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Financial Crisis in Medicine

For the last three weeks, a supposed cyberattack on Change Healthcare, a unit of the United Healthcare & Optum organization, has dramatically disrupted the business of health care providers across the United States.

Medicare and all commercial insurances have stopped reimbursing medical offices, including ours, for nearly four weeks.

In asking these health plans for clarification, all we’ve heard is crickets.

When you or I call our insurance companies about this, we get told “there is nothing wrong” and “payments are being made.”

There is either a major breakdown in the communication in these health plans or they are lying.

Change Healthcare is a juggernaut in the health-care world, processing 15 billion claims totaling more than $1.5 trillion a year, the company says [1]. It operates the largest electronic “clearinghouse” in the business, acting as a pipeline that connects health-care providers with insurance companies who pay for their services and determine what patients owe. It supported tens of thousands of physicians, dentists, pharmacies and hospitals, handling 50 percent of all medical claims in the United States, the Justice Department wrote in a 2022 lawsuit that unsuccessfully tried to block UnitedHealth from acquiring the company [2].

Because of this financial fiasco, small and medium sized clinics are scrambling to stay open.

Today many have closed their doors, because of financial payment and reimbursement coming to a screeching halt.

This has dramatically exposed the fragility of the insurance and billing systems that underpin American health care.

Our office, for example in the last four weeks, has only been paid 10% of what we’ve billed out.

It is not possible to pay staff and keep the lights on in a medical office when you don’t actually get paid.  Most small offices have about a 1-2 week cushion before they are forced to close the doors.

Who really knows if this actually was a cyber-attack?

Because EVERY insurance company including Medicare and hospital systems, have stopped paying in the last three weeks.

Sadly, insurance companies have said nothing directly to us as providers, until today.  As of today, they are claiming payment will start up by the end of the month.

All the information I have gained about this has come directly through the media. They claim that this has prevented insurance payments from processing, leaving many care providers and pharmacies to float the bill up front and hoping to get reimbursed.

After 25 years of medical practice, and dealing with problems like this year after year (Medicare frequently just stops paying in January for no reason), this is the last straw.  My office will no longer be accepting any insurance as of May 1, 2024.

We convert to a cash/fee for service/concierge practice.

Because insurance has still not reimbursed us, our office is requiring a $150 retainer which is for services rendered on the day of service between now and May 1, 2024, or until insurance companies compensate us for the services we’ve rendered and the billing we are due. This retainer is refundable upon receipt of your insurance payment or can be added as a credit on your account toward your deductible.

You can pay this retainer and we are happy to see you, or you can reschedule with us and call your insurance company and find out why they are not paying.

We are sorry for the inconvenience that this is causing.

As of today, you have other alternatives.  They are:

Begin our yearly concierge service – $4500 per year – all medical services in the office including quarterly labs are covered (this does not include spa services).

For Visits with Dr. Nally, you can pay cash or card at the time of service at the rates below:

Establish Patients                                            New Patients

10 minutes – $90.00                                        10 minutes – $140.00

20 minutes – $130.00                                       20 minutes – $180.00

30 minutes – $190.00                                       30 minutes – $240.00

40 minutes – $250.00                                       40 minutes – $290.00

60 minutes – $350.00                                       60 minutes – $450.00

Visits with our nurse practitioner are billed at 75% of the rates above.

Additional fee for service pricing can be seen in the office.

I realized this will dramatically change our practice.  However, this is the only way our office will be able to continue to provide solid and effective medical care.

To your health & longevity,

Adam Nally, DO

References:

  1. https://community.changehealthcare.com/developers/eligibilityandclaims
  2. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.justice.gov/atr/case-document/file/1476901/download

Mask Wearing Has No Scientific Evidence Based Justification

Nearly three years after the start of COVID-19 in early 2020, people are still showing up in my clinic wearing single and double masks, with tremendous fear of getting an infection with COVID-19 or Influenza.  As of the end of 2022, some “so called” experts started telling people in the public to wear masks again, and patients in droves are showing up masked to their medical appointments in the last four weeks.

Before the COVID-19 pandemic, the existing available data about respiratory viruses including influenza and various types of coronavirus showed no evidence or justification for wearing masks to prevent the spread of infection of a respiratory virus.  The legitimate reason for use of a mask is during surgery to lend protection from blood and body fluid splatter between patient and providers or with specific types of filtration masks designed to specifically protect from certain types of bacterial infections.  

Review of the Medical Literature:

Here are key anchor points to the extensive scientific literature that establishes that wearing surgical masks and respirators (e.g., “N95”) does not reduce the risk of contracting a verified illness:

  • Jacobs, J. L. et al. (2009) “Use of surgical face masks to reduce the incidence of the common cold among health care workers in Japan: A randomized controlled trial,” American Journal of Infection Control, Volume 37, Issue 5, 417 – 419. https://www.ncbi.nlm.nih.gov/pubmed/19216002. N95-masked health-care workers (HCW) were significantly more likely to experience headaches. Face mask use in HCW was not demonstrated to provide benefit in terms of cold symptoms or getting colds.
  • Cowling, B. et al. (2010) “Face masks to prevent transmission of influenza virus: A systematic review,” Epidemiology and Infection, 138(4), 449-456. https://www.cambridge.org/core/journals/epidemiology-and-infection/article/face-masks-to-prevent-transmission-of-influenza-virus-a-systematic- review/64D368496EBDE0AFCC6639CCC9D8BC05. None of the studies reviewed showed a benefit from wearing a mask, in either health care worker or community members in households (H). See summary Tables 1 and 2 therein.
  • bin-Reza et al. (2012) “The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence,” Influenza and Other Respiratory Viruses 6(4), 257–267. https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1750-2659.2011.00307.x “There were 17 eligible studies. … None of the studies established a conclusive relationship between mask/respirator use and protection against influenza infection.”
  • Smith, J.D. et al. (2016) “Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis,” CMAJ Mar 2016 https://www.cmaj.ca/content/188/8/567 “We identified six clinical studies . . . In the meta-analysis of the clinical studies, we found no significant difference between N95 respirators and surgical masks in associated risk of (a) laboratory-confirmed respiratory infection, (b) influenza-like illness, or (c) reported work-place absenteeism.”
  • Offeddu, V. et al. (2017) “Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis,” Clinical Infectious Diseases, Volume 65, Issue 11, 1 December 2017, Pages 1934–1942, https://academic.oup.com/cid/article/65/11/1934/4068747 “Self-reported assessment of clinical outcomes was prone to bias. Evidence of a protective effect of masks or respirators against verified respiratory infection (VRI) was not statistically significant.”
  • Radonovich, L.J. et al. (2019) “N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial,” JAMA. 2019; 322(9): 824–833. https://jamanetwork.com/journals/jama/fullarticle/2749214 “Among 2862 randomized participants, 2371 completed the study and accounted for 5180 HCW-seasons. … Among outpatient health care personnel, N95 respirators vs medical masks as worn by participants in this trial resulted in no significant difference in the incidence of laboratory-confirmed influenza.”
  • Long, Y. et al. (2020) “Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis,” J Evid Based Med. 2020; 1- 9. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jebm.12381 “A total of six RCTs involving 9,171 participants were included. There were no statistically significant differences in preventing laboratory-confirmed influenza, laboratory-confirmed respiratory viral infections, laboratory-confirmed respiratory infection, and influenza-like illness using N95 respirators and surgical masks. Meta-analysis indicated a protective effect of N95 respirators against laboratory-confirmed bacterial colonization (RR = 0.58, 95% CI 0.43-0.78). The use of N95 respirators compared with surgical masks is not associated with a lower risk of laboratory-confirmed influenza.”

Conclusion: Masks Do Not Work

No randomized controlled (RCT) study with verified outcome shows a benefit for health care workers or community members in households to wearing a mask or respirator. There is no such study in existence.

Likewise, no study exists that shows a benefit from a broad policy to wear masks in public.

If there were any benefit to wearing a mask, because of the blocking power against droplets and aerosol particles, then there should be more benefit from wearing a respirator (N95) compared to a surgical mask, yet several large meta-analyses, and all the RCT, prove that there is no such relative benefit.

No Evidence or Justification for Mask Wearing

Despite the news media with all their hype, all of the scientific studies done in the world up until 2020 demonstrated that there was absolutely no justification for mask wearing to prevent spread of respiratory illness including influenza and corona-viruses.  The guidelines of the World Health Organization (WHO) and the US Center for Disease Control and Prevention (CDC) also showed that there was no need for wearing masks in the general public. The practice of wearing masks did not, and to this day, have any professional justification.  

In 2020, the recommendation around the world for wearing masks suddenly changed without any new professional support to confirm their effectiveness against respiratory infection.   The vast majority of studies during the pandemic suffered from very low quality and many biases.  

Only Two High Quality Mask Studies Exist

Since the start of the pandemic only two high-quality studies have been completed, one looking at a population of over 3000 people in Denmark, and the other with over 342,000 adults completed in Bangladesh.  The study in Bangladesh found some marginal benefit for people over age 50 years old, but overall both studies show that there is no significant benefit for wearing masks to prevent infection with influenza or the corona-virus specifically.

In fact, the results of both of these studies demonstrate that the wearing of masks actually may do more harm than good.   In addition to these studies, several observational studies demonstrated that wearing a mask can cause headaches, concentration difficulty, shortness of breath, decrease in blood oxygen levels, increase in the level of carbon dioxide, bacterial contamination from the mask itself and the existence of substances suspected being carcinogenic as result of lack of regulations and the production of masks.

Wearing a mask for a prolonged period of time can become problematic because of the accumulation of carbon dioxide levels that may exceed permitted standards, might cause tiredness, blurriness, sleepiness and deficiency in judgment, as well as thinking.  

Masks Adversely Affect Social, Mental and Emotional Health

An additional issue I personally found to be a problem in my office, masks create communication difficulty with people who have impaired hearing and need to read lips is a major factor.  Additional studies demonstrated the negative effect of wearing masks on communication and especially with children’s mental and emotional development.

There are a few particular situations in which wearing masks is justified.  In the context of medical treatment when a patient with a respiratory disease is closely examined by medical staff who will be spending prolonged periods of time with that patient, and certainly in the cases of active infectious COVID-19 there is justification for wearing a mask by both the therapist and the patient. However, research still demonstrates the spread to be very low if the contact is less than three hours in length.

As a physician who has practiced medicine for over 20 years, when the patient comes to me with leg pain there is no reason for him or for me to wear a mask.  If a patient comes in with anemia, there is also no reason to wear a mask.    In the medical encounter, the relationship that exist between the doctor and the patient has great significance.  Masks interfere with that relationship and the empathy that should exist between them.  Mask wearing when none is justified creates a subconscious barrier and changes the social and emotional dynamics between the patient and doctor.  Currently, there is a directive for mask-wearing in medical, health and welfare facilities around the world in a number of countries and in a number of hospitals which actually has no scientific justification.

Untrustworthy Medical Journals and Bias

The medical profession and providers within this profession rely heavily on articles published in high-quality journals to provide evidence based guidance and direction for our decisions and actions.  However, in the last three years, bias in these publications has been very significant and misleading in these leading journals.  It has essentially made them untrustworthy.  

Because of this, doctors have passed through a kind of brainwashing by the medical establishment.  They have been receiving inaccurate, misleading and contradictory information from previously trusted sources now swayed by bias, political, governmental and monetary influence, so doctors themselves struggle to know what is right and what is not.

Perhaps most worrisome is the continued refusal to have open professional discussion, and the disdain for different positions backed by poor quality research and data not consistent with the norms of medicine and science.  This has had long-term negative consequences for the medical profession and consequences that every doctor in the world should be concerned about.

As I mentioned above, no study exists that shows a benefit from any broad policy to wear masks in public. There is good reason for this. It would be impossible to obtain unambiguous and bias-free results because:

  • Any benefit from mask-wearing has only a very small effect, since undetected in controlled experiments, which would be swamped by the larger effects, notably the large effect from changing atmospheric humidity.
  • Mask compliance and mask adjustment habits would be unknown and impossible to account for.
  • Mask-wearing is associated (correlated) with several other health behaviors; see Wada (2012).
  • The results would not be transferable, because of differing cultural habits.
  • Compliance is achieved by fear, and individuals can habituate to fear-based propaganda, and can have fundamentally different basic responses.
  • Monitoring and compliance measurement are near-impossible, and subject to large errors.
  • Self-reporting (such as in surveys) is notoriously biased, because individuals have the self-interested belief that their efforts are useful.
  • Progression of the epidemic is not verified with reliable tests on large population samples, and generally relies on non-representative hospital visits or admissions.
  • Several different viruses and strains of viruses causing respiratory illness generally act together, in the same population and/or in individuals, and are not resolved, while having different epidemiological characteristics.

Unless you’re going in to perform surgery, please, for your health and mine, stop wearing a mask.

Cracks in the Armor of Primary Care Medicine

Primary care medicine and the physician’s and providers that provide it are at the breaking point. I’ve provided some of the key points identified in a survey of primary care physicians completed March 1, 2022.

  • 46% of physicians said that primary care is crumbling.
  • 41% said they are mentally and financially fragile.
  • 33% said they have been denied or are over-due serious payment from insurers and health plans.
  • Only 21% of primary care offices are fully staffed.
  • 60% of patient visits take longer due to worsening health of population and exacerbated concerns with delay on access to care during the pandemic.
  • 25% of doctors plan to leave primary care in the next 3 years.
  • 28% of doctors had to limit use of telehealth due to insufficient payment. 
  • Computer literacy is a significant obstacle for 20% of the patients trying to use telehealth.
  • Broadband speed is a significant issue for 20% of patients trying to use telehealth.
  • 36% of physicians state that their burnout is at an all-time high.
  • 53% say that their ability to bounce back and recover from this adversity and burden is severely limited.

“Primary care continues to face a policy emergency regardless of when the COVID-19 public health emergency is rescinded. The findings above continue the ongoing narrative captured in over 35,000 responses to this survey since March 2020. ”

Policymakers, health plans, hospitals and patients alike must respond or watch primary care collapse on their watch.

Ketogenic Diet Halts Tumor Growth

 

Prostate Cancer Cell Replication
Prostate Cancer Cell Replication

It has long been understood that tumor cells of any kind require high levels of glucose to grow and spread (1,2).  It is also recognized that higher levels of insulin, commonly found in patients with insulin resistance or type II diabetes, are 2.4 times more likely to stimulate the development of breast cancer (3). A diet low in glucose has thereby been theorized to be an adjunct to cancer treatment.

Ketogenic diets have been demonstrated to be therapeutically useful in the treatments of epilepsy and cardiovascular disease (4). A ketogenic diet is one in which carbohydrate levels are kept below 50 grams per day and fat intake is increased to the point that the body shifts its metabolism to use triglycerides, and the ketones derived from triglycerides, as the primary fuel source for the majority of the cells within the body.  With this understanding in mind, the application of a ketogenic diet, one high in fat and protein with limited carbohydrate or glucose has been suggested as a adjunct to cancer treatments (5).

KetoOS
KetoOS – Drinkable Exogenous Ketones

A recent study (6) in the Oncology Letters evaluated the benefits of a ketogenic diet in 78 cancer patients in clinical practice.  A novel marker measuring the tumor cells use of glucose called transketolase-like-1 (TKTL1) was closely monitored, as was each of the 78 patients adherence to a ketogenic diet.  Increased TKTL1 was noted in more aggressively active and growing tumors (7,8).

Among the 43 males and 35 females, 7 patients agree to and followed a fully ketogenic diet and 6 of them followed a partially ketogenic diet.  Ketogenic meals were provided by a German company called Tavarlin that would prepare and mail ketogenic meals including oil, fat, snacks, bread, protein and energy drinks.  Dietary journals were reviewed every three months over a period of about 10 months.

40 % of these patients experienced a halting of the tumor progression and 60% experienced improvement noted by normalization of TKTL1 or reduction in TKTL1, respectively.  Those on a ketogenic diet demonstrated an average reduction of TKTL1 by approximately 50%.

This is the first study of its kind and has significant potential.  Could dietary carbohydrate restriction be an effective cancer treatment or adjunct to cancer treatment?

Because the food diaries were based on reporting only, the sample study was very small, and patients treated in the outpatient setting have the possibility of variability in the standard oncologic treatments,  the results must be interpreted with caution.  However, the data is very promising.   This study is one in which I have great interest as I have seen similar results in my clinic on a case by case basis.

Based on the limitations noted above, rigorous randomized control studies are needed, but this is an exciting an promising first step.  Additionally, the presence of a marker for tumor growth that correlates with diet is remarkable.  And, it provides the ketogenic specialist a possible measurement tool that could be used clinically.

 

References: 

  1. Klement RJ and Kämmerer U: Is there a role for carbohydrate restriction in the treatment and prevention of cancer? Nutr Metab (Lond) 8: 75, 2011
  2. Vaughn AE and Deshmukh M: Glucose metabolism inhibits apoptosis in neurons and cancer cells by redox inactivation of cytochrome c. Nat Cell Biol 10: 1477-1483, 2008.
  3. Gunter MJ, Hoover DR, Yu H, Wassertheil-Smoller S, Rohan TE, Manson JE, Li J, Ho GY, Xue X, Anderson GL, et al: Insulin, insulin-like growth factor-I, and risk of breast cancer in postmenopausal women. J Natl Cancer Inst 101: 48-60, 2009.
  4. Paoli A, Rubini A, Volek JS and GrimaldiKA: Beyond weight loss: A review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. Eur J Clin Nutr 67: 789-796, 2013.
  5. Ruskin DN and Masino SA: The nervous system and metabolic dysregulation: Emerging evidence converges on ketogenic diet therapy. Front Neurosci 6: 33, 2012.
  6. Jansen, N., Walach, H.”The development of tumours under a ketogenic diet in association with the novel tumour marker TKTL1: A case series in general practice”. Oncology Letters 11.1 (2016): 584-592.
  7. . Schwaab J, Horisberger K, Ströbel P, Bohn B, Gencer D, Kähler G, Kienle P, Post S, Wenz F, Hofmann WK, et al: Expression of Transketolase like gene 1 (TKTL1) predicts disease-free survival in patients with locally advanced rectal cancer receiving neoadjuvant chemoradiotherapy. BMC Cancer 11: 363, 2011.
  8. Zhang S, Yang JH, Guo CK and Cai PC: Gene silencing of TKTL1 by RNAi inhibits cell proliferation in human hepatoma cells. Cancer Lett 253: 108-114, 2007

Red & Processed Meats . . . The Hidden Agenda

I’ve been hearing it all day.  Almost every patient asked me the question: Is red meat really as bad as the World Health Organization is claiming?  Multiple articles can be found today in the New York Times, and the Washington Post, and even in Money Magazine today.  (Money Magazine . . .  really?!)

The World Health Organization (WHO) is claiming that processed meats are cancer causing or carcinogenic on the same level as alcohol and asbestos.  They also are claiming that red meat is “probably” carcinogenic.   “Probably.” That’s a pretty big hedge for a claim of cancer after years of research was reviewed in meta-analysis.  Probably is defined by Merriam-Webster to mean: “as far as one can tell.”  Well, I can tell you, as far as I can tell, this is bad science being reported as fact to sway the lay mind in following an agenda.

The real story here is NOT that red meat is bad.  The real story, that absolutely no one has mentioned, is the veiled agenda cloaked as blame placed on a source of food.  This is the WHO’s first step in advancing the Global Warming Agenda.

“Oh, no, Dr. Nally.  Here you go talking all that crazy conspiracy stuff!”

No, let me spell it out in the actual words of the World Health Organization.

First, the WHO Director General has published a Six Point Agenda, this year, specifically outlining her vision for high priority issues.  The first point on this list of six is to “drive the global agenda . . . in the context of accelerating progress to the Millennium Development Goals.” (1)   What in the world are Millennium Development Goals you may ask?

The Millennium Development Goals were first identified in 2000 at the United Nation’s Sustainable Development Conference and reconfirmed this year.  These goals specifically outline a transformational vision of the world.  The World Health Organization has taken these 16 goals as their “call to arms.”  Goals #12 and #13 specifically discuss “ensuring sustainable food consumption patterns throughout the world” by “doubling agricultural growth” and restricting food production that worsens the “carbon footprint.” (2)

Over the last ten years, multiple progressive groups and sites have made the claim that the greatest threat to Climate Change is the cattle industry.  They link cattle, livestock and our consumption of red meats to global warming and have been preaching the politics of nutrition.  They claim that the only real way to stop climate change and global warming is to “eat less red meat and dairy products.” (3)

The claim is that if we each reduce the red meat in our diet, it will reduce the number of livestock around the world and decrease methane production . . . that causes global warming.  I can personally attest to you, that if you eat a more vegetarian diet including cauliflower, broccoli, eggplant and legumes, you alone will increase the methane production in the atmosphere!

In fact, the Lancet, a well recognized medical journal, has published a series of articles yearly, starting in 2008, calling for the reduction in red meat, pork and livestock to control climate change. (Wait a minute?  I thought the Lancet was a journal dedicated to diabetes?)  All of their climate change/red meat research is based in meta-analysis consisting of “reported” meals by subjects from memory over a 5 year period.  Who can remember what they ate last week?  These authors then make claims of conjecture, stating that sources of meat “could be,” “may be,” or “probably are” harmful and “have the potential to” reduce climate change (4).lightening_storm

Second, links to cancer using processed meats are very, very small, . . . like a 0.04% chance of colon cancer if you eat processed meats.  You have the same chance of getting hit by lightening in your lifetime – 0.04% chance (5).  To liken this  level of risk in the main stream media to that of smoking or asbestos exposure is immoral and unethical.

Urea Cycle
Urea Cycle

The concern for many regarding processed meats is the nitrate contents from nitrogen byproducts.  About 5% of nitrates are converted into nitrites in the gut, and these can affect the oxidation within the colon an the blood stream.  However, most of us handle these nitrites and nitrates through the urea cycle without any problem.  Third, spinach, lettuce, cabbage, bok choy and carrots have two to five times higher nitrate concentrations than bacon and hot dogs (6).  (Hmmm . . . wonder why the WHO didn’t classify spinach and lettuce as carcinogenic?)  Fish produce nitrites in their waste and plants absorb the nitrites in the ponds and lakes and bodies of water they live in. (Look up aquaponics). Most of us have the ability to block the conversion and clear any nitrites out of our systems. The problem arises when we ingest foods that are high in nitrates in conjunction with high fructose corn syrup or “sugar,” to be simplistic.  The hepatic (liver) metabolism of fructose in the presence of glucose (that’s what happens when we ingest sugar) inhibits endothelial nitric oxide synthase, increases insulin and suppresses the uric acid cycle allowing for build up of nitrites in the system.  Metabolism of FructoseIt’s the decreased nitric oxide and the high insulin response most of us get from eating the bread or juice with the bacon or the sausage that inhibits our ability to block the conversion leading to carcinogenic levels. (It ain’t the meat . . . its the sugar and the insuiln!!)

As for me, “pass the pastrami, I’m going to sit on the porch and watch a really amazing lightening storm.”

Pastrami low carb sandwich

References:

  1. WHO Director General Six Point Agenda, Publications. http://www.who.int/nmh/publications/6point_agenda_en.pdf, October 27, 2015.
  2. United Nations – Sustainable Development Knowledge Platform. Transforming our world: the 2030 Agenda for Sustainable Development.  https://sustainabledevelopment.un.org/post2015/transformingourworld, October 27, 2015
  3. Time For Change. Are cows to blame for global warming? Are cattle the true cause for climate change? http://timeforchange.org/are-cows-cause-of-global-warming-meat-methane-CO2. October 27, 2015.
  4. Demaio, Alessandro R et al. The Lancet. Human and planetary health: towards a common language.  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61044-3/fulltext#back-bib10. October 27, 2015.
  5. National Geographic. Flash Facts about Lightening.  http://news.nationalgeographic.com/news/2004/06/0623_040623_lightningfacts.html
  6. NG Hord et. al.  American Journal of Clinical Nutrition.  Food sources of nitrates and nitrites: the physiologic context for potential health benefits.  July 2009, Vol 90, 1-10.  http://ajcn.nutrition.org/content/90/1/1.full#cited-by.  October 27, 2015.

Don't Fear Fat

Dont Fear Fat

 

Don’t fear the fat.  If you haven’t seen the movie Cereal Killers, you should watch it by clicking here.   D.J. O’Neill ditches wheat and sugar in a food plan consisting of 70% fat – under the guidance of legendary South African Sports Scientist Prof. Tim Noakes.

Fat Phobia . . . The Religion

Low Carb Communication Challenges“You want me to eat WHAT?!  But that’s . . . ,it’s . . . FAT, really?”

” Yes, it is.”

Every day, instruction to my patients is initially seen as Food Pyramid heresy and My Plate iconoclasm. Yes, I want you to flip the Food Pyramid on its head, and push everything off My  Plate and fill it with fat. . . Really. . . Yes, I do.

I was counseled by many school professors over the years that there are two things you should avoid talking about: Religion & Politics. The ketogenic or low carbohydrate dietary conversation involves both.  “Fat Phobia” is a Religion.  We have demonized fat and sainted the treadmill.  You see, fat got a bad wrap when the bomb calorimeter was invented.  We realized that there was twice as much energy found in fat that there was in carbohydrate or protein.  Early nutritionists, understanding that heat is a form of energy, and realizing that energy is conserved, found that food substrates contain a set amount of energy that can be measured in a closed environment.  Naturally,  the Law of Thermodynamics got applied to lend understanding in how people gain or loose weight. We coined the term “you are what you eat” based upon our understanding of the Laws of Thermodynamics. The calorie became “king.”

  • 1 gram of carbohydrate = 4 kcal
  • 1 gram of protein = 4 kcal
  • 1 gram of fat = 9 kcal

For the last sixty years (an entire generation of humans) we have based our diet around the calorimetry of food and have labeled them as good or bad based upon calories. To loose weight, we are taught, you either have to eat food containing fewer calories (fat has the most calories per volume so it must be bad!) or burn it off faster than you take it in (did you go exercise at that new gym next door), right?  Wrong.

First, you and I are not bomb calorimeters.  We are not closed systems. We harbor variable levels of symbiotic bacteria (these also burn fuel at variable rates) and our body temperatures fluctuate to regulate other enzymatic and hormonal processes.

Second, bomb calorimetery functions on the premise that volumes are also held at a constant. Human volume and density change daily.  Simple chemistry tells us that volume = mass / density. The average human mass fluctuates by 5lbs every day and our density changes based upon our hydration status (the amount of water we drink). Because these two variables are not constant in a human being, it is impossible to correctly apply the Laws of Thermodynamics to the human body and accurately predict weight gain or loss.

Third, hormones!  (Anyone married to a pregnant female understands that nothing is as it seems when hormones are involved.) We have a plethora of hormones that change the rate in which fuels are burned or stored in the human body. Our GI flora (symbiotic bacteria in the human gastrointestinal tract) are also affected by hormones and do not have set rates of fuel use or breakdown.  What this means is that you and I process food at different rates and derive different levels of energy and fuel from the same donut.  Genetics plays a leading role in how these hormones are used and turned on and off.  Fat is burned or stored in the body based on a hormonal mechanism I described in a previous post you can read here.

Asking patients to reduce carbohydrate intake to less than 20 grams per day and increasing fat intake to up to 70% of total caloric intake is essentially 20th century nutritional apostasy.

The dietary concepts from the Food Pyramid and My Plate have been embraced by our country for over sixty years.  Changing our views on these as a country will be for many like changing religions.  For those of us “with eyes to see and ears to hear” our work is cut out for us.

Your Work

The Obesity Paradox: The Intersection Where Agricultural Policy Contradicts Health Policy

Intent

The intent of this brief is to analyze the burden of obesity in the United States and to recommend policy changes to reduce the medical costs of obesity imposed upon the individual and country as a whole.

Introduction

Conventional fat reduction/caloric restriction guidelines for the treatment of obesity and associated cardiovascular disease, diabetes, cancer, and hypertension have been recommended since the early 1970’s.  Because these guidelines are based on questionable evidence, the cost of obesity has dramatically risen to almost 21% of overall health care costs in the United States (1).  This brief will analyze the current medical cost of obesity and will explain why the current obesity reduction guidelines perpetuate the problem. In addition, the brief will examine the impact of government agricultural policy on dietary habits, and will recommend changes to farm subsidy legislation in order to reduce the incidence of obesity and decrease costs to the healthcare system.

History & Background

The Cost of Obesity on the Nation

Obesity CostsAs of 2012, obesity accounts for nearly 21% of overall health care costs in the United States.  An obese person incurs $2741 more in medical expenses per year than his or her non-obese counterpart (1).  Medicare spending has increased per person per year by $600 for each obese beneficiary (includes out-patient and prescription drugs) and Medicaid beneficiary prescription drug spending increased by $230 per year per obese person. Private insurance has increased by $248 for prescription drugs and $443 for in-patient services for each obese beneficiary per year (2). That adds up to $190.2 billion spent annually on obesity-related medical problems (3).  This is a drastic change. Health care costs related to obesity were $85.7 billion (9.1% of overall health care costs) in 2006 and $61.2 billion (6.5%  of overall health care costs) in 1998 (4).

Obesity Prevalance 2011The most recent Center for Disease Control statistics reveal that 35.7% of the U.S. adult population is currently obese and another 33% is overweight.  Over 78 million adults and 12.5 million children are obese (5). The addition of 30 million people to the health care roles (current estimation of the Affordable Care Act including Medicaid expansion) means that an estimated $27 billion (in 2012 dollars) more will be spent per year on obesity-related health care costs.

Impact of Government Policy on Consumption

The ‘Farm Bill’ was originally enacted as part of President Franklin D. Roosevelt’s Agricultural Adjustment Act of 1933, which provided subsidies to American farmers in the midst of the Great Depression. Since that time the federal government has paid farmers not to grow seven specific crops – known as commodities – with the intent of decreasing the supply, increasing the demand, and thereby raising the price (7).  Dr. Susan Blumenthal, former Assistant Surgeon General and current SNAP to Health project director, writes, “The Farm Bill has since expanded to include many different categories or ‘titles.’ The last bill to be authorized, in 2008, had 15 titles, including nutrition (food stamps), crop subsidies, conservation, livestock, crop insurance and disaster assistance. The 2008 Farm Bill approved $300 billion in spending: 67% was spent on food stamps; 15% on agricultural subsidies; 9% on conservation; and 8% on crop insurance” (8).

The U.S. Department of Agriculture (USDA) Subsidy Programs tend to favor, either directly or indirectly, foods that increase obesity and other diseases. These subsidies support commodity crops, specialty crops, dairy products, livestock, and federal purchase programs.  Their justification is that they help to stabilize prices in agricultural commodity markets by balancing supply and demand (9).  Between 1995 and 2011, $277.3 billion were given in farm subsidies to almost 40% of U.S. farmers.  Arizona received $1.1 billion (mainly for cotton); however, only 7% of Arizona farms received subsides during this period (10).  These subsidies are incentives to grow and produce specific commodities that have a higher monetary return.  Subsidies also act as a disincentive for farmers to grow fruits and vegetables which fall under the “specialty crops” category.  This restricts both small and large farmers from diversifying their crops, and limits fruit and vegetable production (11).

Arizona farms received $25.3 million in dairy subsidies from 1995-2011 and $29.5 million in livestock subsidies during that same period (9).  Arizona ranks 2nd nationally in its production of cantaloupe & honeydew melons, head & leaf lettuce, spinach, broccoli, cauliflower and lemons, all of which are “specialty crops” and do not receive subsidies (12).  The most recent statistics show that the top five states receiving subsidies are Iowa, Texas, Illinois, Nebraska and Minnesota, with Kansas coming in at a close sixth.  The majority of these subsidies are for corn ($81.7 billion), soybeans ($26.4 billion), rice ($13.3 billion) and wheat ($34.4 billion) from 1995-2011 (10).  It is important to note that the Renewable Fuel Standard of 2012 (legislation protecting the corn-ethanol lobby) mandates that 37% of the corn harvest be used in ethanol production (13).

The food subsidies above have been in place since the Food, Conservation & Energy Act of 2002 and renewed in 2008.  They were only to be available for a period of five additional years and were set to expire September 30, 2012.  However, the American Taxpayer Relief Act of 2012 (H.R. 8), enacted by Congress and signed into law by President Barack Obama, included provisions that extended these subsidies until September 30, 2013 (20).

For many low-income Americans and especially children, federal programs have a direct and significant influence on food choices.  Subsidies where the money goesOver 30 million children receive government subsidized school lunch through National School Lunch Program (NSLP) administered by the USDA Food and Nutrition Service (14).  USDA-purchased meats, dairy products, grains, fruits, and vegetables are supplied to schools for use in meal programs.  Current school lunch recommendations on calorie intake set by the USDA and The Healthy, Hunger-Free Kids Act of 2010mandate school lunches provide 650-850 calories per meal to the 30 million children currently enrolled in this program (15).  Interestingly, that is the same caloric count of a Big Mac®, small fry and Diet Coke® from McDonalds® (16).  The rational for these purchase decisions are based upon agricultural support goals and adherence to national dietary guidelines (14).  A study published in the journal Economics and Human Biology reveals that a person’s body mass index (BMI) increased faster if that personwere on food stamps, and the BMI increased at a faster rate while on the Supplemental Nutrition Assistance Program (SNAP).  “We can’t prove that the Food Stamp Program causes weight gain, but this study suggests a strong linkage,” said Jay Zagorsky,  co-author of the study and a research scientist at Ohio State University’s Center for Human Resource Research (17).  However, much of the food available through the SNAP programs are refined, subsidized high-carbohydrate containing foods.

The price of food influences an individual’s consumption choices (6).  Foods that are refined contain increased amounts of sugar or high-fructose corn syrup. These foods contain more caloric density and are often cheaper and more easily accessible.  These are foods that are usually found in the center of the grocery store and frequently on sale at the end-caps of each isle.  Nutrient-dense, higher fiber foods are frequently associated with higher prices and are consumed less often.  These are the foods you usually find around the peripheral areas of the grocery store (fruits, vegetables, etc.)  Current food subsidy policy found in the Food, Conservation and Energy Act of 2008 extension mandated by the American Taxpayer Relief Act of 2012 drives up the price of fruits, vegetables, and meats. This policy also turns people toward lower cost foods that are higher in simple carbohydrates and caloric density.  Thus, current policy is actually making obesity worse and making America fatter.  Research completed at the University of Illinois at Chicago reveals that small taxes or price changes do not produce a change in a person’s BMI; however, more significant price change has a measurable and significant effect on weight in both adults and children.  Price increases of 100-150% have been shown to change purchasing behavior and thereby affect health (18).  An example of this is the tax levied on cigarette smoking.

The USDA disagrees with the amount of influence they have over the individual American’s food choices.  They state openly on their website that “Some public health advocates have argued that falling real, or inflation-adjusted, prices for many high-calorie foods encourage people to buy and consume more of these foods, leading to poor diet quality and rising rates of obesity. A closer look at how consumers respond to food price variation–over time, across geographic markets, in different types of stores, and in response to taxes and subsidies–reveals how food prices affect people’s food choices, and their waistlines. In short, price matters, but not very much, and it is not the only factor” (19).

Why Current Dietary Guidelines Have Not Been Effective

Why do we get fat?  Why have we not been successful in losing weight via diet and exercise? The obesity paradox was described by Jules Hirsch of Rockefeller University, who proposed two opposing hypotheses:

 

  1. “Obesity is the result of a willful descent into self-gratification” implying that we gain weight because we over-eat (caloric excess) leading to caloric imbalance.
  2. “Alternative hypothesis is that there is something ‘biologic’ about obesity, some alteration of hormones, enzymes or other biochemical control systems which leads to obesity” (22).

The 1977 Dietary Goals for the United States – the first comprehensive statement by any branch of the federal government about the American diet – supported the first theory. The Guidelines were heavily influenced by the American Heart Association’s position that fat intake alone would cause heart disease. The USDA 2011 Dietary Guidelines imply that the “people who are the most successful at achieving and maintaining a healthy weight do so through continued attention to consuming only enough calories from foods and beverages to meet their needs and by being physically active.” (15)

Current research contradicts the caloric restriction or “calorie in – calorie out” theory.  Scientific evidence clearly demonstrates the domino effect of carbohydrate or starch intake increasing insulin levels which thereby stimulates obesity by raising cholesterol and triglyceride levels. Time Magazine recently published evidence that the longstanding recommendations to “eat less high-fat red meat, eggs and dairy and replace them with more calories from fruits, vegetables and especially carbohydrates” is now seen as incorrect (45).  Even our medical textbooks from 1965, like the introductory chapter of the Handbook of Physiology, make it clear that carbohydrate intake cause weight gain and raise triglyceride and cholesterol levels (22), (23), (24).

Current Policy

The current version of the Farm Bill was set to expire September 30th, 2013.  If it had been allowed to expire, the results would have returned us to the 1949 Farm Bill legislation and theoretically double the price of milk. However, this would have had the effect of freeing up over $5 billion dollars of federal spending per year and would also lead to decreased consumption of a major source of carbohydrates in the standard American diet like wheat and corn.  Senator Debbie Stabenow (D-MI), and chairwoman of the Senate Agriculture Committee, had repeatedly said she was opposed to an extension; however, she agreed to a compromise extending the bill for another year to help the farmers experiencing serious drought conditions in 2012 (7).  Two additional extensions were passed in the House and Senate, but because these differed so significantly, it was referred to a House-Senate Conference Committee to work out the compromise details.  With only $23 billion in spending reductions, The Agricultural Act of 2014 was passed on January 29, 2014 (46).   

Outcomes and Stakeholders

Obesity Trends 1960-2008If the United States continues its current course, up to 58% of the population will be obese by 2030 (26).  Many believe that the USDA Dietary Guidelines are to blame.  Richard David Feinman, President of the Nutrition and Metabolism Society and Professor of Cell Biology at SUNY Downstate Medical Center said, “The previous Guidelines have not worked well.  It is unreasonable to ask the Dietary Guidelines Advisory Committee (DGAC) to audit its own work.  An external panel of scientists with no direct ties to nutritional policy would be able to do a more impartial evaluation of the data.  This would be far better for everyone.” (27) A recent Gallup Poll reveals that 63% of Americans believe the USDA Guidelines that a low fat, calorie restricted diet will help in reduction of obesity, and the same study showed that 48% of Americans worry about their weight “all of the time or some of the time” (28).  Recent evidence from the Women’s Health Initiative Dietary Modification Trial studying 49,000 women supports Dr. Feinman’s conclusion above. It did not show any statistically significant evidence that following a low-fat or caloric restricted diet had any effect upon obesity (29). Other nutritional experts from the Salt Institute and the National Health Coalition have expressed their support for significant changes to the USDA Dietary Guidelines (30).  The Weston A. Price Foundation, which according to its website is “dedicated to restoring nutrient-dense foods to the human diet through education, research and activism,” also supports the view that the current USDA Dietary Guidelines have been a significant cause of obesity and have been an active voice promoting legislative change (31).

On the other hand, the Sugar Association has issued statements that sugar is not the cause of obesity and “continually eating too much food and sedentary lifestyles are the major contributing factors to increasing rates of obesity – not sugar intake” (32).  In addition, the American Beverage Association has stated that sugars are not the problem with obesity, but instead, “overweight and obesity are a result of an imbalance between calories consumed and calories burned” (33).

Attempts at modifying the Farm Bill with legislation like the 2012 DeMint Amendment (SA 2276 ) were supported by both Arizona Senators McCain (R-AZ) and Kyl (R-AZ) with a “Yes” vote, as well as Senators Ayotte (R-NH), Brown (R-MA), Burr (R-NC), Coats (R-IN), Coburn (ROK), Cornyn (R-TX), DeMint (R-SC), Graham (R-SC), Hatch (R-UT), Heller (R-NV), Johnson (R-WI), Lee (R-UT), McConnell (R-KY), Murkowski (R-AK), Paul (R-KY), Rubio (R-FL), Sessions (R-AL), and Toomey (R-PA).  However, because of a large lobbying agricultural coalition, it was voted down (34).  Changing farm subsidies will be a great challenge as 40% of the farmers in the U.S. now have some degree of dependence upon these subsidies.  The following agricultural groups have historically had significant monetary interest in the farm subsidies that these amendments would affect:

  • American Beekeeping Federation
  • American Farm Bureau Federation American Mushroom Institute
  • American Sheep Industry Association American Soybean Association
  • National Cattlemen’s Beef Association National Corn Growers Association National Cotton Council
  • National Council of Farmer Cooperatives National Farmers Union
  • National Milk Producers Federation National Pork Producers Council
  • National Potato Council
  • National Sorghum Producers
  • National Watermelon Association
  • Produce Marketing Association
  • United Dairymen of Arizona
  • United Egg Producers
  • United Fresh Produce Association
  • Western Peanut Growers Association

The following groups have formed coalitions in support of the Farm Bill: Health/Food Justice/Farm Group partnerships, Specialty Crop Farm Bill Alliance, Community Food Security Coalition, Center for a Livable Future at Johns Hopkins University, Collaboration for a Healthy Sustainable Food System, and the Healthy Farms, Healthy People: A Farm & Food Policy Summit for a Strong America.

The American Heart Association’s position is that the Farm Bill needs to be modified to include increased access to fruits and vegetables (35).  The American Medical Association’s position in 2008 and 2011 has been for cutting the size and budget of the current Farm Bill (36).  The American Osteopathic Association does not currently have a formal position on the Farm Bill.

If certain crops like corn or wheat were no longer subsidized,drastic changes will be likely in the food manufacturing industry, which would likely be the largest proponent against change.  Unintended consequences of modifying the Farm Bill and not extending its subsidies could have the short term effect of escalating the price of a number of commodities to two to three times their current price.  For example, the price of milk would increase to $6-$8 dollars a gallon without federal subsidies (37).  This would likely deter the use of carbohydrates containing dairy products, but may also increase the price of meats and cheeses as well.

The USDA’s Rural Development Progress Report claims that the subsidies it distributed “saved more than 75,000 jobs” in 2006 and over 400,000 jobs in 2011 (38), (39). They claim that without federal farm subsidiesthere would be significant loss of jobs; however, studies from the Cato Institute actually show the opposite.

“Job gains are weak and population growth is actually negative in most of the counties where farm payments are the biggest share of income. Job growth is decidedly weak in the counties most dependent on farm payments. The vast majority of such counties (483) had job gains below the 19 percent national average from 1992 to 2002. A considerable number (167) had outright job losses over the period. In short, farm payments are not yielding robust economic and population gains in the counties where they should have the greatest impact. If anything, the payments appear to be linked with sub-par economic and population growth. To be sure, this quick comparison cannot answer whether growth would have been even weaker in the absence of the payments.  Still, farm payments appear to create dependency on even more payments, not new engines of growth” (40).

As of 2010, obesity costs about $73.1 billion per year in lost productivity in the United States (43).  The worsening obesity epidemic poses further workforce productivity losses up to 20% more by 2030.  Even small improvements in obesity will improve workforce productivity and has substantial potential for savings.  Currently, the Affordable Care Act allows employers to charge obese employees 30-50% more for health insurance.  Without correcting this epidemic, it may be impossible for many to afford health care, opting out to pay the less expensive tax penalty. This would have the effect of increasing commercial premiums across the country, feasibly pushing private insurance companies out of business and forcing a single payer governmental system.

Recommendations

This brief points out that the overall U.S. healthcare costs associated with obesity have increased by 68% in the last fourteen years.  It provides evidence that using current dietary low-fat caloric restriction guidelines show poor statistically significant improvements in obesity.  And it provides evidence that obesity is not caused by excessive caloric intake and fat, but by insulin response to carbohydrate intake.  Lastly, this analysis provides evidence that the Farm Bill propagates continued worsening obesity rates in the US by providing access to cheap, fattening food.

The USDA 2011 Dietary Guidelines need to be revised to reflect current evidence-based obesity prevention and weight reduction research.  The guidelines should include information about limiting the intake of foods high in carbohydrates.

The food subsidy extension provided in the American Taxpayer Relief Act of 2012 was extended five years by the Agricultural Act of 2014.  Had it been allowed to expire, it would have saved the country over $200 billion over the next ten years.  However, because of so many entitlements involved in this bill, the House and Senate convened in Conference that resulted in a compromise of only $23 billion dollars in spending reductions, the first SNAP reforms since 1996 reducing waste, but did nothing in eliminating subsidies that drive or influence eating behavior (46).

When significant price changes occur, eating behavior will change.  As the price of fattening carbohydrates increases, people will eat less of them, leading to a national decrease in obesity and overweight.  The current reforms did nothing that will change our dietary behavior.

References

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