Colleges Open Food Pantries To Address Campus Hunger and Community Food Banks Address Community Needs



14657323_990803671049292_5706119886531990609_nAfter listening to the continual media garbage in this horrid election campaign I thought that I would post something “nice.” I predict that the campaign will only get worse and that the mud will fly fast and furiously. It has become one of the worst and dirtiest on both sides from both parties. I hope that we all can recover.

But now about the good in the world, at $68,000 per year, George Washington University in Washington, D.C., is one of the most expensive schools in the country, and yet some students — most of whom receive financial aid — still don’t have enough to eat every week.

William Atkins/Courtesy of The George Washington University

The university, bolstered by a national survey by the College and University Food Bank Alliance, discovered that nearly half of its student population matched the national rate of 48 percent of respondents who experienced food insecurity.

So the school opened a food pantry for students, joining over 300 other schools across the nation that have done the same.

College meal plans vary throughout the country, from traditional dining hall settings to a la carte combinations. And some plans focus on options all around the city, says Tim Miller, associate dean of students at George Washington, which is embedded in a well-to-do neighborhood of the nation’s capital.

“The population at GW does a lot in the city,” Miller says. “They intern a great deal. So we have a plan that allows students to meet that need.” He adds that many of the university’s students also cook for themselves.

The school’s food pantry is unmarked. Students fill out forms that list their email addresses and student ID numbers, but they do not have to give their names or discuss their finances.

“One of the things that we learned from talking to all the other universities that we spoke to this summer was one of the concerns for students is anonymity around this and being able to feel like they can use us without having any judgment,” Miller says.

He describes one student who walked in terrified of not knowing what the pantry would be like and was overjoyed and brought to tears when she saw it was like a grocery store.

“She felt like she could go to every shelf and take what she most needed versus being directed you have to take this, this and this. But the fact that there’s an empowering part of this is really something we’ve heard a lot about from the students who’ve used it so far,” he says.

And students are using it. In September, the university did a soft-launch of the food pantry, without any advertising, and 21 students signed up immediately. Now, 147 students are enrolled in the program.

“We have gotten amazing notes back from students about how this has been a blessing to them and how this really has helped them focus on what they thought they could be able to do here,” says Miller.

Because of George Washington University’s sticker price, Miller says it’s important to listen to students.

“We want to have faith in our students that if they say they need this, that they do and trust them to take what they need,” he says, adding that the school has focused a lot on affordability and tries to do everything possible, including partnering with other organizations, to provide support.

But the growing number of food pantries on college campuses may well be taken as yet another sign that a college education in general is just too expensive.

Miller says the idea is a positive response to a really challenging situation, but it’s not the ultimate solution.

“I think we have to look at, how do we help our students afford it? And how do we manage the cost of higher education for all students? We’re also looking for what that final solution is.”

And yet another wonderful positive thing done for a community- Laura Benshoff is a reporter with member station WHYY wrote that for 12 years, Chester, Pa., had no supermarket. In an effort to end this so-called food desert, a local food bank plunked down a nonprofit grocery store in the impoverished Delaware County city in October 2013.

Area food bank Philabundance opened the new store, called Fare & Square, in the same footprint as a former supermarket at the corner of Trainer and 9th streets.

When it opened, the store was touted as a philanthropic venture and a boon to Chester, a city of about 34,000. A third of the population lives below the poverty level.

After raising $7 million in startup funds through grants, donations and loans, Fare & Square launched with a two-pronged mission: become a sustainable business and make people in Chester healthier.

But when Fare & Square first opened its doors, a lot of the stock wasn’t winning over customers.

“Watercress lettuce — that didn’t sell too well. Leeks — that didn’t go too well. Rutabagas, parsnips — that didn’t go over well,” says produce manager Nate Sumpter, a self-proclaimed carnivore.

On first glance, Fare & Square is intentionally laid out like an upscale grocery store, with produce front and center.

“Our model is, we want to have all kinds of healthy stuff, so when people walk in they’re like, ‘Wow, what’s all this?’ ” says operations manager Mike Basher.

But the store also wants people to see what they’re used to seeing in grocers — and that includes processed and junk food. TastyKake displays line the checkout aisles. Cases of soda lurk below eye level, behind displays of fruits and vegetables.

The supermarket business is notoriously tough: razor-thin margins on a product that can quite literally rot on the shelves if it doesn’t sell. Big chains rely on high volume to get the lowest prices on what they sell, and the returns from a successful store may prop up new or underperforming locations. A one-off grocer has neither advantage.

Those chains also average profit margins of only 1 or 2 percent and generally take three to five years to get back into the black.

To get and keep customers, Basher and his crew started tinkering with what they carried. They cleared products that weren’t selling from the shelves and replaced them with goods customers asked for, like Caribbean and Latin American food.

On a recent visit, a lot of people in Fare & Square’s checkout line were buying packaged foods and fresh foods together. Sales have grown year over year, but Fare & Square needs to take in 20 percent more to break even. For now, it it is subsidized by Philabundance.

Making money presents one challenge. Changing people’s eating habits is another tall order.

Fare & Square has been experimenting with incentives to get customers to spend more of their food dollars on healthful and fresh food by lowering the cost of things like produce.

Customers who self-declare as living on less than 200 percent of the poverty level receive 7 percent back on all of their all purchases through a program called Carrot Cash — but they get back more for each dollar they spend on fruits and vegetables.

Anne Palmer, a food researcher at Johns Hopkins University, says research into food deserts shows that just because more healthful food is on shelves doesn’t guarantee customers will buy it.

“If you’re on a budget, you’re not purchasing food with the intent of improving your health. You’re purchasing food to satisfy hunger,” she says. “You make choices you can afford on things you know your family will eat.”

Food that is unfamiliar or difficult to make therefore constitutes a risk: If your family doesn’t eat it, that’s money down the drain. At the same time, restricting what people can buy to only healthful food is unrealistic, says Palmer.

“We have to recognize everybody wants a wide range of foods. … [Packaged goods] might be what it takes to bring people in, recognizing that if you don’t do that, they’re going to go somewhere for that food,” she says.

The relationship between incentives like Carrot Cash and more healthful eating hasn’t been studied long enough to determine whether there is a link, according to Palmer. Researchers at Swarthmore College did conduct a field study at Fare & Square, pending publication, that showed giving customers a coupon for produce led them to spend more total food dollars on fresh food, whereas receiving a coupon for any food in the store did not.

Employees at Fare & Square say one of the company’s goals for the next year is to use more of its customer-level data to learn more about how promotions and incentives affect healthy eating habits.

No matter what they’re buying, people shopping in the store say they are grateful to have an affordable option in Chester.

When asked how often they shop at Fare & Square, Chris and Kyisha Smith, a young married couple perusing the meat case, answer in unison: “Every week.”

“They got everything, chicken, steak. … They the best though, I ain’t even gonna lie to you,” says Chris Smith.

In recent years, Chester has seen both a deep-discount grocer and a members-only food co-op come and go. The folks behind Fare & Square hope they’ve found a sweet spot that is viable, somewhere in the middle.

Aren’t thee positive strategies refreshing and a change for the better? Wouldn’t it be nice if more programs like these could provide additional services?

But maybe we should be concerned regarding why services such as these are needed and what are the real solutions?

Then back to what is scaring me most, do either of our candidates running for the highest office in our country have solutions for what really ails our country and are their solutions sustainable and effective?




Teen Health Care Called a Smart Investment

14470624_978183495644643_5868853190292882850_nOver the last several weeks I have noticed the push for HPV vaccination in our Male and female young patients. These vaccinations are important if we are pushing for a health care system, which is sustainable, that which supports preventive health care. HPV is short for Human Papillomavirus, a common virus. In the United States each year, there are about 17,500 women and 9,300 men affected by HPV-related cancers that’s a new case every 20 minutes.. Many of these cancers could be prevented with vaccination. In both women and men, HPV can cause anal cancer and mouth/throat (oropharyngeal) cancer. It can also cause cancers of the cervix, vulva and vagina in women; and cancer of the penis in men.

For women, screening is available to detect most cases of cervical cancer with a Pap smear. Unfortunately, there is no routine screening for other HPV-related cancers for women or men, and these cancers can cause pain, suffering, or even death. That is why a vaccine that prevents most of these types of cancers is so important.

HPV is a virus passed from one person to another during skin-to-skin sexual contact, including vaginal, oral, and anal sex. HPV is most common in people
in their late teens and early 20s.Almost all sexually active people will get HPV at some time in their lives, though most will never even know it.

Most of the time, the body naturally fights off HPV, before HPV causes any health problems. But in some cases, the body does not fight off HPV, and HPV can cause health problems, like cancer and genital warts. Genital warts are not a life-threatening disease, but they can cause emotional stress, and their treatment can be very uncomfortable. About 1 in 100 sexually active adults in the United States have genital warts at any given time.

All preteens need HPV vaccination and it is recommended for preteen girls and boys at age 11 or 12 years so they can be protected from HPV infections that cause cancer. Teens and young adults who didn’t start or finish the HPV vaccine series also need HPV vaccination. Young women can get HPV vaccine until they are 27 years old and young men can get HPV vaccine until they are 22 years old. Young men who have sex with other men or who have weakened immune systems can also get HPV vaccine until they are 27.

HPV vaccination is a series of shots given over several months. The best way to remember to get your child all of the shots they need is to make an appointment for the remaining shots before you leave the doctor’s office or clinic.

HPV vaccination has been studied very carefully and continues to be monitored by CDC and the Food and Drug Administration (FDA). No serious safety concerns have been linked to HPV vaccination. These studies continue to show that HPV vaccines are safe.

The most common side effects reported after HPV vaccination are mild. They include pain and redness in the area of the arm where the shot
was given, fever, dizziness, and nausea. Some preteens and teens may faint after getting a shot or any other medical procedure. Sitting or lying down for about 15 minutes after getting shots can help prevent injuries that could happen if your child were to fall while fainting. HPV vaccines offer the best protection to girls and boys who receive all three-vaccine doses and have time to develop an immune response before they begin sexual activity with another person. This is not to say that your preteen is ready to have sex. In fact, it’s just the opposite—it’s important to get your child protected before you or your child has to think about this issue. The immune response to this vaccine is better in preteens, and this could mean better protection for your child.

This brings up another topic, the health care of our teens and preventative care. This group of patients is so important if we are truly going to improve our health care system with sustainability and in order to prevent more severe disease. reviewed the topic of adolescent health. Adolescents (ages 10 to 19) and young adults (ages 20 to 24) make up 21 percent of the population of the United States. The behavioral patterns established during these developmental periods help determine young people’s current health status and their risk for developing chronic diseases in adulthood.

Although adolescence and young adulthood are generally healthy times of life, several important public health and social problems either peak or start during these years. Examples include:

  • Homicide
  • Suicide
  • Motor vehicle crashes, including those caused by drinking and driving
  • Substance use and abuse
  • Smoking
  • Sexually transmitted infections, including human immunodeficiency  virus (HIV)
  • Teen and unplanned pregnancies
  • Homelessness

Because they are in developmental transition, adolescents and young adults are particularly sensitive to environmental—that is, contextual or surrounding—influences. Environmental factors, including family, peer group, school, neighborhood, policies, and societal cues, can either support or challenge young people’s health and well-being. Addressing the positive development of young people facilitates their adoption of healthy behaviors and helps to ensure a healthy and productive future adult population.

Adolescence is a critical transitional period that includes the biological changes of puberty and the need to negotiate key developmental tasks, such as increasing independence and normative experimentation.,

There are many examples of effective policies and programs that address adolescent health issues. They include:

  • State graduated driver licensing programs
  • Teen pregnancy prevention programs
  • Violence prevention programs
  • Delinquency prevention programs
  • Mental health and substance abuse interventions
  • HIV prevention interventions

Teen birth rates in the United States have declined to the lowest rates seen in seven decades; yet still rank highest among developed countries. Contributing to this decline are increases in the proportion of teens who have never had sex, combined with increases in contraceptive use among sexually active teens.  As a health care provider, you play a critical role in further reducing teen pregnancy rates through the care you provide to your adolescent patients.

  • Teens need regular health care services to receive comprehensive sexual and reproductive health counseling about the importance of delaying the initiation of sexual activity and about their contraceptive options. They need counseling on which method would be best for them, and on how to use that method correctly and consistently. Parents and guardians also need guidance and information to help them talk with their teens about sex, pregnancy, and contraception.

The financial burdens of preventable health problems in adolescence are large and include the long-term costs of chronic diseases that are a result of behaviors begun during adolescence. For example, the annual adult health-related financial burden of cigarette smoking, which usually starts by age 18, is $193 billion.

There are significant disparities in outcomes among racial and ethnic groups. In general, adolescents and young adults who are African American, American Indian, or Hispanic, especially those who are living in poverty, experience worse outcomes in a variety of areas (examples include obesity, teen pregnancy, tooth decay, and educational achievement) compared to adolescents and young adults who are white.

The leading causes of illness and death among adolescents and young adults are largely preventable. Health outcomes for adolescents and young adults are grounded in their social environments and are frequently mediated by their behaviors. Behaviors of young people are influenced at the individual, peer, family, school, community, and societal levels.

As illustrated by the following examples of research findings, health outcomes are linked to multiple environmental factors.


  • Adolescents who perceive that they have good communication and are bonded with an adult are less likely to engage in risky behaviors.
  • Parents who provide supervision and are involved with their adolescents’ activities are promoting a safe environment in which to explore opportunities.
  • The children of families living in poverty are more likely to have health conditions and poorer health status, as well as less access to and utilization of health care.


  • Academic success and achievement are strong predictors of overall adult health outcomes. Proficient academic skills are associated with lower rates of risky behaviors and higher rates of healthy behaviors.
  • High school graduation leads to lower rates of health problems and risk for incarceration, as well as enhanced financial stability during adulthood.
  • The school social environment affects students’ attendance, academic achievement, and behavior. A safe and healthy school environment promotes student engagement and protects against risky behaviors and dropping out.

Adolescents growing up in distressed neighborhoods characterized by concentrated poverty are at risk for a variety of negative outcomes, including poor physical and mental health, delinquency, and risky sexual behavior.

Adolescents who are exposed to media portrayals of violence, sexual content, smoking, and drinking are at risk for adopting these behaviors.

Two important issues influence how adolescent health will be approached in the coming decade. First, the adolescent population is becoming more ethnically diverse, with rapid increases in the numbers of Hispanic and Asian American youth. The growing ethnic diversity will require cultural responsiveness to health care needs and sharpened attention to disparate health and academic outcomes, which are correlated with poverty, especially among adolescents from minority racial and ethnic groups.

The second emerging issue is the increased focus on the use of positive youth development interventions for preventing adolescent health risk behaviors. Youth development interventions can be briefly defined as the intentional process of providing all youth with the support, relationships, experiences, resources, and opportunities needed to become successful and competent adults. There is growing empirical evidence that well-designed youth development interventions can lead to positive outcomes. Ongoing, rigorous evaluation will determine what works, why it works, and how successful interventions can be applied.

Molly Walker wrote that adolescents face considerable health challenges on a global scale, most notably from injuries, common infectious diseases, mental health conditions, and sexual and reproductive health problems, according to a new report released by a global health commission.

Though global efforts have succeeded in slowing the mortality rates of young children less than 5 years of age, the same cannot be said for the adolescent population, where the decline in deaths has been slower. Examining causes of preventable death worldwide, younger adolescents (ages 10-14) were more likely to die of HIV/AIDS, road traffic accidents, and drowning, while older teens and young adults (ages 15-19 and ages 20-24) were more likely to die of traffic accidents, self-harm, and violence, reported George C. Patton, PhD, of the University of Melbourne, in Australia and colleagues, in The Lancet commissions.

Diseases such as diarrheal and infectious diseases, lower respiratory infections, and malaria comprised about a fifth (21%) of deaths among younger adolescents. Not surprisingly, the leading risk factors for death among this group include unsafe water, unsafe sanitation, and lack of hand washing.

While the leading cause of ill health among younger adolescents was iron deficiency (18.8% males and 15.6% females), the fastest growing cause of ill health in 23 years was unsafe sex (up to 2nd place in 2013 from 13th place in 1990).

Linda Arnold, MD, of the American Academy of Pediatrics (AAP) section on international child health, said that a key to combatting preventable disease was education — both in terms of schooling and in terms of reproductive health education, especially among young girls.

“We need to speak out in support of access to free, high quality secondary education, the single best investment for improving health and well-being,” said Arnold in an email to MedPage Today. “Clinicians can support adolescents by identifying and addressing their health needs at a local level, reducing barriers to access, and ensuring that services are available to all, regardless of gender, ethnicity or [socioeconomic status].”

The authors themselves noted the importance of education in a statement, saying “every year of education beyond age 12 is associated with fewer births for adolescent girls and fewer adolescent deaths for boys and girls.”

“Our data show a clear need for renewed efforts to improve health and reduce the burden of disease in young people. Continued inaction will have serious ramifications for the health of this generation and the next,” said co-author Ali Mokdad, PhD, of the Institute for Health Metrics and Evaluation (IHME) in Seattle, in a statement. “Most of these health problems are preventable and treatable and tackling them will also bring huge social and economic benefits.”

To combat this problem, the authors suggest a multi-tiered approach that not only includes investing in secondary education for adolescents, but in laws that “empower and protect” adolescents, such as making 18 years of age the minimum legal age for marriage.

They also suggest more investment in mental health resources, especially since depression is the number one cause of ill health among adolescents, affecting 10% of the global adolescent population.

“In a rapidly changing world, we must work across sectors to transform health systems at all levels, ensuring universal access to services targeted to meet the complex physical, mental and reproductive health needs of all adolescents,” said Arnold. “Doing so represents an investment with substantial immediate and long-term returns at individual, societal and global levels.”

The recommendations of the commission are similar to those from the World Health Organization’s (WHO) Global Strategy for Women’s, Children’s and Adolescents’ Health, which was launched in September 2015. Noteworthy are the twenty-three new commitments, corresponding to over $2 billion in pledges for women’s, children’s and adolescents’ health and well-being were announced on the margins of the UN General Assembly on Thursday. This includes a pledge by Save the Children for global health and nutrition work in both development and humanitarian settings.

A new Global Investment Framework for Women’s and Children’s Health demonstrates how investment in women’s and children’s health will secure high health, social, and economic returns. Researchers have evaluated health systems strengthening and six investment packages for: maternal and newborn health, child health, immunization, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. They then used simulation modeling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending. What a great return on a small investment and imagine what we could do just within our own country. Are we able to take the initiative and invest in our youth? I will discuss women’s health and the investment in their health care and preventative medicine in a future post.

Adult ADHD, a Risky Diagnosis and What is the Treatment-Drugs or Therapy?

14457249_983142311815428_5901937613860034631_nAs adult ADHD diagnoses increase, so do stimulant overdoses


  • by John Fauber, Reporter, Milwaukee Journal Sentinel/MedPage Today; Matt Wynn Staff Writer, MedPage Today; Kristina Fiore 
Associate Editor, MedPage Today 

Public health officials have focused attention on the staggering increase in opioid overdoses and abuse of prescription painkillers, but little has been said about another growing threat — abuse of drugs used to treat attention deficit/hyperactivity disorder (ADHD) in adults.

My concern is that often in our present medical system the clinicians often find that the easiest way of treating their patients is to prescribe a drug. Often I find when I see patients in my office that they have a laundry list of medications, some of which are contraindicated with others in their list. This is true especially in a number of psychological/psychiatric diagnoses. I recently had a personal situation involving a close friend who when he asked his psychiatrist if he could have ADHD, instead of performing testing and even therapy when on to add a drug to treat his “ADHD”. I questioned this addition due to his medication that he was already on for his anxiety disorder. The problem was that this new drug increased the risk of suicide ideations, etc. When I discussed this with a friend who is a psychologist he said that ADHD is over diagnosed, especially in the adult patient and that psychological therapy is the first line of treatment.

Since 2013, the FDA has received 19,000 reports of complications from ADHD drugs, most of which are stimulants like Adderall (amphetamine and dextroamphetamine), Concerta (methylphenidate), Ritalin (methylphenidate), and Vyvanse (lisdexamfetamine), according to a Milwaukee Journal Sentinel/MedPage Today analysis.

Of those, adults were far more likely than children to suffer severe complications, such as death and hospitalization.

Among those age 26 or older, recreational use of Adderall, rose almost four-fold, from 345,000 people in 2006 to 1.4 million in 2014, according to the latest available federal data.

In emergency departments around the country, the number of cases involving two common ADHD drugs — Adderall and Ritalin — quintupled over 7 years.

In Florida, a bellwether state for drug abuse problems, overdose deaths involving stimulants increased more than 450% between 2008 and 2014.

Taken together, the data show the drugs — which have been heavily promoted by the pharmaceutical industry — left a trail of misuse, addiction and death, a Journal Sentinel/MedPage Today investigation found.

Twenty years ago, adult ADHD was a seldom-diagnosed disorder. But this diagnosis is now common in mainstream medicine, a paradigm shift that appears to be driven by two factors: reworked — many say less stringent — diagnostic criteria, and marketing by makers of these drugs, one of which helped fund a study that claimed 1 out of 23 adult Americans are affected by the condition, which would put the adult ADHD population at roughly 10 million.

“The streets are awash with Adderall,” said Nicolas Rasmussen, PhD, MPH, a medical historian who has studied the history of amphetamines in the U.S. “Amphetamines are grossly overused.” Other critics question whether adult ADHD truly is truly a widespread condition requiring treatment with potent drugs.

It is among several conditions identified by Journal Sentinel and MedPage Today in which diagnostic definitions were expanded — the bar lowered — to create a larger market for treatment with expensive, often dangerous drugs. In many instances the “evidence” proffered to expand those definitions came from research funded in whole or part by the pharmaceutical industry.

In the case of adult ADHD, the definition was relaxed in 2013 by the American Psychiatric Association. Under the new definition, adults need to have five of nine possible symptoms from either of two categories, down from six of nine, and the symptoms must have been present before age 12. The earlier definition required symptoms to be present prior to age 7. Of the experts on the panel that approved the changes, 78% had financial ties to drug companies, according to a 2012 analysis published in the journal PLoS Medicine.

In a Journal Sentinel/MedPage Today investigation published in May, MPH, an APA spokesman said financial conflicts of interest among panel members were limited to $10,000 a year, which included funds received for work as industry speakers and consultants. The $10,000 limit is one commonly used — and just as commonly criticized — by organizations promulgating guidelines. Regier also defended inclusion of the adult ADHD definition in the APA’s diagnostic manual, saying that even though ADHD once was thought to be a childhood condition, for some, it remains in adulthood.

Spokespersons for drug companies say adult ADHD is a real and treatable medical condition affecting millions of Americans. Jessica Castles Smith, a spokesperson for Janssen Pharmaceuticals, which makes the ADHD drug Concerta, said the company continually monitors the safety and effectiveness of its drug in cooperation with the FDA. She said any new data are incorporated into the product’s label so that doctors and patients can make informed decisions. “All medicines, including Concerta, have both benefits and risks,” she said.

Charlie Catalano, a spokesman for Shire, which makes the ADHD drugs Adderall and Vyvanse said it has been approved by regulators around the world based on an acceptable benefit-risk profile. “Our medications are proven to be effective when used according to prescribing practices of a licensed, trained healthcare professional,” he said. Eric Althoff, a spokesperson for Novartis, which makes Ritalin, said their drug “has been used safely and effectively for more than 60 years.” Given that Ritalin has been used “for decades, the labeling [information] reflects the safety data gathered over years of experience,” he said. He noted “if used inappropriately, the results could be serious, just like with the misuse of any other medication.”

The symptoms of the condition typically involve an inability to focus on tasks, fidgeting, or interrupting others. Experts note the symptoms are vague, can be caused by other conditions, and are easy to fake. One study published in 2010 found that 22% of adults tested for ADHD had exaggerated their symptoms.

For years, the legitimacy of adult ADHD was based on the belief that for some it was a condition that started in childhood and persisted into adulthood. But that belief was undermined last year, when researchers published the results of a long-term study that began in the early 1970s and followed more than 1,000 New Zealand children until age 38. The study found little overlap between those who had ADHD as children and those who were diagnosed as adults.

While none of the symptoms are life threatening, the drugs approved by the FDA to treat adult ADHD can raise heart rates and blood pressure, and have been linked to sudden cardiac death. They also carry a high potential for abuse and dependence. The long-term risks and benefits in adults are not known. Drugs often are tested for a year or more, but rigorous clinical trials of ADHD drugs on adults have not lasted more than a few weeks or months.

Among the adverse events reported to the FDA:

  • A 41-year-old woman was hospitalized with kidney failure after abusing methylphenidate, the stimulant in Ritalin.
  • A fatal heart attack in a 41-year-old man with known heart disease who was taking two ADHD drugs as well as atorvastatin and losartan.
  • A 33-year-old man on the ADHD drug Vyvanse was hospitalized after suffering a panic attack, an increased heart rate, chest pain, and dizziness.

The Journal Sentinel/MedPage Today analysis of the FDA data focused only on adverse event reports from healthcare professionals and drug companies, both of which are required to file adverse event reports. The FDA also collects patient reports, but this analysis does not include patient reports.

James Stein, MD, a cardiologist at the University of Wisconsin, said he has treated adult patients who developed serious problems after being misdiagnosed with ADHD and put on prescription stimulants. One patient developed extremely high blood pressure; another developed an irregular heartbeat, he said. Stein said he worries about the increase in prescriptions and marketing of ADHD drugs to patients. “I don’t think these are the kinds of drugs that should be thrown around willy nilly,” Stein said.

Between 2010 and 2015, sales of ADHD drugs jumped from $7.9 billion to $11.2 billion, according to data from IMS Health, a drug market research firm. Prescriptions increased from 67 million to 87 million. The surge came on the heels of a pattern starting in 2008 in which prescriptions written for adults jumped 53% over 4 years, according to Express Scripts, a national prescription benefit plan provider.

Those numbers only tell part of the story:

  • In the last decade, the U.S. Drug Enforcement Administration authorized increased production of legal methylphenidate, the stimulant in Ritalin, from 38 tons to nearly 106 tons. That’s enough to provide every man, woman and child in America with 30 tablets of Ritalin — a month’s supply.
  • In Tacoma, Wash., the presence of amphetamines in wastewater samples collected near college dormitories was eight times higher during final exams week than the first week of classes, according to a 2013 study.
  • On the user-driven website Reddit, nearly 5,000 readers share tips on abusing the drug Adderall, ranging from how to convince doctors to write a prescription to dealing with skin outbreaks from snorting the drugs.

Rasmussen, the medical historian who has studied amphetamines, said the drugs are prone to abuse because “people often feel it makes their lives better. It’s an antidepressant, it offers weight loss, and it improves confidence.” “Someone might start out with methylphenidate or Vyvanse, but then their tolerance builds and they want more,” he said.

While opioids are more lethal than prescription stimulants, some experts see parallels between the opioid epidemic and the increase in problems tied to stimulants. In the opioid epidemic, users switched from prescription narcotics to heroin and illicit fentanyl. With the ADHD drugs, patients are switching from legally prescribed stimulants to illicit ones, such as methamphetamine and cocaine. Some say the similarities extend to loose criteria for diagnosing the underlying condition and the large number of prescription drug options — more than a dozen in the case of ADHD. The relaxed definition of adult ADHD also has played a role.

“Doctors get more patients; patients have their symptoms ‘medically explained,’ and pharma has a new group of people to use their medications,” said Lewis Nelson, MD, chair of emergency medicine at Rutgers New Jersey Medical School. “Clearly it becomes a cat and mouse game of new diagnoses begetting new drugs.”

Petros Levounis, MD, chair of psychiatry at Rutgers, said he saw an increase in people seeking help for stimulant addiction when he opened a treatment center aimed at college students. Levounis said he believes ADHD is poorly understood, which leads to both under- and over-treatment. In some cases, people who need treatment don’t seek help, he said. Other times, doctors are quick to diagnose ADHD when other conditions are causing the problems. “Medicine has a huge responsibility with what happened with the prescription opioid epidemic,” Levounis said. “If there is something brewing with prescription stimulants, we should be doubly, triply concerned about it.”

Overdoses and deaths involving prescription stimulants are not tracked by any one government entity. To assess the scope of the adult ADHD drug problem, the Journal Sentinel and MedPage Today examined data from federal, state, and municipal authorities. The analysis of FDA adverse event reports showed most problems occurred in children, for whom ADHD has long been a common diagnosis. But when adults did report problems, they were more likely to be the most serious.

Adults accounted for just over one-third of reports, but made up more than half of all hospitalizations and nearly 85% of deaths. Users reported several psychological problems. Hallucinations, suicidal thoughts, and depression show up in hundreds of reports. Quitting the drugs also posed a problem, as several reports indicated withdrawal symptoms.

Except for atomoxetine (Strattera), nearly all adult ADHD drugs are stimulants. That drug has not been shown to lead to abuse, but carries the FDA’s most stringent warning because it can create suicidal thoughts in children and adolescents. Adults are warned that it can cause serious cardiovascular problems, including strokes, heart attacks, and sudden death. In 1972, the Drug Enforcement Administration set up a system to monitor emergency room visits caused by drug abuse. Though the program, known as the Drug Abuse Warning Network, stopped collecting data in 2011, in its final years a rise in stimulant-related visits stood out.

In 2004, just two ADHD drugs played a role in 10,800 emergency department visits. By 2011, the figure jumped to 42,000, a nearly fourfold increase in less than a decade. The increase involved methylphenidate, the stimulant in Ritalin, and amphetamine/dextroamphetamine, the stimulant in Adderall. Increasingly, adults were affected. In 2004, the number of emergency amphetamine/dextroamphetamine-related visits in those age 25 and older was so low it couldn’t be estimated. By 2011, 10,000 25- to 44-year-olds went to emergency rooms after using the drug.

In the 5 years since the tracking program ended, the U.S. Drug Enforcement Administrationapproved a 60% increase in amphetamine production and the number of prescriptions for ADHD drugs jumped 20%. The tracking ended due to a lack of funding, said Elizabeth Crane, an analyst at the Substance Abuse and Mental Health Services Administration, which last oversaw the program. “It was unfortunate timing,” she acknowledged.

The CDC does not separate overdose deaths caused by prescription stimulants from those due to illicit stimulants. Still, the number of deaths in the overall category increased by 22%, on average, every year since 2008. In 2014, the most recent year available, there were 5,100 deaths. Other data suggest that deaths attributed to prescription stimulants demonstrated a significant spike. While a few of the drugs can be used to treat conditions such as narcolepsy and binge-eating disorder, the most stimulants are prescribed for ADHD.

In Florida, medical examiners cited amphetamine use in 1,318 cases from 2008 to 2014, ruling that prescription amphetamines contributed to 277 deaths. In 2008, the drugs led to 12 deaths. In 2014, reports peaked at 67 deaths. If that rate were applied to the nation, it would mean there were more than 1,000 deaths from prescription stimulants in 2014.

Preliminary data indicate a substantial increase in deaths in Florida again in 2015. “It looks to me like it’s an under-the-radar epidemic,” said psychiatrist Ken Duckworth, MD, medical director of the National Alliance on Mental Illness. “It’s a real phenomenon.”

And how are we going to address this epidemic? Maybe the deaths are not as significant as those in the heroin epidemic, but this is real and we need to get a handle on the problem and we need to have a better way of identifying patients with a “real” diagnosis of ADHD, if this is a real diagnosis at all, as well as the proper treatment. We as practitioners need to rethink our reflex behavior of treating all diagnoses with drugs although this becomes increasingly difficult due to the expensive advertising campaign pervasive in all media-TV, cable TV, social media, the Internet, etc. Hey, first thing in the morning on TV the drug ads appear almost every 5-7 minutes. So the patients now believe that they have a diagnosis and need the most new medications and are ready to convince their therapists, primary care docs and psychiatrists.

Are we as physicians really practicing good medicine or is the pressures of practice to see more patients, fill out all the templates required by federal regulations making us less clinicians and more pharmacists?

I am concerned!


What Would a Republican or Democrat Win Mean for Health Policy and is It Already Predetermined?


Do you all remember Dr. Gail Wilensky? She was in charge of the role out of the Affordable Care and Protection Act (ACA). Her husband was a plastic surgeon in Washington, D.C. and since I was a plastic surgeon my doctor friends harassed me because I wasn’t doing more for the defeat of the ACA. And now we find Gail Wilensky, PhD discussing, in the New England Journal of Medicine, the Republican possibility of victory and that although it’s not unreasonable to ask how a Republican victory in the 2016 presidential election would affect health policy, it’s important to remember how policy becomes law. Presidents can propose policies — but preferably not in the form of legislative language, as President Bill Clinton did in 1993, when he sent a 1342-page proposal to Congress. Even though Democrats were in control of both the House of Representatives and the Senate, Clinton’s Health Security Act never came up for a vote — largely because of opposition to the policies it contained, but also because resistance was exacerbated by the way the executive branch had dealt with Congress. Only Congress can pass legislation enacting domestic policy, although as President Barack Obama has shown, substantial change can also be enacted through executive action. Of course, such changes can be undone in the same manner.

So understanding what a party “win” would mean requires not only understanding what a presidential candidate has proposed and what his or her party has included in its platform, but also guessing the outcome of the congressional elections and what the combined outcome of all national races means for health policy.

As a candidate, Donald Trump has supported several policy changes commonly proposed by Republicans. These include repealing the Affordable Care Act (ACA), though with little indication of what would replace it; expanding the availability of health savings accounts (HSAs, nontaxable money that can be used to cover medical expenses not covered by insurance and that can be rolled over from one year to the next, unlike flexible spending accounts); permitting insurance to be sold across state lines; turning Medicaid into a block-grant program; protecting people from large increases in insurance premiums or exclusions because of preexisting conditions, as long as they maintain continuous coverage; and allowing people without employer-sponsored insurance to deduct their premiums from their taxes. Unlike other Republicans, Trump has also proposed allowing drug importation and permitting Medicare to negotiate drug prices (though he hasn’t provided any details about what that would mean).

The Republican platform committee adopted policies that reflect some of the positions advocated by House Speaker Paul Ryan (R-WI) and the House Republicans, which are more expansive in some ways than Trump’s proposals. The platform’s wording more clearly recognizes the limits of presidential power, stating that the president should use “legitimate waiver authority . . . to halt [the advance of the ACA but] then, with unanimous support of Congressional Republicans, [should] sign its repeal” — a distinction that congressional Republicans have not always made. Ending the tax discrimination against non–employer-sponsored insurance, block-granting Medicaid, allowing the purchase of insurance across state lines, capping through tort reform the noneconomic damages for malpractice, and expanding the availability of HSAs are also included in the platform.

In the House, Ryan discussed alternative visions of health care reform both before and after the passage of the ACA, and he promised as speaker to release a House Republican health care plan. This plan was released in June, a month before the Republican convention.

Though not as specific as legislative language would be, the proposal provides much more detail than had previously been available about what a Republican replacement for the ACA would include. It also tackles some politically thorny issues, proposing gradually raising the Medicare-eligibility age to 67 and converting Medicare to a premium-support program that would include traditional Medicare as well as private-plan alternatives.

Some of the ideas in Ryan’s plan are traditional Republican proposals, such as selling insurance across state lines and expanding the use of HSAs. Existing ACA premium subsidies would be replaced by a refundable tax credit available to people not covered by Medicare, Medicaid, or employer-sponsored insurance. The credit would be financed by limiting the currently unlimited tax exclusion for employer-sponsored insurance — a more progressive answer to the “Cadillac tax,” a flat 40% excise tax on plans costing more than a specified threshold, because the tax imposed above the threshold level would be based on the individual’s tax rate and would thus be higher for higher-income employees.

Exclusions for preexisting conditions and higher-than-normal premiums would be prohibited for individuals who maintained continuous coverage. Premium prices would be allowed to vary by age, with the price for the oldest family member permitted to be five times that for the youngest (which is estimated to be closer to the actuarially calculated variation in health care costs) rather than the currently allowed 3-to-1 ratio, whereby younger enrollees implicitly subsidize the care of the just-pre-Medicare population. Medicaid would become a per-person block grant to states, and states would have more power, including the ability to require able-bodied adult recipients to work.

Senate Republicans have not collectively released a comparable proposal, but individual Republican senators such as Orrin Hatch (UT) and Richard Burr (NC) and former Senator Tom Coburn (OK) have been involved with proposals to reform Medicare or enact an ACA alternative.

Predicting election outcomes is always risky, and this year’s outcome seems more unpredictable than usual. Voter anger and dissatisfaction with political parties and traditional candidates has made political polling challenging. It is hard to forget the unexpected Brexit vote, which contradicted the results of polls conducted right before the vote, which had suggested that a majority of the population wanted Britain to stay in the European Union.

The easiest call in the 2016 U.S. elections is that split government seems highly likely. The House will probably remain in Republican control, according to most polls. The control of the Senate is likely to switch to the Democrats, if for no other reason than 24 Republican seats but only 10 Democratic seats are up for election. Whenever there’s such an imbalance (reflecting a lopsided election 6 years earlier), change in control becomes likely; a similar imbalance will occur again in 2018, when more Democratic than Republican seats are up for election. Political analysts such as Charlie Cook expect a relatively close split between parties, which means that the Senate will be subject to filibusters.

Democratic nominee Hillary Clinton is currently ahead in the polls, both nationally and in the “swing states,” and so appears to be the more likely winner — but polls have been wrong this cycle, and complacency is always a concern for frontrunners.

So what will split government mean for health policy? Any changes will have to be reached with bipartisan support — because Republicans and Democrats are each likely to control one house of Congress and there’s unlikely to be a supermajority in the Senate.

Republicans may be willing to provide support for strategies to help stabilize the ACA insurance exchanges — such as continued use of risk corridors (which limit the amounts that insurers can gain or lose through risk sharing) after 2016, perhaps with some increased funding from existing appropriations in exchange for increased flexibility using innovation waivers (1332 waivers), such as allowing budget neutrality to be measured over 3 years rather than 1 and allowing states to pool savings from Medicaid with those from exchanges. Agreement that states that have not previously expanded Medicaid should be given 100% federal funding for Medicaid for 3 years after 2016 might be attractive to both Republicans and Democrats. The government could also smooth transitions between Medicaid and exchange coverage by letting people use their Medicaid subsidies to buy insurance in the exchanges and their exchange subsidies to buy Medicaid coverage.

Ultimately, the biggest question is whether, if Republicans lose the presidency, the Senate, or both, they will be willing to work to “fix” the ACA, rather than focusing all their messaging and energy on repealing it.

And then Jonathan Oberlander, PhD, also in the same issue of the New England Journal of Medicine, went on to discuss what happens to Obamacare after its namesake leaves the White House? The Affordable Care Act (ACA) has faced fierce opposition from congressional Republicans and many GOP-led state governments, survived unexpected legal challenges, and overcome a disastrous rollout of Through it all, ACA supporters could count on President Barack Obama to defend the law. But come January 20, 2017, that will change. If Donald Trump becomes president and Republicans maintain congressional majorities, the GOP could seek to repeal major ACA provisions, though Trump’s health care agenda is uncertain.

If Hillary Clinton wins the presidency, however, Democrats can advance the ACA. For decades, reformers sought to enact universal health insurance. Now that they’ve taken a major step toward that goal, what happens next? Victory in the 2016 elections could allow Democrats to shift their focus from preserving the reforms to strengthening and improving them. The ACA’s record reflects both substantial accomplishments and significant shortcomings. One priority should be to make health plans more affordable and thereby achieve further gains in coverage.

The ACA has had remarkable success in reducing the uninsured population — from 48.6 million in 2010 to 27.3 million in January–March 2016, according to the National Health Interview Survey. But many Americans with modest means have not signed up for coverage in the insurance exchanges (marketplaces) created under the ACA


(see graph Percentage of Potential Exchange-Plan Enrollees Who Selected Exchange Plans in 2016, by Income Level.).

Even with government subsidies, insurance premiums can still amount to a substantial share of enrollees’ income. In addition, ACA marketplace plans generally have high deductibles and cost-sharing requirements, and people with incomes above 200% of the federal poverty level (FPL; in 2016, $11,880 for an individual and $20,160 for a family of three) receive only limited subsidies to offset such costs.  Given limited financial assistance and the modest penalty for not obtaining insurance, many Americans have declined to buy coverage. That is one reason why exchange enrollment is much lower than projected, though many people are buying policies outside the exchanges and fewer than expected have lost employer-sponsored coverage. More than 6 years after the ACA’s enactment, insurance affordability remains problematic.

Even as the ACA substantially reduces the uninsured population, underinsurance persists. Many Americans are paying more out of pocket for medical care, especially for deductibles. This trend, which began before the ACA was passed, extends beyond the exchanges. For workers with employer-sponsored insurance, the average annual deductible increased from $303 in 2006 to $646 in 2010 and $1,077 in 2015. Clinton has proposed a refundable tax credit (up to $2,500 for an individual and $5,000 for a family) for Americans with high out-of-pocket costs. She’s also outlined a plan to cap out-of-pocket prescription-drug costs for persons with serious or chronic health conditions. Yet if major gains are to be made in marketplace enrollment, ACA plans may have to be made more attractive, with larger premium subsidies and better cost-sharing protections. Higher enrollment could also be achieved by increasing the penalty charged for not obtaining insurance, but that would be controversial.

A related priority is stabilizing the marketplaces. Premiums are rising for ACA plans, and some insurers are requesting large increases for 2017, though state experiences vary widely and through 2016, exchange plans’ premiums have been much lower than expected. Three major insurers — UnitedHealthcare, Humana, and Aetna — have decided to curtail participation in the exchanges, citing financial losses and risk pools of people who are sicker and more expensive than anticipated (though Aetna’s announcement followed an Obama administration challenge to its proposed acquisition of Humana). Other insurers are doing well financially with their marketplace plans, and in some states insurance competition remains strong. But in a growing number of geographic areas, consumers shopping for insurance on the exchanges have little choice, since one insurer has a monopoly.

Ironically, private insurers’ withdrawals could revive interest in a reform they intensely oppose: creation of a Medicare-like government insurance plan that would compete alongside private plans in the marketplaces. Clinton has endorsed such a public option. Although it will face an uphill struggle in Congress unless (and even if) Democrats regain House and Senate majorities, some states could use innovation waivers, which will be newly available in 2017, to create their own public options. Democrats could also pursue another policy Clinton supports: enabling people 55 years of age or older to enroll in Medicare — though that proposal, too, faces considerable political barriers.

As use of state innovation waivers begins, policies aiming to stabilize the marketplaces will end. Reinsurance and risk corridors, which protect insurers against the costs of enrolling expensive patients and potentially large financial losses, are scheduled to expire later this year (and because of restrictions passed by Congress in 2014, insurers have actually received only 12.6% of the risk-corridor payments the government owes). The expected expiration may be contributing to 2017 premium increases, which might dampen enrollment. One fix would be to maintain these policies — which are already a permanent feature of Medicare’s Part D prescription-drug program that relies on private insurers. The Obama administration has taken steps to steady the marketplaces and improve insurers’ risk pools, including limiting the use of special enrollment periods outside of scheduled open enrollment. The next administration may have to consider additional stabilization measures. Indeed, this could emerge as Clinton’s most pressing health policy challenge.

Making marketplace health plans more affordable would help stabilize insurer participation and ensure further progress in reducing the uninsured population. Democrats could also remedy the “family glitch”: under the ACA, people deemed to have unaffordable options for employer-sponsored coverage can receive premium tax credits to buy marketplace plans, but many people are ineligible for such subsidized coverage because affordability is evaluated on the basis of the premium cost for an individual worker, not on the price for family coverage.

Another way to boost coverage rates would be to persuade more states to expand Medicaid. Three million uninsured low-income people would become Medicaid-eligible if their state accepted the ACA expansion (19 states have declined to do so). A Democratic victory in November could convince some GOP-governed states that the ACA is here to stay and that they should heed Medicaid expansion’s economic and fiscal logic, as well as political pressures from health care provider lobbies. As an incentive, Clinton has proposed extending provision of 100% federal funding for the first 3 years to any state expanding Medicaid. Making that funding level permanent — it’s scheduled to phase down to 90% by 2020 — could further entice states. There are also about 9 million uninsured Americans who are eligible for but not enrolled in Medicaid or the Children’s Health Insurance Program. Vigorous outreach and enrollment efforts are needed to reach these people and those eligible for subsidized marketplace coverage — together, they account for nearly half the remaining uninsured population.

Although the challenges in extending coverage gains are drawing attention, the cost of medical care could also become a prominent issue in coming years. Growth in health care spending has been remarkably moderate since 2008, and the ACA has cost much less than initially forecast. Obamacare has produced considerable Medicare savings, though its precise contribution to the spending slowdown outside that program is unclear. We don’t know how effectively the ACA’s payment and delivery reforms will slow medical spending over the long term. If spending accelerates, policymakers could consider strengthening those reforms or adopting alternative approaches, which are already in the wings with payment bundling, MACRA, MIPS and Meaningful Use. You wonder why more and more physicians are getting burned out??!! Implementation of the Cadillac tax on high-cost private plans, a cost-containment policy favored by many economists but opposed by much of the public, has been delayed from 2018 to 2020. Clinton supports its repeal, a call that’s likely to grow louder if she is elected president and is running for reelection in 2020.

The biggest obstacle to building on the ACA’s achievements and addressing its flaws is hyper-partisanship. Lawmakers are deeply polarized, and public attitudes about health care reform are divided. Even modest changes can become existential struggles in this environment. If Clinton is elected, her chances of strengthening the ACA will depend on whether Democrats have congressional majorities — and on her ability to advance reform in this extraordinarily polarized time.

But what these writers are forgetting is that Hillary has already “promised” a Medicare For All or the public option. Either will result in a system more like the Canadian or European system and we all know the failures, delays, and restrictions.

The Republicans with all the possibilities of alternatives and the threat of repeal of the ACA have not really proposed a worthy alternative to the ACA.

I would be very surprised if Mr. Trump can pull it off and win the election, therefore we will be looking at a public option or Medicare For All health care system.

I will be discussing and dissecting this public option in a future post and what we really need for a sustainable healthcare, which is fair to the majority delivering the best health care for all. Is this even a possibility?

Tune in again in the weeks to follow and send me your comments and suggestions.


Clinton, Trump Release More Health Info Should We Care and is it Really About the Heath of the Candidates or About We Americans and Our Health?

14317555_970886899707636_8500770228802268880_nAs the presidential election draws closer, controversy continues over how the two major presidential candidates have handled the release of their personal health information, as well as what experts are saying about the candidates’ health. The interesting thing is that our nation is poised to elect one of its oldest presidents. Trump at 70 would be months older than Ronald Reagan on his election day, and Clinton will have just turned 69.

Joyce Frieden the News editor for MedPage expanded on the issues that the Presidential candidates Donald Trump and Hillary Clinton have both revealed more information about their own health, although it is unclear whether they’ll satisfy critics — and the method of delivery may also raise additional questions. Actual knowledge of the candidates’ physical fitness has come so far from letters released by their personal physicians.

Clinton recently released a letter from her physician and Trump took to the airwaves: handing “Dr. Oz” a two-page document detailing the results of his latest exam.

“On Friday, September 2nd, I evaluated Mrs. Clinton for a 24-hour history of a low grade fever, congestion and fatigue,” Lisa Bardack, MD, wrote in a letter released by the Clinton campaign. “On examination, she was noted to have a temperature of 99.4; her vital signs were otherwise normal as was her physical exam. She was advised to rest, put on a short course of antibiotics and continued on her allergy medications for an upper respiratory tract infection in the setting of her seasonal allergies. Over the next several days as she traveled, her congestion worsened and she developed a cough. She was advised to see me when she returned from her travels for further testing.”

Bardack continued: “On Friday, September 9th, she was seen and evaluated in my office. A non-contrast chest CT scan, including a CTA calcium score, was performed. This test allowed for specific imaging of her lungs while also following up on cardiac risk stratification from 2010 given her family history of heart disease. The results of the CT scan revealed a small right middle lobe pneumonia; her coronary calcium score was again zero. She was treated with antibiotics for pneumonia and advised to rest. This was a mild non-contagious bacterial pneumonia.”

“On Sunday, September 11 at the 9/11 Memorial event, she became overheated and dehydrated and as a result felt dizzy,” Bardack wrote. “I examined her immediately upon her return home; she was rehydrating and recovering nicely. I advised her to stay home and rest for the next several days. Mrs. Clinton has since been evaluated by me several times and continues to improve.” The letter also addressed other areas of Clinton’s medical history, noting “Mrs. Clinton’s current medications include Armor Thyroid, Coumadin dosed as directed, Levaquin (for a total ten days), Clarinex, as well as B12 as needed. … She remains up to date on all of her immunizations, including Prevnar and Pneumovax. Her Coumadin levels have been adjusted as needed according to regular lab testing. She had a normal mammogram and breast ultrasound.”

In terms of lab tests, “Her laboratory testing … was normal, including cholesterol of 189, LDL of 103, HDL of 56 and triglycerides of 159,” Bardack said. “Her vital signs showed blood pressure of 100/70, heart rate of 70, respiratory rate of 18, temperature of 97.8 and pulse-oximetry of 99%. The remainder of her complete physical exam was normal and she is in excellent mental condition.”

Several physicians weighed in on the results. “From a cardiovascular risk point of view, she is low-risk with her coronary calcium score of 0 and her excellent lipid levels,” Christopher Cannon, MD, professor of medicine at Harvard Medical School, in Boston, wrote in an email to MedPage Today.

However, he added, “It is not specified why she is taking warfarin/Coumadin. This would be additional information that would be helpful to fully understand her health status.”

Stephen Cook, MD, MPH, an internist at the University of Rochester (N.Y.), applauded Clinton’s disclosures. “I’m remarkably pleased with the objective and open information that was provided by Mrs. Clinton’s doctor, and assuming with her permission,” Cook wrote in an email. “I’m very much into prevention, so hearing that candidates are up to date with immunizations and cancer screening is great to hear.”

Remember, that we were also previ to another letter from her physician. The first letter to be released came in July 2015 from Lisa Bardack, MD, an internist in Mount Kisco, N.Y. and Hillary Clinton’s personal physician. Bardack’s letter, which was eight paragraphs long, contained both specific and general information about Clinton — for example, it said that Clinton’s most recent physical, in March 2015, found that her blood pressure was 100/65 and that her total cholesterol was 195, with an HDL of 64 and triglycerides of 69. It also noted that she is taking vitamin B12, antihistamines, and Armour Thyroid for hypothyroidism.

More generally, the letter said that Clinton “does not smoke and drinks alcohol occasionally. … She eats a diet rich in lean protein, vegetables, and fruits. She exercises regularly, including yoga, swimming, walking, and weight training.” Question: How does she do these exercises with her schedule?

The letter also makes note of two episodes of deep vein thrombosis in 1998 and 2009, and an incident in December 2012, in which Clinton “suffered a stomach virus after traveling, became dehydrated, fainted, and sustained a concussion.” Clinton had follow-up evaluations that found a transverse sinus venous thrombosis, and she was given anticoagulation therapy as well as glasses with a Fresnel prism to treat double vision resulting from the concussion.

“She had follow-up testing in 2013, which revealed complete resolution of the effects of the concussion as well as total dissolution of the thrombosis,” the letter continued. “As a precaution, however, it was decided to continue her on daily anticoagulation” in the form of warfarin (Coumadin). Bardack concluded by saying that Clinton “is in excellent physical condition and fit to serve as president of the United States.”

First, regarding Mr. Trump, lets start with his physician’s letter. Donald Trump’s physician, Harold Bornstein, MD, of New York City, released a letter in December 2015 that was much shorter and lighter on details. “Mr. Trump had a recent complete physical examination that showed only positive results,” Bornstein wrote in a four-paragraph letter. “Actually, his blood pressure, 110/65, and laboratory results were astonishingly excellent.”

Bornstein wrote that Trump had lost 15 pounds in the past year and that he takes 81 mg of aspirin daily along with a low dose of a statin. “His PSA test score is 0.15 … His physical strength and stamina are extraordinary.” Trump’s cardiovascular status is “excellent,” and he has no history of alcohol or tobacco use, Bornstein added.

After noting that Trump has no cancer and has never had any orthopedic surgery, Bornstein concluded, “If elected, Mr. Trump, I can state unequivocally, will be the healthiest individual ever elected to the presidency.”

That last line raised concerns for Peter Whitehouse, MD, PhD, and professor of neurology at Case Western Reserve University, in Cleveland. “The physician who wrote this letter undermined his credibility by saying that,” he said in a phone interview. “The physician who wrote this letter undermined his credibility by saying that,” he said in a phone interview. “Based on reading the letter, I would have doubts about referring to that physician; he has limited knowledge of the [health of] the 40-odd presidents we have had.”

These health disclosures should be seen in the same light as candidates’ income tax disclosures, Whitehouse continued. “I’d do it on a voluntary basis” — that is, candidates shouldn’t be required to disclose their health records, “but if you don’t … you’re subject to scrutiny as to why not.”

Meanwhile, Trump appeared on the “Dr. Oz” syndicated television show on Thursday with his own medical report. The show’s host, Mehmet Oz, MD, went through a brief review of systems with Trump, who answered “no” to questions about whether he had any history of neurologic problems, stroke, cancer, stomach problems, or other ailments. As far as his family medical history, Trump mentioned that his father developed “what was probably Alzheimer’s” during the last few years of his life; he died at age 93.

Trump also handed Oz two pages that the candidate said included results of his latest exam and test results from a series done at Lenox Hill Hospital last week. Oz read the results to the audience and Trump campaign released the documents.

  • Height: 6’3″                                         PSA: 0.15 ng/mL
  •          Weight: 236 lbs.                                 Blood pressure: 116/70 mmHg
  • Total cholesterol: 169 mg/dL         Blood sugar: 99 mmol/L
  • Calcium score: 98 HU                       HDL: 63 mg/dL
  • LDL: 94 mg/dL                                   Testosterone level: 441 ng/dL
  • Triglycerides: 61 mg/dL

As for exercise, Trump said he was “speaking in front of 15,000 or 20,000 people and I am up there using a lot of motion; in its own way it’s a pretty healthy act. A lot of times these rooms are very hot, like saunas, so I guess it’s a form of exercise.”

His doctor, Harold N. Bornstein, MD, wrote that Trump takes rosuvastatin (Crestor) and low dose aspirin, but he did not indicate the exact dose in either case. Trump said he has never needed much sleep and noted, “I feel as good today as I did when I was 30. When I play golf, I feel may be a better golfer today than I was 15-20 years ago … I hit the ball better; I putt just as well.”

According to the American College of Cardiology/American Heart Association’s cardiovascular disease risk calculator, Trump’s numbers put him at about a 13% risk of developing cardiovascular disease in the next 10 years, Cannon wrote. Using that same risk calculator, Robert Eckel, MD, professor of medicine and director of the lipid clinic at the University of Colorado Denver Anschutz Medical Campus, noted that Clinton’s 10-year risk score comes out to 4.7%. “Her coronary calcium score by CTA is zero — good news. I don’t feel that I have sufficient information to comment on her need for Coumadin or thyroid hormone.”

Greg Rosencrance, MD, chairman of the Cleveland Clinic Medicine Institute, said that overall, “The health information on the candidates is useful, but it’s important to recognize that it’s in the form of a summary, not the full records, and therefore we would be reliant on others for interpretation. The details included along with the vital signs are good indicators of someone’s overall current state of health.”

Maybe, besides the full disclosure of the Candidates’ health information we need to know what type of REAL exercise program they engage in daily, not just standing up in front of a crowd and hand motioning, or whatever! Although Mrs. Clinton’s doctor did say that she engaged in swimming and yoga regularly. Doctors often tout how exercise can help ward off disease, but previous research hasn’t concluded just how much physical activity is needed to reap those benefits. I was going to discuss the benefits of exercise as research has proven, but that would only deflect our discussion about relevance of these other issues.

We all know that this is all a distraction from the real issues….. and yes if you want to stay on the subject… the real issues of the health of the healthcare delivery system and the health of we Americans.

I think that we all agreed that some degree of medical disclosure for candidates was necessary — the question is, how much information should they disclose? “Candidates for very high office, like president, do have an obligation to disclose if they have a serious health problem, like if they have cancer or have had a stroke.” said Doug Brugge, PhD, professor of public health and community medicine at Tufts University in Boston. “If they just have risk factors — like high cholesterol — most of us have risk factors, so that is not such a big deal.”

“As a matter of public policy, public interest and what may remain of a ‘right to know’ for the electorate, the medical fitness of a prospective U.S. president is important,” Jay Wolfson, D.Ph., JD, professor of public health, medicine, and pharmacy at the University of South Florida, in Tampa, wrote in an email to MedPage Today. “Prospective and actual public officials lose some of the private prerogatives they may have enjoyed (or presumed) prior to their entrance on the stage of public service. And being a candidate is being on that stage.”

Clinton’s concussion and its aftermath have been the subject of much speculation, including from physicians. Drew Pinsky, MD, discussed Clinton’s medical record on his TV show in January, saying that as a result of the concussion, “she had to wear these prism glasses. … That is brain damage, and it’s affecting her balance.”

Some mental health specialists have weighed in on Trump as well. Trump has “textbook narcissistic personality disorder,” Ben Michaelis, PhD, a clinical psychologist in New York City, told The Atlantic last November. Howard Gardner, PhD, a professor of cognition and education at Harvard, agreed, calling Trump “remarkably narcissistic.”

I have discussed this in a previous post that many such pronouncements have been made in the press that the American Psychiatric Association reminded its members earlier this month of the association’s “Goldwater Rule” — named for the late Republican presidential candidate Barry Goldwater — which prohibits psychiatrists from offering opinions for someone they haven’t personally evaluated.

Experts were generally in agreement that clinicians of any kind should not be diagnosing either candidate from afar. “I do think it is questionable for physicians to make comments about anyone as it pertains to their health without actually personally evaluating them,” said Mohana Karlekar, MD, medical director for palliative care at Vanderbilt University, in Nashville, Tenn. “Physicians must be mindful that any statement they make that includes a medical assessment will be interpreted by the general public as a valid assessment.”

Neil Wenger, MD, MPH, professor of medicine at the University of California Los Angeles, agreed. “A professional would not act as a physician in this way,” he said in an email. “When doing so, a physician has become a media personality or entertainer or is fulfilling some role, as did Senator Frist in the Schiavo case.” Wenger was referring to Terri Schiavo, a woman in a persistent vegetative state whose husband wanted her life support removed; former senator Bill Frist, MD (R-Tenn.) argued against doing so and suggested that Schiavo might not be in a vegetative state. Schiavo’s life support was eventually removed following a lengthy court battle; she was found on autopsy to have had severe, irreversible brain damage.

As bioethisist Arthur Caplan stated this morning in the Washington Post, “if we really care about Trump’s or Clinton’s health, the way to find out about it is not to ask them, their staff, their doctors, Dr Oz, etc. It is to have them supply their medical histories and submit to a thorough examination by an independent panel of doctors in areas such as internal medicine, oncology, geriatrics, psychiatry and neurology.”

I like his idea. Then the National Academy of Health would appoint the panel of doctors and tell the candidates to show up in August for a 2 day physical, with the results to be reported before the end of the month, not like an IRS audit and take years for the public to see, read or hear about it in the press.

He  also said that although diagnosis from afar is never appropriate, there is a role for historical analysis: “Historians can take a look at people’s behavior and comment on likely pathologies, whether it’s Woodrow Wilson’s stroke or Ronald Reagan’s memory loss; it’s not appropriate to preclude historians from examining how the health of leaders can affect their behavior. What I’m objecting to is clinicians who don’t know the person putting on clinical labels with any degree of certitude.”

“Age always matters” when it comes to risk for disease, said well-known aging researcher S. Jay Olshansky of the University of Illinois at Chicago, but he cautions that it shouldn’t be a litmus test for the presidency.

Trump at 70 would be months older than Ronald Reagan on his election day, and Clinton will have just turned 69. With life expectancy at a record high and a generation of more active seniors, older presidential candidates are no surprise. But older age also raises concern about the risk of Alzheimer’s disease. Reagan, who turned 70 shortly after his first inauguration, was diagnosed with Alzheimer’s several years after leaving office.

Olshansky’s research found many presidents outlived the life expectancy of their time, likely thanks to wealth and access to top medical care that Clinton and Trump also have. Hey, what happened to the excellent health care that we are supposed to get with the Affordable Care Act?

Possibly the factor most promising for longevity is that both candidates’ parents lived into their 80s and 90s, Olshansky noted. “We have sufficient information to believe the two of them are both likely to be healthy long enough to survive eight years in office,” Olshansky said.

Even with Dr. Caplan’s suggestion for a 2 day examination, etc….is this solution going to happen? We all know that it isn’t because while discussions of Clinton’s pneumonia and Trump’s weight make for employment for media TV idiots and help fill the empty air time on cable news channels, you really don’t need to be all that healthy to be president, much less a politician and more importantly…… the voters really don’t care.                                                                                                                      Caplan went on to point out that we have had people in or near the White House with bad hearts, consider President Eisenhower and Dick Cheney who both had heart attacks while in office. We have had presidents who have abused alcohol and pain medications, such as John Kennedy and Richard Nixon, and before he took office, George Bush. And at least one president surpassed any missteps exhibited by Clinton, frequently stumbling, tripping or banging his head, Gerald Ford.

I think that we all can agree that most if not all politicians are crazy and as Americans have health concerns. But as I have said earlier, we should be focusing on real policy- economic, health care, educational and social issues and more importantly the health of the average American, who is obese, rides motorcycles and bicycles without helmets, doesn’t exercise regularly, eat billions of dollars of junk foods and doesn’t follow the “suggestions” of their own doctors.

So, how much do we know — and should we know — about how physically fit Donald Trump and Hillary Clinton are for the job?

Maybe we should be more concerned about the V.P. candidates (Republican vice presidential candidate Mike Pence released a letter by his campaign, Saturday from his doctor Saturday stating that he is in “excellent general and cardiovascular health,”) or more importantly our own health and more importantly, how our health will be effected by a Single Payer Health Care System?????

Obese patients ‘surgery ban’ in York, England and is the future?

14192739_961430727319920_9123964988708776032_nInteresting fact, there is a move that could see obese patients refused surgery in an attempt to save money is to be reviewed after Britain’s national NHS bosses intervened. This article (3 September 2016
From the section 
York & North Yorkshire) peaked my interest because it could and probably will happen here in the U.S.A. if and when the single payer system is finalized.

It is a known fact that cigarettes are highly addictive, but they are legally available without limitation to the public. Users do pay a tax for use but it does not come anywhere close to paying for their overall increased health care cost due to smoking. Obesity is rapidly increasing in this country- by 250% incidence over the past 20 years. While the causes of obesity are multifactorial, there is no doubt the singularly major factor is consumption of excess calories. The sources of these excess calories frequently are sugary foods and fast foods, yet there is no limit on what may be consumed nor is there any tax on these foods to help offset the increased costs associated with obesity. If there were a way to require those who engage in ill-advised health behaviors to pay for their impending increased utilization of the health care system, then this may be a viable alternative. To penalize those who have already developed these conditions by withholding care seems foolish and punitive unless there are outcome studies demonstrating specific procedures or interventions have a high failure rate in these patients. A proposed restriction by the NHS Vale of York Clinical Commissioning Group would have seen non-life threatening procedures delayed by a year for those with a body mass index exceeding 30.

The rule would also apply to smokers. NHS England, which can intervene as the CCG is under special measures, said the group had agreed to rethink the move.

Under the move, obese patients in the Vale of York area could have secured a referral in less than a year if they shed 10% of their weight.

Similarly, if smokers refused to quit they would face having procedures delayed for up to six months, which could be accelerated if they stopped smoking for eight weeks.

The CCG said the proposals, announced as part of a package of measures being considered to reduce costs, came at a time when the local system was under “severe pressure”.

The new rules would only apply to elective surgery for non-life threatening procedures, for example hip and knee operations.

‘No blanket bans’

But a spokesman for NHS England said: “Reducing obesity and cutting smoking not only benefits patients, but saves the NHS and taxpayers millions of pounds.

“This does not and cannot mean blanket bans on particular patients such as smokers getting operations, which would be inconsistent with the NHS constitution.”

Chris Hopson, the head of NHS Providers representing acute care, ambulance and community services, said he was worried about plans such as this being made.

NHS bosses now believed they had reached the point at which the health service was simply being asked to deliver too much for the funding that was available, he told BBC Radio 4’s Today programme.

He said rather than commissioning groups making “piecemeal decisions”, there should be a national debate about the future of the healthcare system.

Robert Pigott, BBC health correspondent analyzed this possibility looking at the financial impact.

When front-line health services revealed a deficit of £460m for the first three months of the financial year, hospital trusts said it was time for a national debate about what the NHS could now afford to do if it were to remain free.

Although it is now under review, the proposal by the Vale of York Clinical Commissioning Group to exclude obese people and smokers from non-emergency surgery has started that debate in earnest.

The CCG estimates obesity cost the NHS in the Vale of York £46m in 2015, but is it right to target obese people to bring costs down?

There is a clinical rationale. Obese patients suffer more complications during and after surgery than those of “normal” weight.

Despite this, some might see the decision as sending a signal of disapproval to those who are overweight.

The implication could be that being overweight is a personal lifestyle choice, adopted at the expense of the wider community.

Obesity has been linked with being poorer, and living in so-called “obesogenic” environments, where unhealthy, fattening, food is easier to get than more expensive, healthy, alternatives.

It is often hard to lose weight to which the body has adapted itself, and delaying operations on hips and knees might further limit the prospect of success.

The proposal could have benefited obese people as well as the health service if it succeeded in persuading them to lose weight.

Whatever the rights and wrongs of the Vale of York approach, it does, in effect, suggest a revised contract with patients – a new deal that requires people to take reasonable steps to preserve their own health, rather than expecting the NHS to pick up the pieces.

Shaw Somers, a bariatric surgeon based in Portsmouth, said it was a fairly logical step to save money, but was short-term and discriminatory.

“Obesity is an illness and for these people, they are not deliberately waking up each morning thinking ‘how do I stay fat?’,” he told the Today programme.

“They are trying to lose weight in the vast majority of cases and to deny them treatment that they need on the basis of their weight, without then offering them effective help to help them lose weight is rather like discriminating [against] a segment of the population on the basis of their colour or religious persuasion.”

Body Mass Index

  • Body mass index (BMI) is used to calculate whether a person is underweight, a healthy weight, overweight or obese for their height
  • It is calculated by dividing someone’s weight in kilograms by the square of their height in metres
  • Generally the higher your BMI, the greater your risk of a large range of medical problems
  • A BMI above 30 is medically classified as obese
  • Some doctors say it can be inaccurate if you’re an athlete or very muscular

The Royal College of Surgeons (RCS) described the proposed restrictions as “some of the most severe the modern NHS has ever seen”.

Clare Marx, RCS president, said: “Smokers and overweight patients should unquestionably be helped to stop smoking or lose weight prior to surgery for their overall health.

“We would support any attempts by Vale of York to expand its weight loss and smoking cessation programmes, but introducing blanket bans that delay patients’ access to what can be life-changing surgery for up to a year is wrong.”

A major study of the global obesity problem by Imperial College scientists found there were 6.8 million obese men in the UK in 2014, and 7.7 million obese women.

Former health minister Norman Lamb said: “This is just the latest in a growing list of local decisions to ration care – any rationing not based on clinical need is outrageous.”

A statement from the Vale of York Clinical Commissioning Group said: “NHS England has today asked us to review the draft approach, which we will now do, and will hold off implementing anything until we have an agreed way forward.

“We will ensure any plans are implemented in line with national guidance, are in the best interests of our patients and are clinically robust.”

It said the group wanted to support work to help people in the community to stop smoking and, where needed, lose weight.

Clinical Commissioning Groups were introduced in 2013 and became responsible for commissioning or buying local health and care services but are overseen by NHS England, a national body formed by the same parliamentary act.

A number of studies showed various conclusions such as The influence of body mass index on functional outcome and quality of life after total knee arthroplasty authored by J. Y. Chen, N. N. Lo, H. C. Chong, H. R. Bin Abd Razak, H. N. Pang, D. K. J. Tay, S. L. Chia, S. J. Yeo investigated the influence of body mass index (BMI) on the post-operative fall in the level of haemoglobin (Hb), length of hospital stay (LOS), 30-day re-admission rate, functional outcome and quality of life, two years after total knee arthroplasty (TKA) studying a total of 7733 patients who underwent unilateral primary TKA between 2001 and 2010 were included. The mean age was 67 years (30 to 90). There were 1421 males and 6312 females. The patients were categorised into three groups: BMI < 25.0 kg/m2 (normal); BMI between 25.0 and 39.9 kg/m2 (obese); and BMI ≥ 40.0 kg/m2 (morbidly obese).

They concluded that though morbidly obese patients have a longer LOS and higher 30-day re-admission rate after TKA, they have a smaller drop in post-operative Hb level and larger improvement in OKS and KSKS at two years follow-up. The ten-year rate of survival of TKA was also comparable with those with a normal BMI.

Take home message: Morbidly obese patients should not be excluded from the benefits of TKA from the article: Bone Joint J 2016;98-B:780–5.

Another study ( concluded that morbid obesity significantly increased the risk of subsequent revision, reoperation, and reinfection following two-stage revision total knee arthroplasty for infection. In addition, these patients had worse pain relief and overall function at intermediate-term clinical follow-up. Although two-stage revision should remain a standard treatment for chronic periprosthetic joint infection in morbidly obese patients, increased failure rates and poorer outcomes should be anticipated.

As well as another study ( that also saw a higher complication rate Morbid obesity is associated with increased rates of re-revision, reoperation, and PJI after aseptic revision TKA. As the time-sensitive nature of revision surgery may not always allow for patient or comorbidity optimization, these results emphasize the need for improving our care of patients with morbid obesity earlier on during the osteoarthritic process. Additional studies are needed to risk stratify patients in the morbidly obese population to better guide patient selection and effective optimization.

There are 2 separate issues here, firstly is it reasonable to deny treatments where risk variables can be changed, especially where the outcomes are measurably poorer. I suspect that most people would accept this premise, and if patients are unable to alter their weight, or habits, then perhaps the treatment thresholds should vary to reflect the changed risk profile.

The second question is however, should we consider those less perfect people ‘undeserving’ of publicly funded healthcare, the modern equivalent of the victorian ‘undeserving poor?’

Before answering that, consider that in almost every country in the world, smokers and drinkers would have contributed far more in voluntary taxes than economically matched controls, and are likely to have a reduced life expectancy, mainly in retirement, saving pension payments by the public purse.

Deciding who is and is not deserving of treatment is not something that anyone should have to do, and particularly not a doctor, whose obligation is to treat the patient to the best of his or her ability.

The important issue here in US is that we are soon to be payed on outcomes and “value”. CMS/Medicare will not pay for re-admissions for surgical complications and so the surgeon and the hospital will have to “eat” the cost of the admission and the cost of treatment.

However, as one learns in a very litigious society if we do not limit elective procedures to those who have a lower complication risk, we heath care providers and society will suffer.

I also consider blood sugars in my own criteria. If the patient has a blood sugar higher than 200 the patient’s elective surgery gets delayed until their weight is below a BMI of 39.5 and their blood sugars are controlled below 200. I have canceled cases just before surgery in those who do not comply. A surprisingly large number of patients remain tobacco-free 6 and 12 months after surgery. I have had a few patients (very few) get angry with me about this policy in my 33 years of practice, but it is not rare to have someone call me 1-2 years later and thank me for my insistence. Most smokers say they “knew” they should quit, but never had a physician demand quitting before helping them.

Research findings published in the December issue of the Journal of the American College of Surgeons, Chicago, December 3, 2013, confirm that factors such as smoking and obesity increase the odds of early implant loss in women who undergo mastectomy and immediate breast reconstruction with implants. Further studies concluded that smoking, obesity, and hypertension were similarly associated with reconstructive failure.

An additional multiple logistic regression analysis of complications following microsurgical breast reconstruction from the Department of Plastic Surgery, Georgetown University Hospital, Washington, DC, USA corroborates findings from previous studies. Tobacco use was demonstrated to be a significant risk factor for infection, seroma, and pneumonia. Obesity was demonstrated to be a significant risk factor for infection.

With these considerations and that it all goes to a financial bottom line set of decisions, if a single payer government health care system is what we end up with we will see these panels, whatever you want to call them, making broad decisions restricting surgical care and eventually medical care in general.

Is this what we really want? It is already what is seen in other single payer government run health care systems. Beware!!!

What do you think about this plan? Would this decision affect you?

Suicide in Our Youth and What Is Being Done About the Epidemic!

unnamed-2I saw this article in nprEd by Kavitha Cardoza regarding teen and even younger suicide victims and was truly scared. Every day, thousands of teens attempt suicide in the U.S. — the most extreme outcome for the millions of children in this country who struggle with mental health issues.

As we’ve reported all week, schools play a key role, along with parents and medical professionals, in identifying children who may be at risk of suicide. And one of the biggest challenges: myths that can cloud their judgment.

“People are afraid of the whole topic,” says David Jobes, the head of Catholic University’s Suicide Prevention Lab. “It just feels like something that’s left unsaid or untouched.”

Jobes says one of the most common — and most dangerous — myths about suicide is that young children just don’t kill themselves.

It’s just not true.

Children as young as 5 take their own lives every year.

Another myth? Suicides are an impulsive decision, made in the heat of the moment.

Again, not true.

Jobes says kids can spend weeks thinking about and planning for their own deaths. And that, he says, is where schools have a role to play.

“They’re going to be letting their friends know, dropping hints, writing essays that their English teacher might pick up, telling coaches,” Jobes says. The one thing teens considering suicide won’t do are tell their parents.

Jobes was asked to walk the author through a few other common misperceptions of suicide.

Myth 1: Asking someone about suicide will cause him to become suicidal

“There’s already issues and struggles around mental illness within our culture and society. It’s highly stigmatized, and suicide is even more stigmatized. It feels like something that’s just best left unsaid or untouched, kept under the rug, and that’s a problem in terms of saving lives. Because we need to ask, and we need to intervene to actually save lives. You need to be direct. ‘Sounds like you’re really down, have you thought about taking your life?’ Just be very direct. The more direct the better.”

Myth 2: Depression causes all suicides

“That’s just not true. So, we have millions of Americans who are depressed. A small fraction of them take their lives, a very small fraction. So depression and suicide are not synonymous.

“On average, about a hundred and some Americans die each day [from suicide]. About 40 to 50 of them might be depressed. Other diagnoses are relevant — like schizophrenia, psychotic disorders, substance abuse, anxiety disorders. It’s not just all about depression.”

Myth 3: We cannot really prevent suicides

“We know very clearly that, with proper identification, proper support and treatments that are suicide-specific, we absolutely can make a difference and save lives. Most suicidal people who talk about suicide don’t really want to be dead. They’re giving other people lots of indications, lots of warning signs, lots of communications that this is something that they would like to not do, but it requires people identifying that and getting them the proper help.

“Some of the warning signs would certainly be depression and … loss of concentration. People not seeming like themselves. Insomnia can be a big risk factor. Other warning signs might include irritability, withdrawal. And the thing that’s really critical: Lots of people have those symptoms and are not thinking about suicide. It’s really when the symptoms add up in the mind of that person, where they think ‘The way I deal with this is to take my life.’ ”

Myth 4: Suicides always happen in an impulsive moment

“People contemplate, think about it, imagine it, fantasize about it, write suicide notes, post things on the Web. After many days or weeks, [they] then perhaps make a fatal attempt. There is a major theory in the field that says that no suicides are impulsive. That there is always a history if you dig deep enough.

“The idea that they come out of the blue may happen, but it’s actually quite rare. A small number of people, especially among adolescents or school kids, are not going to communicate their intent. But that’s the exception. They’re going to be mostly letting their friends know, dropping hints, writing essays that their English teacher might pick up, telling teachers and coaches. So when people say this, they’re not crying wolf. It’s something to take seriously.

“Kids telling other kids is really critical because that’s who they’re gonna tell. They are not going to typically tell their parents. They get oftentimes a very negative reaction, even a punitive reaction. So, schools are in a position to try to communicate to kids that talking to your friends is fine, but if you really are a friend of this person, keeping a secret about something as serious as suicide is not in their best interest. And they need to pass that information up to teachers or the principal or to guidance counselors who are in a position to get professional help involved.”

Myth 5: Young children, ages 5 through 12, cannot be suicidal

“Young children do take their lives. In the United States each year, about 30 to 35 children under the age of 12 take their own lives.

“It’s hard for a lot of us to imagine that a child that young — a 5-, 6-, 7-year-old — could actually know what it means to say, ‘I want to kill myself.’ But we do research with young children and know that kids are saying these words.

“They do intend it, and they do sometimes take their lives. Oftentimes, by running into traffic and getting hit by a car. We don’t know a lot about young children taking their lives. The suicide prevention literature kind of begins at age 12 to 14. It’s almost as if, even in the professional literature, young children can’t be suicidal. And it’s just not the case.”

Myth 6: When there has been a suicide, having a school assembly seems like a good idea

“There’s literature and a professional take on all this that in post-vention, which is intervening after a suicide has occurred in a school, you want to find a response that is not overreacting, which would cause other kids to copycat or to follow that behavior.

“Alternatively, you don’t want to underreact. And so there is a very useful literature out there, professional associations that provide guidelines where we try to find that sweet spot of attending to the fact that this happened, providing necessary information and then resources, but not letting the whole school out to go to the funeral. Or not having an assembly where everybody comes to hear from an expert about suicide.

“We really want to have these conversations in smaller groups, especially among those kids who were most affected by the suicide. So, just a wholesale didactic event is not necessarily in the school’s best interest and not necessarily the best way to prevent copycat suicides or additional suicides.

“The American Foundation for Suicide Prevention does have very useful guidelines that are specific to schools. The American Association of Suicidology has also had a task force. There is extensive literature that is accessed through those organizations about what is optimal, school-based post-vention.

“We certainly know that children and adolescents are heavily influenced, especially teenagers, by their peers. And that’s developmentally normal. So one of the things that we do worry about with kids is the idea of copycat effects, or modeling effects. That a child in a school system who may seem sort of invisible takes his or her life raises awareness and then suddenly everybody is abuzz about this horrific event.

“For other kids who look at that, they might say, ‘Wow, that’s something I could do, too.’ And that’s the nature of the suicidal mind in a child — to not really think about this in a rational way. And that’s where modeling effects are especially worrisome. And then we, of course, worry about clusters or contagion effects. And there is an extensive literature on how to manage that modeling effect so that there aren’t additional suicides to add on top of what is a tragic event in most school systems.

“High school guidance counselors are mostly focused on getting kids into college or getting them registered for courses. They don’t typically — in fact rarely do they — have a mental health background. So when a suicide does occur, a lot of these counselors are naturally approached assuming that they have a mental health background, and they don’t.

“That’s where school systems need to have access to mental health professionals and to people who really know what they’re talking about. And that’s where different guidelines [come in] — for example, the ones from the American Foundation for Suicide Prevention or Sources of Strength. There are different programs that are out there, especially Sources of Strength, which have an excellent evidence base that have been shown to be effective in adolescent populations.”

My question is why are kids as young a 6 or 6 attempting suicide. There must be some really difficult challenges for them or they don’t have the necessary skills to manage daily problems, which are thought to be minimal as compared to adult challenges. What are we missing in these kids? Do these children have underlying mental problems that are not being diagnosed or is their a hostile environment with physical or mental abuse, no role models or a living situation that none of us would even put an animal in?

Also, do we have the necessary man and womanpower and finances to search and find these “lost children” and care for them? Will the Affordable Care Act be able to support programs for these needy children?

But then I was encouraged by this article about some positive actions to help with firearms and suicide. John Daley wrote in his Public Health article about the Centennial Gun Club.

It’s ladies night at the Centennial Gun Club in a suburb of Denver. More than 80 women are here for safety instruction and target practice.

Tonight the club is offering more than shooting, though. The women rotate through the firing range, and in another large room, they hear a sobering presentation from emergency room doctor Emmy Betz. She’s part of a collaboration between gun shops and public health leaders in the state to help prevent suicide.

“If you’ve been touched by suicide somehow, if you could, raise your hand,” she asks. About half the hands go up.

Colorado has the nation’s seventh-highest suicide rate. In a typical year, more than half involve guns. Research suggests suicide is often an impulsive act, Betz says, and attempts are much more likely to be lethal when a firearm is used. If people survive a suicide attempt, they are far less likely to eventually die from suicide.

“Unfortunately, with firearms typically there’s not that second chance,” she says.

There’s a new push in the national conversation about gun violence that is attempting to sidestep the political rancor, to find common ground on one thing — guns and suicide. The campaign in Colorado is called the Colorado Gun Shop Project.

Centennial Gun Club is one of 46 on board. The project formally started in the summer of 2014, modeled after a similar one by the New Hampshire Firearm Safety Coalition.

During Betz’s talk, organizers hand out Life Savers candies to drive home the message. Gun owner Lily Richardson says she thinks the information could do just that: save lives. “I think those who are aware and taking the initiative to talk about it can help make the difference,” she says.

Nancy Dibiaggio, a new gun owner, agrees. “It’s a big issue, and I think it’s great Colorado is jumping on the wagon with this.”

Dick Abramson, Centennial’s owner, says he welcomes the opportunity to facilitate the discussion. “The difficulty is that it’s not a topic people want to just bring up and talk about over the cocktail table, right?”

He says workers at his store have refused to sell a gun to someone they’re concerned about or feel is having an especially bad day. “My honest feeling is this is a nonpartisan issue,” he says. “This is something that everybody can get behind. It should be a universal concern of everyone.”

In another Denver suburb, the Bristlecone Shooting, Training and Retail Center is also part of the project. At its range, shooters take target practice at bowling pins lined up on the far wall.

In the shop’s showroom, store owner Jacquelyn Clark shows off literature on display “that talks about suicide prevention and what to do if somebody you know or you yourself are in crisis,” she says.

A poster reads, Gun Owners Can Help! Under a photo of a lone elk in the mountains, it lists signs someone may be suicidal and a phone number for the National Suicide Prevention Lifeline.

Clark says there’s now an 11th commandment on gun safety rules: Consider off-site storage — family, friends, some shooting clubs, police departments or gun shops — if a family member may be suicidal. Clark says most people don’t realize that the majority of gun deaths are not homicides but suicide.

A survey of hospital emergency rooms by the Centers for Disease Control and Prevention in 2011 found an estimated 21,175 suicides involving firearms compared with 11,208 homicides involving guns.

“The gun community itself is more at risk than the regular community, not because gun owners tend to have more mental health issues but just because they have more access [to firearms],” Clark says.

Jarrod Hindman, director of the Suicide Prevention Resource Center in Colorado, says he appreciates that local gun advocates are taking the lead. “This is their project,” he says. “We’re just helping to facilitate the process.”

Look at these statistics: more than 500 Coloradans took their own lives with a firearm in 2014, says Hindman, but talking about the role of guns is hard.

“Obviously this is a very contentious topic, and we’ve found a way to find middle ground in a topic where we didn’t think there was a middle ground,” he says.

And now, a large trade association for the firearms industry, the National Shooting Sports Foundation, is teaming up with the American Foundation for Suicide Prevention to develop a suicide prevention campaign for the gun group’s 13,000 members. Their goal is to reduce the annual suicide rate by 20 percent in the next decade.

This topic of suicide is worrisome and it was my contention to pursue more discussion of physician involvement. Remember my discussion of the high suicide rate in physicians and in the medical students and the interns and residents training for their eventual medical practice. But suicide in teens and the children is chilling.

We need to become more aware of this severe problem and dedicate whatever finances necessary to save our children. I will, in another post, discuss the mental health problems in our children and our lack of support in the education and health care systems to care for these children.

Happy Labor Day!