Modifying Your Alzheimer’s Risk

One of the most feared illnesses today is Alzheimer’s disease. Aloysius Alzheimer, a German psychiatrist and neuropathologist, first described the characteristic brain changes and associated dementia more than one hundred years ago.  Despite the rapid advance of medicine and technology over the intervening century, we still know far too little about this devastating and incurable disease.

Diagnosing Alzheimer’s dementia requires expensive testing looking for particular damage due to accumulation of beta-amyloid and tau protein, which cause the signature plaques and tangles in the brain. As a result, many patients with dementia never get tested and may not get labeled with actual Alzheimer’s disease. Regardless, most dementia – 80% – is the result of Alzheimer’s.

Alzheimer’s disease can last more than a decade, starting with mild cognitive impairment (MCI) and relentlessly progressing to more difficulty solving problems, personality changes, getting lost, forgetting people or significant life events, and ultimately losing the ability to care for oneself, to toilet, to speak, to walk. Some people progress more rapidly than others. The Alzheimer’s Association website https://www.alz.org/ can be a great resource for caregivers or those wanting more information.

Unfortunately, currently available prescription medications, which may help somewhat with mental function, mood, behavior, and ability to perform activities of daily living (like bathing, dressing, eating, etc.), do little to change the course of the illness or the rate of decline. We don’t yet have a magic bullet.

Genetic factors can increase risk of dementia, but most dementia cases occur sporadically in older adults in whom multiple genes influence risk.  We cannot – yet – modify our genes. Changing our lifestyle, however, is one way to improve the odds of developing dementia, even for those with high genetic risk.  Many of the dietary and lifestyle habits and activities recommended to improve overall health (think heart disease, cancer, diabetes) may also be of some benefit with dementia.

One Mediterranean-type diet, which researchers named the MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diet, focuses on foods that impact brain health: leafy green vegetables, berries, nuts, olive oil, fish, wine in moderation, and avoiding red meat.    The point is these broad dietary recommendations are not new and not exclusive to affecting Alzheimer’s risk. Let’s just call it healthy eating.

In addition, physical and mentally stimulating activities – such as reading or crossword puzzles – are important as we age. Both diet and exercise may help with Alzheimer’s risk by virtue of preventing conditions like diabetes, hypertension, and coronary artery disease that can exacerbate cognitive decline. Most older adults cannot keep up the same rigorous workout routine they might have when they were younger. But exercising at least 150 minutes a week, whether by biking, walking, swimming, gardening or doing yard work, can increase the flow of blood to the brain, improve the health of blood vessels and raises the level of HDL cholesterol, which together help protect against both cardiovascular disease and dementia.  One study found that people who engaged in more than six activities a month—including hobbies, reading, visiting friends, walking, volunteering, and attending religious services—had a 38% lower rate of developing dementia than people who did fewer activities.  Along with physical and mental activity and a healthy diet, individuals who avoid smoking tobacco have a lower dementia risk. 

There is mixed evidence about the use of fish oil supplements to improve thinking and memory in Alzheimer’s.  Given the benefit for cardiovascular health, it is reasonable for most people to take a fish oil supplement.   Vitamin D deficiency has been identified as an independent risk factor for the development of dementia of any cause, and supplementation is recommended for patients in whom deficiency is diagnosed.  Finally, no dietary supplement has been proven to be effective in boosting memory or preventing dementia. It is wise to talk to your doctor about the risks and benefits of any over-the-counter medications or supplements you are taking.

As with any recommendations, we must acknowledge that playing by the rules will not guarantee we will prevent Alzheimer’s (or any other disease, for that matter). Probably two-thirds of the risk of developing Alzheimer’s simply can’t be modified.  But adopting a healthy lifestyle with heart- and brain-healthy diet and exercise habits will lessen your chances of developing any number of chronic and life-threatening illnesses. When we all work toward that goal, our entire community is healthier. That’s worth striving for!

Vaping Dangers are Frightening

Over the last few months, a rapid rise of vaping related acute lung disease has come to light. Both the CDC and the Food and Drug Administration (FDA), which regulates electronic nicotine delivery systems (ENDS, which includes products known as “e-cigarettes”), are actively engaged in investigating this outbreak, which some are calling an epidemic.  Certainly, vaping is epidemic among our youth.

As of the end of September, the number of confirmed or probable cases of life-threatening vaping-related lung disease has risen to 805 across 46 states and the US Virgin Islands. About three-quarters of the reported cases are male; nearly 4 in 10 are age 21 or younger.   Most importantly, all reported cases have a history of e-cigarette product use or vaping. Patients often require ICU and ventilator support. Thirteen people have died so far.

Authorities don’t know which chemical(s) are responsible for these vaping-related illnesses. An early idea was that only illicit THC products (black market marijuana oils) were to blame, but this evidently is not the case. Yes, these illnesses are more prevalent among THC vapers than users who self-report using only nicotine products, but vapers who don’t use THC are also getting sick. Vitamin E acetate is also being considered as a potential cause, but no single chemical has been consistently identified in all of the samples tested. At the present time, no particular device, brand, flavor or substance has been definitively linked.

According to the Centers for Disease Control and Prevention (CDC), symptoms of lung injury reported by some patients in this outbreak include  cough, shortness of breath, and chest pain, nausea, vomiting, or diarrhea, fatigue, fever, or abdominal pain. These symptoms usually have a rapid onset over a few days, but some patients have reported that their symptoms developed over several weeks. A lung infection does not appear to be causing the symptoms. NPR reports that in all confirmed cases, patients reported vaping within 90 days of developing symptoms, and most had vaped within a week of symptom onset. 

What should you do?

If you vape, stop. There are other ways to control nicotine addiction. Playing Russian roulette with your lungs is not smart and not cool. Certainly, anyone who vapes should not buy products off the street or add any substances, like THC or CBD oils.  If you have recently vaped and you have symptoms, see a healthcare provider, and let them know of your concern. They can notify the health department or CDC if necessary.

Vaping is not a harmless fad. Our lungs are elegant, fragile, life-giving organs that don’t react kindly to smoky chemicals, whatever the source. The acting head of the FDA admitted recently in testimony before a House subcommittee that the FDA “should have acted sooner” to contain the youth vaping epidemic.  And the CEO of Juul, maker of vaping products that targeted kids with enticing flavors like mango, grape, and strawberry lemonade, stepped down amid intensifying scrutiny of the brand’s marketing practices.  His replacement, unfortunately, is a seasoned tobacco executive, so don’t expect Juul to give up the fight. Too much money is at stake.

But our kids’ health and future is at stake as well. We must remove flavored e-cigarettes from the marketplace. And any marketing practices that target kids with addicting and dangerous products are unacceptable. E-cigarette products flooded the marketplace and were never appropriately reviewed. Frankly, the FDA dropped the ball on this, and people are dying as a result. Finally, until and unless sales to kids can be prevented, online sales of e-cigarettes should be stopped.

Let’s hope our federal agencies can act quickly and forcefully both to identify what is causing these illnesses and deaths and to regulate access to e-cigarette products. If the federal government won’t act, our state legislators should. The health and safety of our kids is at stake.

Money, Insurance, and Health: An Unfair Relationship

Money doesn't buy happiness, or so they say. But money can buy better health. Add one more difference between the haves and the have nots.

There are many determinants of health. Some behaviors are more under our individual control than others. The Big Three, as I like to call them – smoking, diet, and exercise – would, at first glance, seem to be entirely personal choices. That would be untrue.

Social and economic factors are a major determinant of health. These factors include education level, employment, income, family and social support, and community safety. Each of these factors is correlated with financial well-being. In fact, these social and economic factors as a whole are more important even than individual health behaviors, such as tobacco use, diet and exercise, alcohol and drug use, and sexual activity, since health behaviors also correlate strongly with educational level, employment, income, etc. In other words, we cannot address health behaviors in isolation; we must simultaneously address education, jobs, social services, and community safety if we are to improve health.

Another significant determinant of health – the one that gets the most national attention – is access to and quality of healthcare. In the United States, that access is governed primarily by insurance coverage. Every country rations healthcare; in the United States, we just happen to ration it by separating the insured from the uninsured, and that is very much along economic lines. A privileged few are wealthy enough to be able to pay out of pocket for whatever care they need, but they rarely need to. They have insurance. Good insurance. They can afford to pay their deductible, however high it may be. The working poor, however, have some income but little or no savings and often no health insurance coverage at all. They are the ones who get hit with the entire, undiscounted bill for their care. Bankruptcy is an all-too-common result.

Our healthcare system does make some patchwork provision for the truly indigent, but no one should kid themselves that charity care is in any way equivalent – either in breadth of coverage or ease of use – to what we want for ourselves. Even those with insurance are burdened with astronomical deductibles and copays that most simply can’t afford. These persistent financial burdens can force patients to choose less expensive procedures or to go without care altogether.

And then there is Obamacare.

Implementation of the Affordable Care Act, aka Obamacare, started in 2010, when 16% of the US population – more than 40 million people – were uninsured. Healthcare provided since the advent of Obamacare is, as promised, both more affordable and more available. The percentage of people without health insurance has been cut in half.

The dirty little secret is that many healthcare providers don’t take Obamacare plans, funneling patients into inadequate primary care networks and forcing them to drive long distances for more specialized care. In other words, even under Obamacare we continue to ration care with money-related barriers. No question, Obamacare is far from perfect, but it is still better than nothing.

Ray Perryman, considered by many to be the Texas economist par excellence, issued a report in April 2019 titled Economic Benefits of Expanding Health Insurance Coverage in Texas. In this report, Dr. Perryman states, "Health care needs do not simply go away because individuals do not have insurance coverage. Instead, medical issues tend to escalate and lead to higher costs and worse outcomes. Texas would gain over $110 billion in new Federal health spending during the first 10 years." For the callous who are only interested in the economic benefit accrued to the state’s coffers, this report delivers that in spades.

Guess what, though? According to the Perryman Group report, expanding health insurance coverage in Texas also would result in enhanced “health and wellbeing of individuals directly affected by receiving coverage” as well as “reductions in the numbers of uninsured, fewer emergency room visits, improved health outcomes, enhanced employment and productivity, and other desirable developments.” That is a win-win, my friends.

There has been little political appetite to expanding coverage in Texas for fear of “socialized medicine” and an ever-more-intrusive Federal Government. I get it. We can have differences of opinion about whether and how much healthcare is a “right”, how much “responsibility” is required along the way, and the role of government in healthcare. But, leveraging $9.00 in federal resources for every $1.00 in state funding that results in improved health and return on investment is a bet I would make any day of the week.

Our individual and community health depends on many things. Money – or lack thereof – is the most insidious factor. Improving the health of an entire county, as measured by the Robert Wood Johnson County Health Rankings, will require a concerted effort on both the public and private sector fronts and with both large and small scale efforts. Expanding health insurance coverage in Texas via the Affordable Care Act would be an impactful place to start.

We Need Tobacco 21 Legislation Now

Who knew that candy apple, bubble gum, cherry cola, marshmallow, orange soda, s’mores, chocolate, and taffy were literally so addictive? Every one of those flavors – and thousands more! – are available in e-cigarettes today. Tobacco and e-cigarette use – seductively called vaping – are increasingly sucking our youth into a lifetime quicksand of addiction with health and financial costs certain to follow.

A coalition of many partners, including the American Cancer Society Cancer Action Network, American Heart Association, American Lung Association in Texas, Texas Medical Association, Texas Hospital Association, and numerous health systems throughout the state, have come together as Texas 21 to save lives by preventing tobacco use. One simple legislative change that Texas 21 supports can impact hundreds of thousands of lives down the line: raising the age to buy tobacco products to 21.

Almost all smokers start before age 21. In Texas alone, more than 10,000 kids become daily smokers every year. Lest you think raising the age to buy tobacco products to 21 is a radical idea, six states have already done so, as well as hundreds of cities across the country (including San Antonio in 2018). In fact, more than a quarter of the nation is covered by such T21 legislation.

My home county – Angelina County in deep East Texas – has the dubious distinction of ranking dead last in Texas for health behaviors according to the Robert Wood Johnson Foundation (accessible online at www.countyhealthrankings.org). Our higher than average adult smoking rate is a major factor in that determination. If we are to change the health behaviors of an entire county, we must address some factors more globally. Smoking is one of them.

Raising the smoking age to 21 will not have a big economic impact on retailers, as only 2% of US cigarette sales go to those under age 21. But the long-term impact on our taxes, of which too much goes to smoking-caused healthcare, will be significant. In Texas, Medicaid costs caused by smoking amount to almost $2 billion annually. Total annual healthcare costs in Texas directly caused by smoking reach nearly $9 billion. If fewer kids start smoking, we will – over time – see a significant decrease in smoking-related expenditures. Not to mention that our kids will enjoy longer and healthier lives.

Our children are so vulnerable to influence when they are in their early teens. On average, kids in the US try smoking for the first time even before they are 14 years old. They get their first cigarettes from older teens. Most high school seniors can legally buy cigarettes even before they graduate high school, because the legal age to purchase currently is 18. This gives younger teens easy access to nicotine and tobacco though their peers.

States and cities that have enacted T21 legislation have seen a significant drop in youth smoking initiation. The Institute of Medicine (now the Health and Medicine Division of the National Academy of Medicine) notes that raising the tobacco sale age will not only significantly reduce the number of adolescents and young adults who start smoking, it will reduce smoking-caused deaths and immediately improve the health of adolescents, young adults and young mothers who would be deterred from smoking, as well as their children.

It’s not just about cigarette smoking, though. E-cigarettes must be included in any T21 legislation. The tobacco industry, seeing overall declines in US smoking rates, cleverly (and sinisterly) purchased e-cigarette companies and began refining and marketing these nicotine delivery systems to our kids. Vaping became mainstream.

The power of the tobacco industry to addict people to nicotine is evident in the fact that e-cigarette company Juul – in which tobacco giant Altria owns a large stake – has grown quickly to be worth as much as $38 billion by some estimates. Juul’s annual revenue is said to be $2 billion. Addicting teens with flavors like mango, creme brulee, and mint has resulted in more kids using electronic cigarettes than regular cigarettes. In fact, e-cigarette use among youth is now considered to be an epidemic.

Juul and other vaping devices are not toys. Evidence continues to build that for young people, using e-cigarettes increases the likelihood of smoking cigarettes. Some of the chemicals in e-cigarettes are harmful as well. And the effects of nicotine on developing brains are not fully known. Especially worrisome is evidence that nicotine can cause impaired brain development, especially of the prefrontal cortex, which affects judgement and impulse control. To flavor a highly addictive chemical and sell it to children is not only sinister and dangerous; it is appallingly profitable for the very tobacco companies who have been driving up our healthcare costs killing us with cancer, heart disease, COPD, and many other illnesses for decades.

What can we do right now? Polls show nearly 70 percent of voters across party lines favor T21 legislation. Over half of voters strongly favor it. Sen. Joan Huffman and physician Rep. John Zerwas have introduced Senate Bill 338 and House Bill 749 — both of which include e-cigarettes — to protect kids from tobacco addiction and save lives by raising the tobacco age in the state to 21. This something we can all agree on. Let’s pass T21 legislation in Texas this session.

The Truth about Big Tobacco

There was some big, big news recently that you probably haven’t heard. After years of legal wrangling, the tobacco industry has not only been found guilty of fraud, conspiracy, and racketeering, but they have been ordered to run television and newspaper ads admitting the truth that they fought so hard to suppress for decades.

Let’s go back to the beginning. It was more than 50 years ago, in 1964, when Luther Terry, the 9th Surgeon General of the United States, issued a landmark report linking smoking to lung cancer and a host of other diseases. Since that time, Big Tobacco lied, deceived, and in every way engaged in a no-holds-barred battle against every attempt to regulate or curtail the sale of tobacco products. In the meantime, tens of millions of U.S. citizens have died prematurely from tobacco use.

In 1999, the Department of Justice took on Philip Morris and other tobacco giants under the Racketeer Influenced and Corrupt Organizations Act (RICO), alleging that the tobacco companies had engaged in a decades-long conspiracy to (1) mislead the public about the risks of smoking; (2) mislead the public about the danger of secondhand smoke; (3) misrepresent the addictiveness of nicotine; (4) manipulate the nicotine delivery of cigarettes; (5) deceptively market cigarettes characterized as “light” or “low tar,” while knowing that those cigarettes were at least as hazardous as full flavored cigarettes; (6) target the youth market; and (7) not produce safer cigarettes.

Seven years later, in 2006, Federal District Court Judge Judy Kessler ruled that Philip Morris and other tobacco companies engaged in fraud, conspiracy and racketeering – all to deliberately deceive the American public about the health risks of smoking and secondhand smoke. Her ruling noted that Big Tobacco had “marketed and sold their lethal product with zeal, with deception, with a single-minded focus on their financial success, and without regard for the human tragedy or social costs that success exacted.” Judge Kessler ordered that these companies admit their guilt publically by running newspaper and television ads detailing their deception.

It took eleven more years – and a lengthy appeal process – for Big Tobacco to finally agree to any sort of public mea culpa about the health effects of smoking and their role in addicting hundreds of millions of people. Their watered-down admissions of guilt (known in legal parlance as “corrective statements”) will appear in about 50 newspapers and for a year on major television networks. One startlingly honest (and obvious) fact that must be publicized is that Altria, R.J. Reynolds Tobacco, Lorillard, and Philip Morris USA intentionally designed cigarettes to make them more addictive.

Think about that. At a time when we rightly are criticizing pharmaceutical companies for how they market pain medications (which actually have a therapeutic use), we still give a pass to the companies that market the most addictive, useless, and deadly product around. At least Big Tobacco now must admit publically that “More people die every year from smoking than from murder, AIDS, suicide, drugs, car crashes, and alcohol combined.”

Other statements you may see are, “Many smokers switch to low tar and light cigarettes rather than quitting because they think low tar and light cigarettes are less harmful. They are not,” and “There is no safe level of exposure to secondhand smoke.” Sadly, we have known all of this for years. No, decades.

These ads started on November 26, but I have yet to see one myself. I wonder if anyone who needs to see them will see them. Major newspapers and even television are not the way our vulnerable youth consume media these days. I am sure Big Tobacco is counting on that.

In the meantime, tobacco sales continue at a brisk pace. A Wall Street Journal article in April of this year noted that revenues for U.S. tobacco companies hit $117 billion in 2016, up from $78 billion in 2001, despite lawsuits, rising taxes and declining smoking rates. Americans spent more than $90 billion on cigarettes in retail stores last year.

Stores that sell tobacco products today are complicit in the very deception that Big Tobacco is guilty of. The retail markup of tobacco products, according to the Wall Street Journal, is 17%, higher than that on groceries. No wonder grocery and convenience store chains put tobacco products front and center in their stores – or even out in front of their stores. Easy money. Dirty money.

The conservative/libertarian argument about supply and demand and “personal choice” is, pardon the pun, smoke and mirrors when people are knowingly addicted to the product in question. Cigarettes are not sugar water. I don’t mind companies making a profit – even obscene profits – as long as it isn’t by addicting us and killing us.

If nothing else comes from this mea culpa – these “corrective statements” – I hope tobacco and related products become so regulated and so taxed that not only is it not possible to become addicted, but it is too expensive for our youth to even consider starting. Nothing short of a world without tobacco will do. Perhaps that is a pipe dream, but our kids are worth it.

What I Would Like to See in Healthcare Reform (Part 2)

Last month, I wrote about the bloated, incredibly inefficient federal bureaucracy that eats up hundreds of billions of dollars annually in administrative costs. I mentioned that Obamacare was not, in my opinion, true healthcare reform and did not address these inefficiencies; rather, it simply added people to the rolls of a broken system.

In this column, I am not intending to argue for or against Obamacare or whether we “repeal and replace” or go with “Obamacare Lite”, whatever that might be. I am simply pointing out areas where I see daily a burden for both patients and providers. My dream would be for simplification of much of the process of valuing, coding, and billing for healthcare services. Whether any of these thoughts are achievable or affordable, I don’t know.

Let’s start with that dreaded hospital bill. Medical billing is indecipherable. Even patients with advanced degrees can spend hours trying to interpret the bill they receive for a hospital stay. And that bill is obscenely higher than what either the hospital or the providers are going to get paid. What’s ironic is that bill often has no correlation with the actual cost of the care received or the value that the federal government (or the insurance company) places on that care. We must simplify how we charge for medical care and how hospitals and providers get paid. Unfortunately, the only patients who get stuck with the full, inflated bill are those without insurance – the ones who can least afford to pay it. That is unethical.

The overall cost of care (and your bill) is determined by coding every aspect of care, from the Kleenex and bedpan to the heart valve. For every cancer patient I treat, there are dozens of separate codes submitted for reimbursement covering all different aspects of planning, designing, QA’ing, and delivering treatment. I have no doubt that much of that could be combined into, say, a fixed reimbursement for treating prostate cancer. The problem is, when the government wants to bundle procedures together, they do it to cut overall reimbursement immensely. We still do the work; we deserve to get paid. Why can’t we work out a way to simplify, cut administrative costs, and make it a win-win both for the providers and the payors?

Along the same lines, consider a simple office visit to the doctor. The complexity required to determine whether I get paid a level 2 or level 3 office visit – which reimburse only $25 and $50 – is outrageous. These so-called Evaluation and Management (E&M) codes – and there are many of them – are based on four different possible levels of complexity of three aspects of the patient encounter: history, examination, and medical decision-making. Take history, for example. The proper level of complexity is determined by the presence or absence of documentation for four sub-elements: chief complaint, history of present illness, review of systems, and past, family, and/or social history. Do you see where I am going with this? Documentation of these encounters (consultations, follow up office visits) often takes longer than the encounter itself! And, any "error" in billing is considered fraud and abuse. It is common to hear patients complain that their doctor never looked at them, but was always looking at the computer screen. We need to simplify coding and put physicians back face-to-face with their patients.

Then there is the ever-increasing burden of deductibles and co-pays. We have such a mishmash of healthcare plans, each with their own deductibles and co-pays, that it is virtually impossible to keep it all straight. At the beginning of every year, doctors’ offices and hospitals cringe. Did a patient change insurance plans, or did their insurance lapse? What about the deductible for the new year? What about co-pays? More than half of Americans have less than $1,000 in savings. Deductibles for individuals enrolled in the lowest-priced Obamacare health plans will average more than $6,000 in 2017. Can the majority of Americans afford that? Certainly not! This is an unfair burden both on patients and on providers, who end up providing that care for free. Why? Most of it gets written off, but only after we spend a lot of personnel time and effort proving we try to bill for what we can’t collect in order to avoid the appearance of fraud and abuse. Those patients who are forced to pay may rack up credit card debt, get sent to a collection agency, and/or go bankrupt. Some go without the care they need rather than add to their debt. I truly believe co-pays and deductibles are a vestige of a bygone era. I would like to see the dollars saved by decreasing the administrative burden of healthcare go to actually paying hospitals and providers what they deserve and earn, and do away with co-pays and deductibles. There should be one price for a procedure or encounter, and that cost should be paid 100% by insurance.

What about insurance companies? In the best of circumstances, they pay fairly and quickly. But too often they can and do delay patient care and prevent patients from getting the care they need in a timely manner, if at all. They do this through a process called precertification or prior authorization (read: denial). And sometimes when they do give prior authorization, they still deny payment. This ought to be illegal. But it happens without recourse because the state insurance regulations are written in favor of the insurance companies. We need to loosen the precertification grip on the practice of medicine, and we need to be able to hold insurance companies accountable to their agreements. A preauthorization is a contract to pay.

The two hospitals in Lufkin (Woodland Heights Medical Center and CHI St. Luke’s Health Memorial) have spent tens of millions of dollars on electronic health records, not to mention what individual and group physician practices have spent, all mandated by the federal government. To what end? This was supposed to be about “quality”, but that emperor had no clothes. There is precious little improvement in communication between providers and hospitals than before electronic health records. The various doctor’s offices use a number of different vendors, and each hospital uses their own separate vendor. None of them share information with each other. I dream of a truly universal electronic health record language with seamless interconnectivity between offices and hospitals, but I sure don’t want to live through the incredible expense, time and effort it would take to get there. But I do dream.

Finally, let’s talk about rights. I have never felt that free or universal healthcare was a “right”. Hear me out. No one has a "right" to healthcare without some responsibility. That responsibility may be in purchasing insurance, but that is not the only way to contribute. The most glaring, but not the only, example is smoking. Half of long-term smokers will die of a smoking-related illness. If you smoke, the rest of us are burdened with some (or all) of your healthcare costs. On average, a pack of cigarettes in the US costs a smoker $5.51, while the combined medical costs and productivity losses attributable to each pack are approximately $18.05, according to researchers. This is where consumption taxes are attractive, but only if the tax truly goes to help offset the cost of healthcare. How we balance rights and responsibilities in healthcare is a good subject for a doctoral dissertation.

As well all hear about and read about proposed healthcare changes over the next year or two, look for what they are really trying to change, and ask yourself, are they really improving the system, or are they just trying to squeeze more people under a broken umbrella? Can they do both? Let’s hope they try.

Support Raising the Smoking Age to 21

The 85th Texas Legislative Session is in full swing. On Wednesday, February 15, a bill was filed in the House by Representative (and physician) John Zerwas (R) to raise the smoking age in Texas to 21 (so-called Tobacco 21, or T21 for short). A companion bill has been filed in the Senate. This is truly a bipartisan effort and is a great idea. For decades now, the legal drinking age has been 21. Tobacco kills far more people than alcohol, and almost all long-term smokers start smoking before they reach the age of 21.

Deep East Texas contains the lowest ranked counties in Texas for health outcomes, and part of that is due to our higher smoking rates. Nearly 90 percent of adults who smoke started smoking before the age of 18 and nearly 100 percent started by age 26. 18- and 19-year-old smokers are a major supplier of cigarettes for younger kids, who rely on friends and classmates to buy them. Raising the smoking age to 21 can help decrease our smoking rates as well as save tax dollars on future healthcare spending related to tobacco use.

Speaking of tax dollars, annual Texas health care expenditures directly caused by tobacco use amount to a whopping $8.85 billion, and we taxpayers bear part of that cost. The State Medicaid program’s total health spend as a result of tobacco use is $1.96 billion. No, we can’t save all of that, unfortunately, unless no one smokes. However, Jeffrey Fellows, PhD, in a Center for Health research report wrote, “Increasing the smoking age to 21 [in Texas] would result in 30,500 fewer smokers after three years, and lead to $185 million in reduced healthcare expenditures and productivity costs over five years. Lower cigarette excise tax revenue of $3.4 million would reduce the 5-year net savings; however the state would still generate a net financial savings of just under $182 million.”

It isn’t just about dollars; it’s about lives, too.

The Institute of Medicine predicts that smoking prevalence would decline by 12 percent if the national minimum age of sale was raised to 21. One of their models also predicted that raising the national minimum age of sale to 21 would result in approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those individuals born between 2000 and 2019. Smoking kills.

In case you wonder if the tobacco companies think this will work, here’s a quote from a 1986 Philip Morris report (one of the largest suppliers of tobacco products worldwide): “Raising the legal minimum age for cigarette purchaser to 21 could gut our key young adult market (17-20) where we sell about 25 billion cigarettes and enjoy a 70 percent market share.” To the tobacco industry, it is always and only about market share and profit.

Raising the smoking age to 21 isn’t the only answer to our smoking and poor health epidemic. Many cities and even entire states have gone smoke-free. Texas needs to. Dietary and exercise components of good health also need to be emphasized. But if we can lessen the number of the next generation who start to smoke simply by increasing the smoking age of to 21, why wouldn’t we? That’s right… there is no good answer. For a healthier Texas and Angelina County, support Tobacco 21.

Resolve to Improve the Health of our Region

January is a time of resolution, and often our New Year resolutions focus on diet and exercise. My friends, we need a city, county, and region resolution to lose weight!

In July, 2016, Sabrina Perry wrote an article for HealthGrove.com – a health data analysis and visualization site – titled, The County with the Highest Obesity Rate in Every State. She repeated the American Medical Association’s contention that obesity is a disease and noted that the World Health Organization considers obesity a global epidemic. I perused the article with interest, looking for the county in Texas that got the dubious honor of being the fattest. Unfortunately, it was our very own Angelina County.

Look around and it is evident. Angelina County has the highest obesity rate in Texas, coming in at 37.5%. That means nearly 4 out of 10 of us aren’t just overweight; we are downright fat. To achieve the dubious distinction of being fat, you have to get to a body mass index (BMI) of over 30. To give you an idea what it takes to qualify as obese, consider a 5’11” male such as myself. My appropriate weight is less than 180 pounds (and probably more like 160 pounds). Any more than that and I am considered overweight. But to be considered obese – which is what 37.5% of Angelina County residents are – I would need to weigh 215 pounds or more. For me, that would be at least 35 pounds overweight, if not more. I routinely see patients with a BMI of 40 or more, which is considered extreme (or morbid) obesity. That would be a whopping 100 pounds overweight for me.

What can we do?

Dan Buettner, author and founder of bluezones.com, has been writing for years about particular geographic pockets around the world where people live longer. According to the website, “Residents of the Blue Zones live in very different parts of the world. Yet they have nine commonalities that lead to longer, healthier, happier lives.” So much of this is what has been preached to us for decades: don’t smoke, eat your vegetables and legumes, exercise, don’t overeat, and drink wine in moderation. On top of this are stress-related factors, having strong family and friend relationships, and spirituality.

It’s not just that we are obese. Our overall health is terrible. The Robert Wood Johnson Foundation ranks population health by county. In Texas, many of the lowest ranked counties are in deep East Texas. Wouldn’t it be great if Lufkin could be known not just for pump jacks and forests, but also for the health of our citizens? This can only work for communities if each of us individually works at it. We have family, friends, and lots of churches. Strengthen those relationships. And, let’s stop smoking, exercise, and eat right!

I recently participated in a set of strategic planning sessions hosted by the Texas Forest Country Partnership called Stronger Economies Together, or SET. The purpose was to set goals for growth across a broad spectrum of our regional economy, from forestry and tourism to manufacturing and healthcare. Our SET healthcare workgroup noted that we have significant work to do if we are going to impact the poor healthcare factors and outcomes the Robert Wood Johnson Foundation identified in the deep East Texas region. We set an ambitious goal simply to raise our overall health ranking from the lowest 20% to the next lowest; in other words, from poor to still below average. But we have to start somewhere.

This will require a multi-year effort working with all aspects of the healthcare and social service community to start to move the dial toward a healthier region. We can do it, but we all need to make – and keep – that that resolution for better health!

Colorectal Cancer Screening: 80% by 2018

Katie Couric has raised awareness of colorectal cancer ever since her husband died of the disease in 1998. Yet colorectal cancer remains the second leading cause of cancer death in the United States, only surpassed by lung cancer. Both are preventable: lung cancer by not smoking, and colorectal cancer by screening for and removing precancerous polyps.

The American Cancer Society has teamed up with the CDC (the Centers for Disease Control and Prevention) and other organizations to set an ambitious goal of screening 80% of eligible people for colorectal cancer by the year 2018. Screening for colorectal cancer is incredibly important because removing precancerous polyps actually prevents colorectal cancer. Across the nation, if 80% of the eligible population gets screened, it would prevent 277,000 new cases of colorectal cancer and 203,000 deaths (270 of those in Angelina County!) within 20 years. Those are staggering numbers.

Why so high? Because one in three adults in the United States between ages 50 and 75 – about 23 million people – are not getting tested as recommended. In Texas in 2016, there will be 9,680 new cases of colorectal cancer and 3,520 deaths. This translates in Angelina County to about 36 new cases and 14 deaths this year alone. Remember, these are preventable deaths.

How are we going to achieve this screening goal locally?

The Angelina County & Cities Health District, CHI St. Luke’s Health Memorial, the Temple Cancer Center and our local gastroenterologists have teamed up with the American Cancer Society and CPRIT – the state-funded Cancer Prevention Research Institute of Texas – to educate our area population and screen eligible patients for colorectal cancer through a cooperative grant headed by UT Tyler. Most insurances cover routine screening, but this group stands ready to make sure that any eligible patient, whether insured or not, has access to life-saving screening and, if a cancer is found, treatment as well.

There are many ways to be screened, but I want to focus on the two most available. These two  - colonoscopy and FIT testing – are also funded under the CPRIT grant and by almost all insurances. Having a colonoscopy is the best test, in my opinion, because if any polyps are found they can be removed right then and there. If the colonoscopy is negative, nothing else needs to be done for 10 years! My wife and I had ours done the year we turned 50, and it really is not a big deal. Yes, you have to do a bowel prep to clean out your colon, but that is a small price to pay for peace of mind for 10 years.

The second test covered under the CPRIT grant – and the one that will be done most often at the Health District – is the FIT (fecal immunochemical) test. It is a test for hidden blood in the stool, which can be an early sign of colon cancer. This test is done at home by using a small brush to collect some stool and place it on a test card. The test kit is then mailed back to the clinic for processing. The FIT test must be done every year, as opposed to the colonoscopy every 10 years, but it is cheaper and doesn’t require a bowel prep. If the FIT test is positive, a colonoscopy is then necessary.

If you are between the ages of 50 and 75 and have not had a colonoscopy in the last 10 years or had an annual FIT test, ask your doctor to schedule you for one. If you do not have insurance, call Angelina County Connects at (936) 633-1442 and ask the eligibility specialists if you qualify to be screened under the CPRIT grant. Let’s work together to prevent cancer and get to 80% by 2018!

Lung Cancer Screening Saves Lives

For more than 50 years now, we have known the dangers of smoking. That smoking causes heart disease, emphysema, and lung and other cancers is not in dispute. For fifty years, we did not have an effective screening tool for lung cancer.

Now we do.

Medical imaging has improved so much that we are now able to do computerized tomography (CT) scans with significantly lower dose to the patient and at a low enough cost to warrant widespread use as a screening tool. Not everyone needs a scan, of course. But smokers who are at high risk of developing lung cancer now have an option for screening, much like mammography for early detection of breast cancer.

In 2011, the results of the National Lung Screening Trial (NLST) were published in the New England Journal of Medicine, arguably the foremost medical journal in the world. This trial screened current or former heavy smokers aged 55 to 74 with low-dose CT scanning of the chest and compared it to standard chest x-ray. The NLST primary trial results show 20 percent fewer lung cancer deaths among trial participants screened with CT compared to those who got screened with chest x-rays. This is huge news, because we haven’t cured a lot of lung cancer over the last 50 years! Based on these results, the Centers for Medicare & Medicaid Services (CMS) decided in 2015 to start paying for the procedure on January 1, 2016.

According to the American Cancer Society, in 2016 an estimated 224,390 people in the U.S. (117,920 men and 106,470 women) will be diagnosed with, and 158,080 men and women will die of, cancer of the lung and bronchus, the leading single cancer killer in the U.S. If everyone who was eligible got screened, more than 30,000 deaths from lung cancer could be averted every year.

There are more than 94 million current and former smokers in the U.S. at high risk for lung cancer. In 2014, an estimated 18.1 percent, or 40 million U.S. adults, were current cigarette smokers. Unfortunately, smoking rates in East Texas are higher than state and national averages. That means a lot of East Texans are eligible to be screened.

Starting last fall, CHI St. Luke’s Health Memorial began offering low-dose CT lung cancer screening to eligible patients. Medicare covers ages 55-77 (commercial insurance 55-80, but Aetna 55-79). Even within those age ranges, an eligible patient must be a current smoker (or quit no more than 15 years) with at least a 30 pack-year history of smoking (for example, smoking 1 pack per day for 30 years, or 2 packs per day for 15 years). And, eligible patients must have no symptoms of lung cancer (such as coughing up blood or unexplained weight loss of more than 15 pounds in the last year). If lung cancer is suspected, a standard CT chest should be done.

Finally,  Medicare requires “shared decision making” on the risks and benefits of lung cancer screening, which means you must meet face to face with your primary care provider to get an order for screening.

Since we started screening at CHI St. Luke’s Health Memorial, more than 70 patients have been screened. Six abnormalities have been found (including an incidental kidney mass), and two lung cancers have been diagnosed. Those two cancer patients’ lives may have been saved by screening; only time will tell.

Of course, the best way to prevent lung cancer is by not smoking. Ever. Quit if you do smoke. And if you meet the criteria listed above, talk to your doctor about getting screened for lung cancer. If you have questions, feel free to contact the Temple Cancer Center at (936) 639-7466 for more information.

Cattle Baron's Gala Supports Local Cancer Patients

I always look forward to the Pineywoods Cattle Baron's Gala. Not only do I have a good time, I know the money raised is going to a great cause - the American Cancer Society. Unfortunately, there has been recurrent grumbling - from what I hope is an unenlightened minority - that the money raised doesn't stay local. I understand this "local first" mindset and agree that we should expect local return on our charitable giving. The American Cancer Society delivers that in spades.

Yes, the American Cancer Society is a national organization. But did you know that the American Cancer Society has a regional office building right here in Lufkin? This office was built thanks to generous local foundation, business, and individual support. Did you know this office houses eight employees and serves a 12-15 county region? Annual payroll, benefits and overhead is about $450,000 per year. These are good local jobs that feed back into the local economy at a time when all local jobs are significant.

But it isn't just about the jobs. Every dollar raised has local impact in many more ways. Since I started practice in Lufkin nearly 23 years ago, the overall cure rate for cancer has increased from 50% to over 70%. That translates to local lives saved, not in small part due to the incredible research funded by the American Cancer Society. Statistically, an additional 120 people who come through the Temple Cancer Center every year are cured! Now, that is local impact!

Did you know that the American Cancer Society National Cancer Information Center in Austin handles close to 1 million requests for cancer information annually, including calls from Lufkin and deep East Texas? Those calls, emails and online chats provide direct, one-on-one support and information about local services for local patients, including navigation and information on how to access insurance coverage when possible. (By the way, some of these services, like rides for patients to appointments, require local drivers. You can volunteer to help!)

Did you know that every new cancer patient seen in the Temple Cancer receives accurate, specific educational material provided by the American Cancer Society? And local cancer patients have access to wigs, supplies, and support services whether they receive treatment locally or not.

Did you know that the American Cancer Society funds efforts to increase screening rates for cancer? More than 4.6 million women in need have been helped since 1991 through the national breast and cervical cancer early detection program. The latest project is to screen 80% of the eligible population for colorectal cancer by 2018. Colorectal cancer screening can find and remove polyps before they become cancerous, and that prevents colorectal cancer. And what about the incredible American Cancer Society work in the area of tobacco control? Locally, the American Cancer Society Cancer Action Network was instrumental in the passage of smoking ordinances in both Lufkin and Nacogdoches.

What about local patients who choose to travel to the Texas Medical Center for treatment? Soon they will have access to free lodging at Hope Lodge Houston provided by - guess who? - the American Cancer Society. The TLL Temple Foundation generously provided the lead gift for the Hope Lodge Houston. 

What about the various treatments we recommend for cancer patients? Those treatments very well may have been developed from research supported by none other than the American Cancer Society. The American Cancer Society has funded an incredible $4 billion in research grants since 1946. In Texas alone, this year nearly $36 million is currently invested in research.

Website presence? The American Cancer Society's website, cancer.org, is the most trusted website available when it comes to cancer information, with 61 million hits logged in 2014.

The suggestion that funds raised by American Cancer Society events don’t stay local (or don’t benefit our local community) simply can't be supported by facts. Not only that, it misses the point that we can accomplish so much more together than what we can by ourselves. Isn't that our community spirit anyway?

Join me this Saturday night, October 10th, at the Moore Farm for the 2015 Pineywoods Cattle Baron's Gala in support of the American Cancer Society’s lifesaving cancer research, education, and truly local services. Call (936) 634-2940 for ticket information.

Winning the War on Cancer

“I have cancer.” What is your first reaction when someone tells you that? Not the same as when you hear, “I have diabetes,” or, “I high blood pressure.” Something about cancer scares the bejesus out of us. But, should it?

Twenty-plus years ago, when I first started practice, I would quote that we cured around fifty percent of patients. People didn’t believe me then, and you may not think we cure that many today. In fact, we now cure fully two-thirds of cancer patients! We have made remarkable progress in the war on cancer, thanks in no small part to the work of the American Cancer Society. In lung cancer alone, there has been a 20% decline in cancer death, largely due to decreased rates of cigarette smoking.

We just celebrated the fiftieth anniversary of the Surgeon General’s report on smoking and health. This major report, relying on research conducted by the American Cancer Society, exposed the lies of the tobacco industry and laid to rest any doubt that smoking causes lung cancer. We still don’t cure very many lung cancers today – about 15 out of 100 – but we can prevent the vast majority of cases. Since the Surgeon General’s report, eight million lives have been saved, and almost 20 years of life have been added to those lives saved!

Unfortunately, lung cancer is a global problem. There were six trillion cigarettes consumed in 2009! Last century, tobacco killed 100 million people worldwide. This century, tobacco is projected to kill 1 billion people, mostly in the developing world.

Decreasing lung cancer death rates in the United States is just one success story. Over the last nearly 40 years, breast cancer cure rates have increased from 75% to 90%, colon and rectal cancer cure rates have risen from around 50% to two-thirds, and prostate cancer 5-year survival has gone from 68% to 100%. How did we do it?

Better yet, how did YOU do it? You got your mammograms, Pap smears, PSA blood tests, and colonoscopies. You prevented cervical cancer by taking care of precancerous lesions found on Pap smear, or by getting your HPV vaccine. You prevented colorectal cancer by having precancerous polyps removed. You caught your breast cancer or your prostate cancer early by getting a mammogram or a PSA blood test. You noticed a mole changing and had it removed. YOU took charge of your health!

But there is a new danger lurking: obesity. Predictions are, obesity will surpass tobacco as the leading cause of death in the next two decades. Like with tobacco, both cancer and heart disease risk are increased with obesity. Fighting obesity is a lifestyle change, for sure. To change up an old phrase, “An ounce of prevention… is a TON or work!” And, unlike screening tests, you have to work at the diet and exercise continually. (Funny how I preach to myself in these columns!)

Anyway, next time you hear someone say, “I have cancer,” know that they are quite likely going to beat it. The war on cancer isn’t over. We still need to support research, provide prevention and detection programs, work for access to quality healthcare programs, and advocate for smoke-free public places. Walk in Relay for Life on Friday, May 2, 2014 at 6:00 PM at Lufkin Middle School! Support the Cattle Barons Gala, which will be October 25th! The American Cancer Society is the backbone in the fight against cancer. Finally, be a friend and encourager to those with cancer. It’s all about more birthdays, after all!

Your Role in Cancer Prevention

Cancer. Got your attention now? I live and breathe cancer. It's my job. Who knows, I may die with cancer. But my odds are improved because of some choices that I make. First of all, I do not smoke. Ninety eight percent of the patients I see with lung cancer either smoke or have smoked, and lung cancer remains the most preventable cause of cancer death. I try not to get too much sun exposure. That's not easy living in Texas (and driving a convertible). I also exercise regularly and strive to maintain a healthy weight. Finally, once I turned 50, I had my first screening colonoscopy in case there were any polyps that needed to be removed. Removal of polyps can prevent colorectal cancer. My wife, for her part, has regular mammograms (to detect breast cancer early when it is highly curable) and Pap smears (again, to detect changes that could lead to cervical cancer).

Of course, that does not guarantee that I won't get cancer. But the good news is that we cure two-thirds of cancers today. That's right... cure. Most people mistakenly think of cancer as a death sentence. Of course, if you get lung cancer, your chance of cure may only be about 15%. Terrible. Especially since it is almost always preventable. But if you detect breast, prostate, or colorectal cancer early - some of our most common cancers - cure rates run 80-90% or greater. Fantastic!

What are you doing to improve your cancer risk? Do you smoke? Quit! Are you overweight and inactive? Diet and exercise! Are you getting your mammograms, Pap smears, screening colonoscopies, checking your skin for irregular or changing moles? Take charge of the risks that you can.

It is not enough to cure cancer or just diagnose cancer earlier. We want to prevent cancer altogether. What can YOU do to help us win this fight?

Participate in CPS3 - Cancer Prevention Study 3! The American Cancer Society has undertaken a huge, nationwide, multiyear study to better understand the lifestyle, environmental and genetic factors that cause or prevent cancer. If you are between the ages of 30 and 65 years old and have never been diagnosed with cancer, you are eligible to enroll.

Participating is easy and involves the following:

1. Read and sign an informed consent form.

2. Complete a survey packet which will ask for detailed information on lifestyle, behavioral, and other factors related to your health.

3. Be measured for waist circumference.

4. Give a small blood sample (similar to a doctor’s visit). The blood sample is drawn by a trained, certified phlebotomist.

5. Completing a mailed survey every few years over the next 20-30 years

All personal information and any individual results of blood analyses that may be performed will be kept strictly confidential by CPS-3 research staff. There will be no cost to you to participate.

Enrollment will be available at the following locations, your choice:

Tuesday, October 15th (7:30am–11:00am) - Memorial Health System of East Texas, Lufkin

Tuesday, October 15th (4:00pm–7:30pm) - C. L. Simon Recreational Center, Nacogdoches

Thursday, October 17th (1:30pm–5:00pm) - After Power of Pink! at Lufkin Convention Center

Saturday, October 19th (9:00am–12:30pm) - Lufkin Industries

Sunday, October 20th (9:30am–1:00pm) - Lufkin First Assembly of God Church

We need 500 people locally to enroll, and we need ALL racial and ethnic groups to participate. To sign up, go to cancerstudytx.org or call toll-free 1.888.604.5888. Do it for your friends or loved ones who have had cancer. With your help, we can finish this fight!