Aaron E. Carroll's Blog, page 99

Healthcare Triage News: The Trump Administration and Family Separation. It’s Bad.

I’m late to posting this, but, unfortunately, it’s still all-too-relevant. Watch and share:



@aaronecarroll

JAMA Pediatrics Podcast: Association of Gestational Age at Birth With Symptoms of ADHD in Children

As you know, 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 “Association of Gestational Age at Birth With Symptoms of Attention-Deficit/Hyperactivity Disorder in Children”:

This audio summary describes a national survey study that used NHANES data to characterize trends in the use of dietary supplements among children < 20 years old between 2003 and 1014.

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

@aaronecarroll

Sleep apnea is more serious than many may realize

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

One of the lighter moments along my journey to receiving a sleep apnea diagnosis was learning that “heroic snoring” is a clinical term. It sounds more like an oddball super power — snores that can be clearly heard through walls. Many of us have such a snorer in our lives, and some endure the disruption it causes nightly.

We hardly need research to appreciate the difficulties this poses. Yet some studies on it have been done, and they document that snoring can lead to marital disruption, and that snorers’ bed partners can experience insomnia, headaches and daytime fatigue.

But heroic (and less-than-heroic) snoring can also be a sign of an even deeper problem: obstructive sleep apnea, which is marked by a collapse of the upper airway leading to shallow breathing or breathing cessation that causes decreases in blood oxygen.

Sleep apnea can be downright deadly, and not just for those who have it. It’s associated with a greater risk of depression, heart attacks, strokes and other cardiovascular conditions, as well as insulin resistance.

As I learned, there’s no reason to meekly accept sleep apnea: There are many treatment options that can control it.

The stakes are not small. In the last five years, crashes involving an Amtrak train in South Carolina, a Long Island Rail Road train, a New Jersey Transit train and a Metro-North train in the Bronx have resulted in multiple deaths, hundreds of injuries and tens of millions of dollars in property damage. Undiagnosed or untreated sleep apnea were blamed in each case.

And these are far from the only sleep apnea-related accidents involving trains, buses, tractor-trailers and automobiles. Up to 30 percent of motor vehicle crashes are caused by sleepy drivers. Drivers with sleep apnea are nearly five times more likely to be involved in a motor vehicle accident than other drivers. One study found that 20 percent of American truck drivers admit to falling asleep at traffic lights.

You can have sleep apnea without being a loud snorer, just as you can snore without having sleep apnea. But because they’re related, what controls sleep apnea also controls snoring. A variety of machines and devices, even surgery for extreme cases, can address both conditions. But relative to the population that snores (about 40 percent of adults) or that has sleep apnea (about 25 percent of adults), few are diagnosed or get treatment. One study, for example, found that 90 percent of people with sleep apnea aren’t diagnosed.

There are several reasons the condition often goes undiagnosed and untreated. For one, it’s not always evident you have it. Though sleep apnea disrupts sleep, you usually remain unconscious while it does so, and not everyone with the condition notices feeling tired or snores in ways that seem problematic. I can attest to the fact that even light sleepers and occasional (non-heroic) snorers (like me) can have sleep apnea and not know it.

But it ultimately wears you down. If snoring doesn’t drive you to the doctor, fatigue may. Still, many power through, gradually becoming too tired to perform their jobs well or safely. Untreated train, bus and truck drivers clearly pose a significant public safety risk.

Definitively diagnosing the condition requires a sleep test — either at home, or more extensively in a lab. Getting wired up for bed isn’t much fun, which is another reason people may avoid seeking a diagnosis. Professional drivers and train operators also may worry that doing so could threaten their livelihood. To dodge screens for the condition, they may underreport feeling drowsy.

There may also be fear of sleep apnea treatments. The gold standard for treatment is a continuous positive airway pressure machine, which forces the airway open with pressure delivered through a mask. The prospect of sleeping with a mask, and next to a machine, can be off-putting and, for some, uncomfortable. Compliance with treatment is about 60 percent. But the devices have become far more comfortable and quiet over the years. (The newest models are entirely silent.)

For obese patients, losing weight can reverse sleep apnea. But keeping the weight off is notoriously hard.

Other options include oral appliances (think of them as fancy mouth guards), nasal patches and, for extreme cases, surgery. Costs for devices can range from hundreds of dollars to thousands. Even at the high end, you may feel a considerable boost in quality of life that could be worth the cost.

Although these options work for snoring, too, insurance won’t cover them for that condition. Similar over-the-counter oral appliances are cheaper, but less extensively studied, making it hard to say for whom they will work well. Studies document that patients use over-the-counter versions less, perhaps because they may be less comfortable than professionally customized ones. So, although snoring is highly curable, the cost and uncertainty of exactly how to do so may be a barrier for many to treat it.

There’s a public safety interest in treating sleep apnea more widely. Yet last summer, in an effort to reduce regulations, the Trump administration withdrew a proposed rule that would have required drivers of trucks and buses, as well as railroad engineers, to be tested for the condition. This may be one area where a little more regulation is warranted.

@afrakt

A puzzle about standing, resolved.

A few weeks back, I raised a question about Texas’s latest challenge to the Affordable Care Act: do the plaintiffs even have standing to sue? Now that the Justice Department has thrown in the towel and declined to the defend the statute, that question has become a lot more urgent.

To demonstrate standing, Texas and its compatriot states recruited two individuals, John Nantz and Neill Hurley, who say that they’re healthy, self-employed, and not eligible for Medicare and Medicaid. Taking all that as true, the law as a whole causes the two men an injury sufficient to ground standing. If the law were wiped from the books, insurers wouldn’t have to set premiums at levels adequate to cover unhealthy people. They could instead refuse to sell insurance to the sick, allowing them to charge Nantz and Hurley a lower price that reflects their relatively low risk.

But the plaintiffs’ legal claim is not that the ACA as a whole is unconstitutional. It’s that Congress, when it zeroed out the mandate penalty, knocked the constitutional legs out from under the penalty-free mandate that nominally remains on the books. That unenforceable mandate, however, doesn’t cause Nantz and Hurley any harm. As Jonathan Adler put it, “[t]here is no longer any penalty for failing to comply with the individual mandate, so no one is injured by it, so there is no standing to sue. Case dismissed.” (In its amicus brief, the AMA develops this argument in more detail.)

Here’s the puzzle, then: Texas believes that, if it wins, the entire ACA should fall. And the Supreme Court’s decision in Steel Co. v. Citizens for a Better Environment says that “jurisdiction [must] be established as a threshold matter” before the court can turn to the merits of the plaintiffs’ claims. In assessing standing, must the court therefore assume at the threshold the validity of Texas’s remedial claim? Must it do so even though that remedial claim—the assertion that the entire ACA must fall—is laughable?

The answer, mercifully, is no. The courts do not have to assume the validity of a plaintiffs’ severability argument. On at least two occasions, including in INS v. Chadha, the Supreme Court has itself treated a question of severability as part and parcel of its standing analysis. And for good reason. As the Supreme Court has held, “standing is not dispensed in gross,” and “a plaintiff must demonstrate standing for each claim he seeks to press and for each form of relief that is sought.” Those principles wouldn’t count for much if a plaintiff could manufacture standing through the simple expedient of making outlandish remedial claims.

Kevin Walsh made these points in a forceful Stanford Law Review article (p. 75-77) written during the first round of litigation over the Affordable Care Act. He also addressed the significance of Alaska Airlines v. Brock, which Texas has invoked to defend its standing. The trouble for Texas isn’t just that Alaska Airlines doesn’t so much as mention standing (though that is a problem). As Walsh explains, Alaska Airlines also wasn’t a case in which a plaintiff sought to take down a sprawling, complex statute because of a constitutional flaw in a discrete part of it.

Rather, the unconstitutional provision was part and parcel of the specific portions of the statute that the airlines sought to challenge. “Alaska Airlines,” Walsh wrote, “is therefore far removed from the circumstances facing the states who seek to challenge the individual mandate in Florida v. HHS on the basis of statutory provisions dealing with different matters in different sections of comprehensive legislation.” That analysis is as sound today as it was six years ago.

In other words, the right outcome in the case is a dismissal for want of jurisdiction. That’s consistent with the case law, and it’s also consistent with the broader aim of standing doctrine, which is to keep the courts from resolving abstract disputes that should be left to the political process. In asking the courts to overturn Congress’s judgment about whether the ACA should remain the law of the land, Texas has invited the courts to assume an intrinsically legislative role. The courts should reject that invitation.

@nicholas_bagley

A Tribute to Uwe Reinhardt’s Moral Voice

Len Nichols, Director of the Center for Health Policy Research and Ethics (CHPRE) and a Professor of Health Policy at George Mason University, made the following remarks at the conclusion of the 2018 AcademyHealth Annual Research Meeting session on Uwe Reinhardt.

Uwe was not a Believer in the traditional sense, but he was a student of all religions and of human behavior. He relished weaving his expansive knowledge of both into discussions of health economics or health policy issues, with his characteristic wit, whenever possible. In doing this he modeled, for those of us privileged enough to see him in action, exactly how to make the self-satisfied and powerful question themselves, in private later, if not in public in the immediate face of his often hilarious but quite pointed challenges to the moral wisdom of decisions already made.

I’d like to mention two of his more memorable invocations. One, Uwe frequently reminded elected representatives that a governmental budget in a democratic society is really a kind of Memo to God about our collective priorities. Uwe thought it is the duty of the elected to express those priorities with tax and spending and policy rules that allocate resources accordingly, and to put these documents in public so that God and everyone may see and review them to learn which priorities are being pursued. (Even God has to read the fine print since one can’t always discern the actual priorities from what politicians actually say).

When you think about this elected duty, and then when you think about what tax and spending and policy priorities our federal government is pursuing today, well you can imagine for yourselves what Uwe would think in general. Uwe who was a young boy during WWII in Germany, somehow made his way with nearly nothing to Canada and then to the United States, who found great success in academic, public intellectual and personal life, living the American Dream, literally, with a sweet and lovely and brilliant woman who had navigated her own hardships coming out of a rapidly transforming China — you can imagine indeed what Uwe would say, at length, about the Memos being written to God today in Washington, DC.

But the specific event I want to put in your memory is the day I saw him ask the New Jersey legislature, who respected him enough to invite him to address them. I wish you could have been there to see him ask them how they could square their own surely deeply pious religious beliefs with the Memo to God they had just happily written that said to pay doctors for treating a child on Medicaid exactly ¼ of what private insurers were paying doctors for treating middle class children at that time. Did they really think a poor child was worth ¼ of what a middle class child was worth? Of course Uwe made ‘em all laugh first, but the moral power of that question still rings in the air in Trenton, I would bet you a very nice lunch.

Second I will mention one of my special treats, for in the last 15-20 years I was sometimes privileged to speak on the same program, though unfortunately invariably AFTER Uwe, and Uwe knew I am an Episcopalian but grew up a rural Arkansas Methodist so unlike most Episcopalians I’ve actually read the Bible, even the Old Testament and especially the Torah, the first five books. And Uwe, you may not know, had read the Bible completely through at least 3 times, and unlike most Christians other than my grandmother he actually remembered ALL of it.

Anyway, if Uwe knew I was going to speak later that day he would always say, “Len Nichols and I have a pact, to mention Jesus in all of our talks,” and he would always do his part to bring the morality attributed to the carpenter from Nazareth into the health policy discussion of the day. One of my favorite examples was when he asked an audience of executives of Catholic hospitals, “What would Jesus charge for cardiology today?”

Uwe has today been properly extolled for clarifying that a high price IS the original sin of American health care, but his pointed question to the administrators of the Holiest hospitals that day was designed to remind them that 2x, 3x, even 4x Medicare might not be what the humble footwasher from Galilee would have recommended, even though it did pay for that very nice new maternity wing that had just been added, plus that very tasty meal we had consumed the night before with wine three notches above communion grade, not to mention our own non-trivial speaking fees.

Now the C-suite would also think and say the overpriced cardiology also paid for uncompensated care and of course they would be correct, and Uwe’s larger criticism was not wholly directed at the hospitals since overpriced cardiology may very well be a 2nd best necessity in a country that refuses to write properly inclusive Memos to God so that all God’s children can get the care they need at reasonable prices.

But Uwe loved to let the questions hang there and eventually poke their way into the hearts of his loving audiences, and that is the moral economics voice I wanted to recall for all of you today. Despite his erudition and wisdom, it was an humble voice, designed to make each of us examine choices we have made and will make, not the COMMANDING voice of a self-righteous scold, but rather a firm but gentle voice of moral clarity reminding us that we can still do better in finding our own paths to the right way to allocate resources for the health and well-being of our fellow citizens of the world we share.

Health insurance is complicated. In many states, it’s about to get worse.

That’s the opening of a piece of mine in the Wall Street Journal (gated, unfortunately) about what states should do in response to the Trump administration’s anticipated relaxation of rules governing short-term plans.

Where states allow short-term plans without restriction, the plans will be a lot cheaper than those sold on the exchanges because they don’t have to comply with the ACA. But that low price comes with big tradeoffs.

Short-term plans don’t have to sell to all comers, nor do they have to cover pre-existing conditions. Sick people will have no real choice but to buy insurance on the exchanges. To cover the medical costs of a relatively sicker group of people, exchange insurers will have to increase their premiums.

People who earn less than four times the poverty level will be shielded from the price increases because the ACA caps premiums at no more than about 10% of income. The federal government, however, has to pick up the rest of the tab-so as prices go up, federal outlays will, too, squandering an estimated $38.7 billion over 10 years.

Hurt worst will be people who earn more than four times the poverty level. Federal actuaries estimate that they’ll pay 6% more on account of the short-term rule by 2022. That will come on top of price increases associated with Congress’s repeal of the individual mandate. In 2019 alone, the Urban Institute predicts that insurance prices will grow, on average, by about 18%.

Beyond that, people who buy short-term plans may be surprised to discover just how stingy they are. Insurance is complicated: people rarely read, much less understand, all the fine print. And there’s a lot of fine print.

@nicholas_bagley

The severability question is not hard

In a lengthy blog post about the Texas lawsuit that’s trying to bring down the ACA, Josh Blackman takes aim at an amicus brief filed by a bipartisan group of law professors (including me). The brief argues that the Affordable Care Act should stand, even if the penalty-free individual mandate is held unconstitutional. Blackman isn’t so sure. Although he “hasn’t made up his mind yet” about the case, “[t]his case presents a lot of really, really difficult issues that have been dismissed far too easily.”

No, it doesn’t.

When a court holds that a portion of a statute is unconstitutional, it has to decide what to do with the rest of the statute. Severability doctrine instructs courts to guess at what Congress would have done had it known about the constitutional defect. In most cases, that presents a tough counterfactual. Here, however, it doesn’t. As the amicus brief explains, “this guessing-game inquiry does not come into play where, as here, Congress itself has essentially eliminated the provision in question and left the rest of a statute standing. In such cases, congressional intent is clear—it is embodied in the text and substance of the statutory amendment itself.”

Blackman’s analysis doesn’t start with modern Supreme Court precedent, but with a law review article by James Durling and E. Garrett West. (That should be your first clue that something is very wrong.) Drawing on a 1929 case called Frost v. Corporate Commission of Oklahoma, Durling and West argue that the proper remedy for any constitutional isn’t the invalidation of all or part of the ACA, but instead “to strike down the repeal of the tax penalty.” New Jersey and the other blue states that have intervened in the Texas litigation make the same argument.

But Durling & West—and Blackman and New Jersey—misunderstand Frost’s application to this case. Frost is simple: it involved (1) a statute that was perfectly constitutional upon its adoption and (2) a later proviso that the Supreme Court held to be unconstitutional. “[S]ince that body sought to express its will by an amendment which, being unconstitutional, is a nullity and, therefore, powerless to work any change in the existing statute, that statute must stand as the only valid expression of the legislative intent.”

Frost would be on point if the 2017 Congress had acted unconstitutionally when it repealed the mandate penalty. But it didn’t. Congress is perfectly free to zero out a tax if it wishes to. Its action may have knocked the constitutional legs out from under the preexisting, $0-penalty individual mandate, but the penalty’s elimination is itself perfectly constitutional.

Nonetheless, Blackman says he agrees with Durling & West “in the abstract.” Oddly, however, he then dismisses their argument, saying that no one’s challenged the constitutionality of the penalty’s elimination.

Having ditched his opening gambit, Blackman turn to what he views as the key question: “The severability analysis, as always, turns on Congress’s intent. But which Congress: the Congress that enacted the ACA in 2010 or the Congress that enacted [eliminated the mandate] in 2017?”

With all due respect, this is not a hard question. A later Congress is perfectly free to amend a prior Congress’s handiwork. And that’s what happened here. Congress had a menu of options available to it, ranging from full repeal to nothing. What Congress chose to do was significant but modest: it repealed the mandate penalty and left the rest of the statute alone.

Blackman says that he’s “been unable to find any authority to support the proposition that the earlier findings of Congress in 2010 are irrelevant.” But why give the 2010 findings such totemic importance? They relate, after all, to a mandate backed by financial penalties (e.g., “if there were no requirement, many individuals would wait to purchase health insurance until they needed care”). They don’t speak to Congress’s views about whether a mandate lacking a financial penalty is similarly essential.

In any event, the authority that Blackman is looking for is right under nose. As the Supreme Court explained in Dorsey v. United States (and elsewhere):

[S]tatutes enacted by one Congress cannot bind a later Congress, which remains free to repeal the earlier statute, to exempt the current statute from the earlier statute, to modify the earlier statute, or to apply the earlier statute but as modified. And Congress remains free to express any such intention either expressly or by implication as it chooses.

Congress in 2010 said that the mandate penalty was indispensable; Congress in 2017 nonetheless dispensed with it. In so doing, Congress superseded its original finding. It’s a straightforward application of the last-in-time rule.

To conclude otherwise is to assign to the 2017 Congress a bizarre attitude toward the mandate. We know for certain that it believed it could safely ditch the mandate penalty and keep the rest of the ACA intact. We know because that’s what it did. Blackman (and Texas and the Justice Department) would nonetheless have us believe that the 2017 Congress would never have done that—indeed, that it would rather have invalidated all or part of the ACA, including the protections for preexisting conditions—had it known that a penalty-free mandate would no longer be constitutional.

In other words, the 2017 Congress would have had to hold two thoughts in its head: both that an enforceable mandate wasn’t essential to the ACA, but that an unenforceable mandate remained absolutely vital. No member of Congress expressed such a view, and for good reason: it’s daft.

For all of Blackman’s efforts, this case remains easy. Congress repealed the mandate because it thought it was bad policy and left the rest of the ACA standing. That’s all it did, and that’s all it should be taken to have done.

@nicholas_bagley

Why the Medical Research Grant System Could Be Costing Us Great Ideas

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

The medical research grant system in the United States, run through the National Institutes of Health, is intended to fund work that spurs innovation and fosters research careers. In many ways, it may be failing.

It has been getting harder for researchers to obtain grant support. A study published in 2015 in JAMA showed that from 2004 to 2012, research funding in the United States increased only 0.8 percent year to year. It hasn’t kept up with the rate of inflation; officials say the N.I.H. has lost about 23 percent of its purchasing power in a recent 12-year span.

Because the money available for research doesn’t go as far as it used to, it now takes longer for scientists to get funding. The average researcher with an M.D. is 45 years old (for a Ph.D. it’s 42 years old) before she or he obtains that first R01 (think “big” grant).

Given that R01-level funding is necessary to obtain promotion and tenure (not to mention its role in the science itself), this means that more promising researchers are washing out than ever before. Only about 20percent of postdoctoral candidates who aim to earn a tenured position in a university achieve that goal.

This new reality can be justified only if those who are weeded out really aren’t as good as those who remain. Are we sure that those who make it are better than those who don’t?

A recent study suggests the grant-making system may be unreliable in distinguishing between grants that are funded versus those that get nothing — its very purpose.

When a health researcher (like me) believes he has a good idea for a research study, he most often submits a proposal to the N.I.H. It’s not easy to do so. Grants are hard to write, take a lot of time, and require a lot of experience to obtain.

After they are submitted, applications are sorted by topic areas and then sent to a group of experts called a study section. If any experts have a conflict of interest, they recuse themselves. Applications are usually first reviewed by three members of the study section and then scored on a number of domains from 1 (best) to 9 (worst).

The scores are averaged. Although the bottom half of applications will receive written comments and scores from reviewers, the applications are not discussed in the study section meetings. The top half are presented in the meeting by the reviewers, then the entire study section votes using the same nine-point scale. The grants are then ranked by scores, and the best are funded based on how much money is available. Grants have to have a percentile better than the “payline,” which is, today, usually between 10 and 15 percent.

Given that there are far more applications than can be funded, and that only the best ones are even discussed, we hope that the study sections can agree on the grades they receive, especially at the top end of the spectrum.

In this study of the system, researchers obtained 25 funded proposals from the National Cancer Institute. Sixteen of them were considered “excellent,” as they were funded the first time they were submitted. The other nine were funded on resubmission — grant applications can be submitted twice — and so can still be considered “very good.”

They then set up mock study sections. They recruited researchers to serve on them just as they do on actual study sections. They assigned those researchers to grant applications, which were reviewed as they would be for the N.I.H. They brought those researchers together in groups of eight to 10 and had them discuss and then score the proposals as they would were this for actual funding.

The intraclass correlation — a statistic that refers to how much groups agree — was 0 for the scores assigned. This meant that there was no agreement at all on the quality of any application. Because they were concerned about the reliability of this result, the researchers also computed a Krippendorff’s alpha, another statistic of agreement. A score above 0.7 (range 0 to 1) is considered “acceptable.” None were; the values were all very close to zero. A final statistic measured overall similarity scores and found that scores for the same application were no more similar than scores for different applications.

There wasn’t even any difference between the scores for those funded immediately and those requiring resubmission.

It would be easy to mistake this study as a death knell for the peer review process. It’s not. A careful reader must note that all of the grants in this study were exceptional. They succeeded, after all. Since the N.C.I. funds only about 10 percent of grants, we’re looking only at proposals in the best decile, and it’s likely that there might be less variability in scores among those than among grants occupying the full spectrum of quality.

This should still concern us greatly. This system was devised back when more than half of submitted grants were funded. That’s very different than what we see today.

The current system favors low-risk research. If you’re going to fund only a small percentage of proposals, you tend to favor the ones most likely to show positive results. You don’t want to have to defend null findings as a “waste of money.”

The current system favors experienced researchers over new ones. They have thicker curriculum vitae, more preliminary data and name recognition. Moreover, they know how to work the system. At this point in my career, I know how to write multiple grants efficiently. I’m better at it than I used to be.

The current system can also be biased against women and minorities in ways that could keep them out of funding range. The system is not blinded, and many studies have shown that even after controlling for other factors, the ways in which grants are discussed, scored and funded can favor men over women, and whites over minorities.

If researchers are getting into the top 10 percent more than others based on such factors, especially with less and less money available, many great proposals — and many great researchers — are being sidelined inappropriately.

We may be missing out on a lot of excellent, and perhaps novel, work that can’t break into the top 10 percent because of structural problems. There are things we could do to fix that. One might be, of course, to increase funding across the board. John Ioannidis has proposed that we fund researchers, not research. A group of informaticists from Indiana University has suggested a percentage of funding be put to all scientists for a vote.

Other solutions are more radical. One might involve a modified lottery. The current system seems to do reasonably well at discriminating between “bad” and “good” grants. Once those good ones are put aside, we might do better by assigning funding through chance. Ferric Fang and Arturo Casadevall, who are researchers and journal editors, have proposed that such a system could reduce bias and increase diversity among researchers, suggesting that seniority and other factors still play too large a part in funding decisions.

They make the case that we already have a de facto lottery now, except it’s not random, and therefore unfair.

The current granting system doesn’t just fund the researchers of today — it also steers the careers of tomorrow. Should it fail, the repercussions will be felt for decades.

@aaronecarroll

Healthcare Triage: Why Don’t We Invest More in Public Health?

Many, many studies conclude that investing in public health is more effective than continually increasing spending on expensive treatments. So why doesn’t the US spend more on public health?

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

@aaronecarroll

JAMA Pediatrics Podcast: Dietary Supplement Use in Kids

As you know, 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 “Prevalence of Dietary Supplement Use in US Children and Adolescents, 2003-2014”:

This audio summary describes a national survey study that used NHANES data to characterize trends in the use of dietary supplements among children < 20 years old between 2003 and 1014.

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

@aaronecarroll