Archive for November, 2011

So is it your thyroid after all?

Wednesday, November 30th, 2011

Is this woman depressed, hypothyroid or both?

On November 21, 2011, The New York Times had an article entitled “For Some, Psychiatric Trouble May Start in Thyroid." As a mental health therapist who is hypothyroid, my wife has a particular interest in this subject and pointed out the article for me.

The premise, put forth by Dr. Russell Joffe, a New York psychiatrist, and a group of his professional peers, is that subclinical hypothyroidism may play a significant role in depression. A Brown University professor of psychiatry and human behavior also commented on this connection asking, “Is there an underlying thyroid problem that causes psychiatric symptoms, or is it the other way around?

From the endocrinology side, Dr. James Hennessey, at Beth Israel Deaconess Medcsl Center in Boston, noted "Psychiatric symptoms can be vague, subtle and high individual."

A study, published five years ago by Chinese researchers, gave six months worth of  thyroid hormone replacement therapy (see links below for the NIH's info sheet on this medication, levothryroxine and other info from, to patients with subclinical hypothyroidism and found improvements in brain scans, memory and executive functions.

sketch of the thyroid gland

So how is this condition diagnosed? and what does your thyroid do anyway? Most of us are familiar with this two-lobed, twenty to sixty gram,two-inch structure, located in the front of our necks and wrapped around our windpipe. It's a hormone producing gland with two products, thyroxine or T4 and its active hormone, triiodothyronnine or T3. I've always thought of its function as a major regulator of metabolism, but in reality that's only one of its duties: it does control how speedily we use energy, but also has a role in how we make proteins, how we react to other hormones and how our bodies handle calcium.

I've spent much of today reading about the thyroid; some things I knew; some I hadn't reviewed since med school basic science classes (1962-1964) and other were brand-new to me. Fetal development of the gland is stimulated by two other hormones released by the hypothalamus and pituitary and those are at high enough levels to cause the fetus to make T4 in clinically significant amounts by 18-20 weeks of gestation. The active hormone, T3, stays at low levels for another 10 gestational weeks, then increases until term.

The net result, it is felt, is protection of fetal development, especially of the brain, in the event the fetus's mother is herself in a hypothyroid state.

But back to adults and the link between thyroid status and mental health.  One of the crucial measurements of thyroid function is the level of TSH, thyroid stimulating hormone. Normal levels for this pituitary hormone are 0.4 to 5.0 in most labs in the United States; nearly nine years ago, the American Association of Clinical Endocrinologists recommended the doctors consider treating patients whose TSH levels are higher than 3.0. Other scientific groups agreed.

If a TSH level above 5.0 is abnormal, then ~5% of our adult population is hypothyroid. But if that level is reduced to 2.5 to 3.0, then ~20% of us are hypothyroid.

I wonder if a new field of medicine, halfway between the endo folk and the mental health practitioners, is on the horizon.

Issues with Psychiatric Drug use

Saturday, November 26th, 2011

Are drugs always the answer?

An article in the Wall Street Journal for November 16th caught my eye. My wife is a mental health therapist (the non-prescribing variety) and I knew this one would interest her. The title was “Psychiatric Drug Use Spreads: Pharmacy Data Show a Big Rise in Antipsychotic and Adult ADHD Treatments.”

She wasn’t especially surprised to hear that one in five adults were taking at least one psychiatric drug.  But as opposed to anti-anxiety drug use, both of us were struck by the comment that drugs given (and perhaps overused) for kids with ADHD are also increasingly being given to adults.

I went to the Internet to find the data. There’s an enormous company called Medco that provides pharmacy services for greater than 65 million people. I had never heard of the firm, but it’s rated number 35 of the Fortune 500 and in 2009 reported revues just under $60 billion.

Their senior psychiatrist, a Dr. David Muzina, has a great CV, working in major roles at the Cleveland Clinic from 1999 to 2009. I did note his “Summary” claimed “17 year’s of Cleveland Clinic experience as a Staff Psychiatrist,” but he graduated from medical school in 1993, presumably finished his Psychiatry residency in 1997 and then ran an inpatient psych unit at Lutheran Hospital (location unspecified) for two years.

In any case Medco, where Dr. Muzina is a Vice President, in and presumably heading their Neuroscience Therapeutic Resource Center, published an extremely interesting report titled “America’s State of Mind.” (see link below). This summarizes research on the prescriptions of greater than two million people in this country from 2001 to 2010.

The trends are stunning.

Boys and girls, men and women are all now more likely to be taking a drug used for mental health problems. Fifteen percent of adult men are on one or more of these medications and, amazingly, twenty-six percent of adult women.

In reality the ADHD drug use in adults is still comparatively uncommon (less than 2%), but NPR recently reported a severe shortage of Ritalin. Newer drugs which treat ADHD will enter the generic market in 2012; that should save patients considerable amounts of money.

The real impact is in the antidepressant arena: twenty-one percent of women 20 and over take these meds and the percent rises with age. It’s 16% of women ages 20 to 44, 23 percent of those between 45 and 64 and 24% of women over 65 years old. For men in comparable age groups the percent are 8, 11 and 13.

Then there’s regional distribution: what I call the “Middle West” and my own Mountain region have the lowest percentage on mental health drugs while Kentucky, Tennessee, Alabama and Mississippi have the highest.

So how many are actually taking their meds as prescribed? And how many are having serious side effects?

An issue raised in one of the publications is that of patients not taking prescribed dosages of their meds (if any), having increased symptoms and physicians therefore increasing their medication dosage.

Then if they do start taking the drug as prescribed....


Slim down those truckers

Wednesday, November 23rd, 2011

some truckers are relatively slender

I have two series of posts going, but couldn't resist the article I found in the New York Times while riding a recumbent bike in the gym. The title alone, "A Hard Turn: Better Health on the Highway," was enough to grab my attention.

The first story was typical, a trucker driving long hours every day, eating all the wrong foods, getting no exercise, gaining huge amounts of weight. I found the online abstract of a 2007 Journal of the American Dietetic Association article cited: long-haul truckers of necessity eat at truck stops and of 92 such truckers stopping at a Mid-eastern US truck stop nearly 86% were overweight and 56.5% were obese.

One of our family members used to be a truck driver and I've heard his stories of long days spent behind the wheel, eating greasy foods when he stopped. He's slimmer now and in better shape as his current employment allows him more exercise time and a choice of where and what to eat.

Now that insurance costs are rising sharply, the trucking firms are getting involved and the truckers themselves, there's over three million of them in the US, are coming to grips with the issue out of necessity. One group ran a blood-pressure screening clinic for 2,000 truckers at a truck show. Twenty-one were immediately sent to a nearby emergency room; one had a heart attack before reaching the hospital.

drive carefully around trucks like this

Trucks are involved in 400,000 accidents a year and 5,000 fatalities. I just watched a nearly eighteen minute video on how we, as drivers of passenger vehicles, contribute to those accidents; 70% are caused by the drivers of other vehicles (see link below). Yet many of the ones caused by trucker driver error occur because the trucker has a health problem or falls asleep.

Some truckers are taking steps to decrease their weight and its accompanying risks for themselves and those who share the roads with them. A number of companies are helping (and perhaps finding a lucrative new client group). I just looked at a website for "Rolling Strong," and found a gym in my area that offers fitness programs for truckers. Others are joining Weight Watchers, a solid organization that my slender wife has belonged to for many years (she says she was "chunky" in high school) or creating their own programs for fitness: one carries a fold-up bike in his 18-wheeler and uses it whenever he stops for a break. Many are cooking in their trucks or even hiring a trainer.

Others joined the Healthy Truckers Association of America, paying $7.50 a month to belong to an organization that is rapidly growing (see link below to Chicago tribune article). That group now offers truckers a prescription drug card enabling its members to save ~60% on meds.

I applaud all these moves; if I'm on the road with a large truck or a series of them, I'd like their drivers to be in shape and wide awake.

Do our kids have a bleak future?

Saturday, November 19th, 2011

As close to a salad as he'll get

I'm taking a break today from my series of posts on greenhouse gases, alternative energy source, volcanoes and global warming. All of those will affect the generations to come and those now growing up, but I want to re-examine another side of their issues. This morning I read two articles and one newspaper report on the heart health prospects for our American kids (and, by extension, kids elsewhere in the developed/rapidly developing world). The initial article came from a section of the Wall Street Journal I hadn't gotten around to reading yesterday and was about to recycle. Then I saw a title that caught my eye, "Kids' Hearth Health Is Faulted."

I found a CDC website with an explanation of the National Health and Nutrition Examination Survey, NHANES. This is a continuation of a US Public Health Service effort started 40 years ago and is updated annually. Medically-trained interviewers may well come to your town and even to your front door someday. The data they obtain is used in many ways (I'll paste in a website that leads you to some comments on NHANES as well as to a link to a video).

Now a portion of the survey/study looked at 5,450 kids between 12 and 19, finding they were a long ways from matching the American Heart Association's (AHA) seven criteria for idea cardiovascular health (see 2nd link below to Harvard's Beth Israel Deaconess Medical Center's article on the subject). The adult health measures, known as Life's Simple 7, are: 1). Never smoked or quit more than a year ago; 2). Body Mass Index (a measure of height versus weight) <25; 3). Physical activity on a weekly basis for 75 minutes (vigorously) or 150 minutes (moderate intensity).; 4). a healthy diet (four or more components meeting AHA guidelines); 5). total cholesterol <200 mg/dL; 6). blood pressure (BP) <120/80; and fasting blood glucose (AKA blood sugar) <100 mg/dL. The original article was published in the journal Circulation January 20, 2010 and is available free online. The metrics are slightly different for kids.

So where do our kids stack up? If you exclude eating a healthy diet, only 16.4% of boys and 11.3% of girls meet the standards for the other six criteria; if you include diet, none of them do. They don't eat four to five servings of fruits and vegetables a day; they also don't get enough whole-grains or fish and they consume far to much salt and sugar-sweetened drinks. Only one fifth of them even eat "fairly well."

drop that hamburger and run for an hour

Many of then also don't exercise on a daily basis for at least sixty minutes (50% of the boys do and 40% of the girls). More than a third are overweight or obese.

There's some hope: a just-published article in the New England Journal of Medicine, examining the data from four studies following 6328 kids, found that those who do manage to lose weight had lower risk for type 2 diabetes, hypertension, abnormal lipids and carotid artery disease.

So I'm heading to the health club and will read the 2010 Circulation tome on an exercise bike.

Thus far my one biologic grandson, about to be 12,  is physically active and slender. I'll encourage him to stay that way and the non-biologic grandkids to follow his example.

More on this subject to come.

Check out these articles:

Survey Results and Products from the National Health and Nutrition Examination Survey

AHA Defines "Ideal" Cardiovascular Health


Biofuels, greenhouse gases and you: Part one of many

Thursday, November 17th, 2011

Not the right choice for a sustainable biofuel

The excursion into what was initially a vaguely known arena started with a Wall Street Journal article on 11-8-2011, but then strayed far afield as my learning curve tilted steeply upward.

The article itself dealt with airlines trying out newer biofuels: Alaska Airlines and United were highlighted as having pilot projects in this area. As I read further, scanning online material, international carriers, especially KLM, with 200 flights using 50% biofuels and, impressively, Lufthansa with 1,200 flights using 50% biofuels, are far ahead in this arena.

The fuels come not from corn, as in the United States, or sugarcane, as in Brazil (more on the latter in a subsequent post), but rather from algae, cooking oil, animal fat, and two plants I'd never heard of, Camelina (I'm trying to find it as a cooking oil) and Jatropha.

We had dinner company a few days ago; I was cooking a cabbage dish from the Shan people of Northern Thailand and Mynamar, Lynnette made squash and potatoes simmered in olive oils with both vegetables coming from our weekly CSA allotment. The dinner and subsequent conversations and disagreements (these are close friends and we have differing views on a wide variety of topics) lasted from just after 6 PM to just before 11.

It was immediately obvious that our friends favor oil, gas and coal as fuels. They don't think biofuels, solar energy, wind power, geothermal or tidal energy are economically feasible. They would approve of nuclear energy with appropriate precautions (avoiding building nuclear power plants on known earthquake faults or in areas prone to tidal waves comes to mind).

I think we haven't put enough time, money or brainpower into developing alternative energy sources and urgently need to do so. The political will to accomplish this seems lacking and our faltering, argumentative Congress, polarized as it currently is, hasn't helped the situation.

I certainly agree that subsidizing the growth of corn to be converted into ethanol isn't the way to go. And Brazil, despite its exceedingly osuccessful and sustainable biofuels program, isn't going to be able to supply enough ethanol to fuel the rest of the world.

Mount Saint Helen's in a quiet mood

Our friends said one volcano can add enough greenhouse gas (GHG) to make all our cars' polluting, to mix a metaphor, seem a drop in the bucket.

I don't disagree that the rare volcanic eruption can be catastrophic in this sense as in others (local loss of life and property among them). We've visited Mount Saint Helens (I strongly suggest reading Tim McNulty's 1998 retrospective on the explosion; just Google his name and add that of the mountain).

He makes the point that in this natural disaster, as opposed to industrial clear-cutting, damage was variable, trees, animals and insect survived and the area has come back strongly. I liked the line, "The ecosystem has been through this before."

Yet adding our dollop of pollution is not natural; it may tip us over an edge.

So I am in favor of the pursuit of alternative sources of energy. These may vary from country to country or within a country as the local winds, tides & solar-project possibilities permit.

But it's time and very nearly past time.

Early cholesterol testing now recommended

Saturday, November 12th, 2011

We're seeing more obese kids

With our sweeping epidemic of childhood obesity ( current estimates say over one-sixth of American kids are obese, three times the prevalence rate seen thirty years ago), it's time to take some additional steps. On Friday 11, 2011, sweeping new guidelines for childhood lipid testing were espoused by both the NIH's Nation Heart Lung and Blood Institute and The American Academy of Pediatrics. I found these, of all places, not on the websites of the two august bodies, but on the front page of the Wall Street Journal, an NPR article and in the Los Angeles Times.

The actual article in the journal Pediatrics, won't be out for two more days and should find a fair amount of opposition. Previous position papers by the AAP and the US Preventive Services Task Force have either suggested lipid studies be done in focused groups (eg. family history of heart disease or lipid disorders) or, if universally, no earlier than age 20. The CDC (actually the acronym has changed since it's now the Centers for Disease Control and Prevention), in a 2010 report, commented that a single elevated LDL cholesterol reading in a child may be found to be normal in subsequent testing.

The current recommendation panel, headed by Dr. Stephen R. Daniels, an MD, PhD who is Chairman of Pediatrics at the University of Colorado School of Medicine, is quick to avoid any suggestion of widespread statin use for children found to have high levels of "bad cholesterol," LDLs over 190 milligrams per deciliter. Another panel member, Dr. Elaine M. Urbana, director of preventive cardiology at the Cincinnati Children's Hospital Medical Center, was quoted as saying, "This documents on the fact that this generation may be the first to have a shorter life expectancy than their parents."

So go back to the facts: one-third of US kids are overweight and about 12.5 million of them are actually obese. Even here in Colorado, the thinnest state in the nation, I see some of those kids every day. We're not just talking about high schoolers; some of these fat kids are as young as two.

What's missing is a balanced diet with emphasis on fruits and vegetables and a reasonable amount of daily exercise.

earlier blood tests may let them live longer

Daniels comments, "...the atherosclerosis process really begins early in life." he also said, "Heart disease is the number one killer in our society...people who are able to maintain a low risk through childhood and early adulthood have a lower risk (of dying from coronary artery disease)."

From my perspective, it's our responsibility as parents and grandparents, to help prevent childhood obesity, the accompanying risk of later type 2 diabetes and the huge risk of early heart disease. I filled out a health history form yesterday and noted my mother had a heart attack at age 74 (she lived 'till 90), but ignored my father's need for an artery unclogging procedure shortly before his 90th birthday. That may be something I can put off by eating well and exercising, but that's not the focus here.

I never want to see a child or grandchild die of a heart attack in their 50s or 40s or 30s or 20s.

So blood tests between ages 9 and 11 and again between 17 and 21 make sense.



Seemingly disparate topics tied together with MRSA

Thursday, November 10th, 2011

Staph bacteria growing on a culture media

I read two NYT articles  about medical diseases that conflate to a really frightening juncture. They led me to find background data from a medical website and to do a Google search on one lead author.

Let's start with MRSA, the acronym for methicillin-resistant Staphylococcus aureus.  Roughly 25% of us are staph carriers, but only 2% of us carry MRSA, the antibiotic resistant form that causes deadly complications so frequently  and is so difficult to treat. Infections with "ordinary" staph bacteria can be very serious, but respond, in most cases, to the drugs commonly used. The NIH has an excellent summary of MRSA issues and I'll paste in a link to it below.

An August 11, 2011 NYT article mentioned that MRSA skin infections occur in those more prone to cuts and scrapes: athletes, the military and our kids among them. A professor of Medicine and Pediatrics at UC Davis Medical School is quoted as saying, " most communities, community acquired MRSA has become the dominant cause of soft tissue infection requiring emergency department care and inpatient care."

In a previous post I noted that a neighbor ended up in our local ICU for a prolonged stay after a scape on his elbow resulted in a rapid spread of redness up his arm unto his chest. As you might surmise, this was an MRSA-caused illness.

MRSA is a major urgent medical problem; almost 19,000 people died from this dire staph in 2005. In that timeframe most MRSA infections were felt to occur in immunocompromised patients.

But now hospital admissions for skin infection in kids have climbed; the rate of these more than doubled between 2000 and 2009. The overall rate still seemed low, 9.4 cases per 10,000 children, but that translates into just under 72,000 kids being hospitalized in that one year.

In the average year roughly 4,000 kids wind up in pediatric ICUs yearly because of severe flu infections and of course many times as many have mild cases of flu. The current study, headed by an associate professor of Anesthesia at Harvard, looked at children who got flu infections during the 2009-2010 H1N1 epidemic and were admitted to ICUs in 35 different locations. Of those  838 youngsters, nearly nine percent, 75 of those kids, died; their median age was 6.

More than a quarter of the children in the study were previously considered totally healthy; they didn't have asthma or a neurological disease; they were not immunosuppressed and didn't have other chronic conditions. So of the total, 251 kids were otherwise healthy prior to getting the flu; 18 of them died. The only predictor of death in healthy children in this group was MRSA infection; if they had this co-existing risk factor their risk of dying increased eight times when compared to those who did not have MRSA.

Please ask your pediatrician about flu vaccination

My take on the study, and that of the lead researcher, is it's time to make sure our kids and grandkids get vaccinated for flu on a yearly basis.  There are still people who never want their children vaccinated; physicians in almost all cases would disagree with them.

Talk it over with your own pediatrician.

Kudzu: the semi-good, the bad and the stinky

Saturday, November 5th, 2011

kudzu growing over abandoned vehicles in Tennessee

I'm way afield on this post, but I just couldn't resist. I was reading The Wall Street Journal one recent morning and ran across an article with the intriguing title, "Bug Battle: An Invasive Plant Now Faces Its Own Attacker." The plant of course was kudzu. I thought it was widespread...somewhere in the South, and accidentally introduced, forty years or so ago,  into the United States. I decided due diligence was needed here as in my other background research and looked for both the "bug" and the history of kudzu itself. I was hooked on the story within an hour.

It turns out that the introduction of kudzu into North America was more complex and multi-layered than I had ever suspected. The first mention of it in the United States dates back 135 years to the Centennial Exposition of 1876. Then, as one small part of a multi-national effort to celebrate the birth of our country, kudzu was shown as an ornamental vine at the Japanese Pavilion. In 1902 a botanist named David Fairchild, who had seen it used as pasturage in Japan, planted seedlings around his Washington, DC home. In the 1920s owners of a Florida nursery promoted its usage for forage and sold plants through mail-order.

Then came the Great Depression of the 1930s: the Civilian Conservation Corps gave jobs to hundreds of men planting kudzu for erosion control. In the 1940s Channing Cope, the farm editor of the Atlanta Journal-Constitution and one of the South's best-known and most influential radio broadcasters, started Kudzu Clubs to honor the so-called "miracle vine (July 4, 1949 edition of Time Magazine).

Kudzu spread, growing as much as a foot per day in the Southeast during Summer and sixty feet a year overall. In 1953, the US Department of Agriculture banned kudzu as a cultivated crop, but by then its aggressive growth had started taking over many thousands of acres. One prominent US Forest Service researcher tried various herbicides as control methods: over an 18-year period  he didn't find a single agent that effectively controlled the vine; one actually promoted its growth.

A variety of uses for kudzu have been promoted by ingenious American scientists and merchants: an Agronomist at Tuskegee University found that angora goats could control the noxious plant on otherwise unusable land while simultaneously producing wool and milk. Others sell baskets made from kudzu, turn its blossoms into jelly and produce hay high in nutritive value. Potential drugs developed from kudzu are in the research pipeline, but not yet ready for human use in this country (though utilized for hundreds of years elsewhere).

But it now occupies over eight million acres of the Southeast and its native antagonist, a relative to stink bugs, wasn't found in the United States until 2009.

The Kudzu bug

Now it's here, first discovered on the exterior of homes in northeast Georgia, but spreading rapidly to sixty Georgia counties, parts of the Carolinas and Tennesee. Megacopta cribaria, kudzu bugs, are small (4-6 mm long), olive-green and when crushed or disturbed, produce a "mildy offensive" odor. They also munch kudzu effectively with estimates of up to a third of the current infestation being eaten over the next decade. Unfortunately, perhaps inevitably, they like soybeans as well; perhaps the next step is to import the wasp that eats their eggs in Japan.

But then what...

Great tongue-in-cheek article on growing kudzu: 32nd Annual Blythewood Kudzu Festival Kudzu Growing Tips

Should the kids be in the middle? It may depend on the kid's middle

Tuesday, November 1st, 2011

This is not the example you should set

Wall Street Journal headline caught my eye, "Obesity Fuels Custody Fights." It noted that childhood obesity is frequently being used by one parent or the other as grounds for custody changes with accusations concerning poor diets and lack of exercise flying back and forth.

That led me to a July 13, 201 article in The Journal of the American Medical Association (henceforth JAMA), "State Intervention in Life-Threatening Childhood Obesity."

We're not talking about mildly overweight kids here; in 2009 a 555-pound fourteen-yer-old boy, living in one of the southeastern states, was taken  by court order from his mother and placed into foster care. She in turn was charged with criminal neglect as the Department of Social Services for that state felt they must intervene or the boy would be at considerable risk for major obesity-related problems, especially diabetes type 2. I found a photo online of the boy and my jaw dropped.

The JAMA article notes "even relatively mild parenting deficiencies" can contribute to a child's weight problems: having junk food in the home, frequently taking the kids to fast food restaurants, failing to model an active lifestyle.The CDC estimates `17% of America's kids and teens are obese (we're not just talking mildly overweight); that's 12.5 million kids at risk. The two Boston authors who wrote in JAMA quote a study showing 2 million of those obese kids are grossly obese with a BMI at or beyond the 99th percentile for their age (a very small percentage of those grossly obese kids, it turns out, may have a genetic abnormality; in those rare cases, the parents aren't to blame).

What can we do about this horrendous problem? Well, there are a variety of "bariatric" operations available in pediatric surgery programs; in dire cases state legal action may be

this makes more sense

necessary. But I liked what I saw the other day walking Yoda, our nine-year-old Tibetan terrier, on his morning constitutional (he gets an evening walk as well, which means either my wife or I or both get some extra exercise).

We came near the elementary school near us and there was a long line of kids, punctuated by an occasional teacher, running past. We stopped to watch, realized these were kindergarden and/or first grade kids, and finally had an opportunity to ask one of the teachers what was going on.

"It's a new program we've started in the Poudre School District," she said. "We keep the kids moving for thirty minutes. They can run and most do, or twirl around and walk the field next to the school, but they've got to keep moving."

The conclusion in the JAMA article was stark, but offered a road to resolution. The authors noted, "An increasing proportion of US children are so severely obese as to be at immediate risk for life-threatening complication including type 2 diabetes." They mentioned the pediatric weight loss surgical programs and state protective services, but finished with our need to decrease the need for those options through beefing up the social infrastructure and policies to improve both kids' diets and guide them toward more physical activity.

Those solutions may work.