Friday, February 8, 2013

What doctors worry about | TED Playlists | TED

We worry about what our doctors will tell us -- and so do they. Doctors, scientists and medical researchers weigh in on health care and better health practices.

The future of medicine | TED Playlists | TED

Take this tour of medicine's future with some of the trailblazing doctors charting its course. Once you've seen a transplantable human kidney created from a 3D printer, almost anything is imaginable.

Curing chemophobia: Don’t buy the alternative medicine in “The Boy With a Thorn in His Joints.” - Slate Magazine

When I read Susannah Meadows' account in the New York Times Magazine of her desperate search for an effective treatment for her son Shepherd's juvenile idiopathic arthritis, as a mother, I totally got it. I flashed back to a night 10 years ago, the sleet pinging on our minivan's roof as I careened down the street in the middle of an ice storm at 2 a.m., listening to my 8-year-old son struggle to breathe in the back and praying that the lights would all be green on the four-minute drive to the ER.
We were frequent flyers at the ER that winter, as every respiratory virus that made the rounds settled in Mike's throat, swelling his vocal cords until they threatened to cut off his airway. I would lie awake at night after each episode, unable to sleep for fear I wouldn't hear him if the croup returned, as we were warned it might. His pediatricians were concerned and mystified; croup severe enough to land an otherwise healthy elementary schooler in the hospital is rare. My husband and I were distraught.
We got a lot of advice, much of which I scribbled on a pad now stuffed into a worn manila folder full of articles from medical journals, old appointment cards, and notes from consultations with specialists that is still in my filing cabinet. Some of it was tough to take, literally: daily meds that tasted vile. No more mint chocolate-chip ice cream? Mike was bereft.
I questioned every bit of it. I'm a scientist, which makes me a professionally annoying skeptic. Why? What's the evidence? How was it obtained? Is it plausible? And above all, what are the risks?—because there are always risks. I'm an equal-opportunity skeptic, as willing to ask these questions of specialists as I am of well-meaning friends of friends.
Meadows, on the other hand, suffers from a condition that makes it difficult to be an equal-opportunity skeptic and infinitely harder to make informed decisions about her son's treatment: chemophobia. An irrational fear of chemicals, which drives her to let a friend of a friend—a social worker and massage therapist—prescribe her son's drug treatment.
Meadows isn't alone in her molecular paranoia. We are a chemophobic culture. Chemical has become a synonym for something artificial, adulterated, hazardous, or toxic. Chemicals are bad—for you, for your children, for the environment. But whatever chemophobics would like to think, there is no avoiding chemicals, no way to create chemical-free zones. Absolutely everything is made of atoms and molecules; it's all chemistry.
In some ways, chemophobia is more like color blindness than a true phobia, such as a fear of heights. Chemophobics are blind to the vast majority of chemicals they encounter. Every breath you take has almost as many molecules in it as there are stars in the universe, and each breath contains dozens of different chemicals, some of which, like oxygen, you can't do without. Some chemicals are superheroes—antibiotics and anesthetics come to mind—others are villains that prey on the unwary: Every year, an average of 450 people in the United States are killed by the carbon monoxide produced by their furnaces and generators. The vast majority of chemicals are like the vast majority of people, doing their jobs, day in and day out, without fuss or recognition: DNA, caffeine, water, oxygen.
In "The Boy With a Thorn in His Joints," Meadows writes that Shepherd's arthritis spiraled out of control while he was taking the first-line drug, naproxen. His rheumatologist then prescribed methotrexate, an anti-cancer drug that at low doses can send juvenile arthritis into remission. Meadows' chemophobia immediately flared up. In a panic and "desperate to find a way to solve Shepherd's problems without the drugs," she called Char Walker, a friend of a friend whose son had also been diagnosed with juvenile arthritis. Walker recommended Montmorency cherry juice and four-marvels powder, a traditional Chinese medicine. The regimen sounds warm and friendly—like something a Disney princess would use—and above all, safe. In contrast, naproxen and methotrexate sound harsh and forbidding. There is nothing in either name that give any otherwise well-educated nonscientist a clue what the remedy is made from, other than a (presumably nasty) chemical. When it comes to naming our stuff, I admit, chemists tend to be more ponderous than poetic.
The simple names favored by the alternative medicine community provide an illusion of safety and comprehensibility that the chemical names can't match. Another common chemical name for methotrexate is amethopterin, which comes from the roots meth, Greek for wine, which I might stretch to spirits, and pterin, Greek for feathers. And naproxen is a chemical analog of salicylic acid, which can be extracted from willow bark. I strongly suspect that if Shepherd's rheumatologist had called what he prescribed spirits of feathers and an extract of willow, rather than methotrexate and naproxen, Meadows would have been happier.
Let me point out that the active chemicals—yes, chemicals, the stuff everything is made from—in four-marvels powder include quercetin, berberine, and achyranthine, names that don't smell quite as sweet as Montmorency cherry juice. Meadows is not unique in being seduced into complacency by language. Psychologists call this "processing fluency" —we cope better and trust information more when the words it's couched in are easy to pronounce and familiar. Terms that don't roll easily off our tongues make us nervous. Given the choice, more people would rather take smooth-sounding Aleve than naproxen, though they are the precisely the same chemical.
When Meadows' husband has serious reservations about her desire to ditch the advice of not one, but two, pediatric rheumatologists, Meadows implies he was the poorly informed one: "I was nervous about keeping Shepherd on methotrexate, but Darin didn't share my squeamishness. He has always been more comfortable with pharmaceuticals, more trusting in general."
She seems blissfully unaware that the four-marvels powder that Walker's naturopath recommended is a recognized pharmaceutical, just one from a pharmacopeia that she is unfamiliar with, that of traditional Chinese medicine. Four-marvels powder, or si miao san, has long been prescribed by Chinese medicine practitioners for arthritis and other inflammatory disorders. My quibble is not that it is ineffective (although many traditional medicines are pure placebos, several recent peer-reviewed studies have shown that at least one of the active drugs in four-marvels powder, quercetin, exhibits anti-inflammatory activity). My concern is that four-marvels powder is not a chemical-free remedy but a drug, and one that Chinese medicine practitioners would hesitate to prescribe to pregnant women, which might give me pause before I started pouring it down my young child's throat. Apparently neither Meadows nor Walker is concerned that they are being too "trusting."
The reality is this. Meadows has been tricked by the language, maliciously or not, into considering switching her child from a carefully measured weekly dose of this molecule:
To four doses a day of an unknown amount of this chemical:
I want to be absolutely clear. Neither of these chemicals is benign or nontoxic. The LD-50 (the "lethal dose" amount that kills 50 percent of mice fed the chemical) is about the same for quercetin as it is for methotrexate, roughly 150 milligrams per kilogram of body weight.
Meadows admits to obsessing at night over the potential side effects of methotrexate, which are clearly—and frighteningly—detailed on the prescribing information. Nausea, dizziness, liver damage. What was she doing to her little boy?
But what does Meadows know about the risks of what she calls Walker's regimen? Four-marvels powder has no FDA-mandated, rigorously reviewed package insert. Berberine, one of the drugs found in four-marvels powder, has been documented to cause brain damage in infants. Hello? Exactly how much of this have you been giving your son? And that may be the most important question. Meadows has no idea that she is giving her son this drug, and she certainly has no idea how much he is taking. Appallingly, the FDA trusts manufacturers and marketers to decide for themselves if an herbal remedy is safe, they will take action only if problems are reported later, essentially letting the dietary supplement and herbal remedy industry field-test their products on the public, with no supervision.
Meadows' "better the molecule I don't know, than the molecule I do" stance may help her sleep better, but it is ignorance nonetheless. The chemicals are still there, even when you squint your eyes closed so you can't see them.
As a chemist, a teacher, and a parent, I think (and blog) a lot about how to immunize people against chemophobia. It's not because I want to keep chemical companies in business, but because I want to keep my students and friends from being duped into using chemicals that are unsafe, whatever their source. So here is my best advice to keep you from succumbing to the chemophobia pandemic: One, everything is a chemical. Two, don't take medical advice from a magazine writer, however impassioned and well-intentioned, however popular her story is on the New York Times' "most read" list, who trusts a massage therapist over medical experts. And three, there are risks to all chemicals, even the ones with friendly names like Montmorency cherry juice and four-marvels powder. Next time, before you click "share" on an article, be annoyingly skeptical. We can stamp out chemophobia in our lifetimes.

Cases Database | Unlock the value of medical case reports

Documenting a patient's case history to inform physicians how the patient has been evaluated and the subsequent progression of his or her disease is arguably the oldest method of communicating medical evidence. And in the 21st century case reports play an equally important role.

Since the launch of Journal of Medical Case Reports in 2007 and the more recent introduction of case reports to the broad-scope journal BMC Research NotesBioMed Central has acknowledged the value of case reports to the scientific record.  To strengthen this commitment we have developed a valuable new resource – Cases Database, a continuously-updated, freely-accessible database of thousands of medical case reports from multiple publishers, including Springer, BMJ and PubMed Central.
By aggregating case reports and facilitating comparison, Cases Database provides clinicians, researchers, regulators and patients a simple resource to explore content, and identify emerging trends.

Effective Addiction Treatment -

Countless people addicted to drugs, alcohol or both have managed to get clean and stay clean with the help of organizations like Alcoholics Anonymous or the thousands of residential and outpatient clinics devoted to treating addiction.
But if you have failed one or more times to achieve lasting sobriety after rehab, perhaps after spending tens of thousands of dollars, you're not alone. And chances are, it's not your fault.
Of the 23.5 million teenagers and adults addicted to alcohol or drugs, only about 1 in 10 gets treatment, which too often fails to keep them drug-free. Many of these programs fail to use proven methods to deal with the factors that underlie addiction and set off relapse.
According to recent examinations of treatment programs, most are rooted in outdated methods rather than newer approaches shown in scientific studies to be more effective in helping people achieve and maintain addiction-free lives. People typically do more research when shopping for a new car than when seeking treatment for addiction.
groundbreaking report published last year by the National Center on Addiction and Substance Abuse at Columbia University concluded that "the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care." The report added, "Only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works."
The Columbia report found that most addiction treatment providers are not medical professionals and are not equipped with the knowledge, skills or credentials needed to provide the full range of evidence-based services, including medication and psychosocial therapy. The authors suggested that such insufficient care could be considered "a form of medical malpractice."
The failings of many treatment programs - and the comprehensive therapies that have been scientifically validated but remain vastly underused - are described in an eye-opening new book, "Inside Rehab," by Anne M. Fletcher, a science writer whose previous books include the highly acclaimed "Sober for Good."
"There are exceptions, but of the many thousands of treatment programs out there, most use exactly the same kind of treatment you would have received in 1950, not modern scientific approaches," A. Thomas McLellan, co-founder of the Treatment Research Institute in Philadelphia, told Ms. Fletcher.
Ms. Fletcher's book, replete with the experiences of treated addicts, offers myriad suggestions to help patients find addiction treatments with the highest probability of success.
Often, Ms. Fletcher found, low-cost, publicly funded clinics have better-qualified therapists and better outcomes than the high-end residential centers typically used by celebrities like Britney Spears and Lindsay Lohan. Indeed, their revolving-door experiences with treatment helped prompt Ms. Fletcher's exhaustive exploration in the first place.
In an interview, Ms. Fletcher said she wanted to inform consumers "about science-based practices that should form the basis of addiction treatment" and explode some of the myths surrounding it.
One such myth is the belief that most addicts need to go to a rehab center.
"The truth is that most people recover (1) completely on their own, (2) by attending self-help groups, and/or (3) by seeing a counselor or therapist individually," she wrote.
Contrary to the 30-day stint typical of inpatient rehab, "people with serious substance abuse disorders commonly require care for months or even years," she wrote. "The short-term fix mentality partially explains why so many people go back to their old habits."
Dr. Mark Willenbring, a former director of treatment and recovery research at the National Institute for Alcohol Abuse and Alcoholism, said in an interview, "You don't treat a chronic illness for four weeks and then send the patient to a support group. People with a chronic form of addiction need multimodal treatment that is individualized and offered continuously or intermittently for as long as they need it."
Dr. Willenbring now practices in St. Paul, where he is creating a clinic called Alltyr "to serve as a model to demonstrate what comprehensive 21st century treatment should look like."
"While some people are helped by one intensive round of treatment, the majority of addicts continue to need services," Dr. Willenbring said. He cited the case of a 43-year-old woman "who has been in and out of rehab 42 times" because she never got the full range of medical and support services she needed.
Dr. Willenbring is especially distressed about patients who are treated for opioid addiction, then relapse in part because they are not given maintenance therapy with the drug Suboxone.
"We have some pretty good drugs to help people with addiction problems, but doctors don't know how to use them," he said. "The 12-step community doesn't want to use relapse-prevention medication because they view it as a crutch."
Before committing to a treatment program, Ms. Fletcher urges prospective clients or their families to do their homework. The first step, she said, is to get an independent assessment of the need for treatment, as well as the kind of treatment needed, by an expert who is not affiliated with the program you are considering.
Check on the credentials of the program's personnel, who should have "at least a master's degree," Ms. Fletcher said. If the therapist is a physician, he or she should be certified by the American Board of Addiction Medicine.
Does the facility's approach to treatment fit with your beliefs and values? If a 12-step program like A.A. is not right for you, don't choose it just because it's the best known approach.
Meet with the therapist who will treat you and ask what your treatment plan will be. "It should be more than movies, lectures or three-hour classes three times a week," Ms. Fletcher said. "You should be treated by a licensed addiction counselor who will see you one-on-one. Treatment should be individualized. One size does not fit all."
Find out if you will receive therapy for any underlying condition, like depression, or a social problem that could sabotage recovery. The National Institute on Drug Abuse states in its Principles of Drug Addiction Treatment, "To be effective, treatment must address the individual's drug abuse and any associated medical, psychological, social, vocational, and legal problems."
Look for programs using research-validated techniques, like cognitive behavioral therapy, which helps addicts recognize what prompts them to use drugs or alcohol, and learn to redirect their thoughts and reactions away from the abused substance.
Other validated treatment methods include Community Reinforcement and Family Training, or Craft, an approach developed by Robert J. Meyers and described in his book, "Get Your Loved One Sober," with co-author Brenda L. Wolfe. It helps addicts adopt a lifestyle more rewarding than one filled with drugs and alcohol.

Thursday, February 7, 2013

Depression and the Limits of Psychiatry -

I've recently been following the controversies about revisions to the psychiatric definition of depression.  I've also been teaching a graduate seminar on Michel Foucault, beginning with a reading of his "History of Madness."   This massive volume tries to discover the origins of modern psychiatric practice and raises questions about its meaning and validity.  The debate over depression is an excellent test case for Foucault's critique.
At the center of that critique is Foucault's claim that modern psychiatry, while purporting to be grounded in scientific truths, is primarily a system of moral judgments. "What we call psychiatric practice," he says, "is a certain moral tactic . . . covered over by the myths of positivism."  Indeed, what psychiatry presents as the "liberation of the mad" (from mental illness) is in fact a "gigantic moral imprisonment."
Foucault may well be letting his rhetoric outstrip the truth, but his essential point requires serious consideration.  Psychiatric practice does seem to be based on implicit moral assumptions in addition to explicit empirical considerations, and efforts to treat mental illness can be society's way of controlling what it views as immoral (or otherwise undesirable) behavior. Not long ago, homosexuals and women who rejected their stereotypical roles were judged "mentally ill," and there's no guarantee that even today psychiatry is free of similarly dubious judgments.   Much later, in a more subdued tone, Foucault said that the point of his social critiques was "not that everything is bad but that everything is dangerous."  We can best take his critique of psychiatry in this moderated sense.
Current psychiatric practice is guided by the "Diagnostic and Statistical Manual of Mental Disorders" (DSM).   Its new 5th edition makes controversial revisions in the definition of depression, eliminating a long-standing "bereavement exception" in the guidelines for diagnosing a "major depressive disorder."   People grieving after the deaths of loved ones may exhibit the same sorts of symptoms (sadness, sleeplessness and loss of interest in daily activities among them) that characterize major depression.  For many years, the DSM specified that, since grieving is a normalresponse to bereavement, such symptoms are not an adequate basis for diagnosing major depression.  The new edition removes this exemption.
Disputes over the bereavement exemption center on the significance of "normal."   Although the term sometimes signifies merely what is usual or average, in discussions of mental illness it most often has normative force.  Proponents of the exemption need not claim that depressive symptoms are usual in the bereaved, merely that they are appropriate (fitting).
Opponents of the exemption have appealed to empirical studies that compare cases of normal bereavement to cases of major depression.  They offer evidence that normal bereavement and major depression can present substantially the same symptoms, and conclude that there is no basis for treating them differently. But this logic is faulty.  Even if the symptoms are exactly the same, proponents of the exemption can still argue that they are appropriate for someone mourning a loved one but not otherwise.  The suffering may be the same, but suffering from the death of a loved one may still have a value that suffering from other causes does not. No amount of empirical information about the nature and degree of suffering can, by itself, tell us whether someone ought to endure it.
Foucault is, then, right: psychiatric practice makes essential use of moral (and other evaluative) judgments.  Why is this dangerous?  Because, first of all, psychiatrists as such have no special knowledge about how people should live.  They can, from their clinical experience, give us crucial information about the likely psychological consequences of living in various ways (for sexual pleasure, for one's children, for a political cause).  But they have no special insight into what sorts of consequences make for a good human life.  It is, therefore, dangerous to make them privileged judges of what syndromes should be labeled "mental illnesses."
This is especially so because, like most professionals, psychiatrists are more than ready to think that just about everyone needs their services.  (As the psychologist Abraham Maslow said, "If all you have is a hammer, everything looks like a nail").   Another factor is the pressure the pharmaceutical industry puts on psychiatrists to expand the use of psychotropic drugs. The result has been the often criticized "medicalization" of what had previously been accepted as normal behavior-for example, shyness, little boys unable to sit still in school, and milder forms of anxiety.
Of course, for a good number of mental conditions there is almost universal agreement that they are humanly devastating and should receive psychiatric treatment.   For these, psychiatrists are good guides to the best methods of diagnosis and treatment.  But when there is significant ethical disagreement about treating a given condition, psychiatrists, who are trained as physicians, may often have a purely medical viewpoint that is not especially suited to judging moral issues.
For cases like the bereavement exclusion, the DSM should give equal weight to the judgments of those who understand the medical view but who also have a broader perspective.  For example, humanistic psychology (in the tradition of Maslow, Carl Rogers, and Rollo May) would view bereavement not so much a set of symptoms as a way of living in the world, with its meaning varying for different personalities and social contexts.  Specialists in medical ethics would complement the heavily empirical focus of psychiatry with the explicitly normative concerns of rigorously developed ethical systems such as utilitarianism, Kantianism and virtue ethics.
Another important part of the mix should come from a new but rapidly developing field, philosophy of psychiatry, which analyzes the concepts and methodologies of psychiatric practice.  Philosophers of psychiatry have raised fundamental objections to the DSM's assumption that a diagnosis can be made solely from clinical descriptions of symptoms, with little or no attention to the underlying causes of the symptoms.  Given these objections, dropping the bereavement exception-a rare appeal to the cause of symptoms-is especially problematic.
Finally, we should include those who have experienced severe bereavement, as well as relatives and friends who have lived with their pain.  In particular, those who suffer (or have suffered) from bereavement offer an essential first-person perspective.  As Foucault might have said, the psyche is too important to be left to the psychiatrists.
Gary Gutting is a professor of philosophy at the University of Notre Dame, and an editor of Notre Dame Philosophical Reviews. He is the author, most recently, of "Thinking the Impossible: French Philosophy since 1960," and writes regularly for The Stone. He was recently interviewed in 3am magazine.

Tuesday, February 5, 2013

Feeding a Disease With Fake Drugs -

MORE than eight million people get sick with tuberculosis every year, according to the World Health Organization. In 2011, 1.4 million died from it, making it the world's deadliest infectious disease after AIDS. Thanks to billions of dollars spent on diagnosis and treatment over the past decade, deaths and infections are slowly declining. Yet a disturbing phenomenon has emerged that could not only reverse any gains we've made, but also encourage the spread of a newly resistant form of the disease.

In the largest study of its kind, to be published today in the International Journal of Tuberculosis and Lung Disease, colleagues and I have found that fake and poorly made antibiotics are being widely used to treat tuberculosis. These substandard drugs are almost certainly making the disease more resistant to drugs, posing a grave health threat to communities around the world.

Our research team collected samples of two commonly used medicines, isoniazid and rifampicin, from neighborhood pharmacies and markets in 17 countries where tuberculosis is pervasive across Africa, Asia, South America and Europe. Nearly one of every 10 pills we collected failed to meet basic quality standards. In African countries, one in six pills was substandard.

Failing pills typically had too little of the active ingredient — the molecule that destroys tuberculosis bacteria. Most of these drugs came from legitimate manufacturers; they were either poorly made or corroded in transit. The rest appeared genuine, but after researchers tested them and more closely analyzed the packaging, they turned out to be fakes — produced and distributed through criminal enterprises. A pack of fake pills might sell for a dollar on the streets of India, but estimates of the global market for fake drugs range into the tens of billions of dollars.

The World Health Organization recommends that tuberculosis patients receive supervised treatment and quality medicines provided by public health departments. But traveling to the clinics where this treatment is dispensed can be very expensive, especially for poorer patients. Private markets for tuberculosis drugs — where we procured our samples — are often easier to access. For patients in Zambia, for example, treatment through the national tuberculosis program is three times more expensive than self-administering treatment with drugs purchased at local markets. In addition, counterfeiters in emerging markets can infiltrate the legitimate supply chain by submitting falsified paperwork and lying about where the drugs originated. When this happens, most pharmacists have no idea that the products they sell won't work.

Some patients will die outright when shoddy medicines fail to cure them. Others will take drugs with too little active ingredient, killing some of their infection's bacteria but leaving the strongest to multiply. These patients could go on to spread a drug-resistant form of the disease, which is deadlier and vastly more expensive to control.

Back in the 1990s, New York City spent more than $1 billion on an epidemic of drug-resistant tuberculosis. Today, curing a single case of it in the United States can cost more than $200,000. The financial and public health risks for Americans are so great that the Department of Homeland Security has called the most lethal known form of the disease, an extremely drug-resistant tuberculosis called XDR-TB, an "emerging threat to the homeland." Virtually unknown 10 years ago, XDR-TB has now been identified in at least 77 countries — including the United States.

The Food and Drug Administration recently approved a drug called Sirturo, designed to target drug-resistant forms of the disease. While this provides a welcome new hope, we fear it will not be enough. Tuberculosis will not be brought under control until we reduce patients' exposure to substandard medicines.

This is not a problem for just the developing world. While stronger manufacturing practices, more effective regulatory agencies and more alert customs officials help protect the supply here, the United States is not impervious to bad drugs. Last fall, a generic version of Lipitor produced in India was recalled after it was found to contain particles of glass. Since the United States is currently facing a shortage of tuberculosis medicines, it will look to sources outside the country. It must ensure that these drugs are of sufficient quality.

The United States Centers for Disease Control and Prevention is best positioned to lead the fight against substandard and fraudulent tuberculosis drugs. The agency works with public health organizations around the world to stop health threats before they reach our shores. And it is run by Dr. Tom Frieden, who led New York City's successful campaign against drug-resistant tuberculosis in the '90s. The C.D.C. should work with the State Department's new Office of Global Health Diplomacy and the World Bank to help foreign governments, law enforcement agencies and pharmaceutical companies strengthen drug supply chains and prevent companies from making substandard products.

They should follow the lead of the President's Malaria Initiative, which tests every batch of drugs it provides to patients in poor countries, and encourage authorities to do the same for tuberculosis drugs. Drug regulators should also confirm that available medicines are really registered where they say they are (we found that unregistered medicines were more likely to be substandard). Finally, they must prosecute and imprison makers of lethal fake drugs.

As long as substandard tuberculosis drugs are permitted in the marketplace, people will continue to die in pursuit of a cure. And without a coordinated response, growing resistance will eventually render even the highest quality drugs obsolete.

Roger Bate, a resident scholar at the American Enterprise Institute, is the author of "Phake: The Deadly World of Falsified and Substandard Medicines."

Aging Poorly: Another Act Of Baby Boomer Rebellion : Shots - Health News : NPR

Baby boomers have a reputation for being addicted to exercise and obsessed with eating well.

But that story didn't jibe with what physician Dana E. King and his colleagues see walking through the door of their family practice every day in Morgantown, W.Va.

"The perception is that the baby boomers are very active — they are, you know, climbing up mountains, and they are a very healthy bunch," says King, a professor in the department of family medicine at the West Virginia University School of Medicine. "We actually see people that are burdened with diabetes, hypertension, obesity, [and] who are taking an awful lot of medication."

So King and his colleagues mined data from the National Health and Nutrition Examination Survey, a big federal survey, to compare baby boomers — those who are now in their late 40s to 60s — with people from two decades ago who were in that age bracket.

There were some surprises, says King, who, along with his colleagues, reports the results in the journal JAMA Internal Medicine.

Baby boomers are healthier in some important ways. They are much less likely to smoke, have emphysema or get heart attacks. But in lots of other ways, the picture's not so great.

"The proportion of people with diabetes, high blood pressure and obesity [is] increasing. And perhaps even more disturbing, the proportion of people who are disabled increased substantially," King says.

Double the percentage of baby boomers, as compared with the previous generation, need a cane or a walker to get around. And even more have problems so bad that they can't work.

"Only 13 percent of people said they were in excellent health compared with 33 percent a generation ago, and twice as many said they were in poor health," King says. "And that's by their own admission."

King says the reasons are pretty clear: big increases in obesity and big decreases in exercise.

"About half of people 20 years ago said they exercised regularly, which meant three times a week, and that rate now is only about 18 percent," he says. "That's an astonishing change in just one generation."

The impact could be far-reaching if millions of baby boomers are already in such bad shape just as they're starting to grow old.

"The implications for health care costs in the next decade are astounding," King says. "The baby boomers are going into those high medical-use years in much worse condition than their forefathers."

The report comes at a time when the baby boomers are starting to enter old age in large numbers. "There are ... something like 10,000 a day reaching 65," says Richard Suzman of the National Institute on Aging. "It doesn't look good."

Part of the reported decline in health may be that baby boomers look sicker. They're getting diagnosed and treated for health problems their parents never knew they had.

But there may also be something else going on. "I'm part of the leading edge of the baby boom, and I know from personal experience that we have high expectations of life," saysLinda Martin, who studies health trends at the Rand Corp. "And so it could be that the decline in reports of excellent health could simply be that we have [a] higher expectation of what excellent health is."

Despite all this, baby boomers are living longer than their parents. But along the way, they're having a lot more knee operations and taking a lot more pills for blood pressure, cholesterol and diabetes.