Facts and ideas from anywhere

William C. Roberts, MD

AFFORDABLE CARE ACT

Is it affordable? Is it desired by Americans? The nonpartisan Congressional Budget Office predicts that “Obamacare will reduce the nation's labor supply by 800,000 workers” (1). Some private economists predict a nationwide loss of up to 2 million jobs. A recent Chamber of Commerce survey indicated that 74% of small businesses say the law makes it more difficult to hire new workers. The law contains $813 billion of new taxes and is estimated to cost almost $2 trillion. The law takes $500 billion from Medicare. It creates a panel of 15 unselected bureaucrats—the Independent Payment Advisory Board—and empowers it to effectively ration health care to seniors. Its decisions can only be overturned by an act of Congress. This board is only one of 159 new federal boards, commissions, and programs that will soon be inserted between Americans and their physicians, not to mention the current 12,000 pages of new rules and mandates. Granting the federal government power over private medical decisions will have many ramifications. The 2700-page bill provides no reform of medical liability. It is estimated that 20% of all health care dispensed is defensive medicine due to fear of litigation, not medical necessity. The bill does not allow Americans the opportunity to buy health insurance across state lines. Today, the same policy for the same individual can cost twice as much depending upon the state in which he or she resides. The bill does not allow seniors the option of choosing their own Medicare policy through a premium-support system, a bipartisan idea. Our medical system certainly can be improved. So can our legal system; so can our educational system, etc. There is doubt whether the Affordable Care Act is the way to do it.

OBESITY CAMPAIGN

Gary Taubes, the author of Why We Get Fat, in a recent piece in Newsweek described how the government is going about its campaign to prevent obesity by stressing the wrong message—that we get fat because we eat too much and exercise too little (2). Taubes begins by pointing out that the very first childhood obesity clinic in the US was founded in late 1930 at Columbia University by a young German physician, Hilde Bruch, who had arrived in New York City in 1934 and was “startled” by the number of fat kids she saw—really fat ones, not only in clinics but on the streets and subways and in schools. And the year she arrived was the worst year of the Great Depression, an era of bread lines and soup kitchens, when 6 in 10 Americans were living in poverty. Taubes emphasizes that the most important item to prevent obesity is to decrease the quantities of sugar we take in: sucrose, the white granulated stuff that is metabolized by nearly every cell in the body, and high fructose syrup, which is metabolized by liver cells and is converted into fat. He stresses that the single most important way to lose weight or to prevent weight gain is to stop drinking sugar-sweetened beverages.

The other item Taubes presses is the myth that physical activity plays a meaningful role in keeping off pounds. We need to remember that we have to walk 35 miles to lose 1 pound, assuming we do not stop at one of the fast food chains during the walk. One reason Taubes likes the hormonal thesis of obesity is that it explains the fat kids in the Depression era in New York City. The problem could not have been that they ate too much because they didn't have enough food available. The problem then, as now, across the USA is the prevalence of sugars, refined flour, and starches in their diets. These are the least expensive calories and they can be plenty tasty without a lot of preparation and preservation. They make us fat while other foods (fruits, proteins, and green leafy vegetables) do not. I would also suggest the use of the drug Xenical 120 mg per day with the heaviest meal. (It has been withdrawn in the USA and now can be obtained via Internet from Canada.)

LORCASERIN HYDROCHLORIDE

The Endocrinologic and Metabolic Drugs Advisory Committee of the US Food and Drug Administration (FDA) approved a new drug application for lorcaserin hydrochloride, a selective serotonin 2c receptor agonist indicated for weight management in obese patients (body mass index ≥30 or ≥27 kg/m² if accompanied by weight-related comorbidities) (3). The recommended clinical dose is 10 mg twice daily.

AMERICAN DIETARY HABITS SPREADING

In the 1930s when Stalin enforced a drive toward collective farms, the czarist tradition of breeding meat cattle was lost (4). Subsequently, Russia has mainly slaughtered retired dairy cows for meat, and those dairy cows yielded tough and thin portions, not something that beef lovers desire. When the Soviet Union fell in the 1990s, Russia started importing beef from New Zealand, Argentina, and the US, and soon the Russians acquired a taste for better cuts. In 2011, Russia purchased 1.1 million tons of beef and veal from abroad, the equivalent of about 3.3 million fattened steers. Beef imports in 2011 were valued at $2.6 billion, making up about 33% of domestic consumption. Putin is now on a campaign to provide more good beef for his expanding middle class, and he has imported several Texas cattle experts to help expand beef production in Russia. The 10 US ranchers employed by the Russians are teaching them ways to handle livestock, different methods of feeding, and signs of different illnesses and injuries. Thus, the US is engaged in a process of worsening Russian health.

And our fast-food chains have moved into Kuwait. Now only 12% of Kuwaitis are at ideal body weight (body mass index 18.5 to 25 kg/m²), meaning that at least 88% of Kuwaitis are overweight (5). According to data from the World Health Organization, Kuwait is the second most obese nation in the world, behind the USA! The obesity boom in Kuwait can be traced to the build-up to the 1991 Gulf War. That was when hundreds of thousands of US troops descended on the Gulf nation, bringing with them Taco Bell, Hardee's, Baskin Robbins, and Nathan's Famous Hot Dogs, among other chains. When the American military went in, they wanted fast food, which means in actuality quick plaques. Although war introduced fast-food chains to Kuwait cities, peace made them a permanent fixture. Some 3400 US troops remained in Kuwait after the war enforcing the no-fly zone over Iraq. McDonald's first opened in Kuwait in 1994, 3 years after the war ended. Malls and food courts stocked with American franchises such as Burger King, Domino's, and Krispy Kreme Doughnuts have since proliferated in Kuwait. The high-end Manhattan burger chain Shake Shack opened one of its two international outposts in Kuwait City. The other is in Dubai.

As waistlines in Kuwait and across the Persian Gulf have expanded over the last 3 or 4 years, so too has bariatric surgery. Ten years ago, there were only two bariatric surgeons in Kuwait. Today there are 20. By 2015, it is predicted that there will be 40. At least five major hospitals in Kuwait now perform hundreds or even thousands of stomach-stapling procedures each year. Each operation at the Royale Hayat Hospital, a gleaming 5-star resort/wellness center, costs between $8000 and $12,000. For those willing to be operated on at a state-run hospital, the procedure is free, but patients have to pay for the staples, which usually cost between $2500 and $3600, and there is a 2- to 3-year wait. At least 5000 people in Kuwait underwent the procedure in 2011, compared with 3000 in Canada, which has more than 30 times the population of Kuwait.

Other obesity-related businesses are also sprouting across Kuwait, ranging from gyms and weight-loss camps to diet centers and personal caterers that specialize in low-calorie meals. An array of sporting equipment manufacturers, drug companies, medical clinics, and health spas are sprouting. The mostly Indian and Pakistani tailors who sew the white robes, or dishdashas, for men and black robes, or abayas, for women are constantly busy in Kuwait letting out or taking in their customers' clothes.

There are some disincentives to move and to eat less in Kuwait. In 2011, for example, the Kuwaiti government gave each of its 1.1 million citizens about $3600 in subsidized food. In 2012, it gave all state employees a 25% raise. This coddling apparently has encouraged lethargy. The temperature also adds to the lethargy. Summer temperatures of 110°F to 120°F from 10:00 AM to 4:00 PM hinder walking in the streets. All of this, I suspect, does not make Americans proud.

NEW FARM BILL

A recent Bloomberg BusinessWeek carried a piece discussing the old and new Department of Agriculture Farm Bills (6). The past one expired September 2012, and the new one, like the old one, will last 5 years. The new Farm Bill is a 1000-page law which Karen Weise indicates will cost $500 billion. The first Farm Bill was passed during the Great Depression, and it propped up prices by paying strapped farmers not to plant. In the 2008 bill that just expired, the largest share of the budget went to food stamps ($189 billion), which were first added to the Farm Bill in 1973. In addition to the food stamps, that Farm Bill included $42 billion for commodities, $24 billion for land conservation, $22 billion for crop insurance, and just over $7 billion for miscellaneous items, for a total of $284 billion. The original Farm Bill in 1937 was for $335 million, and $324 million of that went to farmers not to plant crops.

In the 1980s, the US government began shifting toward agriculture subsidies that led to an explosion of cheap, bountiful carbohydrates and meat. As a consequence, Americans consume nearly 20% more calories a day now than they did in the early 1980s. Since 1934, the federal government has limited sugar imports to boost domestic prices, a perk the industry fiercely protects. In June 2012, sugar lobbyists successfully worked to kill a Senate amendment to end the support. Without it, it is estimated that sugar prices would have dropped as much as 34%. Corn was the king of US crops: in 2011, growers got $2 billion in direct government support. It is no wonder that Americans eat more of it than Europe and China combined—including 11 billion pounds of breakfast cereal a year. And soy is well supported by the government. The ink in newsprint is now soy-based. Permanent-press cotton is a result of soy research. When large subsidies for ethanol, made from corn, were inserted into the 2002 Farm Bill, they were sold as a way to promote clean fuel and reduce dependence on oil. Ethanol became a bonanza for corn farmers. Increased demand has helped fuel record prices.

The Senate version of the new Farm Bill doubles funding for energy programs, including ethanol, to $1.5 billion over 10 years. When the price of milk drops, the government steps in to pay farmers and even buy cheese and powdered milk (276 million pounds of it in fiscal year 2009) to drive daily prices back up. The 2008 Farm Bill required the US Department of Agriculture to crack down on anticompetitive contracts—a reform intended to make it harder for buyers to favor large ranchers while freezing out smaller independents. This year, beef lobbyists may convince the senators to reverse the rule. The Senate version of the new bill adds $1.9 billion in disaster assistance for farmers whose animals or crops are wiped out by natural disasters, such as blizzards, wildfires, or droughts. And not just cows and chickens—bee keepers qualify for government cash if at least 17.5% of their insects die. Potatoes are not included in the Farm Bill, because they aren't commodity crops, i.e., traded on exchanges, and the Farm Bill promotes and protects markets. Like most fruits and vegetables, potatoes are considered specialty crops, eligible for grants but not direct subsidies. The new Farm Bill would eliminate $5 billion in yearly payments to corn farmers and replace them with subsidized insurance based on revenue. Sixty-three percent of the government's agricultural subsidies for domestic food products in recent history have directly and indirectly supported meat and dairy production. Less than 1% of these subsidies have gone to fruits and vegetables. I wonder how many of the representatives and senators read the 1000-page bill.

TWO OBSERVATIONS SUGGESTING THAT WE DIE IN VENTRICULAR SYSTOLE

Does it take more energy for the cardiac ventricles to contract or to relax? And if it takes more energy for the ventricles to relax than to contract, would it be reasonable to believe that we die in ventricular systole rather than in ventricular diastole?

Two observations suggest that we die in ventricular systole. One, as illustrated in the Figure, if the minute size of the left ventricular cavity represents ventricular diastole, what size could possibly represent ventricular systole? Two, the thickness of the left ventricular free wall at necropsy corresponds to the thickness measured during life by the echocardiogram during ventricular systole, not during ventricular diastole (7).

Figure.

Cross-section of cardiac ventricles at the base showing (a) both ventricles and (b) a close-up of the left ventricle only in a 79-year-old man who died of a noncardiac nonvascular cause. The left ventricular cavity is minute.

If the left ventricle is dilated during life, it will also be dilated after death, and therefore in these circumstances it is not possible to know at necropsy that death occurred during ventricular systole. When the left ventricular cavity is of normal size during life, however, the left ventricular cavity is small or minute after life.

VANISHING ANIMAL LABORATORIES IN MEDICAL SCHOOLS

Dr. Neal Barnard, president of the Physicians Committee for Responsible Medicine, for years has been trying to eliminate the use of nonhuman animals for teaching purposes in medical schools (8). I remember the physiology class in medical school where we did one or more procedures on dogs during each laboratory and put the dead dog in a bag at the end. Dr. Barnard has found other ways of teaching and learning. The number of medical schools with animal laboratories has drastically decreased since 1985. Dr. Barnard has been very successful with his endeavors.

DETERMINING THE QUANTITY OF ALCOHOL CONSUMED

Questioning patients about their consumption of alcohol (ethanol) is an important part of history taking. To determine the specific quantity, it is essential to understand how much alcohol is in a bottle of spirits or a bottle of wine or a bottle of beer and the container sizes in which they are consumed. I am reminded of the executive who asked his assistant to come into his office: “Aren't you proud of me?” he asked. “I am down to one cup of coffee a day.” An enormous cup —probably holding 3000 mL—was sitting on his desk.

Spirits: The small container of spirits provided on commercial airline carriers to individual passengers contains 50 mL. Since the 50 mL generally contains 40% alcohol (80 proof), there is 20 mL (2/3 oz) of alcohol in each small bottle. The usual 750 mL bottle of spirits purchased in a store contains 40% alcohol or 300 mL of alcohol, an amount equal to 15 of the 50 mL bottles of spirits.

Wine: The small bottles of wine provided on commercial airline carriers to individual passengers contain 187 mL, and since they consist usually of about 13.5% alcohol, those containers provide 25 mL of alcohol. The usual bottle of wine purchased in a store contains 750 mL, the same quantity as the usual bottle of spirits, but the alcohol content is usually about 13.5%. Thus, the quantity of alcohol in a 750-mL bottle of wine is approximately 100 mL, such that consuming an entire bottle of wine provides essentially the same quantity of alcohol as consuming five 50-mL bottles of spirits. Four of the 187-mL–sized bottles of wine are equivalent to the 750-mL sized bottle.

Beer: The alcoholic content of beer varies, but usually in the US it is about 5% by volume. Thus, a 12-fl oz (355-mL) bottle or can contains 18 mL of ethanol, such that the alcohol content of five beers roughly equals drinking a full 750-mL bottle of wine or a third of a 750-mL bottle of spirits.

Alcohol equivalence: In general, drinking 12 oz of beer equals drinking 5 oz of wine or 1.5 oz of spirits. Or, 285 mL of beer equals 120 mL of wine or 30 mL (single jigger) of spirits. It is easier to keep track of beers than wine or spirits, particularly in homes or at parties. Wine glasses are often refilled before they are emptied, and wine glasses vary considerably in size (4, 5, 8, 12, 16, and 20 oz). The glasses are generally filled higher with red wine than with white wine. Becoming savvy to glass size obviously is important. Some hosts and party providers measure spirits before glasses are filled, and others do not. Thus, knowing glass sizes and watching the servers is helpful in estimating the quantity of alcohol consumed.

Calories in alcohol: They amount to 7 calories per mL or gram of alcohol. Thus, the 50-mL bottle of spirits with 40% by volume alcohol (80 proof; 20 mL of alcohol) provides 140 calories, and most spirit pourers provide at least this amount per cocktail. An ounce of 80-proof (40% alcohol) whiskey, gin, vodka, rum, tequila, and brandy contains 65 calories. Liqueurs (Drambuie, Cointreau, Kahlua) contain about 125 calories/oz. A 5-oz glass of red or dry white wine, sherry, or champagne contains about 100 calories. A regular 12-oz (355-mL) bottle or can of beer contains 150 calories and “light” beer, 110 calories. And beer and wine also provide calories in the nonalcoholic portions of those drinks. Thus, although a little alcohol may be useful for our coronary arteries, lots of alcohol is bad for our brains, livers, and bellies.

DRUG ABUSE—OPANA

Prescription drug abuse is the nation's fastest-growing drug problem (9). The Centers for Disease Control and Prevention has classified the misuse of these powerful painkillers as an epidemic, with 1.3 million emergency room visits in 2010, a 115% increase from 2004. Overdose deaths on opioid pain relievers surpassed deaths from heroin and cocaine for the first time in 2008. The rise of Opana, whose active ingredient is oxymorphone, illustrates the adaptability of drug addicts and the never-ending challenge facing law enforcement authorities, addiction specialists, and pharmaceutical companies.

For years, drug abusers favored an extended-release version of OxyContin, a narcotic painkiller, for a powerful high. They would crush or dissolve the pill's time-release coating to get the full punch of the opioid oxycodone. But oxycodone's manufacturer reformulated it in August 2010, making it nearly impossible to crush, dissolve, and inject. By the beginning of 2011, more than 95% of prescriptions were being filled with reformulated OxyContin. As the supply of the old formulation dwindled, panicked drug abusers flooded Internet chat rooms in an attempt to find ways to outsmart the new technology, from pounding it with hammers to soaking it in acid.

Opana ER, an extended-release painkiller containing oxymorphone, came on the market in 2006. Although the manufacturer had completed development of a crush-resistant pill in 2010, approval from the FDA was delayed until late 2011. In the meantime, the old Opana formulation proliferated and its oxymorphone became one of the most common drugs found in the blood of overdose victims. The old formulation of Opana was not removed from the market until June 2012.

MILITARY SUICIDES

They are rising, as Mark Thompson and Nancy Gibbs point out (10). More US soldiers have killed themselves than have died in the Afghan war. Military suicides are at record levels. At the current pace, there will be 186 suicides in the army, 73 in the air force, 62 in the navy, and 45 in the marines in 2012. From 2001 to July 2012, 4486 US troops have died in Iraq, 1950 have died in Afghanistan, and 2676 have died by suicide. Of the suicides, 83% occurred in the US, 10% in Iraq or Afghanistan, and 7% in other sites; 38% of those who died had been deployed to Iraq or Afghanistan, 11% had had some combat experience, and 6% had witnessed killing in combat. Further, 26% had histories of substance abuse, 7% of major depression, 5% of posttraumatic stress syndrome, and 3% of traumatic brain injury.

The causes of death in the military in 2011 were as follows: combat, 26%; suicide, 20%; transport accidents, 17%; other accidents, 8%; cancer, 6%; heart disease, 5%; and other, 18%. The 20% suicide rate in the military compares to a 7% rate among civilian men aged 17 to 60 years. Active duty US troops die by their own hand at an average rate of 1 a day. Among all veterans, the rate is 1 every 80 minutes. So sad.

FIRST TEST-TUBE BABY

Leslie Brown, the mother of the world's first “test-tube baby,” died June 6, 2012, in Bristol, UK (11). She was 64 years old. She is survived by her two daughters and three grandchildren. Her husband, John Brown, died in 2007 at age 64.

The in vitro fertilization technique that produced her daughter, Louise, was developed by Mr. Robert Edwards and Dr. Patrick Steptoe. Although in vitro fertilization is an established treatment now, it had a long, slow, and rocky start. The research by Mr. Edwards, a biologist, and Dr. Steptoe, a gynecologist, had gone on for 10 years, and the treatment had failed in about 60 couples by the mid 1970s. It had produced only one pregnancy, and that was ectopic and had to be aborted. Then, Leslie Brown and her husband, John, came along. She was a homemaker; he, a railroad employee. They had been trying for 9 years to conceive a child.

In vitro fertilization at the time was “an incredible leap into the unknown.” Even if a pregnancy did result, would the baby be healthy? Critics predicted that the treatment could lead to terrible abnormalities. Ms. Brown became pregnant on the first try. Once the news got out, public fascination with her case was unrelenting. She was a quiet woman and the attention stunned her. Louise was born on July 25, 1978, and her birth was an instant global sensation and a turning point in the treatment of infertility. After Louise's birth, the Browns went home from the hospital to find reporters camped out on their street. For months, Leslie Brown could not leave the house without being chased, so the family moved to another house with a backyard allowing her to take Louise outside in peace. Four years later they had another daughter, Natalie, also conceived by in vitro fertilization, also on the first try.

It took time for in vitro fertilization to gain acceptance. Fears that it could harm mothers and children lingered, and there are still some religious objections. But overall, the technique has proved safe, and success rates have climbed to rival those of natural conception. About 5 million babies worldwide have been born through in vitro fertilization. In some developed countries, those methods now lead to 3% of all live births. In 2010, about 59,000 births in the US resulted from in vitro procedures. In 2010, at age 85, Mr. Edwards received the Nobel Prize in physiology/medicine. Unfortunately, his health had declined mentally and he was not in a position to understand the honor.

REDUCING SALT INTAKE

High salt intake has a direct relationship to blood pressure: the higher the salt intake, the higher the blood pressure. The higher the blood pressure, the higher the frequency of stroke, kidney disease, and aortic dissection. A 2000–2001 survey found that the mean estimated salt intake in adults in the UK was 9.5 g per day (12). In 2003, the British government committed to a nationwide salt reduction initiative to reduce the average salt intake to 6 g per day. To achieve that target by 2010, in 2006 their Food Standard Agency introduced voluntary salt reduction targets for the food industry for 85 categories of food. Publication of the UK dietary sodium excretion survey in 2008 showed that the average estimated salt intake for adults in the UK was 8.6 g per day, a 10% reduction compared to the 2000–2001 survey. Since that time further reductions have been targeted. The 2011 study aimed to collect usable 24-hour urine samples from 600 participants, aged 19 to 64 years, living in private households in the UK. The results of this latest survey were announced in June 2012: salt intake had fallen in adults in the UK from 9.5 g to 8.1 g per day, an approximate 1.5 g per-person per-day fall. This level is now the lowest salt intake of any developed country in the world. The British investigators estimated that this 1.5 g reduction in average daily salt intake, through the reduction it has on blood pressure, would prevent approximately 20,000 strokes, heart attacks, and heart failure, 850 of which would be fatal in the UK every year. This reduction provides huge cost savings. If the UK achieved the 6 g target, an estimated additional 17,000 lives a year would be saved. A successful policy depends on the rigorous setting of progressively lower salt targets, which are adopted voluntarily by the food industry. The US, Canada, and Australia now are beginning to follow the UK's lead in setting their own targets.

I had dinner recently with a prominent physician who after his plate appeared picked up the salt shaker and vigorously shook it over the food before he had a single bite. Although apparently only about 14% of the salt Americans take in each day comes from the salt shaker, there is no need to add additional salt at the table. It takes about one month to get used to eliminating the salt shaker. It is not impolite anymore to just pass the pepper shaker.

MANUFACTURING PROBLEMS OF DIETARY SUPPLEMENTS

In the last 4 years, the FDA has found violations of manufacturing rules in half of the nearly 450 dietary firms it has inspected (13). Some firms do not even have recipes, known as master manufacturing records, for their products. Others make their supplements in unsanitary factories. Others are unable to verify the identity of the ingredients that go into their products. The FDA began conducting inspections in 2008 to assess compliance with new regulations governing the manufacturing, packing, and holding of dietary supplements. One in four dietary supplement companies inspected by the agencies have received warning letters, considered a significant enforcement action. In 2012, FDA inspectors found violations of good manufacturing practices during two thirds of the 204 inspections they conducted in nearly 200 supplement facilities. Seventy of these inspections resulted in the agency's most serious rating. Some customers have suffered serious health problems linked to companies' poor manufacturing processes. In 2008, >200 people were poisoned by selenium after taking liquid multivitamin dietary supplements sold in health stores and by chiropractors. The products, called Total Body Formula and Total Body MegaFormula, contained an average of 41,000 micrograms of selenium per serving instead of 200.

ConsumerLab.com, an independent testing organization, has analyzed popular dietary supplements for about 12 years. The group says it has found a significant problem with about 1 in 4 products. Of 35 multivitamin products tested in 2011, 24 passed and 11 failed; of 22 fish oils tested, 16 passed and 6 failed; of 11 magnesium products tested in 2012, 9 passed and 2 failed; and of 11 ginseng products tested in 2010, 6 passed and 5 failed.

METAL-ON-METAL HIP REPLACEMENT DEVICES

During my first decade at the National Institutes of Health, I spent a good bit of time evaluating prosthetic heart valves. The 1960s was the first decade of successful cardiac valve replacement. During that 10-year period, there were many changes in the prosthetic valves. Each time a change was made, the manufacturer generally indicated that this change would prevent problems that occurred in the previously available prosthetic valves. That was unfortunately not always the case. For each new device, some time was required to determine whether the change was an improvement or not.

About 10 years ago, manufacturers of prosthetic hips went from plastic or ceramic to metal-on-metal hip sockets. The belief was that the new devices would be more resistant to wear and reduce the chances of dislocation. Recent data gathered in the UK appear to show just the opposite. In March 2012, British experts using the world's largest artificial joint registry advised physicians to stop using metal-on-metal hip replacements (14). They found that 3 times as many metal-on-metal hips have to be replaced within 5 years than the previously used prosthesis (6% vs. 2%). British regulators now recommend that people who have the implants get yearly blood tests to ensure no dangerous metals are seeping into their bodies as the components rub against each other. The FDA has not made recommendations for the estimated 500,000 American patients with the devices.

RETIREMENT LIVING

According to Kelly Greene (15), an estimated 733,000 people in the US live in an assisted-living facility as of 2010, the latest data available. Typically, assisted living consists of a small apartment with services that may or may not cost extra, such as medicine management, personal care, housekeeping and laundry, meals, activities, and transportation to doctors' appointments. A one-bedroom unit in an assisted-living facility costs as much as $9500 a month in 2011. Alternatives to assisted living exist:

Going offshore. Going abroad for long-term care is relatively new. For $3500 a month, a home can be rented in Costa Rica and shared with two other patients. The price includes a supervising nurse, three aides, a care coordinator, and a chauffeur.

Backyard MedCottage. So that older people can be with their families when they start to need help, several companies have developed separate living cottages in another's backyard. A MedCottage, which costs about $85,000, has a 12 × 24 living area with a handicap-accessible bathroom, kitchen, hospital bed, and living area and is outfitted so that the person living there can be monitored online. Building permits are getting easier to acquire.

Cohousing. This arrangement, which originated in Denver decades ago, was designed for those interested in living communally. In a cohousing development, residents live in private homes but share a central “common house” and other facilities. “Senior” cohousing is beginning to spread elsewhere (seniorcohousing.com). By 2020, there should be at least one cohousing community in every metro area in the US, and about one third are expected to serve older adults.

The permanent cruise. Dr. Lee Lindquist of Northwestern University's Fineberg School of Medicine was the first to compare living on a cruise ship to living in an assisted living facility on land. The cost of the two was fairly similar. On a cruise ship, a physician and nurses are available 24/7, while physicians are not always on site at an assisted-living facility. This particular choice appeals to me.

Spa living. Spa resorts increasingly are trying to expand into residential communities. Canyon Ranch's medical and wellness team in Miami Beach is one of these. Stay well.

LIVING 100 YEARS

In 1950, there were 2300 people in the US >100 years of age; by 2050, according to some estimates, that number could be 600,000 (16).

MEDICAL APPS

There are 40,000 medical applications for smart phones and tablets, and the market is in its infancy according to Jenny Gold of Kaiser Health News (17). Medical apps offer the opportunity to monitor health and encourage patient wellness moment to moment, instead of only during visits to the physician's office. Some apps even replace devices in hospitals and doctors' offices, such as glucometers and the high-quality microscopes used by dermatologists to examine various skin lesions. So far the field has been unregulated. It is hard to know which apps live up to their claims or provide accurate information.

In 2011, the FDA released a first draft of guidelines that require developers making medical claims to apply for FDA approval, the same way new medical devices must be proven safe and effective before they can be sold. But there seems to be no way that the FDA can keep up. The Government Accountability Office says that the FDA takes 6 months to approve a device similar to an existing product, and 20 months to review a new one. Many developers apparently are not opposed to regulation, but they believe the FDA process does not fit the industry.

Some top-selling medical apps for iPhones:

• 1Pregnancy++: Tracks the course of a woman's pregnancy, including weight, diet, and exercise. It also includes fetal pictures, a kick counter, and a contraction counter.
• 2Pill Identifier: Allows the user to identify more than 10,000 over-the-counter and prescription pills based on their appearance.
• 3Baby Connect: Tracks a baby's daily activities, including feeding, sleep, growth, health, and vaccines and creates graphical reports and trending charts. The information can be shared between parents, nannies, and health care providers.
• 4Diagnosaurus DDx: Helps health care providers accurately diagnose patients quickly at the bedside. Providers can search >1000 diagnoses by organ system, symptom, and disease and use a special feature to consider alternative diagnoses when multiple conditions are possible.
• 5Instant ECG: Teaches health care professionals the basics of reading electrocardiograms. The app offers video demonstrations of 30 arrhythmias to teach and then test a provider's ability to diagnose irregularities.

AIR-CONDITIONING

John Steele Gordon, the prominent business historian, recently described the development of air-conditioning (18). Before the Industrial Revolution, there were only two ways to stay cool in hot weather. One was to go to the ocean or mountains, and the other was to raise the rate of the evaporation of sweat by increasing air circulation across the skin. Thus, the fan, now 5000 years old, came into existence.

In 1758, Benjamin Franklin experimented with the rapid evaporation of volatile liquids, such as alcohol and ether, to cool water to a point below freezing. He was able to lower the temperature from 64° to 7°F. Franklin wrote to a friend: “One may see the possibility of freezing a man to death on a warm summer's day.”

In 1828, Michael Faraday demonstrated that one could cool water by applying mechanical power to compress a volatile substance such as ammonia into a liquid and then by allowing it to rapidly evaporate.

In the 1830s, John Gorrie, a young physician living in Apalachicola, Florida, recognized that patients were more likely to survive an illness in cool weather than in hot. So, he rigged up pans full of ice near the ceiling in a hospital room. The ice would cool the air around it and because cold air is heavier than hot air would float downward over the patient and then out through holes in the room's floor. It was the first effective system of air-conditioning. Since ice was expensive in Apalachicola because it had to be imported by ship from the north, Gorrie began to experiment with making ice by mechanical means. In 1851, he was granted a patent on a machine that worked on Faraday's principle. He quit medicine to work on perfecting his invention but when his financial backer died, he was unable to carry on and died in poverty in 1855.

In the hot summer of 1881, President James Garfield lay dying of an assassin's bullet. To help keep him cool, naval engineers rigged up sheets of cloth soaked in iced water with a fan blowing air across them. The method kept his room 20 degrees cooler, but it used half a million pounds of ice over a 2-month period and did not lower the humidity, a crucial part of keeping both cool and comfortable.

In 1902, Willis Carrier, a young engineer in the Buffalo Forge Company in Buffalo, New York, invented the first modern air-conditioning to cool a printing plant. (High humidity could cause paper jams and prevent ink from drying quickly.) He used a compressor to liquefy ammonia and then evaporated it to cool water. Running the water through coils, he blew air across them, cooling the air and causing it to lose moisture through condensation on the coils. The air was then sent into the workplace via ducts. While useful for industrial purposes, the Carrier air-conditioning system was both large and dangerous, as ammonia is very toxic. But, by the early 1920s, he had developed a much more efficient compressor and started using a much safer refrigerant (Dielene) as the volatile. (Dupont invented Freon in 1928.)

In 1925, one of New York's movie theaters became the first to be air-conditioned, and it proved a huge hit with moviegoers. Other large theaters rapidly followed. So did department stores, which saw increased summer sales as a result. Office air-conditioning lagged behind, but when studies showed that productivity greatly increased when offices were cool, those buildings also became air-conditioned. The House of Representatives installed air-conditioning in 1928, and the Senate and White House soon followed.

Air-conditioners small enough to fit in a window and cool just one room became commercially available after World War II. In 1948, 74,000 units were sold; by 1953, over a million. The first automobile air-conditioner was offered in 1940; today, 99% of cars sold have air-conditioning.

And obviously air-conditioning had many profound results. Washington, DC, used to be nearly deserted in the summer because of the city's notorious heat and humidity. Today, the government runs year round. In the first half of the 20th century, the South was losing population; air-conditioning played a major role in changing that. When the present Parkland Hospital was built, it was not air-conditioned. That was inserted later at great expense.

STORM SHELTERS

The US Department of Housing and Urban Development and the Federal Emergency Management Agency (FEMA) encourage community shelters by awarding grants to help pay for them (19). Since 1999, FEMA has helped fund over 1300 community safe rooms in 20 cities, including 235 in 2011, up from 124 in 2010. The shelters hold anywhere from 50 to 300 people and some many more. Sounds like a good idea in view of the recent leveling tornadoes and hurricanes.

JUNE 2012 WEATHER

In June 2012 >2 million acres were burned in massive wildfires in much of the West, >110 million people were living under extreme heat advisories, and more than two thirds of the country was experiencing drought (20). In June 2012, 3215 daily high-temperature records were set nationwide. (In March 2012, 15,000 new records were set!) The 12 months ending in June were the warmest 12 continuous months on record in the US. Is all this evidence of global warming? In a report released on July 10, 2012, the National Climatic Data Center concluded that the odds that the unusual heat of the past 13 months was random were 1 in 1.6 million. Bryan Walsh in a piece in Time concluded that “climate change is real, and it's happening now. We can argue about what causes it, how to handle it and how to balance the cost of that action against the risk of doing nothing…. We're living in an igloo this summer and the ice is melting all around us.”

WAGES OF US WORKERS

The number of workers earning wages in the private sector was 131 million during the fourth quarter of 2011, the latest data available (21). Of those, 10.6 million were employed in Texas. Nationally, the average weekly wage was $955, down 1.7% from 12 months earlier. The average weekly wage in Texas was $973. Wages for some occupations in the Dallas–Fort Worth–Arlington metropolitan area were as follows (numbers rounded off): chief executive, $194,000; dentist, $183,000; surgeon, $169,000; airline pilot, $165,000; family practitioner, $164,000; lawyer, $139,000; air traffic controller, $135,000; pharmacist, $112,000; dental hygienist, $73,000; registered nurse, $68,000; secondary schoolteacher, $58,000; chiropractor, $52,000; flight attendant, $47,000; substance abuse counselor, $35,000; and home health aide, $22,000.

AMERICA'S HOUSEHOLD WEALTH

According to the Federal Reserve Survey of Consumer Finances, the median net worth of American families was lower in 2010 than in 1989 (22). For all families, median net worth fell 39% from 2007 to 2010. The drop would have been bigger if measured at the market's 2009 bottom.

FASTEST-GROWING US CITIES

The latest numbers from the US Census Bureau show that 8 of the 15 fastest-growing large cities in the USA were located in Texas (Table 1) (23).

Table 1.

The 15 fastest-growing large US cities by percentage increase from April 1, 2010, to July 1, 2011

	Percent increase	2011 total population
1. New Orleans, LA	4.9	360,740
2. Round Rock, TX	4.8	104,664
3. Austin, TX	3.8	820,611
4. Plano, TX	3.8	269,776
5. McKinney, TX	3.8	136,067
6. Frisco, TX	3.8	121,387
7. Denton, TX	3.4	117,187
8. Denver, CO	3.3	619,968
9. Cary, NC	3.2	139,633
10. Raleigh, NC	3.1	416,468
11. Alexandria, VA	3.1	144,301
12. Tampa, FL	3.1	346,037
13. McAllen, TX	3.0	133,742
14. Carrollton, TX	3.0	122,640
15. Atlanta, GA	3.0	432,427

^∗From the US Census Bureau: http://www.census.gov/newsroom/releases/archives/population/cb12-117.html

US TRAFFIC

According to The Washington Post, the cities that waste the most hours for drivers each year on average are the following (listed by city and followed by the number of hours wasted yearly in traffic): Honolulu, 58; New York, 57; Los Angeles, 56; San Francisco, 48; Bridgeport, CT, 45; Boston, 35; Seattle, 33; Chicago, 32.8; and Austin, 30 (24, 25).

RAISING CHILDREN

A recently released government report found that middle-income families (those with incomes from $60,000 to $103,000 yearly) with a child born in 2011 will spend about $235,000 in child-related expenses from birth through age 17 (26). Housing is the single largest expense, averaging $70,000, or 30% of the total cost, with the Northeast and urban West being the most expensive. The estimate also includes the cost of transportation, child care, education, food, clothing, health care, and miscellaneous expenses. In 1960, it was estimated that the cost of raising a child was just over $24,000 for middle-income families. (That would be $192,000 today when adjusted for inflation.) Child care is the second largest expense. Higher-earning families spend more on their children. Families with three or more children spend 22% less per child than those with two children. The savings result from hand-me-down clothes and toys, shared bedrooms, and buying food in larger quantities.

WHAT NORTH KOREAN CHILDREN LEARN ABOUT THE USA

A framed poster on the wall of a kindergarten classroom in North Korea shows children using rifles and bayonets to attack a helpless American soldier, his face bandaged and blood spurting from his mouth (27). Another poster depicts an American with a noose around his neck. For North Koreans, this systematic indoctrination of anti-Americanism starts as early as kindergarten and is as much a part of the curriculum as learning to count. Toy pistols, rifles, and tanks sit lined up in neat rows on shelves. A favorite school-year game is to throw stones at a dummy of an American soldier with a beaked nose and straw-colored hair. The students in North Korea learn that their country has two main enemies: the Japanese who colonized Korea from 1910 to 1945 and the US, which fought against North Korea from 1950 to 1953. The students are told that North Korea's defense against outside forces remains the backbone of the country's foreign policy. The population is bred to seek revenge, even as the government professes to want peace. They are taught that the American imperialists started the war. The tragedy emerged by which the nation was divided into two parts. Nevertheless, when the rare American is seen in Pyong-Yang, the littlest North Koreans invariably wave and call out “hello” in English, showing fascination rather than fear.

PROLIFIC DIEGO

A Galapagos island is the home to Diego, a prolific, bossy reptile (28). He has sired hundreds of offspring and has been central to bringing the Espanola Island type of tortoise back from near extinction. Diego was plucked from Espanola by expeditioners between 1900 and 1930 and wound up in the San Diego Zoo in California. When the zoo returned him to the Galapagos in 1975, the only other known living members of his species were 2 males and 12 females. His species—Chelonoidis hoodensis—had all but been destroyed, mostly by domestic animals (introduced by humans) who ate their eggs. So, Diego and the others were placed in a corral at the park's breeding center on Santa Cruz, the main island in the isolated archipelago, whose unique flora and fauna helped inspire Charles Darwin's work on evolution. Diego was so dominant and aggressive, bullying other males with bites and shoves, that he had to be moved 8 years later to his own pen with five of the females. The reptiles are not monogamous. Diego apparently became the most sexually active of the bunch because he is the biggest and the oldest of the males, being nearly 3 feet long and weighing 175 pounds. The herpetologist for the Galapagos Conservancy, Linda Cayot, estimates that Diego is the father of 40% to 45% of the 1781 tortoises born in the breeding program and placed on Espanola Island.

At least 14 species of giant tortoises originally inhabited the islands, which are 620 miles off of Ecuador's Pacific coast, and 10 survived. Espanola, which encompasses 50 square miles, is arid, and in order to reach vegetation high enough off the ground, the tortoises developed the longest legs and necks of any of the species in the archipelago. Before humans arrived in the Galapagos, the six islands were home to tens of thousands of giant tortoises. The numbers were down to about 3000 in 1974, but the recovery program run by the National Park and the Charles Darwin Foundation has succeeded in increasing the overall population to about 20,000.

LIFE IN THE US IN 1776

Thomas Fleming's book, What America Was Really Like in 1776, recently appeared (29). He indicates that Americans at that time had the highest per capita income in the civilized world. They also paid the lowest taxes. By 1776, the 13 American colonies had been in existence for over 150 years—more than enough time for the talented and ambitious to acquire money and land. At the top of the South's earners were large planters such as George Washington. In the North, Southern incomes were more than matched by merchants such as John Hancock and Robert Morris. Next came lawyers such as John Adams, followed by tavern keepers, who often cleared 1000 pounds a year, or about $100,000 in today's money. Physicians were paid comparatively little, as were dentists, who were almost nonexistent.

In the Northern colonies, the top 10% of the population owned about 45% of the wealth. In some parts of the South, 10% owned 75% of the wealth. Unlike most other countries, America in 1776 had a thriving middle class. Well-to-do farmers shipped tons of corn, wheat, and rice to the West Indies and Europe, using the profits to send their children to private schools and buy their wives expensive gowns and carriages. Artisans, tailors, carpenters, and other skilled workmen also prospered, as did shop owners who dealt in a variety of goods.

Several hundred miles inland was the “back country,” and at the time of the Revolution few people went there by choice. Most who went were poor and landless—younger sons, for example, whose older brothers had inherited the family's property. Life on the outskirts of civilization was hard and often violent. Morals on the Western frontier were often much more relaxed than they were in the civilized East.

America in 1776 was also a diverse nation. The first census, taken in 1790, revealed that only about 60% of the people came from England. The rest were German, Irish, Dutch, Scottish, Swedish, and African.

Men wore clothes that were as colorful as the ladies' garb. Women regularly spent a half day getting their hair “permanented” for a ball. Ladies seeking to preserve the sheen of youth spent a fortune on “paints” from China and lip salves from India.

Another American tradition beginning to take root was female independence. Although “domestic felicity” was considered vital to everyone's peace of mind, and although divorce was legal, it was rare. Money played a part in marriage among the more affluent, but family life was often full of affection.

By 1776, the Atlantic Ocean had become what one historian called “an information highway” across which poured books, magazines, newspapers, and copies of the debates in Parliament. The latter were read by John Adams, George Washington, Robert Morris, and other politically minded men. They concluded that the British were planning to tax the Americans into the kind of humiliation that Great Britain had inflicted on Ireland. Dr. Benjamin Rush, the Pennsylvanian who signed the Declaration of Independence, wrote that the 8-year war for independence was only the first step in the Revolution's destiny to transform America and the world. History confirmed his intuition.

THE GATE RULE

In one of Peggy Noonan's recent columns, she described the Gate Rule (30): People are either lined up at the gate trying to get out of a country or lined up trying to get in. In the US they are lined up to get in. Compared with many other countries, the US economy isn't in such bad shape. As Peggy Noonan says, “People don't want to come to a place when they know they will be treated badly. They don't want to call your home, their home unless they know you will make room for them in more than economic ways.” The American friendliness, openness, and lack of old hatred are generally welcomed around the world.

SCOTT GORDON JUREK: ULTRAMARATHONER AND VEGETARIAN

Scott Jurek was born on October 26, 1973 (31). He began running long distance as a sophomore in high school to prepare for Nordic skiing. He disliked running at first but after spending summers running on trails with ski poles, he found a passion for trail running. On a challenge from his training partner, Scott ran the Minnesota Voyageur 50-Mile in 1994, placing second in his first attempt at an ultramarathon, without even having run a marathon. Scott was the valedictorian of his high school class and attended the College of St. Scholastica in Duluth, Minnesota, graduating with a master's degree in physical therapy in 1998. During his college years, he competed in a number of ultramarathon races and won many of them. In 1998, he began competing nationally and won two 50-mile runs and placed second in his first 100-mile run. He won his first 100-mile Western States Endurance Run on his first attempt and won it six more times continuously. He achieved the new course record of 15 hours and 36 minutes in 2004. During the next 5 years he notched a number of 50-mile and 100-mile wins. In 2006, he won his first of three consecutive victories in the Spartathlon, a 153-mile race between Athens and Sparta in Greece. Jurek is the only North American to ever win that race. In 2007, he won the Hardrock Hundred, setting a new course record at the time. In 2006, Jurek with a group of runners raced against the Tarahumara in Copper Canyon, Mexico. Jurek narrowly lost to the fastest Tarahumara runner, but in 2007 he won the race. In 2010, Jurek broke the USA Track and Field all-surface record distance run by an American in 24 hours with 165.7 miles.

Jurek became a vegetarian in 1998 and is an advocate of plant-based eating for health and ethical/environmental reasons (32). He cites his diet as the key to his superior athletic performance and recovery. He became a vegan in 1999. When Jurek was very young his mother was diagnosed with multiple sclerosis. Her struggles taught him to persevere in difficult circumstances, and he credits her memory as his major source of strength. He has won at least twenty-five 50-mile, 100-mile, and 152-mile races and holds the US record for 24-hour distance on all-surfaces (165.7 miles). In 2012, his book, Eat and Run: My Unlikely Journey to Ultramarathon Greatness, appeared.

FEMALE VERSUS MALE OLYMPIANS

When the US Olympic Committee unveiled its 2012 530-member team, women outnumbered men for the first time: 269 vs. 261 (33). The increasing presence of female Olympians on the US team is attributed to the growth of opportunities since the passage of Title IV, the 1972 gender-equality law. (For the 1972 US Olympic team, only 21% were female: 84 of 400.)

SPORTS OF PRESIDENTS

The sporting activities of the 20th and 21st century presidents are listed in Table 2 (34). Theodore Roosevelt and George W. Bush appear to be the most physically fit during most of their lives. William Howard Taft, at 300 pounds, was the least fit. Woodrow Wilson was the starting centerfielder for Davidson College in North Carolina but didn't make the cut at Princeton. He played a record 1000-plus rounds of golf as president. Herbert Hoover served as student manager of Stanford's football and baseball teams. Dwight Eisenhower was dubbed the “Kansas Cyclone.” He was linebacker and running back at West Point back when the academy was a football powerhouse. He played >800 rounds of golf as president and was the first president to score a hole in one. John F. Kennedy was a member of Harvard's junior varsity golf, swimming, and football squads and was on the varsity team in sailing. Lyndon Baines Johnson was a fisherman. He was said to have a long drive in golf but could not break 100. Nixon played basketball at Whittier College but mostly rode the bench on the gridiron. He loved bowling in the White House. Gerald Ford was the best athlete of them all. He was an all-American center on Michigan's national football teams and he could have played in the National Football League but instead went to Yale Law School, where he also coached football. Jimmy Carter was a big-time runner in track and cross-country for the Naval Academy. Ronald Reagan was a football player at Eureka College. George H. W. Bush was a star first-baseman and captain of Yale's baseball team. Bill Clinton installed a jogging track on the White House lawn. He cheated big time in golf. George W. Bush is a fitness fanatic. He was the first president to have run a marathon and he still loves mountain biking. Barack Obama was nicknamed “Barry O'Bomber” as a high school basketball player. He is an average golfer at best and is said to have played over 100 rounds of golf during his first 3 years as president.

Table 2.

Sporting activities of US presidents

President	College athlete	Recreational sports
Theodore Roosevelt	+ Boxing Wrestling	Polo Exploring Hunting
William Howard Taft	+ Baseball	Golf
Warren G. Harding	o	Golf
Calvin Coolidge	o	Fishing Horseback riding
Herbert Hoover	o	Fishing
Franklin D. Roosevelt	o	o
Harry S Truman	o∗	o
Dwight Eisenhower	+ Football	Golf
John F. Kennedy	+ Golf Swimming Football Sailing	Golf Sailing
Lyndon Baines Johnson	o	Fishing Golf
Richard Nixon	Basketball Football	Bowling
Gerald Ford	+ Football	Golf Skiing
Jimmy Carter	+ Track	Running
Ronald Reagan	+ Football
George H. W. Bush	+ Baseball	Golf Boating Horseshoes
William J. Clinton	o	Jogging Golf
George W. Bush	o	Running Mountain biking
Barack Obama	o	Golf Basketball

^∗Did not attend college.

MISPLACED VALUES

Long-term contracts have become common in major league baseball. Over time, players who land long-term, big money deals often prove poor investments (35). A few examples: Alex Rodriquez, $275 million for 10 years (expires 2017); Troy Tulowitzki, $157 million for 10 years (expires 2020); Albert Pujols, $252 million for 10 years (expires 2021); Prince Fielder, $214 million for 9 years (expires 2020); Mark Teixeira, $180 million for 8 years (expires 2016); Adrian Gonzalez, $154 million for 7 years (expires 2018); Joey Votto, $240 million for 10 years (expires 2023); Joe Mauer, $184 million for 8 years (expires 2018); C. C. Sabathia, $161 million for 7 years (expires 2015); and Miguel Cabrera, $152 million for 8 years (expires 2015).

CELL PHONE OBSESSION

On June 29, 2007, the first iPhone went on sale (36). The Apple device cost $600 and had no physical keyboard, limited email options, and no copy and paste. In hindsight, it wasn't so hot. Since that date Apple has sold >220 million iPhones worldwide and sparked a commercial, cultural, and behavioral revolution. According to a study of medical workers at Bay State Medical Center in Springfield, Massachusetts, 76% say they have experienced “phantom vibration,” that insistent buzz from an imagined text or phone call, possibly the result of random nerves firing, biochemical noise that our brains easily turn out until they were reconditioned by the iPhone. According to Larry Rosen, a psychologist and author of iDisorder: Understanding Our Obsession with Technology and Overcoming Its Hold on Us, nearly 30% of people born after 1980 are anxious if they can't check Facebook every few minutes. Others repeatedly pat their pockets to make sure their smart phone is still there.

This obsession, of course, has been good for Apple. The company's annual revenue climbed from $24 billion in 2007 to $108 billion in 2011, and its stock price is up almost 400% over the same period. According to Rosen: “The great thing about the iPhone is that we carry it with us all day long. The bad part is that we carry it with us all day long.” That makes people lab rats in a real-time psychological experiment that's altering behavior at lightning speed. By 2016, there may be more mobile devices than people. Thanks to the ubiquity of smartphones, many museum-goers “skip the step of actually looking at the artwork and move straight to photographing,” says Elizabeth Broun, director of the Smithsonian American Art Museum in Washington, DC. Is the iPhone a crutch that does too much of our thinking and increasingly takes the place of real human connections?

William Clifford Roberts, MD

20 July 2012