From hard targets to risk models: Who are we helping?

There’s something appealing about a threshold-based approach to treatment: if your cholesterol is over 200, it’s high. If your blood pressure is over 140, it’s high. If you A1C is over 7, it’s high. It’s clean, easy to understand and easy to communicate. But is it helping to improve meaningful outcomes, and is it doing so equitably? Does 140 for me create the same problem as 140 for you? Is 141 worlds away from 139? These aren’t easy questions to answer. It complicates the already complicated conversations around taking medications for prevention.

We’re starting to see evidence across different conditions that risk-based approaches to treatment, i.e. those that treat based on aggregation of multiple risk factors into a predicted risk of some adverse outcome, might be better. The first major test-case for this was lipid guidelines, but recommendations for other conditions are starting to change too:

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Women’s Health: Beyond the Bikini

Health is complex. Women are complex. Women’s health is complex. So why does “women’s health” so often refer to reproductive issues alone?

The American Heart Association and the American College of Obsetricians and Gynecologists did something smart. They looked at the past few decades of progress in women’s cardiovascular health and asked “why are women still under-informed about their risk of heart disease. . . and why are we still not better at lowering risk?”

Those of us who practice primary care day-in, day-out could probably tell you a lot of reasons: competing priorities, limited time, siloed care— leaving a void for a big-picture assessment of health and health risks. This is a problem for all kind of patients and providers, but it’s particularly acute in women’s health, where issues of reproductive health often take center stage (especially in younger women). A well-woman visit is an opportunity for more than pap smears and birth control! This might be in a primary care practice or a gynecologist’s office (where many young women get their only care). What are we telling women when they come for a well woman visit, and what are they telling us? Are we communicating well, or are we checking boxes on the EHR and making sure we get reimbursed fully? I had a well woman visit myself this year, and I heard a lot about pap tests and nothing about blood pressure or depression.  This is not unusual, but it’s not good.

There’s mounting evidence about sex (biological and physicological) and gender (sociocultural) influences on cardiovascular health and disease. Cardiovascular disease was first identified, studied, and treated in men. Our entire paradigm of the disease is based on men. Yet women’s disease is different, women’s response to disease is different, and the healthcare system’s treatment of women is different. Still, we too often fail to appreciate how these differences matter, and that undermines our efforts as health professionals to address risk.

The million dollar question: How do we identify, communicate, and mitigate women’s cardiovascular risk effectively?

One approach? Treat women’s health as a holistic issue rather than just focusing on the parts covered by a bikini.

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Advice beyond “focus” for academics

I’m an early-career academic and clinician. As such, I need– and receive– a lot of guidance. I have mentors, I have bosses, I have colleagues. Everyone says to focus. Which is nice, but is it helpful? Certainly focus is critical to build a solid and impactful program of scientific research. Does it capture the goals of a long career for someone like me, with varied interests and broad educational preparation? Does “focus” give me the opportunity for impact across different areas or on different levels? Does this idea of “focus” get me to a place where I want to be? The use of the term is so pervasive, it got me thinking. I’m not a photographer, so forgive any technical errors, but what if we thought about an academic career with a more nuanced set of variables?

  • Depth of field. Can you have multiple objects in focus, even if they aren’t right next to each other? If you adjust the aperature, you can let in more or less light, and along with changing the exposure, this can make your focus shallow or deep. Often in a PhD world, you are compelled to bring sharp focus to a tiny part of an image (big aperture) and blur the rest. This can be a good thing, but it’s not the only way. Say, hypothetically, that you want a career with research and clinical practice both, and you also want to be a policy voice. Change the aperture to a smaller size and see— multiple object can be in focus at once. It’s not better or worse, but it brings a different quality to the image.
  • Shutter speed. So you’ve adjusted the aperture— to keep the exposure right, you need to think about how long the shutter is open. A smaller aperture means you need more time. That’s OK, but you have to be aware of it. You want more things in focus? You need to spend a little longer letting light in.
  • Composition. What’s in your shot? How is it framed? Is it a close-up, or a landscape? Is your subject in the center, or are you more interested in a rule-of-thirds kind of thing? The key here is that THERE ISN’T A RIGHT WAY. It’s all about what you want to show and how you want to show it.  That said, some institutions like certain kinds of images more than others. Does your picture fit into their album?
  • Frame rate. Are you shooting a single, perfect image, or a series? Do you want a smooth, seamless progression through a moment, or do you want to capture discrete pieces over time?

varied interests

you want me to pick just one??

So, what’s the upshot? Should we just throw out the advice to “focus” when it doesn’t suit us? No. . . but I do think we should consider it in a broader context and check to see whether our goals are aligned. I may not want to get on a rocket ship to the moon– I might rather be on a cruise ship through different ports.  Well, now that I’ve thoroughly mixed my metaphors, I suspect it’s time to sign off. What are your thoughts on the ups and downs of focus?

Hacks, Trends, and Distractions

There’s a new thing in the health and wellness space about every five minutes, no? A superfood, a supplement, a piece of equiment, some new game-changer. It’s usually expensive, weird-sounding, and above all, new. (And as always with the brand-new, lacking credible evidence). And they just seem so promising! Like this could be the solution— the things that’s finally going to help me get a PR, lose five pounds, be amazing. So sign me up, take my money!

And some of these things probably work. They do lead to some small improvement. But here’s the catch: the added benefit of a hack like this pales in comparison to just doing the work. You can’t add acai to your McDonalds diet and become a new person. There’s so much low-hanging fruit— and that’s where the real magic happens. Start with the tried-and-true basics. Figure out your movement. Your sleep. Your diet. Your stress. If you have those basics truly dialed in and you want to mess around with tweaks and bonuses here and there, you have my blessing. Those fun little gadgets and tonics might give you a tiny boost if you’re already at the pointy end of performance and an ounce or a millisecond is of the essence. But sorry–  you can’t buy health from a link on instagram.


psst. want some of this? it’ll really help.

I see peeps at my gym fall into this trap– they just need the right creatine or BCAA supplement, and then they’ll get their butt in gear. Meanwhile, they’re hitting the drive through on the way home from class. Or they’re not at class at all. They get frustrated with their lack of immediate and complete transformation. . . and then they fall off the wagon. GUYS. Spend your hard-earned cash on veggies, not vitamins, and call me in a few months. I guarantee you’ll be better off. Also you will have more money, and lots of beneficial side effects. Win-win!

Delicious, yet malicious: Reading Salt, Sugar, Fat

No one, as far as I know, will be surprised to find out that highly processed, manufactured food isn’t the healthiest option. No, what’s compelling about Michael Moss’s Sugar, Salt, Fat isn’t some surprising revelation. Rather, it’s the breadth and depth of an issue we kind of already knew about, laid bare. And it ain’t pretty. Here are the take aways, in the cliff’s notes version:

  • Food companies are not interested in your well being. They’re interested in their bottom line. They will make things healthier if and only if it helps them sell more. They are for-profit companies in a cutthroat competitive market. Capitalism, folks!
  • The executives and scientists who make processed food and drinks generally don’t partake of the products they design and sell. Make of that what you will.
  • The copy on food packages is disingenuous. The only information about a food’s

    keeping fly.

    nutritional value is on the actual nutrition facts and ingredients labeling.

  • The history of the government’s dietary guidelines is apalling— this isn’t a conspiracy theory, it’s pretty blatent. The department of agriculture steers the ship— and this department’s primary mission is not, in fact, health. RBG knows— Moss wrote of Ginsberg’s opnion in a 2005 case about the checkoff program for beef marketing that the USDA was simultaneusly promoting beef (advertising paid for by the government program) and telling people to eat less meat (in the USDA guidelines). She couldn’t square that circle, and neither can I: these folks have a texas-sized conflict of interest.

Bottom line: if you want to eat healthy, you have to pay attention, and it’s up to you because neither the food industry nor the government has your back. Bon appetit!

What has CBD ever done for you?

Suddenly, CBD (cannabidiol, which is a cannabinoid found in cannibis plants but which lacks the psychoactive punch of its cousin, THC), is everywhere. You can buy it online. It’s less illegal than plain old marijuana (as far as anyone really knows— You can buy it on the internet, but it’s maybe still classified as schedule 1, if it’s marijuana-derived and not hemp-derrived? But if you live in Indiana, maybe not so much?  Guilt by association? Hey, I’m a nurse, not a lawyer).

girls are no substitute for weed. . . but maybe CBD is?

It’s  touted for relaxation, sleep, pain, inflammation. . . you name it. You can get it in a tincture. You can get it in a gummie. You can get it in a salve. According to GQ, you can rub it all over your body! I’ve seen creams, balms, and salves for topical application recently on friend’s bathroom counters and in fellow-gym-goer’s bags. It’s great for pain, they say! For muscle relaxation! For inflammation! So I had to dig in to the state of CBD and ask: is topical CBD a safe and effective remedy for musculoskeletal aches and pains? Here’s what I found:

First, what the heck is this stuff? Scientifically, CBD is a non-euphoriant, anti-inflammatory analgesic with CB1 receptor antagonist and endocannabinoid modulating effects. It’s considered a minor phytocannabinoid. It can be sourced from hemp or other cannibis-family plants (like the classic marijuana plants you probably think of).

  • CBD a miracle drug! At least. . . if you’re a rodent, or maybe a child with epilepsy. A scientific literature search using PubMed turned up a few studies in animals (it seems to help rats with lab-induced arthritis), and a few looking at some specific medical conditions (MS, IBD, a few rare genetic syndromes). A regular old google search, though, was an embarassment of riches, with top hits from sites “ministry of hemp”, “leafly”, and “”— all touting the miracle effects of products for sale. Ruh roh, this sets off a few alarm bells.
  • Now, to be fair, some of the reason research is sparse is that it’s legally complicated. NIDA restricts federal funding and also access to cannibis in clinical research. I mention this because the “absence of evidence” is a barrier here, and one that’s propped up by the guvmint. There are a total of 138 studies registered in (that’s not a lot— for reference, there are over 10,000 on insulin). The most common indication studied is childhood epilepsy. Some of these were for cannabis which included both THC and CBD. Delivery forms were oils/tinctures, vaporizers, and a spray used in the mouth. There were zero studies on topical or transdermal CBD.

OK, there’s not a lot of evidence, we get it. So, is it safe??

  • Overall, the evidence suggests that the safety profile of CBD is well established. But there are still things we don’t know!
  • In-vitro and rat studies suggest possible hormonal effects, but whether this translates to humans or to doses used is not known.
  • There is the potential for  drug interactions, particularly for drugs cleared by the liver.
  • There is no long-term data.

The next question: topical application of CBD-containing products actually help with pain or inflammation?

CBD topical

i mean, the label says it’s legit.

  • I repeat: there are no clinical studies about this. Zero, zilch, goose-egg. So what follows is mostly theoretical.
  • NIDA reports that CBD in general has neuroprotective, alalgesic, anxiolytic, and anti-inflammatory effects.
  • Research also demonstrates that CBD is absorbed transdermally, meaning that if you apply it to the skin, it is detectable in the bloodstream. However, there are lots of parameters that could impact absorption! It’s not known what effect the carrier, temperature, concentration, or other parameters might have. It also isn’t know whether there is a local effect (the area you apply it) vs. a systemic effect (throughout the body). Since it isn’t absorbred very well orally, transdermal administration is a good option.
  • The rat study I mentioned above suggested that in rats (this is important, since you are not a rat),  transermal application of CBD lead to pain relief— but they did not apply the medication to the affected joint. They just used the skin as a way to get the drug into the body. So they were not studying the local effect on the painful area, as some people assume they were.

So the answer is: CBD is likely safe, it’s in a legal gray area, and there’s no science about whether or not topical application has clinical benefit, and if so, through what mechanism.