Saturday, December 4, 2010

Colorful Images to Help Illuminate the Brain -

Who has seen the mind? Neither you nor I — nor any of the legions of neuroscientists bent on opening the secrets of that invisible force, as powerful and erratic as the wind.

The experts are definitely getting closer: the last few decades have produced an explosion of new techniques for probing the blobby, unprepossessing brain in search of the thinking, feeling, suffering, scheming mind.

But the field remains technologically complicated, out of reach for the average nonscientist, and still defined by research so basic that the human connection, the usual "hook" by which abstruse science captures general interest, is often missing.

Carl Schoonover took this all as a challenge. Mr. Schoonover, 27, is midway through a Ph.D. program in neuroscience at Columbia, and thought he would try to find a different hook. He decided to draw the general reader into his subject with the sheer beauty of its images.

So he has compiled them into a glossy new art book. "Portraits of the Mind: Visualizing the Brain From Antiquity to the 21st Century," newly published by Abrams, includes short essays by prominent neuroscientists and long captions by Mr. Schoonover — but its words take second place to the gorgeous imagery, from the first delicate depictions of neurons sketched in prim Victorian black and white to the giant Technicolor splashes the same structures make across 21st-century LED screens.

Scientists are routinely seduced by beauty. Mr. Schoonover knows this firsthand, as he acknowledged in an interview: for a while his wallet held snapshots not of friends or family, but of particularly attractive neurons. Sometimes the aesthetics of the image itself captivate. Sometimes the thrill is the magic of a dead-on fabulous technique for getting at elusive data.

Consider, for instance, a blurry little black-and-white photograph of a smiley-face icon, so fuzzy and ill-defined it looks like a parody of the Shroud of Turin. The picture is actually a miracle in its own right: the high-speed video camera that shot it was trained on the exposed brain of a monkey staring at a yellow smiley face. As the monkey looked at the face, blood vessels supplying nerve cells in the visual part of the monkey's brain transiently swelled in exactly the same pattern. We can tell what was on the monkey's mind by inspecting its brain. The picture forms a link, primitive but palpable, between corporeal and evanescent, between the body and the spirit. And behind the photo stretches a long history of inspired neuroscientific deductions and equally inspired mistakes, all aiming to illuminate just that link.

It's only fitting that the story should be a visual one, for the visuals had the ancients fooled for millenniums. The brain was so irredeemably ugly that they assumed the mind was elsewhere.

Aristotle, for example, concluded that the brain's moist coils served only to cool the heart, the obvious home of the rational soul. The anatomist Galen pointed out that all nerves led to the brain, but medieval philosophers figured that most of the important things happened within the elegantly curved fluid-filled ventricles deep inside.

Only when the long ban on dissection petered out in the Renaissance did the ventricles prove to be so much empty space — poke the brain around a little, and they collapse and disappear. The gelatinous brain moved into the spotlight, as resistant to study as a giant mass of tightly packed cold spaghetti.

The challenge was twofold: what did that neural pasta really look like, and how did it do what it did?

In 1873 the Italian scientist Camillo Golgi developed a black stain to highlight the micron-thin neural strands. Fifteen years later the Spanish scientist Santiago Ramón y Cajal, deploying the stain with virtuoso dexterity, presented the world for the first time with visible populations of individual neurons, looking for all the world like burnt scrub brush in a postapocalyptic Dalí landscape. The roots, or dendrites, of these elongated nerve cells gather information. The trunks, or axons, transmit it.

Now those same skeletal silhouettes glow plump and brightly colored, courtesy of a variety of inserted genes encoding fluorescent molecules. The most dramatic variation on these methods for highlighting neurons in living color, dubbed the Brainbow by its inventors, turns the brains of living mice into wild neon forests of branching trees.

The electrochemical circuitry that propels information around that forest, from nerve to nerve, has generated its own fabulous images.

One team of researchers harnessed the rabies virus, which has the unusual ability to travel upstream against the neural current. The virus moves from a leg bitten by a rabid dog up the long axons leading to the spinal cord, then jumps to dendrites of other nerves and travels up to the brain, where it causes horrific damage. Modifying the virus by a few genes and inserting it in mice, the researchers captured its path in a photograph, highlighting the long axon of the first nerve in brilliant magenta and then the tangle of dendrites of communicating nerves in yellow.

Meanwhile, the traffic in long groups of neurons all coursing together around the brain becomes visible with a variation on the standard scanning technique called diffusion M.R.I. Here the neurons do look just like pasta — angel hair, perhaps — slightly beaded, draped and purposeful. But if the structure is destroyed (by a stroke, for instance) the strands shatter into fragments, the information highway broken, upended as if by an earthquake.

In the book's final essay, Joy Hirsch, a neuroimaging specialist at Columbia, sympathizes with readers who hate the idea that they — their essential selves, their likes and dislikes, their premonitions, biases and life decisions — are nothing but neural circuits.

"These cells and molecules, awash in various neurochemical cocktails in my basal ganglia, are presumably the basis for my love and attachment to my husband," she writes. "Earlier in my academic journey I would have resisted this unavoidable fact of biology on the misguided rounds that a physical basis would diminish the grandeur and centrality of my choice of a life partner."

Now, however, Dr. Hirsch says she joyfully embraces "the astonishing unity of the physical brain and the mind" for the potential it clearly holds for improving the lot of humankind. And furthermore, she doesn't see that anyone has much choice about accepting it.

"People assumed for thousands of years that there must be something else," the science writer Jonah Lehrer writes in the introduction. "And yet, there is nothing else: this is all we are."

Waking Up From the Pill

On a cold night in mid-October, a couple hundred bejeweled women in gowns file into the Pierre with their dates for a very special 50th-birthday party. Before retiring to a three-hour lobster-and-steak dinner in the hotel's main ballroom, they collect oversize spoons of foie gras as Gloria Gaynor's "I Will Survive" blasts from overhead speakers in a robin's-egg-blue reception room, with a bar festooned with the kind of miniature silver stars that teachers give exemplary students. Neat stacks of East Village party napkins with illustrations of women in vintage clothing rest next to rows of Champagne glasses, each with a different quip at the bottom: "Let's ignore our mother's well-meant advice," says one; "She thought of him fondly as 'Plan B,' " says another; and a wide-eyed Lucille Ball covers her mouth with a yellow-gloved hand in shock at some mishap on the next, asking, "Has anyone seen my hormones?" In the middle of the room, on a tall pedestal, there's an enormous cake, with lettering that spells out ONE SMALL PILL. ONE GIANT LEAP FOR WOMANKIND. ONE MONUMENTAL MOMENT IN HISTORY.

Yes, the birth-control pill, approved by the FDA in 1960, is the "birthday girl" at tonight's gala, which is sponsored by Israeli company Teva Pharmaceutical, the biggest maker of generic drugs in the world. Medications don't usually have their own black-tie events—there aren't galas for antibiotics, or chemotherapy, or blood thinners—but the Pill, after all, is so much more than just a pill. It's magic, a trick of science that managed in one fell swoop to wipe away centuries of female oppression, overly exhausting baby-making, and just marrying the wrong guy way too early. "The Pill created the most profound change in human history," declares Kelli Conlin, president of the National Institute for Reproductive Health, grabbing the mike on a small stage draped with black curtains dotted with a larger version of the same silver stars from the bar. "Today, we operate on a simple premise—that every little girl should be able to grow up to be anything she wants, and she can only do so if she has the ability to chart her own reproductive destiny."

A series of toasts follows, from Kate White, the editor of Cosmopolitan magazine, who talks about "vajayjays," to Dr. Ruth, who, though considerably shrunken from her heyday in the mid-eighties, still giddily declares that tonight's event is "better than sex!" Even the grandson of Planned Parenthood founder Margaret Sanger has stopped by to collect his award, an "honorable mention." "What a treat!" says Alexander Sanger, jumping onstage. "You know, Margaret thought two or, at the outside, three children was the exact right number. Now I'm fourth of six. When my mom told Margaret the news, there was a long pause as she did the math. Then she said, 'You've disgraced me. I'm going to Europe.' " The crowd laughs loudly. "And let me add one thing," says Sanger, his voice rising triumphantly. "I think it's time we had a male Pill also. I'd like to be around for that pill's 50th birthday!"

It's an endless parade of speakers, actually, with the hullabaloo lasting until 10 p.m., including a slideshow of female icons—Jackie O., Wonder Woman, Murphy Brown, Hillary, Oprah, Sarah Palin—and a constant stream of jokes from buoyant mistress of ceremonies Cybill Shepherd, in a red off-the-shoulder pantsuit that could be from her Moonlighting days. "When I grew up in Tennessee, everything I learned about sex my mother told me," she says, wiggling this way and that. "She said, 'It's disgusting, and you'll hate it, and whatever you do, don't do it before you get married.' Did I mention 'disgusting'?" She shakes her head. "Nevertheless, I became sexually active as a teenager. One day, my mom took me to my family doctor. He wrote something on a prescription pad and said, 'Take one of these every day, and all your periods will be regular.' " She laughs heartily. "What a thrill! He didn't even tell me it was birth control."

Shepherd pauses for dramatic effect. "Can you imagine how different my life would have been if I hadn't gotten the Pill?" she says. "In the South in the sixties, you had limited choices—you could be a wife, a mother, a nurse, or a teacher. If you were really lucky, Miss America." She cocks her head. "Wasn't I Miss America? There's a lot I can't remember. Oh, right, Model of the Year." Soon, she passes the mike to The Daily Show's Samantha Bee, who raises yet another glass. "Today, even though we have pills for everything—to make you calm, make you sleep, and engorge your genitals beyond comprehension—you, the Pill, are so important," says Bee. "So here's to my tiny daily dose of freedom, and also estrogen and progesterone. A combination of the three, really." She smiles, a little bit knowingly. "Interestingly, it's the freedom that causes the bloating."

Even if it is laid on a little thick, there's no question that these women are right: The Pill changed the world. These days, women's twenties are as free and fabulous as they can be, a time of boundless freedom and experimentation, of easily trying on and discarding identities, careers, partners. The Pill, which is the most popular form of contraception in the U.S., is still the symbol of that freedom. As a young woman, you feel chic throwing that light plastic pack of dainty pills into your handbag, its retro pastel-colored wheel design or neat snap-to-close box sandwiched between lipstick and cell phone, keys and compact. It's easy to believe the assurances of the guests at the Pierre gala that the Pill holds the answers to empowerment and career success, to say nothing of sexual liberation—the ability to have sex in the same way that guys always have, without guilt, fear, or strings attached. The Pill is part of what makes one a modern woman, conferring adulthood and cool with the swipe of a doctor's pen. "I started taking the Pill when I was a freshman in college, before I even was having sex," says Sahara, 33. "Everyone else was doing it, so I wanted to do it, too."

The Pill is so ingrained in our culture today that girls go on it in college, even high school, and stay on it for five, ten, fifteen, even twenty years. It's not at all out of the ordinary for a woman to be on the Pill from ages 18 to 35, her prime childbearing years. While it is remarkably safe, almost like taking a vitamin, that's a long time to turn one's body into an efficient little non-procreative machine. The Pill (and other hormonal methods of birth control, like the patch and the ring) basically tricks your body into thinking it's pregnant. The medicine takes control of your reproductive processes, pulsing progesterone and estrogen to suppress ovulation. On the Pill, every woman's cycle is exactly the same, at 28 days, even though that is rarely the case in nature, where the majority of periods occur every 26 to 32 days but can take up to 40 or even 50 days. This is a nice effect, but it's not real. And there's a cost to this illusion, one that the women at the Pierre weren't discussing.

The fact is that the Pill, while giving women control of their bodies for the first time in history, allowed them to forget about the biological realities of being female until it was, in some cases, too late. It changed the narrative of women's lives, so that it was much easier to put off having children until all the fun had been had (or financial pressures lessened). Until the past couple of decades, even most die-hard feminists were still married at 25 and pregnant by 28, so they never had to deal with fertility problems, since a tiny percentage of women experience problems conceiving before the age of 28. Now many New York women have shifted their attempts at conception back about ten years. And the experience of trying to get pregnant at that age amounts to a new stage in women's lives, a kind of second adolescence. For many, this passage into childbearing—a Gail Sheehy–esque one, with its own secrets and rituals—is as fraught a time as the one before was carefree.

More ...

Friday, December 3, 2010

Treating Eating Disorders and Paying for It -

Notoriously difficult to treat, eating disorders may persist for years, wreaking havoc not just on the patient's health and personal relationships but often on family finances, as well.

Hospitalizations for problems caused by eating disorders grew 18 percent from 1999 to 2006, with the steepest rise among children under age 12 (up 119 percent), followed by adults ages 45 to 64 (up 48 percent) and men of all ages (up 37 percent), according to the federal Agency for Healthcare Research and Quality.

Care for these patients can be expensive. Many must be seen on a weekly basis by a team of specialists, including a psychiatrist, a physician and a nutritionist. A residential program costs $30,000 a month on average. And many patients require three or more months of treatment, often at a facility far from home. Even after leaving a specialized program, patients may need years of follow-up care.

Yet most insurers will not cover long-term treatment, and some routinely deny adequate coverage of eating disorders on the grounds that there is not enough evidence on how best to treat them, said Lynn S. Grefe, chief executive of the National Eating Disorders Association.

"Eating disorders pose a unique treatment challenge in comparison to other psychiatric illnesses," said Dr. Evelyn Attia, director of the eating disorders research program at the New York State Psychiatric Institute. "They are not always easy to diagnose, and insurers are often not well informed about which treatments work."

Jeanne P.'s 19-year-old daughter has been battling anorexia for eight years and has tried 10 treatment programs. The family has "great health insurance," said Ms. P, who asked that her full name not be used to protect her daughter's privacy. Still, the best doctors are often not in the insurer's network, she says she has found, and the family's insurance has not always fully covered residential treatment programs.

The result?

"We have totally exhausted our retirement savings on her care," said Ms. P.

If you suspect that a family member has an eating disorder or that you may have one, these steps may help you find treatment you can afford.

EARLY DIAGNOSIS No one knows exactly what causes eating disorders, though genetics and environmental triggers play large roles. Anorexia and bulimia tend to run in families, and obsessive dieters, athletes and performers have a higher-than-average risk for developing these conditions.

Whatever the cause, early intervention is critical.

"Eating disorders can become chronic and more difficult to treat over time," Dr. Attia said.

If you suspect a problem, get a professional evaluation immediately. Call your physician or pediatrician, explain the symptoms and ask for a referral to an eating disorders specialist.

The Academy for Eating Disorders has an online tool that can help you locate doctors and therapists, as well as inpatient and outpatient treatment facilities in your area. Also try the National Eating Disorders Association help line (800-931-2237; 8:30 a.m. to 4:30 p.m. P.S.T.) for questions about treatment referrals and support groups and to learn more about eating disorders.

AT-HOME TREATMENT If it is your child who has received a diagnosis of anorexia or bulimia, you may want to consider family-based therapy, also called the Maudsley method.

Costs are minimal for this therapy because families do most of the monitoring themselves. Under the guidance of a trained therapist, the parent takes primary responsibility for helping a child get back to a healthy weight and normal eating habits. One recent study, published in the Archives of General Psychiatry, found that family-based therapy was more effective than individual therapy at helping children reach full remission from anorexia.

While this approach may be cost-effective compared to residential treatment, the emotional toll on families can be extreme. During the first phase of treatment, which can last a few months, the child needs supervision around the clock, tracking meals, snacks and exercise.

To learn more about how family-based therapy works and to find a trained therapist, go to the Maudsley Parents Web site at To find out how one family used this therapy to combat their daughter's anorexia, take a look at Harriet Brown's book, "Brave Girl Eating: A Family's Struggle With Anorexia."

INSURANCE COVERAGE If a high level of care is required — at, say, an inpatient treatment center — be prepared to take on your insurer. Learn as much as you can about your health policy and about the roadblocks you may encounter while trying to get coverage for specialized care.

The National Eating Disorders Association's Web site has useful guidance on insurance issues in the Parent Toolkit section. It includes tips on how to explain to your insurer that the treatment your child requires is medically sound, how to manage an appeal and sample letters to send to reluctant insurers.

If your insurer balks at your requests for coverage, ask to be assigned a case manager, suggested Marcia Herrin, founder of the Dartmouth College Eating Disorders Prevention, Education and Treatment Program.

A case manager can often (though not always) help you get access to additional care. Insurers normally do not cover nutritional counseling, for example, but a case manager authorized six visits to a nutritionist for one of Dr. Herrin's patients.

If the case manager cannot help you, you will have to take a route familiar to almost anyone who has tangled with an insurer. Get in touch with your employer's human resources department, and ask them to go to bat on your behalf. If your employer and your insurer will not budge, make a formal appeal to your insurer. If your appeal is denied or not answered, contact your state's insurance commissioner or even your representative in Congress.

Extreme though that may sound, it has been known to work. Susan M. was able to get her daughter's lengthy residential treatment covered by enlisting the help of her senator's office. An aide called the Department of Labor, and after several more steps, the insurer ultimately agreed to cover the treatment.

You might consider contacting a lawyer for advice on your rights and legal precedents in your state, as well.

FREE TREATMENT Some academic hospitals offer free treatment to individuals who meet specific criteria and are willing to participate in a research trial.

Patients who enroll in Dr. Attia's program at the New York State Psychiatric Institute, for instance, do not pay a dime and can stay at the treatment center as long as they need to, but they must agree to answer surveys and stay in touch with the facility after they check out. All patients receive the best evidence-based treatment, and some may be involved in trials that assess physical activity or different psychotherapy approaches.

To find research programs, go to the Web sites of the National Eating Disorders Association and the Academy for Eating Disorders. Also, try, which lists federally and privately supported research trials conducted worldwide.

FINANCIAL ASSISTANCE If you have limited resources, some treatment programs will provide financial assistance. Be sure to ask about it.

A few foundations also offer scholarships. Moonshadow's Spirit, for instance, offers financial assistance to individuals who are seeking inpatient or partial hospitalization programs. The Kirsten Haglund Foundation and the Manna Scholarship Fund also offer grants to individuals in financial need.

Keep in mind that when aggressive intervention happens early, full recovery is possible. One notable study by researchers at the University of California, Los Angeles, found that 76 percent of anorexic adolescents had fully recovered from the disorder within 10 to 15 years of their initial hospitalizations.

A free pamphlet about illicit drugs that every reporter should download. - By Jack Shafer - Slate Magazine

Where do most people get their information about drugs? From the press. And where does the press get its information? Primarily from other misinformed journalists, lazy cops, grieving parents, clueless drug counselors, spurious Web sites, and gibbering druggies. By indulging their worst class biases, by following their newsman instincts to hype the sensational or dramatic aspects of the story, by giving in to fear and ignorance, journalists keep their readers in the dark about drugs.

It doesn't have to be that way. Newspapers could establish drug beats and fill them with reporters as eager to learn about Mexican tar as budding financial reporters are to understand the workings of the Fed. Press organizations that say they can't afford a drug-beat reporter could at least invest in a few reference works to help their staff cover illicit drug use. One of my favorites,Buzzed: The Straight Facts About the Most Used and Abused Drugs From Alcohol to Ecstasy, is now in its third edition. Thanks to the work of one enterprising soul, the entire text of the 1972 classic Licit and Illicit Drugs is on the Web. Although dated in spots, it's still a solid and valuable overview of the drug universe.

For news desks pleading complete poverty, the U.K. charity DrugScope has produced a free pamphlet (PDF) titled The Media Guide to Drugs: Key Facts and Figures for Journalists, which serves up 140-pages of basic, nonhysterical information about drugs and drug law. Although U.K.-centric, especially in its legal references, the pamphlet's contents are easily translatable to the American scene.

Guardian media blogger Roy Greenslade, who hypes the pamphlet today, also contributed a blurb for its cover that's worth reproducing in full. He writes:

I have despaired over the years about the hysterical and ill informed way in which the media, most especially the largest-selling popular newspapers, report on the subject of drugs. Journalists are too ready to accept myths and, by passing them on, contribute to yet further myth-making by their readers.

By reacting emotionally rather than rationally to the topic, and by denying reality, newspapers do a disservice to society.

This guide will surely help the next generation of journalists because it deals with facts that counter ignorance and prejudice. I believe it will prove invaluable.

The Media Guide to Drugs doesn't pretend to be the final authority on drugs like, say, The Physicians' Desk Reference, but as a place to launch an open-minded journalistic inquiry into drugs, their effects, and the drug laws. The pamphlet's A-Z guide to the most prevalent drugs eschews hysteria in favor of cold facts and presents accurate timelines for each drug discussed.

I'm not as enthusiastic about the pamphlet's pointers on how journalists should cover drug stories as I'd like to be. In my experience, most drug journalism falters because the reporters and editors behind the stories don't ask the skeptical and probing questions they would if they were covering a business or political story. They don't question the numbers the drug warriors give them or the anecdotal accounts of users. They don't look for authoritative information in the medical literature or in academia. They don't even bother to consult Nexis, which contains brilliant articles (not just mine!) that tell the truth about drug-related death, meth-mouth, pot potency, glue sniffing, and more.

But those are quibbles. In a Q&A section, The Media Guide to Drugs smartly implores reporters to ask the essential questions when writing their stories, such as, "What happens when someone takes more than one drug at a time?" and "Why do some people respond so differently to the same drug?" and "Can you become instantly dependent on a drug?" It counsels journalists to seek drug statistics from reliable sources, but even then to be skeptical of data that are under-reported or make unsupportable claims. The sources the pamphlet points to are all British, of course, but any reporter with a Web browser can find their U.S. equivalents with the help of Google.

Those who cover the police, the courts, popular culture, or the legislative and administrative machines should keep a copy of The Media Guide to Drugs for quick reference. It presents more debunking of facts, encourages more sensible doubt, and kills more dangerous preconceptions than any sized volume. Download it. Now.

Thursday, December 2, 2010

Do Patients Need a Chaperon? -

The airline passenger who refused to allow a security pat-down made national headlines quickly. The idea of a stranger touching a person's intimate areas makes most people cringe. But something like this occurs every day in the doctor's office.

In general, the rule is to have a "chaperon" present to protect patients against possible sexual misconduct, and to make them feel more secure during intimate examinations. The official AMA guidelines state, "From the standpoint of ethics and prudence, the protocol of having chaperons available on a consistent basis for patient examinations is recommended."

In fact, most institutions mandate that chaperons be present for rectal, pelvic and breast exams. Whether this actually happens is another story.

In practice, adherence to these rules varies widely. Often the issue is not having extra staff available, or not having enough time to track someone down. Most male doctors are assiduous about having a chaperon when performing a breast or pelvic exam on a female patient, though many do not use chaperons for male patients.

But female doctors, as a group, rarely use chaperons for either male or female patients during genital exams. In some studies, the number was as low as 10 percent.

When I asked various female doctors whether they use chaperons, most responded that they knew they were supposed to but that it was just too hard to manage in a busy clinic day. Others commented that bringing a chaperon into the exam room felt awkward to them, especially with patients they knew well. They felt that it inserted a sense of mistrust into their relationship with the patient And some confessed that it just didn't feel necessary; sexual misconduct by doctors always seemed to involve the male half of the profession, they said.

What's more, it is not clear that having a chaperon in the room actually makes patients feel more comfortable, either.

Studies tend to show remarkably similar results: most female patients want a chaperon present during an intimate exam by a male physician. But if the doctor is a woman, that number is extremely low. In fact, many female patients distinctly do not want a chaperon present when they are being examined by a woman.

This attitude is mirrored by male patients, who overwhelmingly do not want any third party in the room, regardless of the sex of the doctor. For many patients, it turns out, a chaperon can make them feel uncomfortable.

So then we have to wonder whether chaperon policies are protecting the patient or protecting the doctor. If it is harming some of our patients by making an awkward situation even more uncomfortable, then we need to rethink blanket rules that mandate chaperons. On the other hand, we need to ensure our patients feel secure during these more sensitive areas of the physical exam.

Personally, I've always disliked the word "chaperon," even though it is the accepted terminology. There is the assumption that the physician cannot be trusted, and that like a teenager at a prom, he or she must be sharply watched for expected misbehavior. On the other hand, I am aware that the patient is acutely vulnerable — psychologically and physically — during the physical exam.

What probably makes the most sense is for male and female doctors to ask all patients whether they'd like another person present during an intimate exam. It's critical, though, that the question be posed in a neutral way, not implying a preference — or a hassle — with either choice. Our goal is to engender trust and to make our patients as comfortable as possible.

Wednesday, December 1, 2010

AIDS Activism Growing on Campuses -

NEW HAVEN — David Carel was never a rabble-rouser. But amid the clutter of his dorm room at Yale University, Mr. Carel, baby-faced and slight-shouldered at 19, keeps evidence of his new life as an AIDS activist: posters, banners and the flier demanding "$50 bn for Global AIDS" that he concealed in his fleece jacket one Saturday in late October when, heart pounding, he sneaked past security into a Democratic campaign rally in Bridgeport.

There, Mr. Carel did something he "never would have imagined": he heckled the president of the United States.

Cameron Nutt, a medical anthropology student at Dartmouth, says he backs President Obama "100 percent." But, incensed over the president's "failure to remain true" to a campaign promise to spend $50 billion over five years fighting the AIDS epidemic overseas, Mr. Nutt disrupted Mr. Obama this fall at a Boston rally. His co-protesters included Luke Messac, a University of Pennsylvania medical student and a field organizer for Mr. Obama's presidential campaign, and Krishna Prabhu, a Harvard University senior who caucused for Mr. Obama in Iowa in 2008 — and rescheduled his final exam in global health to attend the president's inauguration.

"The promise has not been fulfilled," Mr. Prabhu said, sounding more disappointed than angry.

Roughly a quarter-century after gay men rose up to demand better access to H.I.V. medicines, a new breed of AIDS advocate is growing up on college campuses. Unlike the first generation of patient-activists, this latest crop is composed of budding public health scholars. They are mostly heterosexual. Rare is the one who has lost friends or family members to the disease. Rather, studying under some of the world's most prominent health intellectuals, they have witnessed the epidemic's toll during summers or semesters abroad, in AIDS-ravaged nations like Rwanda, Tanzania and Uganda.

College activism, and AIDS activism in particular, is nothing new. On Wednesday, World AIDS Day, students across the nation will participate in speeches, fund-raisers and the like. But a loose-knit band of about two dozen Ivy Leaguers, mostly from Harvard and Yale, is using more confrontational tactics, as well as some high-powered connections, to wangle encounters with top White House officials in a determined, and seemingly successful, effort to get under Mr. Obama's skin.

Their protests — which have drawn a sharp rebuke from the president (not to mention some disapproving parents) — come as many in the AIDS advocacy community are wondering aloud whether Mr. Obama is as devoted to their cause as his immediate predecessor, George W. Bush. In 2003, Mr. Bush began vastly increasing spending on lifesaving antiretroviral medicines for AIDS patients in impoverished nations; the number receiving the drugs has shot up from 50,000 to more than five million today. Yet the World Health Organization says as many as 10 million lack needed therapy.

While spending on global AIDS has gone up on Mr. Obama's watch, and the United States remains the world's largest contributor to such programs, independent analysts say that the rate of increase has slowed significantly and that it will be difficult for the president to keep his $50 billion pledge — or even meet a lesser goal, set in 2008 by Congress, of $48 billion for AIDS, tuberculosis and malaria by 2013. The task may grow even harder under a new Congress, with the incoming House Republican majority intent on cutting spending and Tea Party-backed Republicans in both chambers expressing skepticism about all types of foreign aid.

Still, armed with data from Health Gap, an AIDS advocacy group, the students are determined to hold Mr. Obama to his word. When Ezekiel Emanuel, a bioethicist and health adviser to the president (and brother of the former White House chief of staff, Rahm Emanuel) spoke at Yale two weeks ago, he wound up sparring with Mr. Carel at a fruit-and-cereal breakfast at the campus Hillel House, a meal arranged by a fellow Yale student, Dr. Emanuel's daughter. Later that day, Mr. Carel led a demonstration outside Dr. Emanuel's talk, which ended with students chanting at the adviser as they followed him down the street.

When Eric Goosby, Mr. Obama's global AIDS coordinator, traveled to Boston in November for a panel discussion with Senator John Kerry, Democrat of Massachusetts, he was collared at a cocktail party by Mr. Prabhu, the Harvard senior. Also on the panel was Mr. Prabhu's professor, Dr. Paul E. Farmer, founder of the global nonprofit Partners in Health.

"These students are my retirement plan," Dr. Farmer said in a telephone interview from Haiti, where he is treating cholera patients. "A lot of them are doing much more than going to protests; they're writing papers and articles, they're doing graduate studies."

Mr. Messac, the University of Pennsylvania medical student, explored the origins of Mr. Bush's AIDS program in a 120-page paper, "Lazarus at America's Doorstep," for his Harvard undergraduate thesis. Mr. Carel, who spent last summer working at a hospital in the rural South African village of Tugela Ferry, now studies Zulu and persuaded a visiting professor from South Africa to let him take her upper-level course on "the political economy of AIDS." (He had to skip Zulu class for the Emanuel protest; he said his professor understood.)

The students have also befriended a longtime veteran of the AIDS wars, Gregg Gonsalves, who at 47 is completing his undergraduate degree in evolutionary biology on a full scholarship at Yale. Mr. Gonsalves often lectures public-health classes on what he calls "ancient history" — the work of groups like Act Up in the 1990s.

"Theirs is not a first-person commitment, in the sense that none of them is living with H.I.V.," Mr. Gonsalves said of the new AIDS protesters. "It's all based out of a sense of solidarity and social justice. I used to wonder where the next generation would come from. They're here."

Inside the White House, Dr. Emanuel, for one, is not impressed. He says the students are serving up tired arguments about dollar amounts that ignore the Obama administration's emphasis on spending money more efficiently and offering services, like circumcision, that can reduce the spread of H.I.V. While Mr. Bush emphasized AIDS and malaria, Mr. Obama is promoting a six-year, $63 billion "global health initiative" that seeks to address a range of diseases, with emphasis on women and children.

"To be honest, and this is no put-down to the sincerity of the students, I didn't hear a new argument that I haven't heard for months," Dr. Emanuel said in an interview after his breakfast with Mr. Carel. "I've not seen a blog post on the number of people we have circumcised, or the number of mothers we treat in maternal-child health. Those are real performance measures."

Dr. Emanuel would not discuss any conversations with the president about the students, but Mr. Obama's reaction when he was disrupted in October at the rally in Bridgeport made clear he was irked. "You've been appearing at every rally we've been doing," the president complained, telling them it was not "a useful strategy."

The students were pleased that he addressed them directly, but their heckling prompted even some fellow AIDS activists to take issue with their tactics. Regan Hofmann, editor in chief of Poz, a magazine for people living with or affected by H.I.V., questioned the wisdom of disrupting the president on the eve of a critical election for Democrats.

Mr. Carel says he and his fellow protesters thought long and hard about that. It was his first demonstration; his parents told him they wished he would be "more respectful." His friends were shocked. Still, he says it was worth it.

"There are very few ways we could have any access to him," he explained. "This was a way to get Obama's ear."

Tuesday, November 30, 2010

Doctors say Medicare cuts force painful decision about elderly patients

Want an appointment with kidney specialist Adam Weinstein of Easton, Md.? If you're a senior covered by Medicare, the wait is eight weeks.

How about a checkup from geriatric specialist Michael Trahos? Expect to see him every six months: The Alexandria-based doctor has been limiting most of his Medicare patients to twice yearly rather than the quarterly checkups he considers ideal for the elderly. Still, at least he'll see you. Top-ranked primary care doctor Linda Yau is one of three physicians with the District's Foxhall Internists group who recently announced they will no longer be accepting Medicare patients.

"It's not easy. But you realize you either do this or you don't stay in business," she said.

Doctors across the country describe similar decisions, complaining that they've been forced to shift away from Medicare toward higher-paying, privately insured or self-paying patients in response to years of penny-pinching by Congress.

And that's not even taking into account a long-postponed rate-setting method that is on track to slash Medicare's payment rates to doctors by 23 percent Dec. 1. Known as the Sustainable Growth Rate and adopted by Congress in 1997, it was intended to keep Medicare spending on doctors in line with the economy's overall growth rate. But after the SGR formula led to a 4.8 percent cut in doctors' pay rates in 2002, Congress has chosen to put off the ever steeper cuts called for by the formula ever since.

This month, the Senate passed its fourth stopgap fix this year - a one-month postponement that expires Jan. 1. The House is likely to follow suit when it reconvenes next week, and physicians have already been running print ads, passing out fliers to patients and flooding Capitol Hill with phone calls to convince Congress to suspend the 25 percent rate cut that the SGR method will require next year.

Such temporary reprieves have increased the potential pain down the road, compounding not only the eventual cut but the cost of doing away with it for good, now estimated in the tens of billions.

The lobbying blitz by doctors also comes amid concern in Washington that Medicare spending is spiraling up so fast the nation can't afford to boost it further by significantly raising doctors' pay. And government analysts and independent experts suggest that although doctors could not absorb a 25 percent fee cut, the claim that they have been inadequately compensated by Medicare until now is wildly exaggerated.

Among the top points of contention is the complaint by doctors that Medicare's payment rate has not kept pace with the growing cost of running a medical practice. As measured by the government's Medicare Economic Index, those expenses rose 18 percent from 2000 to 2008. During the same period, Medicare's physician fees rose 5 percent.

"Physicians are having to make really gut-wrenching decisions about whether they can afford to see as many Medicare patients," said Cecil Wilson, president of the American Medical Association.

But statistics also suggest many doctors have more than made up for the erosion in the value of their Medicare fees by dramatically increasing the volume of services they provide - performing not just a greater number of tests and procedures, but also more complex versions that allow them to charge Medicare more money.

From 2000 to 2008, the volume of services per Medicare patient rose 42 percent. Some of this was because of the increasing availability of sophisticated treatments that undoubtedly save lives. Some was because of doctors practicing "defensive medicine" - ordering every conceivable test to shield themselves from malpractice lawsuits down the line.

"Then you have doctors who order an MRI for an unremarkable headache or at the first sign of back pain," said Robert Berenson, a Commissioner of the Medicare Payment Advisory Commission, an independent congressional agency. "It's pretty well documented that it doesn't help patients to have those scans done in these cases. But if you have the machine in your office ... why not?"

Whatever the cause, the explosion in the volume of services provided helps explain why Medicare's total payments to doctors per patient rose 51 percent from 2000 to 2008.

A review of physicians' incomes suggests that specialists - who have more opportunities to increase the volume of the services they offer than primary-care doctors - reaped most of the benefit.

On average, primary-care doctors make about $190,000 a year, kidney specialists $300,000, and radiologists close to $500,000, figures that reflect the income doctors receive from both Medicare and non-Medicare patients. The disparity has prompted concern that Medicare is contributing to a growing shortage of primary doctors.

Still, even if primary-care doctors had to rely exclusively on Medicare's lower payment rates their incomes would only drop about 9 percent, according to a recent study co-authored by Berenson, who is also a fellow at the non-partisan Urban Institute.

"The argument that doctors literally can't afford to feed their kids [if they take Medicare's rates] is absurd," said Berenson. "It's just that doctors have gotten used to a certain income and lifestyle."

Regardless of their motivation, if doctors skew their patient base away from Medicare too drastically seniors' access to medical care could be limited.

Is that happening? Again, opinions vary. Based on its studies as well as those done by others others, the Medicare Payment Advisory Commission has concluded the share of affected seniors has been small, and perhaps most significantly, lower than the share of privately insured patients ages 50 to 64 who also report access problems.

But the American Medical Association cites a recent online survey that it commissioned in which nearly one-third of primary-care doctors said they are currently restricting the number of Medicare patients in their practice.

For Michael Trahos, the geriatric specialist in Alexandria, that has meant spacing out routine visits by his Medicare patients such that their share of his weekly appointments has dropped from about half to less than one-third. Trahos said that if a Medicare patient has a serious condition, he will see the person more frequently. But Trahos said it makes him uneasy to push even apparently healthy elderly patients back to twice yearly visits.

"Is it the proper thing to do? Probably not," he said. "These are patients who should be scheduled for proper maintenance every three months."

Adam Weinstein, the kidney specialist in Easton, has taken to supplementing his three-doctor practice by doing medical IT consulting several hours a week. But although the pay is far greater than what he would receive seeing Medicare patients, who make up 70 percent of his practice, the side work means he has less time to serve them. Not only must Weinstein make them wait longer for an appointment, he said, he can no longer afford to answer their phone calls.

"It has definitely made my patients feel more distant from me, and I don't know how to deal with that," Weinstein said.

Financial concerns also prompted Weinstein's group to turn down a request from Chester River Hospital Center in Chestertown, Md., an hour's drive north, to do daily consultations with their mainly elderly patients.

That was disheartening news for the doctor who is currently consulting at Chester River. At 69, David Knutson is semi-retired and said he is satisfied with the payments he has been getting from Medicare. But Knutson grew animated as he spoke of all the ways he would use his time if he could find another doctor to take over coming into the hospital six days a week.

"Gardening, sailing, fishing, hunting, going to the opera," he said. "I'm almost 70. If I'm ever going to do all these things that I've been talking about I better start."

Linda Yao, of the District's Foxhall Internists, has opted for the most extreme response - pulling out of Medicare. The group prides itself on keeping the number of scheduled visits low so that patients who need a last-minute appointment can be accommodated the same day. They also offer half-hour office visits, instead of the 15 minutes on which Medicare reimbursements are predicated. It makes for a white-glove experience for patients, but high overhead for doctors.

After 11 years of serving a patient base of whom as many as half were covered by Medicare, Yao concluded the numbers were no longer adding up. As of April, seniors with Medicare must pay their entire bill out of pocket or through supplemental insurance. So far, only 100 of her approximately 1,750 Medicare patients have elected to stay on.

Could doctors see more Medicare patients if they accepted lower incomes?

Perhaps, said Yao, 42.

But, "the whole system would need to change. ... I graduated medical school $100,000 in debt. I worked 110 hours a week during my residency for $30,000 a year and sacrificed all through my 20s. And even now, you're still seeing people all day, with meetings and paperwork at night, on top of the emotional side of worrying when the patients you care for aren't doing well. This is life-and-death stuff. And I feel like that should be compensated."

FRONTLINE: Facing Death | PBS

How far would you go to sustain the life of someone you love, or your own? When the moment comes, and you're confronted with the prospect of "pulling the plug," do you know how you'll respond?

In Facing Death, FRONTLINE gains extraordinary access to The Mount Sinai Medical Center, one of New York's biggest hospitals, to take a closer measure of today's complicated end-of-life decisions. In this intimate, groundbreaking film, doctors, patients and families speak with remarkable candor about the increasingly difficult choices people are making at the end of life: when to remove a breathing tube in the ICU; when to continue treatment for patients with aggressive blood cancers; when to perform a surgery; and when to call for hospice.

"What modern medicine is capable of doing is what 20 years ago was considered science fiction," Dr. David Muller, dean of medical education at Mount Sinai, tells FRONTLINE. "You can keep their lungs breathing and keep their heart beating and keep their blood pressure up and keep their blood flowing. ... That suspended animation [can go] on forever. [So] the decisions at the end of life have become much more complicated for everyone involved."

In this powerful look at the reality of today's medicalized death, FRONTLINE producers Miri Navasky and Karen O'Connor (The UndertakingLiving Old,The New Asylums) introduce us to Albert Alberti, a 53-year-old father of three young children who's hoping to receive a third bone marrow transplant in his fight against leukemia. Bone marrow transplants have the potential to cure diseases that are otherwise incurable, but they are also among the most drastic treatments in oncology. The treatment itself can kill the patient. "He's got to take every step possible," says Deborah, Alberti's wife. "It's tough, but, you know, why give up? What's that going to do?"

"Some physicians can keep giving treatment, and some find it unacceptable, and that, I think, is where the art of science and medicine mix," says Dr. Keren Osman of Mount Sinai's Bone Marrow Transplant Unit. "The lines are blurred, and they're also different for different physicians. Sometimes there are patients for whom ... I wish we'd stopped earlier because I think they suffered unnecessarily. ... Sometimes there are forces outside of the patient and myself that are the patient's family, other physicians. Sorting that out can be very, very tricky in those moments."

John Moloney, a 57-year-old corrections officer, was diagnosed two years ago with multiple myeloma. He has tried every available treatment, including two bone marrow transplants. Now he wants to continue chemotherapy, even though the chance of its working is minuscule. "Bomb me," he tells his wife. "I'd rather be like that than dead."

"It's hard to watch. John was 6 foot 3, 250 pounds. He's like, 150 pounds now," says his wife, Debbie Moloney. "And I told John: `No more cancer treatment, no more chemo. I can't see you be any more debilitated.' But then you talk and you say, `OK, let's try something mild,' because doing nothing -- it's scary to do nothing, because ... I don't want him to die. So ... you want to do something."

Decisions about how aggressively to treat a patient can be complicated for doctors as well. "It's very difficult for me to say to a patient, `I don't think you have any treatment opportunity.' I never said that to any patient, never," Dr. Celia Grosskreutz of Mount Sinai's Bone Marrow Transplant Unit tells FRONTLINE. "I can't humanly say that to a patient. I always say, `Well, we can do this or the other,' even if it's in a palliative way. But I offer. I always say there is something to do."

FRONTLINE also meets Marthe Laureville, who is 85 years old and has dementia. She has been intubated for two weeks, and now her daughters, Nadege, a nurse, and Sherley, a physician, have to decide whether to keep her on a ventilator. "I myself would not want to put Mom through a trach[eotomy]. ... I'm not sure, at this point, what the benefit is of that," says Nadege. "Will that prolong the life that she has right now, for one month or two months?" But Mrs. Laureville's other daughter, Sherley, disagrees: "I don't want to be the one to say [do not resuscitate] and to be responsible for her death before her time. ... I [will] not stop her from breathing. ... I will maintain her until the last minute."

"There are clinical situations where the odds are so overwhelming that someone can['t] survive the hospitalization in a condition that they would find acceptable, then using this technology doesn't make sense," says Dr. Judith Nelson, an ICU doctor at Mount Sinai. "And yet, in my clinical experience, for almost everybody involved, it feels much more difficult to stop something that's already been started." But, according to Dr. Nelson: "Nobody wants to die. And at the same time, nobody wants to die badly. And that is my job. My job is to try to prevent people from dying if there's a possible way to do it that will preserve a quality of life that's acceptable to them, but if they can't go on, to try to make the death a good death."

In the face of death, many patients will do almost anything to live, but new questions are being raised about whether we can afford the growing cost of end-of-life care. "There's a tremendous pressure now to reduce care to numbers as though there's an algorithm for every decision," says Dr. Jerome Groopman, professor of medicine at Harvard University. "When you look at Medicare data on expenditures at end-of-life and what is very glibly termed "waste," 30 percent of all care is waste. That's the new mantra. It's very hard to know what that means. And it's very hard to bring that out of Washington and into a hospital and at the bedside, with a single individual facing death."

Becoming the Guardian of a Parent With Alzheimer’s -

As my grandfather's mind slipped away, first slowly, then quickly, as Alzheimer's disease moved in, he tried to be reassuring. "I remember the important things," he would tell us.

And he did. He may not have remembered that Barack Obama was president or that he just had a bowl of ice cream (my kindergartner nephew took full advantage), but he always remembered his family.

Money management was another matter. Early on in the disease, small red flags began to appear — failure to pay the association fees on the condominium in Florida, overpaid bills or repetitive trips to the A.T.M. Over time, he had to hand off most financial responsibilities to my mother and grandmother.

My grandfather was lucky enough to have relatives nearby who were able to gently intervene before the small mistakes escalated into something more serious, which is all too common.

But family members need to carefully consider how they approach their new role as financial caretaker. For adult children, this is the beginning of the role reversal. You may be stepping up to handle mundane tasks like paying the bills, but it's also the time when you begin to think about your parent's mortality, and perhaps your own.

For the person with encroaching dementia, the loss of autonomy can be devastating. "What often occurs is that the elder loses additional self-esteem, becomes more depressed and in turn becomes less active," said Daniel C. Marson, a neuropsychologist at the University of Alabama at Birmingham.

And that's why these matters must be handled delicately — and before a more serious financial unraveling occurs — whether the individual simply needs you to check in once a month, or you need to become the chief financial officer.

More ...

After a Cycling Injury, a Vow to Never Ride Again -

I crashed on my bike on Oct. 3 and broke my collarbone, an experience so horrific that my first impulse was to say I would never ride on the road again.

Turns out I am not alone.

"Well, you've joined the proud majority of serious cyclists who've busted a collarbone," said Rob Coppolillo, a competitive cyclist in Boulder, Colo., who also leads rock- and ice-climbing expeditions and is a part-time ski guide.

I've since heard from other cyclists who broke bones or were badly bruised and shaken up in crashes. Many say they, too, vowed, at least initially, never to ride outside again. It's not a universal response, but it is so common that cyclists nod their heads when they hear my reaction to my injury.

Yet almost no one swears off running after an injury, even though — and I speak from experience — a running injury can keep you away from your sport at least as long. And that made me wonder: is a cycling injury qualitatively different from a running injury? Is it the drama of a crash, or is it that a crash makes you realize you could actually be killed on a bike? Is it the type of injury? Or the fact that you can feel, as I did, that the accident was unfair and out of your control?

Risk-assessment experts say that it is all of the above, and that the way we respond to various sports injuries reveals a lot about how we assess risks.

My crash came 8.9 miles into a 100-mile ride (of course I knew the distance, because of course I was watching my bicycle computer). My friend Jen Davis was taking a turn leading; my husband, Bill, was drafting — riding close behind her. I was drafting Bill when a slower rider meandered into his path. Bill swerved and I hit his wheel. Down I went.

The first thing I did when I hit the ground was turn off my stopwatch — I did not want accident time to count toward our riding time. Then I sat on a curb, dazed. My head had hit the road, but my helmet saved me. My left thigh was so bruised it was hard to walk. Worst of all was a searing pain in my left shoulder. I could hardly move my arm. But since it hurt whether I rode or not, I decided, like an idiot, to finish the ride.

The next day I went to a doctor and learned, to my shock, that my collarbone was broken. Running is my sport, I thought, and no ride is worth this.

I remembered what Michael Berry, an exercise physiologist at Wake Forest University, once told me. With cycling, he said, it's not if you crash, it's when. He should know. He's a competitive cyclist whose first serious injury — a broken hip — happened when he crashed taking a sharp turn riding down a mountain road.

Then, last June, he was warming up for a race when he hit a squirrel, crashed into a telephone pole and broke his arm so badly he needed surgery.

His reaction to each crash was a variant of mine. He'd taken up cycling about five years ago because he'd injured his hamstring running. "With each wreck I thought, 'Maybe I should try running again,' " he said.

My running friend Claire Brown, a triathlete, crashed a few years ago when she was riding fast on wet roads, getting in one last training ride before a race. Her bike slid on a metal plate in a bridge and she went down, hitting her head and her left hip. She was badly bruised, and even though she broke no bones, she did not feel comfortable riding for the next two years. Even now, she told me, "there are bridges around here I won't ride on, and I definitely won't go downhill fast."

And yet, and yet. Despite how much it hurt, my collarbone fracture was nowhere near as bad as some running injuries. When I got a stress fracture — a hairline break — in a small bone in my foot, I was on crutches for eight weeks. When I finally could run again, my foot hurt because the muscles had atrophied. Running was slow and difficult. I'd lost the rhythm and the stride that make running fun.

With the collarbone fracture, I wore a sling for three weeks but could take it off and ride my bike on my trainer — a device that turns a road bike into a stationary one — and use an elliptical cross-trainer. After four weeks I could run, and running felt good.

George Loewenstein, a professor of economics and psychology at Carnegie Mellon University, says there are several factors that separate running injuries from cycling ones.

Running injuries are often hidden — like a torn hamstring — and tend to heal gradually on their own. Bicycling injuries, he told me, "tend to be more acute and dramatic — often there is blood or even bones sticking out," and "if it's a gory image, it tends to deter us."

Then there's the issue of control. "Control makes a big difference in whether we take risks," Dr. Loewenstein said. "With biking, you feel in control until you have an accident. Then all of a sudden you realize you are not in control. That can have a dramatic effect — you can shift abruptly from excessive daring to exaggerated caution."

With running, even though I realize that I and others who got injured could not have prevented our injuries, somehow I blamed myself. It was "overuse," even though overuse is apparent only in retrospect, as you cast about for a reason why you got injured.

But running is considered to carry less risk than cycling. And, notes Barry Glassner, president of Lewis & Clark College in Portland, Ore., and an expert on fear and risk perception, "anything that is widely perceived as lower risk, we blame ourselves when something goes wrong."

"It's known as the world hypothesis," he said, "this notion that the world should be fair."

Dr. Glassner said "we get especially outraged" when the world is not fair, as with a cycling crash. Or, he noted, "we blame ourselves" for the injustice of it all, as with a running injury.

The hypothesis does let some people continue a risky sport — by deciding that a serious accident was not really random.

"You see it with rock climbers," says Rob Coppolillo. "There will be a fatality or someone will really get hurt. There are those psychological backflips you can make yourself do. 'It won't happen to me.' "

And if you have an accident and you can blame yourself for it, then you can also convince yourself that it won't happen again.

That's how Dr. Loewenstein reasoned when he crashed his bike last winter after riding over a patch of ice. He ended up with a shoulder injury. He decided the whole thing was his fault and could have been avoided.

"I did not experience a loss of control," he said. "I just thought I had been stupid. Whereas if a car had hit me, it would have been different."

If that had happened, he said, he might have vowed never to ride again.

Extra Calcium and Vitamin D Aren’t Necessary, Report Says -

The very high levels of vitamin D that are often recommended by doctors and testing laboratories — and can be achieved only by taking supplements — are unnecessary and could be harmful, an expert committee says. It also concludes that calcium supplements are not needed.

The group said most people have adequate amounts of vitamin D in their blood supplied by their diets and natural sources like sunshine, the committee says in a report that is to be released on Tuesday.

"For most people, taking extra calcium and vitamin D supplements is not indicated," said Dr. Clifford J. Rosen, a member of the panel and an osteoporosis expert at the Maine Medical Center Research Institute.

Dr. J. Christopher Gallagher, director of the bone metabolism unit at the Creighton University School of Medicine in Omaha, Neb., agreed, adding, "The onus is on the people who propose extra calcium and vitamin D to show it is safe before they push it on people."

Over the past few years, the idea that nearly everyone needs extra calcium and vitamin D — especially vitamin D — has swept the nation.

With calcium, adolescent girls may be the only group that is getting too little, the panel found. Older women, on the other hand, may take too much, putting themselves at risk for kidney stones. And there is evidence that excess calcium can increase the risk of heart disease, the group wrote.

As for vitamin D, some prominent doctors have said that most people need supplements or they will be at increased risk for a wide variety of illnesses, including heart disease, cancer and autoimmune diseases.

And these days more and more people know their vitamin D levels because they are being tested for it as part of routine physical exams.

"The number of vitamin D tests has exploded," said Dennis Black, a reviewer of the report who is a professor of epidemiology and biostatistics at the University of California, San Francisco.

At the same time, vitamin D sales have soared, growing faster than those of any supplement, according to The Nutrition Business Journal. Sales rose 82 percent from 2008 to 2009, reaching $430 million. "Everyone was hoping vitamin D would be kind of a panacea," Dr. Black said. The report, he added, might quell the craze.

"I think this will have an impact on a lot of primary care providers," he said.

The 14-member expert committee was convened by the Institute of Medicine, an independent nonprofit scientific body, at the request of the United States and Canadian governments. It was asked to examine the available data — nearly 1,000 publications — to determine how much vitamin D and calcium people were getting, how much was needed for optimal health and how much was too much.

More ...