark back to when trying to understand human health (or the lack there of) in the modern world.  As Andrew, of the wonderfully thought provoking blog Evolvify once said “paleo is a logical framework applied to modern humans, not a historical reenactment.”.

While there is a growing community of individuals who embrace paleo concepts in their personal lives, the idea of evolutionary based medicine has yet to take hold in the medical community.  While there are select situations that are attributed to selective pressures- such as bacterial resistance and the occasional genetic mutation such as sickle-cell, a much wider approach- the idea that natural selection applies to EVERYTHING- is very much lacking in modern medicine.  This is unfortunate, as an evolutionary perspective is increasingly necessary for understanding the complex and pervasive chronic diseases that are becoming all too common.  Specific diseases have specific causes, which once identified can be researched, understood, and hopefully targeted with specific therapy.  A good example of this is Cystic Fibrosis, a condition in which an individual inherits two faulty copies of a gene responsible for transporting chloride ions across membranes.  This condition has a clear cause, which is now well understood.  While treatment of this disease is not easy, great progress has been made.  Similarly, cancers that have specific causes, such as cervical cancer caused by Human Papiloma Virus, have been identified and prevented by diminishing exposure to (or immunization against) the problematic factor.  Alas, most chronic conditions, such as diabetes, hypertension, dyslipidemia, and many autoimmune conditions as well as a number of developmental conditions such as ADHD and autism, have not been traced back to a single cause.  These conditions are multifactorial, and unlike conditions caused by a genetic mutation or infection, the manner in which the condition arises is different from individual to individual.

Since the nebulous and chronic conditions mentioned above do not have a specific cause (an identifiable gene, infection, or exposure) – they do not have a specific cure.  Much research has been conducted (at great expense of time and resources) to understand these conditions, yet the returns on such investments have been limited.  While some measurements of disease can be altered with pharmaceuticals or lifestyle therapies, there is no single factor that can be targeted.  These conditions do not share a single, specific cause.  Broadly, however, these conditions are the result of humans living outside the limits of their body- limits set by thousands of years of evolution.

Because ‘diseases of civilization’ are caused by the intersection of many different factors, they remain resistant to classical scientific and epidemiological techniques.  Trying to find a single cause for hypertension, for example, is about as easy as nailing jello to the wall.  There is no single cause- no one nail- that can pin this problem.  Instead we need a framework to better hold and view the issue.  An evolutionary perspective offers such a framework – it also offers the way to prevent and treat these diseases.

But what if we could find a single way to cure these nebulous disorders… Should we?  If there was a pill that would treat (effectively and completely, with no side effects) these conditions, would it be better to continue living as we are- outside of our limits- but without the nasty side effects?  I tend to think that’s a decision best left to each individual, but I offer this corollary (by way of an anecdote).  I don’t take a multivitamin (I do take Vitamin D during the winter, but that’s a story for another post), as I think that an appropriate diet of real whole foods that I am adapted to eat provides me with everything a multivitamin would provide… and then some.  It’s the second part ‘and then some’ that I think is important to think about.  A multivitamin contains all the vitamins and minerals currently accepted as necessary (or beneficial), but it lacks all the other thing that whole foods contain that we have yet to study and identify that are probably also beneficial for our overall health.  In the same vein- while we may be able to control hypertension and diabetes with medication, preventing these conditions with an appropriate lifestyle offers control of the condition without side-effects from medication, with the added bonus that living within your evolutionary limits likely also offers other benefits that we have not yet fully elucidated.

A pill may fix your hypertension or your blood glucose, but chances are there are still things in your life that are out of whack.  It’s not uncommon to hear someone say ‘I went paleo to lose weight, and my skin cleared up.  Or ‘I went paleo because of my high blood pressure and my joint pain went away”.  It is all connected- and treating the body holistically, instead of treating a symptom, leads to improvements beyond the reduction of a single marker of disease.

When talking about evolutionary health, it’s very easy to slip into something that sounds like a ‘Just So Story’.  It is true that we only have limited clues about the environment in which our ancestors lived.  Geology, archeology, anthropology, biology- particularly genetic analysis- can all offer evidence to help us better understand our evolutionary past, but there is still a lot we don’t know.  What is obvious, however, is that as much as we may fret about the details of the conditions under which our species evolved, it is important to understand the basics.  If eating meats, vegetables, tubers and fruits, moving frequently, and sleeping well is the stuff of ‘Just So Stories’, I’ll take that any day over the modern apocalyptic sci-fi tales of lipid panels for kids, pizza as a vegetable, nutrition from pills and energy from drinks.

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