Aaron E. Carroll's Blog, page 107

Healthcare Triage: Sorry, but Low-Carb and Low Fat Diets Get Pretty Much the Same Results

Have you bought into a low-carb or low-fat diet? Which one is the better answer for people who want to lose weight? It turns out, they both work about the same. A giant new study on nutrition is the subject of this week’s HCT.

This episode was adapted from a column I wrote for the Upshot. Links to sources can be found there.

@aaronecarroll

JAMA Pediatrics Podcast – Effectiveness of Self-regulation Interventions in Children and Adolescents

As I mentioned in a previous post, I’m now the Web and Social Media Editor at JAMA Pediatrics. We’ve got a podcast where I discuss a paper from the journal. I do my best to pick good ones.

Please consider giving this a listen, and subscribe! Doing so makes it more likely that I’ll be able to keep doing this.

This week, I’m covering “Effectiveness of Universal Self-regulation–Based Interventions in Children and Adolescents: A Systematic Review and Meta-Analysis”:

This audio summary reviews a meta-analysis of clinical trials estimating the effects of interventions to improve self-regulation in children and adolescents on their health, academic, and social outcomes.

Audio summary here. Full article here. Subscribe to the podcast at iTunes, Google Play, iHeartRadio, Stitcher, or by RSS.

@aaronecarroll

Wanted: Inappropriate Yoga Voices

I am trying to revive my yoga practice, with some success. I’m using the DownDog iPad app for home practice. I recommend it: it has good sequences, helpful instructions, and clear images to model the poses.

But I have a problem: Daily exposure to the instructor’s Yoga Voice is getting to me.

The Yoga Voice is the one that says that the instructor has Let Go Deeply and that they want you to give yourself double helpings of luscious Self-Care. The Yoga Voice is the cousin of the hated Poetry Voice:

After being introduced, a poet steps onstage and engages the audience with some light social speech. Maybe they talk about their forthcoming book, what they plan to read, how wonderfully warm it is for autumn here, how surprisingly cool for summer, how nice the people of this village and how prodigious the public works projects. During this banter the poet uses a slightly performative but mostly natural voice. It’s the voice they’d use to introduce you to their grandmother. Then they read the title of their first poem and launch into the first line. But now their voice is different. It’s as if at some point between the last breath of banter and the first breath of poem a fairy has twinkled by and dumped onto the poet’s tongue a bag of magical dust, which for some reason forces the poet to adopt a precious, lilting cadence, to end every other line on a down-note, and to introduce, pauses, within sentences, where pauses, need not go.

There’s likewise a Philosophy Voice, in which a bit of Oxbridge suddenly appears in the voice of a guy from Brooklyn, and many local dialects of Prayer Voices (tasting menu: try Canterbury, then Dallas, and finish with a bit of Salt Lake City).

To be fair, performative Voices serve real linguistic functions.

“I think [the Poetry Voice] frames [the poet’s performance] as poetry,” says Deborah Tannen, professor of linguistics at Georgetown University and author of You Just Don’t Understand. In linguistics, “framing” signals what you think you’re doing when you say something — your relationship to the words and to the people you’re saying them to.

So, yes, I am trying to be healthy, and it’s good to have a Voice reminding me that the practice is more than just another freaking chore, and maybe four days out of five the Yoga Voice is what I want to listen to.

However, there is a piece of me that just can’t stand being wholesome. I would be much better able to sustain a daily practice if I could occasionally select the same routine, with the same instructions, but delivered in a profoundly inappropriate voice.

On those days, my ideal Yoga Voice would be deadpan but lucidly drunk Christopher Hitchens telling me to push my top thighs back and stretch my heels down toward the floor.

But he’s no longer with us. So maybe seductive Melanie Griffith?

Or Enraged Lucy Liu at the meeting of the Yakuza in Kill Bill 1? Heath Ledger’s Joker is too obvious (but still, it would be awesomely wrong).

Of course, sometimes Yoga instructors provide counsel about the challenges of the ancient practice, the difficulties of converting healthy intentions into beneficial practice, and the moral duties of ahimsa. For these disquisitions, I would appreciate being able to listen to either one of these guys:

As Bertie remarked,

It was one of those cases where you approve the broad, general principle of an idea but can’t help being in a bit of a twitter at the prospect of putting it into practical effect. I explained this to Jeeves, and he said much the same thing had bothered Hamlet.

― P.G. Wodehouse, Jeeves in the Morning

The aforementioned voices would allow me to stay with Yoga without shirking my commitments to perversity and noncompliance. Your needs may be different. There may be men who do not bristle at Yoga’s wholesomeness but are uncomfortable entering such a strongly feminine environment. For them, here’s a Voice that is resolutely wholesome, yet ruggedly masculine:

However, this is the Yoga Voice I really want:

@Bill_Gardner

The best news, almost

I made it through the red tape more quickly than I expected and have been cleared by my insurer for a CPAP machine. The supplier will even come to my house. This is welcome news.

Here’s the bummer: the process took just long enough that I’m now up against a week’s vacation, and they probably can’t squeeze in delivery of the machine before I leave. I’m on the wait list just in case they get a cancellation. So, in all likelihood, I’ve got about 10 more days of sleep deprivation to endure, plus however much longer to adjust to the machine.

Still, this is far ahead of the schedule I expected, and I should count my blessings that therapy even exists. Oh, how people must have suffered before there was one.

This also means it won’t belong before I can bore you with actual data of apnea events per hour by day (the machines nowadays collect it and I’m pretty sure I can get it).

Other updates:

1. I tried extended release Ambien (6.5mg) two nights ago while traveling. Hotel sleep usually sucks, so I was hoping this would do the trick. I still woke to consciousness with many apnea events between 3AM and 6AM. WTF?!

2. A reader who used to work for “a leading health insurance company” said he did an analysis of CPAP coverage policy about a decade ago. He concluded, at the time, that it would be cheaper not to require a sleep study (which are very expensive) and to let doctors prescribe CPAP machines, then evaluate the data over the next few months. This is plausible because many people get sleep studies and CPAP machines and then stop using them, effectively wasting a lot of expense.

This study had no impact on coverage policy. Had it been in place, it’d have saved me about 10 weeks of delay.

Assuming the analysis is correct, why would an insurer leave money on the table? Some possibilities, all pure speculation: (a) Maybe it would have devastated sleep study labs and maybe they had some clout because they’re needed for other diagnoses. (b) Maybe the savings would be small relative to the headache of changing the policy. It’s not the low lying fruit. (b) Maybe the evidence supporting this idea is thin (it seems like it would be) and insurers don’t want to risk encouraging even a low level of diagnostic errors.

3. I started using the Provent therapy last night. Possibly coincidentally, I do not recall a single apnea event (I’m not claiming there weren’t any, just that I slept through them all). However, I wasn’t on a therapeutic level of Provent, just a training level. Even the training level creates some back pressure though, so maybe it can help a little (?). Confounding the results: (a) I was on Ambien, (b) I was extremely tired from my trip, having sleep poorly the night before (see #1), worked out for the first time in a month, given a talk, and met with tons of people at Ohio State University (tiring for an introvert).

I’ve got three more training nights of Provent before I’m on the real deal. I’ll get a handful of nights of experience with that before I get a CPAP machine — good opportunity to gather info about whether Provent would be helpful for traveling.

@afrakt

Why so public?

In the last few days, three colleagues have admitted to me that they’ve been taking Ambien for years. One has sleep apnea, another suspects he might, and the third has convinced himself he does not. From the correspondence, I think my attention to the condition may persuade one or several of them to get testing/treatment. And that’s just three people I know of. There are probably others who will benefit from my posts about obstructive sleep apnea.

That’s a significant impact from a few hours of my time — possibly a greater impact than thousands of hours I’ve spent on some research projects. It’s reason enough to put in the effort.

But I’ve also benefited tremendously from writing publicly about my health conditions. (Sleep apnea is just the latest. I’ve written about my battle with insomnia and a heart thing too.) The feedback from patients and clinical experts is valuable and rapidly expands my understanding of the problem and treatments for it.

Moreover, it’s cathartic. Encountering a new health problem that brings you into close and frequent contact with our unpleasant health system can be frightening and frustrating. Expressing that is helpful. Finding the humor in it is helpful. Writing is how I do that. This is where I write. You are whom I write to.

Yesterday, a friend asked me if I am concerned about the risks of publicly disclosing my health conditions.

I felt the answer almost before I could reply, “Hell no.” I am offended by the thought of self-censoring. Why would I do that?

Well, maybe some future employer or insurer would deny me employment or coverage, rendering me jobless or uninsured, he suggested. Or maybe disclosure of taking a sleep aid could play some role in some legal proceeding I cannot anticipate, he speculated. These are extremely theoretical and low probability events, at least in my case (YMMV). I think my employment prospects are enhanced, not diminished by the kind of blogging I do, bringing evidence to issues in an accessible way. Writing about my conditions and my experiences with the health system as I address them is just a part of that. It’s personal — when so many of my posts are not — and, therefore, brand enhancing.

I could, likewise, make arguments about why I’m not worried about underwriting. (It’s mostly gone now, but one might worry about its return. Still, I would never conceal my conditions anyway.) And, a legal situation that turns on my taking Ambien for a few nights here and there? I mean, really.

But all of this argument would miss the main point. I am morally offended by the idea of self-censoring. I want to live in a world in which patents can share their stories, publicly, if they wish to. (Naturally, if one wants to keep things private, one should.) I think it’s healthy and normalizing. Nobody should feel they need to live in the shadows. Doing so feeds the erroneous notion that our experiences with poor health are ugly, shameful ones.

Sometimes I know what the morally right thing to do is. It’s the thing that if I don’t do it, I could not live with myself. What I wrote to my friend is, I’d rather be dead than to feel I cannot speak my mind.

* OK, in some cases we might be blamed, if we take reasonably preventable risks.

@afrakt

Healthcare Triage: COCAINE. It’s a Serious Problem Drug, Too

The opioid epidemic is certainly terrible. Even as we’re plumbing the depths of it, we should remember that there are other terrible drugs out there killing people and making lives worse. Cocaine is a big problem as well, and it kills a lot of people. Especially among African Americans.



This episode was adapted from a column Austin wrote for the Upshot. Links to sources can be found there.

@aaronecarroll

Better Car Seats Are Just the Start: Road Safety Lessons From Sweden

The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

Accidents are the No. 1 killer of American children, and car accidents are the most common kind of lethal accidents. It makes sense that health officials focus on making car accidents less common and less dangerous.

Unfortunately, as with many other areas, regulations often don’t fully line up with research.

In 2011, the American Academy of Pediatrics (A.A.P.) released a policy statement on car safety that recommended that children ride in rear-facing car seats until at least age 2. Before that, the recommendation was until 1. This change caused something of an internet firestorm.

It’s not terribly hard to get small babies into an American-style rear-facing car seat, but thosewho are nearly 2 years old are a different story. They often resist. They can fight. It can be miserable for both parties.

The authors of the A.A.P. guideline seemed on solid ground. They relied heavily on a 2007 study in the journal Injury Prevention that extracted data from the National Highway Traffic Safety Administration’s car crash database from 1988 through 2003. They found that children from newborn to 23 months who were restrained in a front-facing car seat were 76 percent more likely to be seriously injured than children in a rear-facing seat. In side crashes, serious injury was four and a half times more likely.

People paid attention. When asked, more than 60 percent of parents said they were complying with the new recommendations. (Obviously, that also meant many weren’t.)

Then in 2016, a biostatistician hired as an expert witness in a lawsuit against a car seat manufacturer tried to replicate the 2007 study. She couldn’t get the numbers to work. She contacted the journal, which contacted the study authors. They realized they had made a mistake with survey weights that, when corrected, made the results no longer significant. The paper was retracted.

The authors, to their credit, went back to work on a new study, with corrected methods. Because time had passed, they could now look at data on car crashes from 1988 through 2015. They were able to include more than 1,100 children from zero to 23 months who were in accidents.

Of these children, 47 sustained significant injuries in the crashes, and only 17 of those were between 1 and 2 years old. From these rare instances, they could not detect any statistically significant differences between children who had been in front- or rear-facing car seats. The researchers concluded, “Field data are too limited to serve as a strong statistical basis for these recommendations.”

This has left people once again debating whether parents in the United States need to keep wrestling children into rear-facing car seats all the way until age 2. The researchers, and the American Academy of Pediatrics, give an emphatic yes, pointing to laboratory “sled tests” on crash dummies and accident data from elsewhere — Sweden.

But focusing on this small age range misses the more useful lessons from this case of corrected science, which is that the United States could do a lot more to make roads safer for children and easier on parents.

The sled tests, which use test dummies, strongly suggest that rear-facing seats perform better than front-facing seats in children through age 3. In Sweden, children use rear-facing seats all the way till age 4, then move to front-facing booster seats. (Here in the United States, we use front-facing car seats from about 2 years old until children outgrow them.)

How do Swedish parents manage this? For one thing, rear-facing car seats in Sweden and other parts of Europe are different from those here. They are often built with a bar that comes down from the car seat to rest on the floor of the car. This allows the seat to rest farther from the back of the car’s rear seat, giving the child much more room. Parents in Sweden find it easier to get bigger children into them. Such seats, which are not available in the United States, were also found to be safer in the sled tests than the versions we use.

But rear-facing car seats for older children are just one of the many differences between the United States and Sweden.

Because accidents are inevitable, Swedish regulations aim to make them nonlethal. Roads rely more on roundabouts, less on intersections. Cars are not allowed to turn at all when pedestrians are crossing. There are national camera enforcement policies. Sweden also focuses on pedestrian bridges, and separates cars from bicycles and oncoming traffic.

Far fewer people drive under the influence of alcohol; stricter policing has reduced impaired driving to less than 0.25 percent of tested drivers vs. about 1.5 percent of American drivers. (Sweden also has a more stringent definition of driving under the influence, 0.02 percent vs. 0.08 percent.) The speed limit in areas where cars might come into contact with pedestrians (think all of New York City) is less than 20 m.p.h. Speed bumps and other traffic-calming interventions are common. The average cost of obtaining a driver’s license is the equivalent of more than $1,800.

All of this seems to work. Over the last 20 years, Sweden reduced pedestrian deaths by 31 percent and overall traffic deaths by 45 percent. In 2013, Sweden’s rate of death from car accidents was about 3 per 100,000 people, about one-quarter the rate in the United States. But Swedes are not necessarily satisfied with that. They have bought into a program known as “Vision Zero,” which is summarized in one sentence: “No loss of life is acceptable.”

If America really wanted to get serious about reducing deaths on the road, especially those of children, a lot could be learned from Sweden. Doing so would mean adopting many significant changes: to roads, to laws and to car seats — namely, using the Swedish-style rear-facing ones until children reach 4.

Dr. Marilyn Bull, a pediatrician at Indiana University School of Medicineand an author of the retracted and resubmitted paper, discussed the state of the latest research and mentioned Road to Zero, a U.S. federal program begun in 2016 that aims to eliminate traffic deaths by 2050.

“The best we can do right now is to keep children rear facing in car safety seats to the highest weight or height allowed by the seat’s manufacturer,” she said. “Our ‘Road to Zero’ deaths on U.S. highways, though, will require us to advocate for support of improved data collection, continued research, as well as regulatory change and design innovation to allow even larger children to ride rear facing.”

As she suggests, setting more toddlers into rear-facing American-style car seats is advisable for making children safer, but it’s only a start.

@aaronecarroll

Rule outs

In the last two days I’ve received some interesting feedback from readers about obstructive sleep apnea that could be valuable to many, but isn’t clearly applicable in my case.

1. One reader who was kind enough to speak with me by phone (video chat, even!) told me about a connection between being tongue tied as an infant (ankyloglossia) and developing OSA. More on this here, here, and here. I was not tongue tied as an infant, but I thought this information might be helpful for others.

2. Another reader wrote that he had success treating OSA with the Buteyko method, which includes, among other things, training to help people who breathe through their mouths and/or sleep on their backs to stop doing so. Both of these will increase risk of OSA and snoring. I do neither.

This doesn’t necessarily mean there’s no value in the other aspects of the Buteyko method for people like me. I certainly cannot know without having done it. A video on it I watched raised an interesting point. One contributing factor to airway collapse may be high velocity airflow during sleep. Bernoulli’s principle tells us that higher velocity means lower pressure. Keeping the pressure higher in the airway is exactly what CPAP machines do. But if the velocity of air during breathing could be decreased through practice, that may help. (It would seem to me that this may only be helpful for mild cases, if at all. The breath can only get so slow.)

Clearly this would take considerable training — to change how one breathes during sleep, if it’s even possible. I gather that’s, in part, what the Buteyko method is about, but I have not examined it closely (there are lots of books and videos out there). Nevertheless, I could not help but think about slowing my breath as I fell asleep last night. I seriously doubt this had any impact on how I breathed during sleep, but it could not hurt any. At the very least, it’s relaxing. Coincidentally (?), I had the best night sleep in weeks, though not without apnea events, only a few of which woke me.

Having said all this, it is important to emphasize that OSA can occur in people who don’t back sleep or mouth breathe. It can also occur in people who are not overweight. I do/am none of these, yet …

More generally, OSA is not always due to things that are (potentially) modifiable with changes in habits, diet, and lifestyle. Sometimes (often? usually? almost always?) other interventions are necessary.

@afrakt

Sleeping mouths and ears

A reader said I was onto something yesterday when I reported I slept better with my tongue suctioned to the roof of my mouth. Apparently, this is one of many techniques and exercises that some practitioners recommend for obstructive sleep apnea.

Holy crap! I just used engineering logic to cook up the approach in the middle of the night. I almost can’t believe I stumbled onto something that’s, well, a thing.

Anyway, according to this general line of thinking, I’m told (no studies have I read), the totally wrong way to hold one’s mouth during sleep is slack-jawed and with the tongue resting on the bottom of the mouth. This is the way I have always slept!

The right way, apparently, is to keep the jaw more tightly shut (but with teeth a little apart) and the tongue glued to the top of the mouth. Is this a general truth or does it just help some people and not others? I have no idea. Anyway, this is my new sleep mouth strategy.

There’s a sleep ear strategy too. Sometimes it’s the sound of the apnea events that wakes me. When that’s the case, and it isn’t always, ear plugs can help. There are studies on this.

Anyway, apart from nights I was on Ambien, last night’s sleep was the best in weeks, perhaps due to these two strategies. Lots of apnea events, of course, some of which woke me. But I was not conscious for any long stretches.

Other updates:

1. A reader shared this link, which has information about the risks of pharmacological sleep aids. The last page has a tapering schedule.

2. The Calgary physician I’ve been corresponding with said getting through a sleep apnea diagnosis would take considerable time there too. But he suggested that once diagnosed, a patient would be on a CPAP machine more quickly than what I’m experiencing. Score one for Canada. (On the other hand, without the prolonged wait, would Canada produce a blog series like this?!?)

@afrakt

JAMA Pediatrics Podcast – Does Maternal SSRI use affect infant brain structure?

As I mentioned in a previous post, I’m now the Web and Social Media Editor at JAMA Pediatrics. We’ve got a podcast where I discuss a paper from the journal. I do my best to pick good ones.

Please consider giving this a listen, and subscribe! Doing so makes it more likely that I’ll be able to keep doing this.

This week, I’m covering “Associations Between SSRI Exposure During Pregnancy and MRI-Assessed Brain Structure and Connectivity in Infants”:

This audio summary reviews a cohort study exploring the association between prenatal exposure to selective serotonin reuptake inhibitors and gray matter volume and white matter structural connectivity in newborn infants.

Audio summary here. Full article here. Subscribe to the podcast at iTunes, Google Play, iHeartRadio, Stitcher, or by RSS.

@aaronecarroll