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What Do You Know About Diabetes?

By Nathan Blake |11/9/16

November is designated National Diabetes Awareness Month.

In 2012, over 9% of the American population—roughly 29 million people—had some form of diabetes. Worse, one in four people with diabetes do not know they have the disease. With over 1.5 million new cases of diabetes being diagnosed every year, this disease is quickly becoming one of the nation’s fastest growing and most serious epidemics. In fact, diabetes was the seventh leading cause of death among Americans in 2010. That number, if current trends continue, is sure to rise.

What is Diabetes?

Diabetes is a group of health conditions that makes it difficult for the human body to properly control the level of sugar in the blood. When we eat, our bodies convert food into sugars, one of which is called glucose, which our cells rely on as a main source of energy to carry out the basic bodily functions of our muscles, brain, heart, liver, and more.

Because of the importance of glucose in everyday health, there are very intricate biological processes at play to regulate glucose in the blood. These processes ensure that our glucose level does not rise above or fall below a healthy range.

The Importance of Insulin

The cells in our body cannot use glucose directly and must rely on a hormone called insulin. After eating, insulin is released into the bloodstream by the pancreas. Insulin attaches to cells and prompts them to absorb glucose from the bloodstream. The cells then turn the glucose into energy.

When there is an overabundance of sugar in the blood—for instance, after a big meal—insulin stores this excess glucose in the liver to be used later when blood sugar levels drop, such as during the period between meals or while exercising. Normally, glucose is kept under tight control by the pancreas which uses insulin to regulate the blood levels. Diabetes occurs when this regulation system fails to control the levels of glucose.

Types of Diabetes

Type 1 diabetes (formerly called “juvenile-onset diabetes”) occurs when the body cannot create its own insulin. This is because the body’s immune system has destroyed the insulin–producing “beta cells” in the pancreas. Without insulin, glucose cannot enter cells. The cells must then use other inefficient sources of energy while glucose levels rise. This metabolic imbalance can be life–threatening. To prevent this problem, patients with Type 1 diabetes must receive insulin injections daily in order to regulate their blood sugar levels.

Type 2 diabetes (formerly called “adult-onset diabetes”) occurs when the body continues to create insulin but the cells have a sluggish response to its effects. The result of this “insulin resistance” is elevated levels of glucose in the bloodstream. Over time, the high glucose level can also affect the pancreas and reduce its production of insulin.

Gestational diabetes, occurring in roughly 4% of pregnancies, results from hormonal changes during pregnancy that inhibit insulin’s ability to regulate glucose levels.

Risk Factors

While the risk factors for developing type 1 diabetes are still being studied, research shows that having a family member with diabetes can increase your risk for developing the disease. Type 1 diabetes occurs most commonly in children and young adults, accounting for roughly 5% of all people diagnosed with diabetes.

More is known about what causes type 2 diabetes, as it is the disease’s most common form. Several risk factors include a family history of diabetes, being overweight, not getting enough regular physical activity, an unhealthy diet, high blood pressure, and increasing age.

Pregnant women at risk for developing gestational diabetes include those over the age of 25, people with a family history of diabetes, and women who are overweight. For reasons that are not fully understood, gestational diabetes occurs more frequently among black, Hispanic, Asian, and Native American populations.

Treatment

Many diabetics require treatment with insulin or other medications that help control glucose. Equally important are lifestyle habits that can be helpful in preventing diabetic complications. Diabetes can be managed by taking the following precautions:

• Eat meals balanced in starches, fruits and vegetables, proteins, and fats.

• Make physical activity a daily routine.

• Monitor blood sugar levels to be sure they are under control.

• Manage blood cholesterol and lipid levels by eating healthy and taking prescribed medications as recommended by a healthcare provider.

• Control blood pressure to a healthy range (below 130/80).

Prevention

Type 1 diabetes cannot be prevented, although many studies have shown that patients can take a few simple steps to drastically reduce their risk for developing type 2 diabetes.

The Diabetes Prevention Program was a federally-funded project that monitored over 3,000 individuals who were at risk for type 2 diabetes. Researchers discovered that adults at risk for the disease were able to reduce their susceptibility by half by following two practices: healthy eating and regular exercise.

Adhering to a low-calorie, low-fat diet and getting at least 30 minutes of physical activity for five days a week were shown to be effective markers for lowering the risk for diabetes.

To learn more about diabetes diagnosis, treatment, and prevention, visit the National Institute of Diabetes and Digestive and Kidney Diseases, supported in part by the National Institutes of Health.

Is Obamacare Affordable?

By Mark A. Kelley, MD |10/13/16

The upcoming election has dominated the media lately. Health care is not far behind with reports about Obamacare, health insurance and drug costs.

What’s behind the headlines?

Obamacare—too expensive?

The Affordable Care Act (ACA, Obamacare) was designed to expand health care coverage for those without insurance. Under the ACA, the federal government subsidizes the insurance for those who cannot afford it.

There have been a few surprises since the ACA was implemented. The newly insured folks have had more health problems than anticipated. This has driven up total heath care costs. Insurance companies had subsidies to cover these losses, but they will soon expire and the losses will increase. As a result, some major insurance companies, such as Aetna and United Health, have pulled out of the ACA.

Some policy experts think that the costs of ACA will go down. The theory is that as newly insured sick people receive medical care, their health will improve and they will need fewer services. No one knows if this will happen. Even President Obama admits that the ACA “has some problems”.

Rising Costs  

Aside from the ACA, other health care costs have been rising. A major driver has been the price of prescribed drugs. A second factor is the cost of expensive technologies especially electronic health records, mandated by federal law. These systems can improve communication but do not reduce costs.

These and other factors have created health care “sticker shock”. Employers are seeing their insurance costs accelerate. To reduce premiums, most employees have an annual insurance deductible, averaging over $1000. Prescribed medications often fall into the deductible. For example, someone who once paid a $20 co-pay for a drug must now, with a deductible plan, pay the insurer’s cost. The price can be ten times the cost of the co-pay. That can be an economic disaster for a patient on many medications.

Corporate Scandal

The recent uproar over the “Epipen” may be the last straw for the American public. The Epipen provides a life-saving injection for patients who suffer severe allergic reactions. The price of this product skyrocketed without any new enhancements. In effect, the company used its monopoly to extract extraordinary profits from families who need this “rescue drug”. This maneuver enraged the public and created distrust of the pharmaceutical industry.

The Flaws in the System  

These reports reflect significant flaws in our health system. Unlike most developed countries, we have few price controls for prescribed medications. We are also more liberal in approving new technologies and devices. Finally, in our private insurance system, insurers pass increased costs to employers and patients so there is no brake on inflation. This makes health care prices difficult to understand and to justify.

Employers are losing patience with rising costs of health care. One alternative is to providing employees with a “defined contribution” i.e. a fixed dollar amount for health insurance. This is how 401K-retirement plans work. Most employers can no longer afford pensions. Instead they provide a fixed amount for the employee to set aside for retirement. How the employee uses the money is up to them.

“Public Option” on the Horizon?

Many policy experts believe that we are headed for a “single payer” system. This means that health insurance would be provided and regulated by the federal government. We already have such a plan—it’s called Medicare.

Medicare controls prices, eligibility and coverage rules. It has kept medical inflation low for the past five years and its payment is accepted everywhere. Medicare is not free. It is supported by taxes and premiums and is very popular with its beneficiaries.

Will “Medicare for all” ever happen? The American public is becoming restless for such a change and politicians have noticed. For years, there have been political discussions about a “public option” similar to Medicare. Now, the federal government pays for almost 50% of our nation’s health care costs. That figure is rising as more “baby-boomers” enroll in Medicare. Some policy makers think that a national health insurance plan is inevitable.

They may be right. Studies and polls show that the majority of physicians and voters favor such a system.

That may be the most significant news of all.

Prostate Cancer — Does Everyone Need Treatment?

By Mark A. Kelley, MD |09/20/16

Last week, the New England Journal of Medicine published an important study about prostate cancer. The research showed that men with early stage prostate cancer can safely choose “monitoring” instead of treatment.

This might seem like a strange recommendation for such a serious disease. However, prostate cancer is an unusual malignancy. It is more common as men age but it rarely causes death.

Prostate cancer can be detected very early with the simple blood test, the prostate-specific antigen (PSA). The treatment is either surgically removing the prostate gland or treating the prostate area with external radiation. Both treatments are effective but can cause impotence and incontinence.

This is an unusual paradox in cancer treatment. A very simple blood test can detect prostate cancer in its early stages but the cancer grows slowly and is rarely fatal. Furthermore, the treatments have important side effects. Should a patient undergo treatment for a cancer that is rarely causes death?

The new study helps to answer that question. The major goal was to determine if prostate-cancer survival is better with early treatment versus to a “watch and wait” strategy. The study recruited over 1600 men between 50-70 years old with localized, early stage prostate cancer. These volunteers were randomly assigned equally to one of three groups: immediate surgery; immediate radiation; or “active monitoring” of their cancer by a medical specialist. During that monitoring, patients whose cancer became more aggressive were offered treatment. All patients, on average, were followed for ten years.

The major results of this study are:

1.  For all patients with localized prostate cancer, the 10-year survival from the disease was 99%.

2. There was no survival advantage from early treatment or the type of treatment (surgery vs. radiation).

3. Progression of prostate cancer occurred in 20% of the “active monitoring group” and in less than 10% in the treatment groups. This difference did not have any affect on survival over the ten years of the study.

4. About 60% of the “active monitoring group” eventually had surgery or radiation during the follow-up period. However, the remaining 40% had no progression of their disease.

What did we learn from this study?

The study confirms that localized prostate cancer does not behave aggressively. Over ten years, survival is excellent. Nearly half of the patents assigned to follow-up had no progression of their disease. They were spared unnecessary procedures. This lends support to follow-up as an option for patients.

What still remains in question?

More of the “active monitoring” patients had progression of their cancer compared to early treatment patients. (20 % vs. 10 %). This difference did not affect mortality in this study. However, the significance of this finding is unknown and warrants further research.

What will physicians recommend now?

Before this study was published, most experts have been offering follow-up as an option for men with localized prostate cancer. This new study gives convincing evidence that follow-up, instead of immediate treatment, can be a safe choice for newly diagnosed prostate cancer patients. In 40% of such patients, the tumor remains stable over a decade and requires no treatment. If the tumor grows during that period, and treatment is needed, the survival rate is still 99%.

A warning: in this study, specialists carefully followed men with “active monitoring”. Men who do not have this follow-up may have less favorable results.

This study may be especially helpful for patients who are hesitant about treatment. Those concerns are often about the complications of treatment or the risks of co-existing medical conditions. For such men, this study confirms that monitoring is a reasonable choice. This information will make it easier for doctor and patient to plan the next steps.

This is a great example of how medical research can help patients make informed choices.

To read more about prostate cancer, see the American Cancer Society website.

 

Are the Health Risks of Smoking Reversible?

By Mark A. Kelley, MD |09/07/16

As a lung specialist, I am often asked whether the body can recover from many years of smoking.  Based on decades of research, the answer is a resounding “Yes” … but only if you quit smoking – completely.

What Are The Risks of Smoking?

Cigarette smoking kills over 400,000 Americans each year – more than the combined deaths from alcohol, illegal drug use, homicide, suicide, car accidents, and AIDS combined.

Cancer – Before cigarette smoking became widespread in the twentieth century, lung cancer was a rare disease. However, as smoking become popular, lung cancer rose to became a leading cause of death.  Scientific research demonstrated that the toxic chemicals in cigarette smoke are carcinogenic. Smoking is also associated with cancers of the throat and digestive tract.

Heart and Vascular Disease – there is a strong association between smoking and the development of atherosclerosis, the “hardening of the arteries” that causes heart attacks, strokes and aneurysms. These conditions are among the major causes of death in smokers. A heart attack is 2-4 times more likely in a smoker than a non-smoker. Quitting smoking is the single most effective way to reduce the risk of a future heart attack.

Lung Injury and COPD – A person’s first puff from a cigarette invariably causes coughing.   This is the body’s warning sign–inhaled smoke damages the lung. Cigarette smoke irritates the lung’s bronchial tubes, causing mucus production.  The smoke also paralyzes the cells that clear mucus and debris out of the lung. . Over time, cigarette smoke causes mucus plugging, swelling and, sometimes, destruction of the bronchial tubes. This makes the lung more vulnerable to infections. When bronchial tubes are blocked or distorted, it is also much harder to move air in and out of the lung. This condition, called chronic obstructive pulmonary disease (COPD), is a leading cause of death and disability.

Nicotine Addiction – Nicotine is one of the most addictive substances known — often compared to heroin.  Nicotine withdrawal produces symptoms similar to opiates, which is why is it so difficult to quit smoking, Cigarette smoke delivers nicotine immediately to brain areas associated with pleasurable sensations. Nicotine also increases heart rate and blood pressure, and constricts blood vessels. This puts strain on the heart and promotes vascular disease..

If You Quit Smoking, Health Risks Fall Dramatically. 

Cancer – Smoking cessation for 10 years cuts the risk of lung cancer in half.  The reason is that the lung is no longer exposed to the carcinogens in cigarette smoke. With continued abstinence from smoking, the risk continues to decline. Similar results have been seen with laryngeal and other forms of cancer.

Heart and Vascular Disease – For someone with known coronary artery disease (CAD), smoking cession reduces the risk of a future cardiac event by 50%. For someone without CAD, quitting smoking for one year reduces the risk of CAD by 50%. If abstinence continues for 15 years, the risk of future heart events is almost the same as a lifetime non-smoker. The same is true for the risk of stroke.

COPD – Smokers expose their lungs to the constant irritation of cigarette smoke, and have a faster decline in lung function than non-smokers.   This decline occurs slowly and is not noticeable until the lung function is so low that it affects everyday activity. At that point, smoking cessation will reduce lung irritation but the chronically diseased lung cannot repair years of damage. The best strategy is to stop smoking before significant damage has occurred. The good news is smoking cessation can halt the rapid decline in lung function before more damage occurs.

Nicotine Addiction – Most smokers want to quit smoking but nicotine withdrawal is a major obstacle. As the old saying goes, “if it were easy, everyone would do it”. Most smokers who try to quit fail multiple times. However, the encouraging statistic is that millions of Americans have kicked the habit. The best results come from planned programs to break the nicotine addiction and eliminate lifestyle habits associated with smoking. (see references below)

In summary, smoking has life-threatening health care risks. Once a person stops smoking, these risks decline significantly over time. While kicking the habit is challenging, the health benefits are enormous. It is never too late to quit.

For more information about smoking and health risks, see the Centers for Disease Control (CDC) and the American Lung Association.

The Sun — America’s Leading Cause of Cancer

By Mark A. Kelley, MD |08/23/16

Skin cancer is the most common cancer in the United States. Here are some facts:

•Over 3 million Americans are treated for skin cancer every year.

One in five Americans will develop skin cancer during their lifetime.

•Skin cancer is preventable and easy to detect.

•When caught early, this cancer is usually curable.

Skin cancer is caused by sunlight damage to the skin. The only way to prevent it is to stay out of the sun, or block the sun’s rays.

People with fair skin are more vulnerable to skin cancer. Those with dark complexions have some natural protection since their skin filters out some of the sun’s rays. Nonetheless, people of color can still get skin cancer.

The sun’s ultraviolet rays can damage the DNA of skin cells. These cells may grow abnormally and eventually become cancerous. This transformation may evolve slowly over many years or may occur earlier in life, particularly if sunlight exposure has been intense.

Sunlight can also lead to another problem–premature wrinkling of the skin.  Sun worshipers believe that a tan is healthy. In reality, a suntan is a sign of the skin injury. If it continues, the damage can destroy the foundations of the skin, and make it look like leather. Tanning also triples the likelihood of developing the most dangerous form of skin cancer, melanoma.

A melanoma starts as a pigmented skin lesion. Early detection and removal can cure this malignancy. However, if untreated, melanoma can spread to other parts of the body and cause death.

The other types of skin cancer are less aggressive and spread slowly to the surrounding tissue. The most common are basal cell and squamous cell carcinoma. These cancers are rarely fatal and in early stages, are easy to remove.  If ignored, they can invade deeply and widely, making surgical removal challenging.

To prevent skin cancer, protect your skin from sunlight:

1. Limit your exposure to the sun. The sun’s rays are most intense between 10 am and 4 pm.

2. If you must go out in the sun, block the sun’s rays with “cover-up” garments and/or with sunblock.

3. Use sunblock that has sun protection factor ratings (SPF) of 15 or more.   An SPF of 15 means that it would take you 15 times longer to get sunburn with the sunblock, compared to none at all.

4. Follow the directions for applying and reapplying the sunblock product. Sunblock can lose its effectiveness after a few hours. It can also be removed by perspiration or swimming.

5. Avoid indoor tanning salons. Research has shown that those using tanning beds have an alarming increase in skin cancer including the most deadly form, melanoma. Click here for more information.

Screening for Skin Cancer

The benefits of routine skin cancer screening are controversial. However, most experts agree that anyone with a suspicious skin lesion or with a history of skin cancer should seek medical advice. Click here for details.

More information on skin cancer can be found at the National Institutes of Health and the Skin Cancer Foundation.

Summer Heat — A Dangerous Health Risk

By Mark A. Kelley, MD |08/15/16

Weather cross the U.S. has been unusually extreme this summer. Most regions have experienced high temperatures, often accompanied by high humidity. Summer heat can be a serious health hazard. This is why weather forecasters issue “heat alerts”, warning people to stay in cool environments.

Historically, heat waves have caused many deaths, especially among the elderly. Heat-related illness has also claimed the lives of younger victims, such as athletes and military trainees. These tragedies are preventable.

Our bodies are vulnerable to heat or cold. Major organs, blood flow and biochemical mechanisms only work within a narrow range of internal body temperature.

The human body can make some adjustments to outside temperature change. When it is cold, blood flow shifts away from our limbs to internal organs to preserve heat.  This is why our hands and feet feel cold.

In hot weather, our bodies do the opposite. We cool off by shifting more blood flow to our skin while producing sweat. When sweat evaporates, it acts like a natural sprinkler system and pulls heat away from the skin. . The extra blood flow to the skin speeds up the cooling process by moving “hot blood” from inside the body to the cooler surface of the skin.

This works well except when the environment is unusually hot and humid.

In that situation, sweat does not evaporate because of the high humidity. This blocks the body’s best method to eliminate body heat, and can lead to high internal body temperatures.

There are two stages of heat-related illness … and both have warning signs.

In the first stage called “heat exhaustion” the patient sweats profusely with cold clammy skin and may feel faint or nauseous. If this continues, the result can be dehydration and failure to sweat. Without any sweat, body temperature can climb quickly.

This can lead to the second and most dangerous stage, called “heat stroke”. The victim becomes confused and may have seizures or trouble walking. If left untreated, heat stroke can result in major organ failure and death. Heat stroke is an emergency that requires immediate medical treatment.

These serious conditions can be prevented. The concept is simple–-avoid environments that raise body heat and keep well hydrated. Here are some tips:

1. Avoid the high heat and humidity by staying out of the sun and seeking cool, well-ventilated, preferably air-conditioned spaces. This will keep your body heat down.

2. Avoid vigorous outdoor exercise in extreme heat. Exercise in these conditions is risky. It quickly raises body heat while the hot, humid air prevents cooling and promotes dehydration. If you must exercise outdoors, choose times early or late in the day when the temperature is lower. This is the strategy used by high performance athletes.

3. Take special precautions if you are elderly or live in an apartment. The elderly are particularly sensitive to extreme heat. During heat waves, apartments and other closed dwellings can become dangerously hot if they do not have fans or air conditioning. In these situations, it is wise to seek temporary shelter in a cooler place, either with friends or relatives or in cooling shelters provided by municipalities.

4. Drink lots of fluids whether or not you are thirsty. Staying hydrated helps your body cope with the heat.

With these sensible approaches, you can safely ride out the heat wave and look forward to cooler days.

For excellent recommendations on prevention, recognition and treatment of heat exhaustion and heat stroke, see the Centers for Disease Control website.

For more detailed information about the hot weather and health, see E-medicine.

How to Fight Zika — Lessons from the Panama Canal

By Mark A. Kelley, MD |08/08/16

The Zika virus continues to capture headlines. Zika virus has been found in Puerto Rico and now in a Miami Florida neighborhood.

Is this the beginning of a major epidemic? Not likely – if we follow the lessons of the Panama Canal.

I recently visited Panama and its famous canal that links the Atlantic and Pacific Oceans. The canal was built between 1880 and 1914 at the cost of many lives. Over 30,000 workers perished, most of them dying from tropical diseases. The most deadly were malaria and yellow fever. The latter could kill some victims within a week.

The tropical disease epidemic in Panama was stopped without the use of any vaccines or drugs. The key was understanding how mosquitoes spread these diseases to humans. Female mosquitoes need blood nourishment to lay their eggs. Infected mosquitoes can transmit the diseases to humans when they sample human blood. Eliminating mosquitoes prevents the disease.

Zika virus, known for almost seventy years, belongs to a group of tropical viruses transmitted by mosquitoes. Among them are yellow fever and dengue fever.
Until recently Zika was not considered a major public health problem because it rarely caused problems in humans.

Now Zika has changed and become dangerous. When the virus is transmitted from an infected woman to her fetus, the infant may be born with major birth defects, particularly of the brain. At the moment we have no drugs or vaccines to fight Zika.

This sounds like the Panama problem in the early 1900s. What stopped the epidemic back then?

The answer came from understanding the aegypti mosquito, the major carrier of these viruses. Each mosquito lives only 2-4 weeks. The female lays hundreds of eggs that hatch immediately upon contact with water. In dry conditions, these eggs can survive for 12 months. The resulting larvae emerge as adult mosquitoes in about ten days.

Aegypti mosquitoes have several important characteristics.

1. They stay close to human dwellings and need very little water for their eggs. These bugs prefer to be close to their victims and hide in and near dwellings –not in the jungle. They love stagnant water to lay their eggs. Human dwellings, with flowerpots and gardens, sinks and toilets, are perfect. During the Panama Canal construction, mosquitoes were happily breeding in the inkwell of the chief physician!

2. The typical female travels no more than a quarter mile during its lifetime. The only way for Zika virus to leave the neighborhood is by “hitching a ride” with a human. In the Miami outbreak, the “neighborhood” where Zika was found is about 10 blocks wide and 20 blocks long. An infected human who leaves this “Zika zone” may bitten by a mosquito in a new location that is “Zika-free”. If that local mosquito becomes infected, it can pass Zika to victims in the new neighborhood.

3. They like to bite humans during the day. This makes prevention more challenging for those who leave their home during daytime.

What stopped the Panama Canal epidemic a century ago? Public officials declared war on these mosquitoes with an aggressive action plan:

• Every house and neighborhood was inspected regularly to eliminate standing water and stop mosquitoes from breeding. All water containers were cleaned weekly to kill any eggs or larvae.

• Irrigation ditches and swampy areas near homes were drained.

• To prevent spread, yellow fever patients were kept in isolation from mosquitoes.

• Workers and the general public covered up with long sleeves and pants to reduce the chance of mosquito bites.

The plan worked. In less than one year, the yellow fever epidemic ended. .

Today, we have many more tools to fight this virus – window screens, air conditioning, municipal sanitation, and effective insect repellant. Also many regions in the U.S. either are too dry or too cool for the aegypti mosquito to thrive.

We still have much to learn about Zika. One surprise is that Zika can be transmitted by sexual contact. This makes things more complicated and prevention recommendations are still evolving. Hopefully, a Zika vaccine may eventually emerge, as happened with yellow fever.

Meanwhile, the lessons of the Panama Canal still hold true:

• Eliminate standing water near humans.

• Prevent mosquito bites by staying inside screened dwellings. When outside, wear clothing that covers the skin and use insect repellent.

These measures are effective. During a five-day visit to Panama City, none of my family and friends was bitten by a mosquito. In fact we never saw one.

For the most accurate and up-to-date information about Zika, check the Centers for Disease Control website. There you will find details about prevention, transmission, and Zika in Florida and other locations.

What is Precision Medicine?

By Mark A. Kelley, MD |08/01/16

In his State of Union address this year, President Obama announced a federally funded program called ”Precision Medicine”. This $215M project is designed to improve disease treatment and prevention by studying the variability in genes, the environment, and lifestyle for each person. A “cohort” of one million volunteers from different parts of the nation will followed over a number of years.

This project resembles the famous Framingham Heart Study, which began almost 70 years ago. That study has provided major insights into the causes of heart disease by following patients over many decades.

In this era, we have many more tools to improve our understanding of how diseases evolve over time. We can track massive amounts of information about patients and analyze their genes. We also have new electronic communication and monitoring tools. The hope is that we can find better ways of prevention, detection and cure of diseases. Already, medical research is facing some important challenges. Here are several examples.

Inherited disease is more complicated that we thought. Medical science has achieved major breakthroughs in understanding how the human genome behaves. Genes control most of the processes in our bodies and slight changes in those genes can cause problems. Some inherited genes have been known for decades – such as sickle cell disease and cystic fibrosis. However, the system is much more complex than ever imaged. Only recently have we begun to understand how inherited genes cause disease.

Genes can control our response to prescribed drugs. Some drugs, such as those for conditions like hypertension and blood clots do not work the same for everyone. Many patients may need higher (or lower doses) and for some, the drug does not work at all. Research suggests that these variances may be due to different genes that control the way the drug interacts with our bodies. How do we know which drugs are best for each person? Should we test everyone for genes that control response to prescribed drugs?

Genes can become abnormal and trigger disease. Curing cancer is at the core of the Precision Medicine project. All cancer is from the uncontrolled growth of cells. In many cancers, genes that control cell growth no longer work normally and the result is a tumor. We do not understand how or why this happens. In some cases, genetic analysis of the patient’s tumor reveals which genes are defective and therapy can be developed to block the effects of these abnormal genes. The influence of genes on human disease is the hottest area of medical research. Precision Medicine will help us understand much more about these processes.

How are diseases related to the environment, including social factors? We know much about toxins and other environmental risks but we need to learn more. The influence of social factors on health is not well understood. Poverty, education, and life style can affect health but the details are lacking. For example, is poverty a risk factor for hypertension when you exclude all other factors except poverty itself?

Fortunately, we have the tools to improve our understanding of these issues. Studying the human gene has become very sophisticated and less expensive. With this technology, we may learn how and when genetic testing is useful in a large population. Supercomputers can analyze enormous volumes of information about patients over many years. This may reveal important clues on disease patterns and risks for individual patients.

We in the United States are a very diverse population and each of us is uniquely different. With Precision Medicine, we may better understand how to provide the best care for every individual.

For more information about Precision Medicine, go to the National Institutes of Health website or the White House webpage.

If you are interested in enrolling in the project, contact the NIH Precision Medicine participation website.

Is Genetically Modified Food Safe?

By Mark A. Kelley, MD |07/25/16

Genetically Modified (GM) Food is a major breakthrough, but, like many discoveries, it has created controversy.

All living things, whether plants or animals, face many challenges to their survival: climate, predators, competition for food etc. Genes that give an organism a survival advantage are passed on to future generations.

There are many examples. Some plants develop their own natural insect repellent. Birds and fish have different colors to attract mates or to hide from predators. Bacteria develop resistance to antibiotics.

Science has now developed laboratory techniques to insert new genes into the DNA of some plants and animals. The goal is to make the food supply more productive. Plants can be changed to be more resistant to drought, heat, and insects. Farm animals can be bred to grow with less feed, water etc.

These biologically engineered animals are termed “Genetically Modified Organisms” or GMOs. You may see foods labeled as “GM” (or GMO) -free”. That means that the plant or animal has not been genetically modified by laboratory techniques.

What are the advantages of GM foods?
With climate change and expansion of the world population, many experts feel that we will need more efficient ways to grow food. Extremes of weather, and shortages of fertile land and water could all contribute to a food shortage. If we can genetically modify plants and animals to adapt to these challenges, the food supply may still thrive.

What are the risks of GM foods? So far, GM foods have proven very safe. One reason is that they must undergo safety tests before they can be introduced into the food chain. The food must be proven safe for human consumption and the plants and animals must not disrupt the environment. One common concern, especially for plants, is whether the new version can cause allergic reactions.

Can the new genes in the plant or animals be transmitted to humans? Eating a food product does not transmit genes. Every food has billions of genes that have no biologic way to mingle with our own genes. However, to artificially change a plant of animal gene, viruses are used to transmit the new DNA. . Some have argued that such viruses might linger in the food and infect humans. This theory has not been proven after decades of research. However, even if that were true, viruses have produced natural genetic changes in plants and animals for millions of years.. So far, humans have suffered so ill effects.

What are the dangers to the environment?
The GM organism could be so successful that it alters the natural balances in the environment. The organism may crowd out competitors or breed with them. We have seen this happen naturally when animals or plants from other continents have reached the US. With no competitors in their new land , these foreign organisms can spread rapidly. Examples include the zebra mussel in the Great Lakes and the Japanese beetle – found in almost every state. So far, no significant “outbreak” has happened with GM organisms.

Based on current information, these are the “take-home” messages about GM food:

• GM technology has improved food production, making food more affordable and available. With increasing pressure on the food supply, it is likely that more GM food will be developed.

• Most countries, including the US, regulate these products carefully, as they do other sources of food.

• The safety record of these GM foods has remained excellent , but the experience has only been over a few decades. Careful surveillance should continue.

• Before GMOs, we made serious mistakes in our food supply. Examples include applying harmful pesticides, and feeding animals growth-enhancing antibiotics that cause the life-threatening infections in food.

• The lesson is that we should always pay close attention to the safety of our food supply. GMOs are no exception. They have many benefits and minimal, if any risks to our health. Whether GMOs will threaten other organisms and the environment remains unknown.

You can learn more about GMOs from the Scientific American and the World Health Organization.

The “Conversation Project” — Planning for the Future

By Mark A. Kelley, MD |07/15/16

Most of us make future plans about careers, finances, retirement etc.   However, few of us plan for the end of our lives.

Medical science has made great strides in treating complex diseases like cancer, heart failure and diabetes. Nonetheless, for these chronic diseases, complete cures remain the exception, rather than the rule.

If you have helped someone with life-threatening disease, you know the stress involved. As the disease progresses and end of life is near, many difficult issues arise: Is a cure still possible?   Will more treatment be helpful?   Will the treatment be worth the result? Will the end come soon?

As an intensive care physician, I have seen patients and their families grapple with these dilemmas in “crisis mode”. This happens when a gravely ill patient’s wishes at the end of life were never discussed. Now, with very little background information, the family and physicians must make some decisions to guide the patient through life-threatening challenges.

The Conversation Project” is addressing this problem. The objective is to facilitate discussion about patient’s goals well before any crisis. The conversation between the patient and his/her family and physician assures that everyone involved knows the patients’ desires.

The Conversation Project describes research showing that patients want this discussion but need help.

1. 90% of people think that talking about end of life care with their loved ones is important—only 27% do.

2. 82% say it is important to put their wishes in writing but only 23 % have done so.

3. If seriously ill, 80% of people would discuss end of life care with their doctor, but only 7% actually do.

The “Conversation Project” has developed tools to facilitate communication about end of life care. Personally, I have found their approach helpful with both my patients and my family.   The best time to begin the conversation is when there is no pressure for an immediate decision.   Ideally, the patient feels well, and family members and physicians can participate.

The most important part of this conversation is for informed patients to set their objectives for the end of life. Patient preferences vary and can even change depending on circumstances. For example, one third of adults would continue treatment even if their disease were incurable. However, other factors can change that decision.   Over 52% of patients with incurable disease would stop treatment if they must depend on a family member for care.

In a third example, some patients would prefer to stop treatment but continue anyway. They do not want their loved ones to remember them as “giving up”.   I have found that this dilemma can often be solved by a candid discussion with the patient, physician and family members together. In this session, the doctor discusses the medical facts, and the patient describes his/he true feelings and desires. With everyone hearing the same important information, the family usually rallies in support of the patient’s decisions.

These circumstances can differ and the details are very personal. However, there is only one “best” outcome: that each patient communicates their plans and desires for the end of life.   That important action assures that the patient’s wishes are fulfilled and greatly reduces emotional stress for all.

Have you and your family had “The Conversation”?   Check out the Project website (http://theconversationproject.org) for some valuable tips.