• How much exercise do we really need?

    Many of you have sent me this piece in the NYT which argues that a new study says that one minute of strenuous exercise achieved the same benefits as 45 minutes of endurance exercise. Let’s let Gretchen Reynolds describe the experiment:

    One group was asked to change nothing about their current, virtually nonexistent exercise routines; they would be the controls.

    A second group began a typical endurance-workout routine, consisting of riding at a moderate pace on a stationary bicycle at the lab for 45 minutes, with a two-minute warm-up and three-minute cool down.

    The final group was assigned to interval training, using the most abbreviated workout yet to have shown benefits. Specifically, the volunteers warmed up for two minutes on stationary bicycles, then pedaled as hard as possible for 20 seconds; rode at a very slow pace for two minutes, sprinted all-out again for 20 seconds; recovered with slow riding for another two minutes; pedaled all-out for a final 20 seconds; then cooled down for three minutes. The entire workout lasted 10 minutes, with only one minute of that time being strenuous.

    This went on for 12 weeks. The outcomes of interest were process measures, including peak oxygen intake, insulin sensitivity index, glucose tolerance tests, and skeletal muscle mitochondrial content. Bottom line, the gains were the same in the interval and the endurance group.

    This is being touted as “one minute of strenuous exercise is as good as 45 minutes”. I’m… not so sure.

    First of all, this was a study of 25 men, not evenly divided between groups. It’s process measures, so my usual grain of salt there. But the biggest thing I see here is that it wasn’t really “one minute of strenuous exercise”. It was probably 10 minutes (at least) of activity that likely led to an increased heart rate for more than that amount of time. Is this really different from, say, walking briskly for 10 minutes?

    Cause if the take-home message of this is that you don’t need to exercise for an hour to get benefits, I’m all in. I already said that:

    The recommendations are for 30 minutes of moderate activity five times a week. Is it possible that less would get the same goals? Maybe. I’d love to see more studies investigating that.


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  • Can we please talk about kids and guns now? If not, when?

    I admit that I’d heard on the news that a two-year-old child killed himself with a gun from his mom’s purse in Indiana this week. I also admit that I’d heard a 13-year-old girl was accidentally shot in Indiana this week as well. The problem is that I hear about this kind of stuff so often, I guess I got kind of inured to it and didn’t really react.

    Then Austin tweeted this passage from Richard Perez-Pena in the NYT, covering the story of a mother who was killed in Wisconsin on Tuesday by her two-year-old, with a gun:

    In the seven days that ended Tuesday, in addition to the death of Ms. Price, a 3-year-old in Georgia, a 3-year-old in Louisiana, a 2-year-old in Missouri and a 2-year-old in Indiana fatally shot themselves; a 4-year-old in Texas shot and wounded a family member; a 16-year-old in California killed a 14-year-old friend in a shooting that officials called accidental; a 15-year-old in Texas accidentally shot and wounded a 16-year-old friend; and a 13-year-old in Indiana accidentally shot and wounded herself.

    This was in a week. A week.

    In 2009, about 7400 kids were hospitalized with gun injuries. Homicide is the number three killer of kids age 1-4 years. Accidents are the number one. Guns are a health risk for kids, and in some states, we aren’t allowed to talk about it by law.

    So can we talk about it now? If not, when?


    P.S. Kudos to Perez-Pena. Sometimes it takes some great writing to get me off my ass.

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  • AcademyHealth: How good is telemedicine?

    As I wrote in my previous AcademyHealth blog post, the vast majority of the two hours or so it usually requires to see a doctor is spent not seeing the doctor. Travel and waiting time take big chunks out of our day. With modern technology, for some kinds of care, that wasted time can be avoided. My new post explains.



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  • Healthcare Triage: Health Services Research, Diabetes, and the YMCA

    More than 86 million people, including 22 million people 65 or older, have pre-diabetes, which increases their risk of heart disease, strokes or diabetes. As we’ve watched that number grow, it has somehow felt that despite billions of dollars of research and intervention, there’s little we can do.

    That feeling shifted last week when Sylvia Mathews Burwell, the secretary of health and human services, announced that Medicare was planning to pay for lifestyle interventions focusing on diet and physical activity to prevent Type 2 diabetes. It’s an example of small-scale research efforts into health services that have worked and that have expanded to reach more people.

    That’s the topic of this week’s Healthcare Triage.

    This was adapted from a column I wrote for the Upshot. References and links to further reading can be found there.


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  • Avoiding Peanuts to Avoid an Allergy Is a Bad Strategy for Most

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company).

    It has become an article of faith among many women I know to eliminate some foods during pregnancy, out of concern that their children could become allergic to them: shellfish, dairy and, most of all, peanuts.

    After their babies arrive, they continue to abstain from certain foods while breast-feeding, and they certainly keep their children from eating them.

    But research in the last few years has consistently shown that all this avoidance often does more harm than good. In many cases, we need to be doing the opposite.

    Mothers didn’t adopt this behavior out of nowhere. In 2000, the American Academy of Pediatrics released guidelineson reducing a child’s risk for developing allergies. They recommended that mothers “eliminate peanuts and tree nuts (e.g., almonds, walnuts, etc.) and consider eliminating eggs, cow’s milk, fish, and perhaps other foods from their diets while nursing.”

    Further, they recommended that children at high risk for allergies be given no solid foods until six months of age, no dairy products until 1 year old, no eggs until age 2, and no peanuts, nuts or fish until age 3.

    A debate has been raging in the health care system for decades on this topic. I was part of a systematic review that examined the relationship between early solid food introduction and allergic disease in children. We found no good evidence to support the idea that being exposed to solid foods earlier led to persistent food allergies.

    To its credit, the A.A.P. changed its recommendations based on new research. In 2008, updated guidelines reported that maternal restrictions in pregnancy or breast-feeding no longer seemed like advice that should be widely recommended. It also acknowledged that there didn’t seem much reason to delay the introduction of “allergy” foods like peanuts after six months, which is around the age babies move from milk or formula to a wider range of food.

    Unfortunately, this did little to change people’s behavior. Many had already internalized the advice. It seemed logical to them that avoiding foods would give children less of a chance to develop allergies. If it was still a good idea not to expose children until they were six months old, why not keep going?

    A study published in the New England Journal of Medicine last year turned all of this on its head. Researchers enrolled 640 infants at high risk for allergies, between 4 and 11 months of age, in a trial and randomized them to one of two groups. One of them was told to avoid peanut protein; the other was told to eat at least six grams of peanut protein a week given in three or more meals. All participants were followed until they were 5 years old.

    What was most surprising in this work was that 15 percent of the infants already had evidence of peanut sensitivity by allergy testing. They were enrolled in the trial despite this, and half of them were given peanut extract every week.

    The results were remarkable. At the end of the study, about 3 percent of those exposed to peanuts had developed a peanut allergy, compared with more than 17 percent among those who avoided peanuts.

    More surprising, if you looked just at the children who already had evidence of peanut sensitivity when they were babies, fewer than 11 percent of those regularly exposed to peanuts developed an allergy. But more than 35 percent of those who avoided peanuts developed an allergy.

    Children who had proven sensitivity to peanuts, but consumed them in their diet regularly, were less likely to develop a peanut allergy than children without sensitivity but who avoided them.

    Recently, follow-up results were published. After the trial ended, researchers asked all the participants who had been regularly consuming peanuts to avoid them for the next 12 months.

    At the end of that period, when the children were 6, there was no significant increase in new peanut allergies in that group. Avoidance at this point made no difference. The critical need for exposure appears to be somewhere from infancy until age 5.

    These results were so convincing that, once again, experts are changing their recommendations. In September 2015, the A.A.P. — along with others— argued that “health care providers should recommend introducing peanut-containing products into the diets of ‘high-risk’ infants early on in life.”

    These changes dovetail nicely within what has become known as the hygiene hypothesis, the gist of which is that as we’ve made our environment more and more sterile, our immune systems develop differently than they used to. Without exposure to outside things to fight, our defenses turn inward and toward more benign substances, leading to increased levels ofeczema, asthma and allergies.

    Of course, many people used to die from infections that no longer threaten us because of advances, so no one should take this as a call for living in filth. Nor should anyone take these recent findings as advice to feed babies and small children peanuts and other foods without concern. All changes to an infant’s diet, especially in children with allergies, should be done in consultation with a health care professional.

    As with many things in health care, however, we went too far with our response to peanut and other food allergies. Avoidance is sometimes needed for those with severe reactions. When we apply those same rules to everyone else, however, things can backfire.


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  • A test only works if you can understand the results.

    From JAMA:

    Along with their screening mammogram results, women in nearly half of US states also receive notifications of breast density, a result of legislation intended to assist in making personalized decisions about further action. Dense breasts can mask cancer on mammography (masking bias), and are an independent cancer risk factor, but evidence does not yet indicate whether or what supplemental screening is appropriate. Rather, risk stratification is proposed to determine who may benefit from supplemental screening (eg, magnetic resonance imaging for women at high risk).

    Yes, it’s law (who cares what patients and doctors might prefer) that women in almost half the states in the US get notifications about their breast density when the get mammograms. Dense breast tissue makes mammograms harder to read. But the women don’t get results through their doctors. They get them in letters, sent to them personally. There’s a problem, though. They’re written at a level that may be hard for many to understand:

    We found wide variation in 23 states’ DBN content, with most having readability at the high school level or above, poor understandability, and discontinuity with states’ average literacy. Such problems may create uncertainty for women attempting to make personalized decisions about supplemental screening and may exacerbate disparities in breast cancer screening related to low health literacy.

    Study after study on health literacy finds that patients don’t understand what their doctors give them to read. Many in the health care arena assume everyone reads proficiently at a very high level. That’s just not the case. Since something like 40% of women have dense breast tissue, they’re getting these notices, probably panicking, and not understanding what’s going on. That’s not good.



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  • Healthcare Triage News: Unnecessary Supplement Use is Rising, Even Among the Elderly

    There are a few topics here at Healthcare Triage that just won’t seem to go away. Vaccines and autism. Diet and exercise. Survival rates. But the one that trumps them all is supplements. Americans seem obsessed with them.

    The one group I thought might not be overtaken by this craze was the elderly. Boy, was I wrong. This is Healthcare Triage News.

    For those of you who want to read more:


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  • Some day

    Via Pascal Meier:

    some day


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  • Suicide is just getting worse. Will we do anything about it?

    In 1999, the age-adjusted suicide rate was 10.5 per 100,000 population. By 2014, that rate rose 24% to 13.0 per 100,000.

    The rate of suicide has increased for both men and women.

    The rate of suicide has increased for every age group under 75 years.

    The rate of suicide increased twice as fast from 2006 through 2014 than it did from 1999 through 2006.



    At what point do you think we’ll do something about this? I talked about this more than a year ago at The Upshot, and no one answered. Will someone now?


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  • A modest proposal for fixing Gobeille.

    I’ve already groused about the Supreme Court’s decision in Liberty Mutual v. Gobeille, which reads ERISA to preempt state laws that ask self-insured plans to share claims data with all-payer claims databases (APCDs). Not only is the decision wrong, but it will hamper price transparency and frustrate health-care research.

    Sensitive to the concerns, the Court toyed in its opinion with a workaround. What if the Labor Department collected the claims data itself and then shared it with the states? It’s a nice idea, but it’s got a big problem (as I explained here): the Labor Department has neither the resources nor the desire to run a massive, national claims database.

    But is there an easier way? Could the Labor Department restore access to claims data from self-insured plans without creating a gigantic new IT infrastructure?

    I think so—and although there are some legal risks, they’re risks worth running. The key to the legal argument is the fact that ERISA delegates to the Labor Department the power to resolve ambiguities about the scope of the statute’s reporting obligations. Among other things, for example, “the Secretary may by regulation exempt any welfare benefit plan from all or part of the reporting and disclosure requirements.”

    Drawing on this authority, the agency could, through notice-and-comment rulemaking, clarify that ERISA’s reporting requirements do not extend to the granular price information that Vermont and other states seek to collect. At the same time, the Labor Department could offer its informed, considered view that state laws that seek such information pose no obstacle to achieving the “the objectives of the ERISA statute.”

    In the rulemaking, the Labor Departments would have to articulate a safe harbor for permissible state reporting laws. Those that require the reporting of price information would be OK because employers remain free to create whatever sorts of plans they want and administer them how they please. But state laws that ask for anything more would be preempted. Otherwise, 50 different states could adopt 50 different reporting regimes, which would clash with ERISA’s purpose of “provid[ing] a single uniform national scheme for the administration of ERISA plans”

    Would this be legal? Could the Labor Department, by regulation, effectively overrule Gobeille? Probably, but it’s not entirely clear. In National Cable & Telecommunications Association v. Brand X, the Supreme Court held that an agency gets Chevron deference when it exercises its delegated power to resolve a statutory ambiguity, even where a court previously construed the statute differently. “Only a judicial precedent holding that the statute unambiguously forecloses the agency’s interpretation, and therefore contains no gap for the agency to fill, displaces a conflicting agency construction.”

    In other words, the Labor Department unquestionably has the authority under Chevron and Brand X to determine the scope of ERISA’s reporting obligations, whatever the Supreme Court assumed about those obligations in Gobeille. What’s less clear, though, is whether the courts also owe Chevron deference to the Labor Department’s conclusion that ERISA doesn’t preempt state laws requiring the reporting of price information. (Breyer and Scalia sparred over that very question at oral argument.)

    In the past, the Court has suggested that such deference would be appropriate. In 1988, for example, the Court held that,

    even in the area of pre-emption, if the agency’s choice to pre-empt [or not, as the case may be] represents a reasonable accommodation of conflicting policies that were committed to the agency’s care by the statute, we should not disturb it unless it appears from the statute or its legislative history that the accommodation is not one that Congress would have sanctioned.

    More recently, however, the Court has been coy, saying that agency decisions about preemption are entitled to “some weight,” without saying how much. After all, who better than the agency to resolve hard preemption questions?

    Congress has delegated to [the agency] authority to implement the statute; the subject matter is technical; and the relevant history and background are complex and extensive. The agency is likely to have a thorough understanding of its own regulation and its objectives and is uniquely qualified to comprehend the likely impact of state requirements. * * * In these circumstances, the agency’s own views should make a difference.

    But how big a difference? Enough for the courts to give Chevron deference to Labor’s preemption determination, even if that determination runs contrary to the Supreme Court’s own conclusion in Gobeille? Or are questions about preemption ultimately for the courts to resolve, not federal agencies?

    That’s a tough question. But agencies have an excellent track record when it comes to defending their preemption determinations in court. This is a fight the administration could win. Given the stakes, why not take a shot?


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