Healthcare, medicine & pharmaceuticals

The obesity paradox

In our last issue, The unbearable weight of obesity explored the problems of growing obesity in the western world. This story says the opposite. It says we have reached an “obesity plateau”, because the prevalence of obesity has not increased markedly since 2008 in the US or other developed countries. Not only this, being overweight may not be such a bad thing after all: some patients may actually live longer if they are overweight than if they are thin.

It sounds too good to be true, perhaps. After all, most people find it’s no fun trying to lose weight, especially if they have just suffered a heart attack as well. Is it time to give up the skinny milk?

One of the culprits in health research is widespread use of the body mass index (BMI), which divides weight by height squared. This index was never meant to be used to measure individual health, yet everyone adopted it, from insurance companies to health organisations, to do just that. From 1980-2008, average BMI rose so rapidly that obesity rates nearly doubled. Then obesity was redefined from a BMI of 30 to 27, rapidly ushering in a new wave of overweight people.

While the link between obesity and chronic diseases continues to occupy researchers and governments concerned about medical spending, there are indications that patients with heart diseases may do better with more weight on than their thinner counterparts do. A cardiologist in Louisiana, Carl Lavie, found lean patients had almost double the mortality rate of those who were overweight or obese. Other research from Sweden found the same thing and those who were underweight were three times more likely to die than the fatter people.

The question is how being fat helps you live longer. One theory is that it contains anti-inflammatory compounds and extra energy to fight disease. Another is that the hormone leptin is stored in fat and has a protective effect.

If fat helps you live longer with a disease, can it help healthy people live longer too? Meta research of 2.88 million people, by Katherine Flegal, found the relationship between health and BMI is not linear but ‘U’ shaped. This means being overweight or mildly obese is better for health than being very underweight or very obese. Naturally, these results are controversial, particularly when so many people are being urged to lose weight and there is an enormous industry set up to help them.

Part of the problem is that BMI is a poor indicator of fat and cannot tell the difference between fat and muscle. It also works better as an indicator for young people than it does for the elderly. Moreover, obesity does not necessarily imply lack of fitness. One study found 46% of obese people were metabolically healthy, that is, they had good blood pressure, cholesterol levels and insulin resistance. Perhaps weight does not matter after all: what counts is physical fitness.

Most controversial of all is the idea that the obesity panic has more to do with discrimination against fat people than it does with public health. One sociologist claims we are into “fat shaming”, rather than encouraging people to lose weight. It’s an interesting idea, given that fattism seems as prevalent as ageism or racism. While we don’t expect people to change their age or their ethnicity, it seems unreasonable to expect them to change their shape. There is another problem – when does a private health matter become a public health issue?

Why sunshine and fresh air make you better

Florence Nightingale had some simple advice for nurses: “Never be afraid of open windows”. She believed that patients needed to breathe air as fresh as possible. How things have changed. UK hospital regulations say windows within reach of patients must open no wider than 10 cms – so people cannot fall out. Nightingale’s wards also had long south-facing sides to let in (northern hemisphere) sunshine, which helped patients with TB. Nowadays, authorities are afraid direct sunshine will give everybody skin cancer.

Does this mean Florence Nightingale was wrong? Researchers concerned about the waning effects of antibiotics are returning to the pre-antibiotic age to look for clues. One time-honoured method, washing your hands, is still a simple and effective way of combating the spread of so-called superbugs like Clostridium difficile and MRSA. The more alcohol in the soap, the lower the rates of MRSA in hospitals.

Another problem is crowded waiting rooms, emergency wards and outpatient clinics, where undiagnosed people mingle with diagnosed ones – this helps to spread airborne bacteria like TB. When a team looked at clinics in Lima, Peru, they found old hospitals had much better ventilation rates than modern ones – and TB was less likely to spread.

Sunlight has been used in the past to treat TB. When researchers installed old fashioned UV lamps in a ward for guinea pigs with TB, they found infection rates fell from 35 to 10%. Now a UV lamp has been developed that emits UV at 207nm, which does not harm skin tissue but kills bacteria like MRSA.

If artificial sunlight works, why not artificial fresh air? Sounds like a paradox. A UK firm called Inov8 found hydroxyl radicals in fresh air are able to kill airborne germs so they invented a portable device that contained hydroxyl radicals. The device did reduce airborne bacteria, but the firm went out of business. The WHO urges healthcare settings to use natural ventilation where possible and there is no reason why other settings could not do the same – US soldiers in the desert had more coughs and colds in air conditioned barracks than they did in tents and warehouses.

This brings us back to opening the windows in hospitals. Is it really better to protect one unfortunate patient from (possibly) falling out of a window than helping the majority of them recover from disease? Or creating a fresh atmosphere for the people working there? As always, the simplest methods seem the best, but the companies with the most to gain tend to keep them complicated.

Medical tourism comes home

In our last issue, we said medical tourism is a $US40 billion a year business serving 780 million patients and it will boom with ageing and low-cost travel. Beware of what you read. It seems Deloitte counted 750,000 American medical tourists in 2007 but McKinsey counted only 10,000 the following year. Patients Beyond Borders now says about 12 million people travel for care, of which 1 million are American. What happened to the “explosive boom”?

First, people don’t want to travel to be treated. They want the comfort and familiarity of home and they are afraid of what might happen if something goes wrong. When Hannaford, a US supermarket chain, offered to pay for knee and hip replacements in Singapore, not one employee took up its offer.

Second, insurers need to embrace the idea too. In fact, only 2% of their spending is on non-urgent procedures that could be done abroad. They also have a lengthy task of choosing foreign hospitals, negotiating contracts and arranging follow-up with domestic providers of care – it all eats into margins.

Third, governments don’t encourage their citizens to be treated overseas because it looks as if their health policies have failed. When Britain allowed long-suffering patients to seek treatment in Europe, it was seen as a “humiliating” failure. German people who choose to live in eastern European homes blame their government because they cannot afford to retire at home – another failure of policy?

Some hospitals are going abroad to find patients, such as Singapore’s Parkway Health setting up hospitals throughout Asia. Meanwhile, American insurers have been negotiating bulk rates with high quality hospitals at home. For example, PepsiCo made a deal with Johns Hopkins in Maryland and Lowes, a deal with Cleveland Clinic in Ohio. In the end, it is up to the paying public where they want to be treated. They are the lucky ones, because the ones without insurance won’t be treated anywhere.

Dating in genes

Imagine you have just met someone on a dating site, you both want children later, and you want to know whether your combination of egg and sperm will create a healthy child. That has just become possible. Two fertility clinics in America are using Matchright technology, developed by GenePeeks, to screen out any sperm donor likely to increase the risk of inherited genetic disease in the child of a woman treated at the clinic. She pays $US1995 for this certainty. Some of the traits are severe diseases, like Tay-Sachs and Zellweger syndrome; some are eye and skin pigmentation or height, breast and waist size. This is controversial, given that parents might easily select children on the basis of superficial characteristics only.

GenePeeks will sequence the DNA of both parents and then digitally create the process of genetic combination to see if there are any likely risks. These algorithms are run thousands of times for each donor, producing up to 10,000 ‘simulated embryos’. Most IV clinics already test for genetic disorders but the GenePeeks method screens for many more diseases and will be used in the future to screen for complex disorders caused by clusters of genes, such as schizophrenia.

Another company, 23andMe, created an ‘inheritance calculator”, which also suggests which traits might be passed on to a couple’s children. It is possible that infertile or gay couples could select a donor based on the kind of traits that are closest to their own, for example, looking like the parent even though he is not the natural father.

Once again, it sails close to the wind because ethics demand that people do not select children only for their blonde hair or green eyes. We don’t want men who won’t date women who could have mentally unstable offspring, or women who only date men who won’t give their children asthma or Alzheimer’s. We think it’s just another case of TMI – too much information.

Do mobile health apps really improve healthcare?

Mobile health or m-health apps are the new wave of gadgets designed to make healthcare more effective and cheaper. Companies are putting their money where their mouths are: of $2.2 billion poured into mostly American healthcare startups in 2013, $564 million went into m-health.

M-health looks like this: a typical patient, with a smartphone and software app, carries a wearable monitor so doctors and carers can observe them remotely and gather data on the effectiveness of their treatment.There are two types of m-health: one to monitor a wearer’s physical fitness, such as Jawbone wristbands, and one to link patients with a medical condition to the healthcare system. The second category appears to have more potential.

For example, Google is working on a contact lens with sensors that measure the amount of glucose in a diabetic’s tears. Qualcomm Life is building a technology platform that is able to combine data about medicines and results of tests, for example, so doctors have a more cohesive picture of their patient.

There are already numerous medical devices, such as glucose monitors, wireless scales, electrocardiograms on smartphones, and the new otoscope, a device that looks inside the ear and sends an app by iPhone to the doctor. One company is even testing a sensor that can assess stomach fluids to find out whether patients have taken their medicine or not!

If the thought of this does not enthuse, you grasp the reticence and conservatism of the healthcare industry, as opposed to techhead fascination for new gadgets. Moreover, doctors are paid per visit, and they may be less enamoured with less frequent visits. Insurers are worried it may lead to hypochondria – the ‘worried well’ might fuss over anomalous readings and so make even more visits to the doctor. There seems to be a clash of interests here.

Some m-health products will have to be approved by the FDA (US) if they do the work of a traditional medical device (as opposed to a pedometer). It is still early days for making rules for these m-health devices too. As The Economist notes, firms “will need plenty of patience and deep pockets”. Surely, like Big Pharma, their pockets will need to be replenished eventually by the patient?

The big question is whether these devices do in fact save money and improve life for patients. There is scant evidence of this so far.

‘e smokes e-cigarettes

When is a cigarette an e-cigarette? When it doesn’t contain tobacco. The tobacco firms are all puffed up because they have invented a product they call “healthy” because it doesn’t seem to hurt the smoker or the people around them. The difference is that one is combustible and one is not. Better still, one is fashionable and one is not.

The e-cigarette contains a computer chip, lithium-ion battery, heating element and a cartridge filled with nicotine dissolved in water. When the vaper (smoker) takes a drag, the heater fires the element to 150 degrees centigrade, heats the liquid so it evaporates, and the nicotine vapour offers its hit. The vaper then exhales mostly water vapour. Tricky eh?

As yet, there is no research on the health effects of e-cigs because it is too early. They certainly affect the cardiovascular system and blood sugar levels and they contain propylene gloycol, which irritates airways. Like the cigarettes of old, nobody knew what effect they had until decades later when, for many people, it was just too late. Could it happen again?

Sales of e-cigs are more than $US2 billion around the world, including 7 million in Europe and 1.3 million in Britain. Brands include BAT’s Vype and Zandera’s E-Lite, and Lorillard’s Blu and they are slightly cheaper than combustibles. A number of celebrities are smoking e-cigs, just to give the growing market a further push; Wells Fargo says e-cig consumption could overtake combustible cigs in western markets within a decade. Since there is no need for health warnings, anybody can buy them and it’s not illegal to sell e-cigs to people under 18 (though BAT insists they are offering an alternative to adult consumers). Almost 50 years later, e-cigs are on billboards and in magazines, just like the old days.

Smokers who are sick of being social pariahs can join their friends again, particularly in football stadia, cruise ships and at Heathrow’s Terminal 4. Restaurants, pubs and bars are not convinced. JD Wetherspoon says it is too hard to differentiate an e-cig from a normal cig, and they just ban them all.

This seems to be the crux of the issue: if it is difficult to distinguish between a cig and an e-cig, what is to stop sales of both kinds growing? If smoking itself becomes cool again, does it negate all the work done to cut the behavior of smoking? The Royal College of Physicians’ Tobacco Advisory Group says that if all the 10 million smokers in Britain switched to e-cigs, there would be 5 million fewer deaths from smoking. But what if more people, especially the young, took up smoking combustible cigs, just because they are more dangerous?