But because people with diabetes do get heart attacks at a rate higher than the general population, it would be nice to know what markers could be trusted to help you know your real risk.
Your A1c and, even more strongly, your post-meal blood sugar levels are helpful in assessing risk. But some people with well controlled blood sugars do develop heart disease. So some recent research published in the journal Diabetes might point to another safe tool you can use to assess your own, personal risk.
You can read the abstract of the study here:
Apolipoprotein B but not LDL Cholesterol Is Associated With Coronary Artery Calcification in Type 2 Diabetic Whites Seth S. Martin et al. Diabetes. Diabetes August 2009 vol. 58 no. 8 1887-1892 doi: 10.2337/db08-1794
Apolipoproteins are proteins that are produced in the intestines and liver. They attach to cholesterol particles released by digestion and are what allow these particles to be transported through the body. Because apolipoproteuns fit receptors on various cells, they play a large part in the processes that allow cholesterol to be metabolized.
Apolipoprotein B (APO B) is the lipoprotein that attaches to LDL cholesterol and helps transport it around the body. It has long been known that it provides a better measure of cardiac risk than does the measurement of LDL cholesterol. This is not news. You can read about that in a study published in 2002:
How, when, and why to use apolipoprotein B in clinical practice. Sniderman Allan D. The American journal of cardiology, ISSN 0002-9149 2002, vol. 90, no 8A (86 p.) (32 ref.), pp. 48i-54i
The reason APO B is useful is so useful is that there is one molecule of APO B associated with every particle of LDL cholesterol. This means that the measurement of APO B points the the actual number of LDL particles. This is especially important because The usual LDL measure you get on your lab report does not. In fact, the LDL value on your cholesterol test result isn't an actual measure of your LDL. It is a calculated number that is derived by applying a simplistic formula to the triglycerides and total Cholesterol that were measured. Because it is a calculation, not a measurement, it can give either erroneously low or erroneously high readings depending on the size of your LDL particles.
Dangerous LDL comes in small particles which are prone to attach to arteries. Very large fluffy LDL molecule tends not to bond to your arteries. The LDL calculation apparently gives something like the total volume of your LDL, so if, like me, you have a modest number of very large fluffy molecules the formula gives an extremely high LDL figure while someone with a lot of very small dense LDL may be told they have a low, misleadingly comforting LDL number.
This is one reason why fully one half of people who have heart attacks have "normal" cholesterol--because just measuring the amount of cholesterol is worthless. You have to know how many cholesterol particles you have to better understand risk since small dense LDL does correlate with your risk of having cholesterol clog your arteries.
So while it isn't new that your APO B value is a useful indicator of risk, the new Diabetes study is useful because it finds that APO B is the only LDL test result that provides useful information to people with Type 2 diabetes.
This may be because most people with diabetes have extremely high triglicerides which skew the LDL calculation. If you have normalized your blood sugar this may mean that the APO B test is not quite as useful for you.
The other reason that the APO B test might be more useful for people with diabetes is that they are usually put on statins which can cut down on the amount of LDL they secrete without changing the characteristics of those LDL particles. So while LDL may drop after taking a statin, the person may still be making a lot of very tiny, dense LDL molecules that give them a heightened risk of clogged arteries, even though their LDL numbers went down.
Reading this study, you might ask yourself, "Why not just get a CAC scan, as Dr. Davis of the Heart Scan Blog (no longer online) suggests. The answer is that the CAC is expensive and may not be covered by insurance. In addition, depending on who offers it, it may expose you to significant amounts of radiation. Dr. Davis points out this doesn't have to be the case, but in practice you may not have the expertise to know if the CAC scanning available to you is being done with low radiation equipment or not, and sadly, you can't trust the people doing the test to give you a trustworthy answer because they have a strong financial interest in selling you the scan.
So if you have a high risk of heart attack and are trying to decide if a heart scan would be worth the money and the radiation exposure, you might consider asking your doctor to do the APO B test to help you get a better feel for whether the scan would provide useful information. If the APO B number is high, it is more likely you would see evidence of significant calcification in your arteries. If you need to see the picture to get motivated to do something about this issue, the scan might be worthwhile.
But this raises an important issue. Medical testing is a waste of money unless result A will lead to your adopting a different treatment than result B. It should never be done just to satisfy your curiosity.
If you believe you have a higher risk of heart attack than a normal person you may already be doing all the things people can do: cutting way down on carbs, monitoring your blood sugar and aiming for the lowest possible A1c, keeping your blood pressure normal, supplementing with Vitamin D, and exercising. If you have had your C-reactive protein measured and it was high, you may already be on a statin.
So before you invest in further cardiac testing you have to ask yourself, "What will I do if the test comes back with a value suggesting I am developing heart disease?"
The answer may be, become obsessive and depressed about health in a way that does not improve the quality of your life and this is the last thing that you want. You can live every day of the next 30 years waiting for your heart attack, or you can do what you can do and extract the maximum pleasure out of today and the days that follow it. My dad lived for 30 years after a diagnosis of "severe heart disease." He did end up having a heart attack--28 years after his diagnosis, at the age of 98. He died of a fall two years later. He led an active life for those last 30 years and would have been far better off without the diagnosis since he spent 28 years waiting for that heart attack--and threatening to have it any time anyone in the family disagreed with him!
Heart disease is a valid concern for people with diabetes, but I hear from far too many recently diagnosed people who are terrified that their diabetes diagnosis is a death sentence. It isn't-if you keep your blood sugar under control.
As I have mentioned in an earlier blog post, researchers are seeing far fewer heart attacks than expected in large scale studies. Many reports about cardiovascular disease use the "risk" statistic, which produces a big, scary number rather than the incidence per 1000 people number which gives a much smaller, more reasonable number.
So if you are already taking the steps a prudent person would take, there probably is no point in pursuing ever more diagnostic tests. If the tests could make a difference in your treatment plan--for example, convince you to take an expensive, side-effect rich statin--they might be worth consideration.
To summarize data I have discussed on the main Blood Sugar 101 web sit, here are the test results most indicative of cardiovascular health:
1. Triglyceride levels. Under 150 is the minimum, much lower is much better. Triglycerides should come down as you cut your carbohydrate levels because triglycerides are the product of the digestion of carbohydrate. If they don't come down with low carb dieting and tight blood sugar control, you should have your doctor explore why.
2. Blood pressure. Keep it under 140/85 and demand aggressive therapy from your doctor if it stays higher for any period of time.
3. Cardiac Specific C-Reactive Protein. High levels point to inflammation in your arteries and suggest you might be one of the people who would benefit from taking a statin.
4. Apo B which can help you interpret your LDL score.
5. LDL particle size is a helpful test since LDL particle size appears to be a very good indicator of whether your LDL will caused clogged arteries but very few doctors will perform it or have even heard about it.
6. EKG to determine if you have had a silent heart attack in the past.
July 31, 2009
Apolipoprotein- B But not LDL Cholesterol Linked to Artery Calcium Build Up
Many of my readers know that despite their doctors' obsession with their Cholesterol levels the evidence has never supported the idea that cholesterol levels predict heart attack. You can read about this issue, with resarch citations, on this page: A1c And Post-Meal Blood Sugar Predict Heart Attack or if you are looking for total immersion in the research regarding cholesterol and cardiovascular disease you can get it from reading Gary Taubes' monumental book, Good Calories, Bad Calories.
But because people with diabetes do get heart attacks at a rate higher than the general population, it would be nice to know what markers could be trusted to help you know your real risk.
Your A1c and, even more strongly, your post-meal blood sugar levels are helpful in assessing risk. But some people with well controlled blood sugars do develop heart disease. So some recent research published in the journal Diabetes might point to another safe tool you can use to assess your own, personal risk.
You can read the abstract of the study here:
Apolipoprotein B but not LDL Cholesterol Is Associated With Coronary Artery Calcification in Type 2 Diabetic Whites Seth S. Martin et al. Diabetes. Diabetes August 2009 vol. 58 no. 8 1887-1892 doi: 10.2337/db08-1794
Apolipoproteins are proteins that are produced in the intestines and liver. They attach to cholesterol particles released by digestion and are what allow these particles to be transported through the body. Because apolipoproteuns fit receptors on various cells, they play a large part in the processes that allow cholesterol to be metabolized.
Apolipoprotein B (APO B) is the lipoprotein that attaches to LDL cholesterol and helps transport it around the body. It has long been known that it provides a better measure of cardiac risk than does the measurement of LDL cholesterol. This is not news. You can read about that in a study published in 2002:
How, when, and why to use apolipoprotein B in clinical practice. Sniderman Allan D. The American journal of cardiology, ISSN 0002-9149 2002, vol. 90, no 8A (86 p.) (32 ref.), pp. 48i-54i
The reason APO B is useful is so useful is that there is one molecule of APO B associated with every particle of LDL cholesterol. This means that the measurement of APO B points the the actual number of LDL particles. This is especially important because The usual LDL measure you get on your lab report does not. In fact, the LDL value on your cholesterol test result isn't an actual measure of your LDL. It is a calculated number that is derived by applying a simplistic formula to the triglycerides and total Cholesterol that were measured. Because it is a calculation, not a measurement, it can give either erroneously low or erroneously high readings depending on the size of your LDL particles.
Dangerous LDL comes in small particles which are prone to attach to arteries. Very large fluffy LDL molecule tends not to bond to your arteries. The LDL calculation apparently gives something like the total volume of your LDL, so if, like me, you have a modest number of very large fluffy molecules the formula gives an extremely high LDL figure while someone with a lot of very small dense LDL may be told they have a low, misleadingly comforting LDL number.
This is one reason why fully one half of people who have heart attacks have "normal" cholesterol--because just measuring the amount of cholesterol is worthless. You have to know how many cholesterol particles you have to better understand risk since small dense LDL does correlate with your risk of having cholesterol clog your arteries.
So while it isn't new that your APO B value is a useful indicator of risk, the new Diabetes study is useful because it finds that APO B is the only LDL test result that provides useful information to people with Type 2 diabetes.
This may be because most people with diabetes have extremely high triglicerides which skew the LDL calculation. If you have normalized your blood sugar this may mean that the APO B test is not quite as useful for you.
The other reason that the APO B test might be more useful for people with diabetes is that they are usually put on statins which can cut down on the amount of LDL they secrete without changing the characteristics of those LDL particles. So while LDL may drop after taking a statin, the person may still be making a lot of very tiny, dense LDL molecules that give them a heightened risk of clogged arteries, even though their LDL numbers went down.
Reading this study, you might ask yourself, "Why not just get a CAC scan, as Dr. Davis of the Heart Scan Blog (no longer online) suggests. The answer is that the CAC is expensive and may not be covered by insurance. In addition, depending on who offers it, it may expose you to significant amounts of radiation. Dr. Davis points out this doesn't have to be the case, but in practice you may not have the expertise to know if the CAC scanning available to you is being done with low radiation equipment or not, and sadly, you can't trust the people doing the test to give you a trustworthy answer because they have a strong financial interest in selling you the scan.
So if you have a high risk of heart attack and are trying to decide if a heart scan would be worth the money and the radiation exposure, you might consider asking your doctor to do the APO B test to help you get a better feel for whether the scan would provide useful information. If the APO B number is high, it is more likely you would see evidence of significant calcification in your arteries. If you need to see the picture to get motivated to do something about this issue, the scan might be worthwhile.
But this raises an important issue. Medical testing is a waste of money unless result A will lead to your adopting a different treatment than result B. It should never be done just to satisfy your curiosity.
If you believe you have a higher risk of heart attack than a normal person you may already be doing all the things people can do: cutting way down on carbs, monitoring your blood sugar and aiming for the lowest possible A1c, keeping your blood pressure normal, supplementing with Vitamin D, and exercising. If you have had your C-reactive protein measured and it was high, you may already be on a statin.
So before you invest in further cardiac testing you have to ask yourself, "What will I do if the test comes back with a value suggesting I am developing heart disease?"
The answer may be, become obsessive and depressed about health in a way that does not improve the quality of your life and this is the last thing that you want. You can live every day of the next 30 years waiting for your heart attack, or you can do what you can do and extract the maximum pleasure out of today and the days that follow it. My dad lived for 30 years after a diagnosis of "severe heart disease." He did end up having a heart attack--28 years after his diagnosis, at the age of 98. He died of a fall two years later. He led an active life for those last 30 years and would have been far better off without the diagnosis since he spent 28 years waiting for that heart attack--and threatening to have it any time anyone in the family disagreed with him!
Heart disease is a valid concern for people with diabetes, but I hear from far too many recently diagnosed people who are terrified that their diabetes diagnosis is a death sentence. It isn't-if you keep your blood sugar under control.
As I have mentioned in an earlier blog post, researchers are seeing far fewer heart attacks than expected in large scale studies. Many reports about cardiovascular disease use the "risk" statistic, which produces a big, scary number rather than the incidence per 1000 people number which gives a much smaller, more reasonable number.
So if you are already taking the steps a prudent person would take, there probably is no point in pursuing ever more diagnostic tests. If the tests could make a difference in your treatment plan--for example, convince you to take an expensive, side-effect rich statin--they might be worth consideration.
To summarize data I have discussed on the main Blood Sugar 101 web sit, here are the test results most indicative of cardiovascular health:
1. Triglyceride levels. Under 150 is the minimum, much lower is much better. Triglycerides should come down as you cut your carbohydrate levels because triglycerides are the product of the digestion of carbohydrate. If they don't come down with low carb dieting and tight blood sugar control, you should have your doctor explore why.
2. Blood pressure. Keep it under 140/85 and demand aggressive therapy from your doctor if it stays higher for any period of time.
3. Cardiac Specific C-Reactive Protein. High levels point to inflammation in your arteries and suggest you might be one of the people who would benefit from taking a statin.
4. Apo B which can help you interpret your LDL score.
5. LDL particle size is a helpful test since LDL particle size appears to be a very good indicator of whether your LDL will caused clogged arteries but very few doctors will perform it or have even heard about it.
6. EKG to determine if you have had a silent heart attack in the past.
But because people with diabetes do get heart attacks at a rate higher than the general population, it would be nice to know what markers could be trusted to help you know your real risk.
Your A1c and, even more strongly, your post-meal blood sugar levels are helpful in assessing risk. But some people with well controlled blood sugars do develop heart disease. So some recent research published in the journal Diabetes might point to another safe tool you can use to assess your own, personal risk.
You can read the abstract of the study here:
Apolipoprotein B but not LDL Cholesterol Is Associated With Coronary Artery Calcification in Type 2 Diabetic Whites Seth S. Martin et al. Diabetes. Diabetes August 2009 vol. 58 no. 8 1887-1892 doi: 10.2337/db08-1794
Apolipoproteins are proteins that are produced in the intestines and liver. They attach to cholesterol particles released by digestion and are what allow these particles to be transported through the body. Because apolipoproteuns fit receptors on various cells, they play a large part in the processes that allow cholesterol to be metabolized.
Apolipoprotein B (APO B) is the lipoprotein that attaches to LDL cholesterol and helps transport it around the body. It has long been known that it provides a better measure of cardiac risk than does the measurement of LDL cholesterol. This is not news. You can read about that in a study published in 2002:
How, when, and why to use apolipoprotein B in clinical practice. Sniderman Allan D. The American journal of cardiology, ISSN 0002-9149 2002, vol. 90, no 8A (86 p.) (32 ref.), pp. 48i-54i
The reason APO B is useful is so useful is that there is one molecule of APO B associated with every particle of LDL cholesterol. This means that the measurement of APO B points the the actual number of LDL particles. This is especially important because The usual LDL measure you get on your lab report does not. In fact, the LDL value on your cholesterol test result isn't an actual measure of your LDL. It is a calculated number that is derived by applying a simplistic formula to the triglycerides and total Cholesterol that were measured. Because it is a calculation, not a measurement, it can give either erroneously low or erroneously high readings depending on the size of your LDL particles.
Dangerous LDL comes in small particles which are prone to attach to arteries. Very large fluffy LDL molecule tends not to bond to your arteries. The LDL calculation apparently gives something like the total volume of your LDL, so if, like me, you have a modest number of very large fluffy molecules the formula gives an extremely high LDL figure while someone with a lot of very small dense LDL may be told they have a low, misleadingly comforting LDL number.
This is one reason why fully one half of people who have heart attacks have "normal" cholesterol--because just measuring the amount of cholesterol is worthless. You have to know how many cholesterol particles you have to better understand risk since small dense LDL does correlate with your risk of having cholesterol clog your arteries.
So while it isn't new that your APO B value is a useful indicator of risk, the new Diabetes study is useful because it finds that APO B is the only LDL test result that provides useful information to people with Type 2 diabetes.
This may be because most people with diabetes have extremely high triglicerides which skew the LDL calculation. If you have normalized your blood sugar this may mean that the APO B test is not quite as useful for you.
The other reason that the APO B test might be more useful for people with diabetes is that they are usually put on statins which can cut down on the amount of LDL they secrete without changing the characteristics of those LDL particles. So while LDL may drop after taking a statin, the person may still be making a lot of very tiny, dense LDL molecules that give them a heightened risk of clogged arteries, even though their LDL numbers went down.
Reading this study, you might ask yourself, "Why not just get a CAC scan, as Dr. Davis of the Heart Scan Blog (no longer online) suggests. The answer is that the CAC is expensive and may not be covered by insurance. In addition, depending on who offers it, it may expose you to significant amounts of radiation. Dr. Davis points out this doesn't have to be the case, but in practice you may not have the expertise to know if the CAC scanning available to you is being done with low radiation equipment or not, and sadly, you can't trust the people doing the test to give you a trustworthy answer because they have a strong financial interest in selling you the scan.
So if you have a high risk of heart attack and are trying to decide if a heart scan would be worth the money and the radiation exposure, you might consider asking your doctor to do the APO B test to help you get a better feel for whether the scan would provide useful information. If the APO B number is high, it is more likely you would see evidence of significant calcification in your arteries. If you need to see the picture to get motivated to do something about this issue, the scan might be worthwhile.
But this raises an important issue. Medical testing is a waste of money unless result A will lead to your adopting a different treatment than result B. It should never be done just to satisfy your curiosity.
If you believe you have a higher risk of heart attack than a normal person you may already be doing all the things people can do: cutting way down on carbs, monitoring your blood sugar and aiming for the lowest possible A1c, keeping your blood pressure normal, supplementing with Vitamin D, and exercising. If you have had your C-reactive protein measured and it was high, you may already be on a statin.
So before you invest in further cardiac testing you have to ask yourself, "What will I do if the test comes back with a value suggesting I am developing heart disease?"
The answer may be, become obsessive and depressed about health in a way that does not improve the quality of your life and this is the last thing that you want. You can live every day of the next 30 years waiting for your heart attack, or you can do what you can do and extract the maximum pleasure out of today and the days that follow it. My dad lived for 30 years after a diagnosis of "severe heart disease." He did end up having a heart attack--28 years after his diagnosis, at the age of 98. He died of a fall two years later. He led an active life for those last 30 years and would have been far better off without the diagnosis since he spent 28 years waiting for that heart attack--and threatening to have it any time anyone in the family disagreed with him!
Heart disease is a valid concern for people with diabetes, but I hear from far too many recently diagnosed people who are terrified that their diabetes diagnosis is a death sentence. It isn't-if you keep your blood sugar under control.
As I have mentioned in an earlier blog post, researchers are seeing far fewer heart attacks than expected in large scale studies. Many reports about cardiovascular disease use the "risk" statistic, which produces a big, scary number rather than the incidence per 1000 people number which gives a much smaller, more reasonable number.
So if you are already taking the steps a prudent person would take, there probably is no point in pursuing ever more diagnostic tests. If the tests could make a difference in your treatment plan--for example, convince you to take an expensive, side-effect rich statin--they might be worth consideration.
To summarize data I have discussed on the main Blood Sugar 101 web sit, here are the test results most indicative of cardiovascular health:
1. Triglyceride levels. Under 150 is the minimum, much lower is much better. Triglycerides should come down as you cut your carbohydrate levels because triglycerides are the product of the digestion of carbohydrate. If they don't come down with low carb dieting and tight blood sugar control, you should have your doctor explore why.
2. Blood pressure. Keep it under 140/85 and demand aggressive therapy from your doctor if it stays higher for any period of time.
3. Cardiac Specific C-Reactive Protein. High levels point to inflammation in your arteries and suggest you might be one of the people who would benefit from taking a statin.
4. Apo B which can help you interpret your LDL score.
5. LDL particle size is a helpful test since LDL particle size appears to be a very good indicator of whether your LDL will caused clogged arteries but very few doctors will perform it or have even heard about it.
6. EKG to determine if you have had a silent heart attack in the past.
July 29, 2009
Device Makers New Code of Ethics Forbids Gifts or Entertainment--for Medical Care Providers
Jim Purdy commented on the last post that just like medical care providers, we medical bloggers need to consider adopting a code of ethics. This sent me off on some research about existing codes of ethics involving corporate gifts, and what a surprise that turned up!
It turns out that the medical device manufacturing community's trade group, AdvaMed, proposed a Code of Ethics for its members in December 2008 which specifically banned all gifts or providing of entertainment to medical care providers.
AdvaMe is short for the Advanced Medical Technology Association, a trade group that claims its members "produce nearly 90 percent of the health care technology purchased annually in the United States and more than 50 percent purchased annually around the world."
Here's what's included in its new Code of Ethics:
Note that the code only applies to "health care providers." Not bloggers or those who maintain online support communities. Which might just have something to do with why a medical device maker is suddenly so interested in us humble bloggers.
Doctors are educated highly-paid professionals who, if anything, we would expect to be less influenced by small gifts and junkets, since they can well afford to spend their own money for such things. But it turns out small gifts have a subtle but very effective impact even on wealthy physicians.
You can read a good summary of research documenting how drug company gifts and junkets affect prescribing information in the following journal article. Follow the footnotes to find the studies summarized:
Do Drug Company Do drug company promotions influence physician behavior? Bob Goodman. West J Med.(BMJ) 2001 April; 174(4): 232–233.
How much more likely are we bloggers to be manipulated by drug and device companies?
Many of us earn very modest incomes or are retired. We make huge sacrifices to find the time and resources to do our health support work for which we are rarely compensated. A couple of boxes of free strips is not a trivial issue for many of us. A plane ticket may be out of reach. I have no doubt that we bloggers are highly ethical people, but the impact of the research suggests that drug and device company techniques work very well to influence ethical people who believe they are not being influenced.
Let's Come Up with Our Own Code of Ethics
In this post, I would like to open discussion to all bloggers, community leaders, and blog readers on the topic of what would be a responsible code of ethics for us NON health care providers who provide health information and health-related support to the online community.
For the purposes of this discussion I will define a new group of Online Health Support Providers (OHSP).
Here are my thoughts:
1. OHSP shall not accept any free or discounted items from any health-care related company that are not simultaneously offered free or discounted to the rest of the online community.
2. OHSP who agree to review a product or service shall review it honestly and shall provide reviews for ALL products or services they accept for review, not just those they can endorse.
3. OHSP who allow advertising on their web pages shall make it clear whether they select and endorse the products advertised on their pages. Because Google Ads are the only advertising vehicle available to most bloggers, bloggers who run Google Ads will indicate on their blog that they do NOT have the ability to control the ads that appear on their pages and that they do not endorse the products appearing in Google Ads. If informed by a blog viewer that an ad (with URL) running on their pages is abusive, OHSP agrees to investigate and if the ad is abusive to block the abusive ad via their Google Ads account.
4. OHSP have the right to report their personal experiences with any health related product or service and to highlight stories in the media or medical press relating to any product or service, however any relationship with the companies who produce these goods and services must be disclosed to readers following the same guidelines as are now required by medical journals. This includes disclosing any personal relationship in the past or present with the companies, including past employment, employment of relatives, or past sponsorships, consultancies, etc. OHSP will disclose any significant holdings in the stock of a company whose products they discuss.
5. OHSP who receive compensation for their blog posts from web sites owned by companies will disclose to their readers that they are paid bloggers and indicate who pays them.
This is just a start. I want to hear your suggestions and Ideas.
It turns out that the medical device manufacturing community's trade group, AdvaMed, proposed a Code of Ethics for its members in December 2008 which specifically banned all gifts or providing of entertainment to medical care providers.
AdvaMe is short for the Advanced Medical Technology Association, a trade group that claims its members "produce nearly 90 percent of the health care technology purchased annually in the United States and more than 50 percent purchased annually around the world."
Here's what's included in its new Code of Ethics:
An explicit prohibition on providing entertainment or recreation to Health Care Professionals (HCPs). The changes prohibit gifts of any type -- including all non-educational branded promotional items -- regardless of value.This Code of Ethics went into effect July 1, 2009.
Note that the code only applies to "health care providers." Not bloggers or those who maintain online support communities. Which might just have something to do with why a medical device maker is suddenly so interested in us humble bloggers.
Doctors are educated highly-paid professionals who, if anything, we would expect to be less influenced by small gifts and junkets, since they can well afford to spend their own money for such things. But it turns out small gifts have a subtle but very effective impact even on wealthy physicians.
You can read a good summary of research documenting how drug company gifts and junkets affect prescribing information in the following journal article. Follow the footnotes to find the studies summarized:
Do Drug Company Do drug company promotions influence physician behavior? Bob Goodman. West J Med.(BMJ) 2001 April; 174(4): 232–233.
How much more likely are we bloggers to be manipulated by drug and device companies?
Many of us earn very modest incomes or are retired. We make huge sacrifices to find the time and resources to do our health support work for which we are rarely compensated. A couple of boxes of free strips is not a trivial issue for many of us. A plane ticket may be out of reach. I have no doubt that we bloggers are highly ethical people, but the impact of the research suggests that drug and device company techniques work very well to influence ethical people who believe they are not being influenced.
Let's Come Up with Our Own Code of Ethics
In this post, I would like to open discussion to all bloggers, community leaders, and blog readers on the topic of what would be a responsible code of ethics for us NON health care providers who provide health information and health-related support to the online community.
For the purposes of this discussion I will define a new group of Online Health Support Providers (OHSP).
Here are my thoughts:
1. OHSP shall not accept any free or discounted items from any health-care related company that are not simultaneously offered free or discounted to the rest of the online community.
2. OHSP who agree to review a product or service shall review it honestly and shall provide reviews for ALL products or services they accept for review, not just those they can endorse.
3. OHSP who allow advertising on their web pages shall make it clear whether they select and endorse the products advertised on their pages. Because Google Ads are the only advertising vehicle available to most bloggers, bloggers who run Google Ads will indicate on their blog that they do NOT have the ability to control the ads that appear on their pages and that they do not endorse the products appearing in Google Ads. If informed by a blog viewer that an ad (with URL) running on their pages is abusive, OHSP agrees to investigate and if the ad is abusive to block the abusive ad via their Google Ads account.
4. OHSP have the right to report their personal experiences with any health related product or service and to highlight stories in the media or medical press relating to any product or service, however any relationship with the companies who produce these goods and services must be disclosed to readers following the same guidelines as are now required by medical journals. This includes disclosing any personal relationship in the past or present with the companies, including past employment, employment of relatives, or past sponsorships, consultancies, etc. OHSP will disclose any significant holdings in the stock of a company whose products they discuss.
5. OHSP who receive compensation for their blog posts from web sites owned by companies will disclose to their readers that they are paid bloggers and indicate who pays them.
This is just a start. I want to hear your suggestions and Ideas.
July 28, 2009
Clarification: Read Before You Flame
ADDED 7/31/09: Check out this blog post about how a huge health care charity, the AHA, co-opted bloggers to spread a "healthy message" while requiring them to avoid reporting on competitors AHA's sponsors Merck and Macy's.
Bloggers Can Spread the Word--Just Not About the Sponsors' Competitors
Now back to my original blog post:
I want to make something very clear: my point in the previous post was not that the people Roche identified as "influential bloggers" were sell outs. My point was that when a company like Roche decides as part of a marketing action to define who is influential in our community, everyone in the community needs to stop and think about what that means.
When I said we need to look at the posts of the people who went to this shindig my point was not that these people had sold out, but that because this was an attempt to co-opt leaders in a vibrant online community, we need to look at what happens next. Did it work? The blogs of these people would be the obvious place to look.
We know that drug companies have a long history of targeting and co-opting doctors who are considered influential. These efforts have been very successful. Not so incidentally, we are about to hear a lot more about the problems with meters, since the FDA is considering taking on the meter manufacturers and demanding they improve their meters' accuracy as there is solid evidence that meters meeting the currently defined woefully broad "acceptable" range of meter accuracy is killing people.
This topic was discussed recently in the NYTimes. I have already blogged about it. Did these other influential bloggers? I don't know. They each have their own area of focus and meter accuracy might not be relevant to the topics they cover. But with this issue emerging, what better time for Roche to build "partnerships" with the blogging community.
I know people like Scott Strumello--the very influential--and brilliant--blogger whose blog clued me into this story--are not about to stop reporting about drug company malfeasance no matter how many plane tickets Roche buys him.
I hope Scott will look into the question of what happened to the patents for all the non-invasive blood sugar meter patents that have been tested over the past decade, found to work well, and then disappeared forever. Usually this kind of product disappearance is a sign a large company has bought the patents to keep them from being used by competitors. Since meter companies make their money selling you strips at $1.07 a piece, a meter that does not use comsumables could destroy their cash cow and the price of buying the patent is nothing compared to lost profits. I think of this every time I use my blood pressure meter, for free.
I understand that some blogs are about reassuring people and reaching out and sharing compassionate friendship to people dealing with a very tough diagnosis. I do not suggest that isn't important. it is very important. If this meeting had been defined as a meeting of people with Type 1 who publish supportive blogs for other people with Type 1 diabetes I would have kept my mouth shut.
But it wasn't. It was described as a meeting of the top influential diabetes bloggers. A look at who was invited made it clear that it included Type 2s and that it included people who, like me, do not do compassionate outreach, but who review and endorse products for Type 2s. But it also stuck out that the people who were included who review product did not publish negative reviews about the random number generator Roche sent them this past winter, either. A salient point? Who knows. If nothing else, it is one worth some discussion.
This is why I raised the issue. Not as an attack on other bloggers but because in all the reports I read of the conference in the blogs of these other bloggers I did NOT see anyone raise the issue of what it means to let a company like Roche define who is influential. No one seems to have a problem, either, with the idea that Roche will decide which bloggers newly diagnosed people should be steered to by giving beautifully produced, glossy blog lists to doctors to distribute to newly diagnosed patients.
If I had been invited, I would have made the exact same points.
If you are invited to a subsequent get together or start receiving marketing materials from Roche--and trust me every communication you get from a company like Roche IS marketing material--give it some thought yourself.
The research on the impact of drug company marketing on doctors is that doctors, when asked, report that they aren't influenced by the meals, toys, classes, junkets etc. they get from drug and device companies, but that their prescribing patterns tell a very different story. That's why the drug and device companies do what they do. And if the are now moving to do it to us, we shouldn't expect to do any better than the doctors.
Bloggers Can Spread the Word--Just Not About the Sponsors' Competitors
Now back to my original blog post:
I want to make something very clear: my point in the previous post was not that the people Roche identified as "influential bloggers" were sell outs. My point was that when a company like Roche decides as part of a marketing action to define who is influential in our community, everyone in the community needs to stop and think about what that means.
When I said we need to look at the posts of the people who went to this shindig my point was not that these people had sold out, but that because this was an attempt to co-opt leaders in a vibrant online community, we need to look at what happens next. Did it work? The blogs of these people would be the obvious place to look.
We know that drug companies have a long history of targeting and co-opting doctors who are considered influential. These efforts have been very successful. Not so incidentally, we are about to hear a lot more about the problems with meters, since the FDA is considering taking on the meter manufacturers and demanding they improve their meters' accuracy as there is solid evidence that meters meeting the currently defined woefully broad "acceptable" range of meter accuracy is killing people.
This topic was discussed recently in the NYTimes. I have already blogged about it. Did these other influential bloggers? I don't know. They each have their own area of focus and meter accuracy might not be relevant to the topics they cover. But with this issue emerging, what better time for Roche to build "partnerships" with the blogging community.
I know people like Scott Strumello--the very influential--and brilliant--blogger whose blog clued me into this story--are not about to stop reporting about drug company malfeasance no matter how many plane tickets Roche buys him.
I hope Scott will look into the question of what happened to the patents for all the non-invasive blood sugar meter patents that have been tested over the past decade, found to work well, and then disappeared forever. Usually this kind of product disappearance is a sign a large company has bought the patents to keep them from being used by competitors. Since meter companies make their money selling you strips at $1.07 a piece, a meter that does not use comsumables could destroy their cash cow and the price of buying the patent is nothing compared to lost profits. I think of this every time I use my blood pressure meter, for free.
I understand that some blogs are about reassuring people and reaching out and sharing compassionate friendship to people dealing with a very tough diagnosis. I do not suggest that isn't important. it is very important. If this meeting had been defined as a meeting of people with Type 1 who publish supportive blogs for other people with Type 1 diabetes I would have kept my mouth shut.
But it wasn't. It was described as a meeting of the top influential diabetes bloggers. A look at who was invited made it clear that it included Type 2s and that it included people who, like me, do not do compassionate outreach, but who review and endorse products for Type 2s. But it also stuck out that the people who were included who review product did not publish negative reviews about the random number generator Roche sent them this past winter, either. A salient point? Who knows. If nothing else, it is one worth some discussion.
This is why I raised the issue. Not as an attack on other bloggers but because in all the reports I read of the conference in the blogs of these other bloggers I did NOT see anyone raise the issue of what it means to let a company like Roche define who is influential. No one seems to have a problem, either, with the idea that Roche will decide which bloggers newly diagnosed people should be steered to by giving beautifully produced, glossy blog lists to doctors to distribute to newly diagnosed patients.
If I had been invited, I would have made the exact same points.
If you are invited to a subsequent get together or start receiving marketing materials from Roche--and trust me every communication you get from a company like Roche IS marketing material--give it some thought yourself.
The research on the impact of drug company marketing on doctors is that doctors, when asked, report that they aren't influenced by the meals, toys, classes, junkets etc. they get from drug and device companies, but that their prescribing patterns tell a very different story. That's why the drug and device companies do what they do. And if the are now moving to do it to us, we shouldn't expect to do any better than the doctors.
It's Official: I'm Not An Influential Blogger
With much ballyhoo Roche just flew what they defined as the 29 most "influential" diabetes bloggers to an all expenses paid talk fest where, it appears, everything diabetes was open to discussion except the price of test strips and the inaccuracy of meters. Roche, in case you forgot, is the company that manufactures the Accu-Chek Aviva meter.
I recognized many of the attendees, who are indeed influential. But by no means all. In fact there were seven "influential" bloggers I had never before heard of including a recently diagnosed person with Type 2 who according to Google Reader has a whopping 38 subscribers.
Roche stated that they intend to publish materials for the newly diagnosed that will point them to these chosen people's blogs, which makes it more than an issue of wounded pride to me that this blog and its associated Blood Sugar 101 blog were ignored.
I have a lot more than 38 subscribers on Google News, folks. My latest Google Analytics report says that over the past month some 65,000 people visited my pages of whom almost 10,000 are returning visitors. Google makes these statistics available to advertisers. They aren't kept secret. I know for a fact that quite a few of the "influential bloggers" are not drawing anywhere near that kind of traffic and, in the case of the diabetes community sites invited, their retention levels--returning visitors month by month--are far lower than my 10,000.
So it does not take advanced paranoia to wonder if the reason I was excluded was that I blogged several times about the egregiously poor performance of Roche's Aviva meter. I have had three of them and all three were dangerously inaccurate, not matching lab results, and more importantly, not matching the meter's own results on closely repeated tests with the same blood draw.
Since the influential diabetes bloggers who were invited report that Roche's reps made it clear that opening a discussion about problems with their meters and strips were offensive, the reasons for my exclusion are clear.
Unfortunately, though, my exclusion means that Roche will finance the production of materials that doctors will give to the newly diagnosed pointing them to blogs full of feel-good posts about living with diabetes, enthusiastic endorsements of products the blogger has gotten for free, and no pointers to the vital information that could keep them from developing diabetic complications.
Because folks, whatever else you read on these pages, the central mission of this blog and the Blood Sugar 101 web site, is to let people know the truth about what blood sugar levels destroy their bodies and what the safe and effective strategies are that they can use to avoid this damage.
This message works. I hear on a regular basis from people who tell me they followed the advice given on the page about How To Get Your Blood Sugar Under Control and brought their A1cs down into the 5% range, even when they started with A1cs as high as 15%. And it isn't just the newly diagnosed. I heard recently heard from someone who brought a 15% A1c down into the normal range with these techniques who was a decade past diagnosis.
So Roche's decision to choose "feel good" diabetes bloggers as representatives of the "online diabetes community" and omit these pages from its list of recommended sites intended to be distributed to all newly diagnosed people with diabetes is not trivial.
It will also mean more people with Type 2 who blame themselves for causing their diabetes will not learn the truth about the real causes of Type 2 Diabetes. Blaming people for causing their Type 2 diabetes is a tragic trend, promoted by the media and all too many doctors.
Why is it tragic? Because guilt and self-hatred leads to denial. I cannot tell you how many people I have heard from who told me that until they learned that they did NOT cause their Type 2 diabetes by reckless overeating they could not bear to do the research it would take to conquer it. I have even heard a truly devastating story--from a local acquaintance--about a woman in her early 50s who refused a kidney transplant because she believed she had caused her diabetes and decided she didn't deserve the kidney.
Beyond that, Roche's move to define and support their choice of "influential diabetes bloggers" and to promote their selection of these bloggesr to the media should be a warning to all of us.
It illuminates the strategies used to control discourse that are employed by the commercial interests that profit mightily by exploiting those of us with diabetes of every type.
If they can't silence the bloggers who tell the truths that don't support their profits they can anoint other, less threatening bloggers, give them a high profile, and hope that by doing so they can herd the newly diagnosed people to bloggers who won't keep them from buying their inaccurate overpriced meters, expensive dangerous drugs, and deceptively promoted high carb "healthy" foods marketed by greedy corporations.
Because it's a simple fact, known to everyone in marketing, that if you give people free air fare, free premium hotel rooms, and expensive meals, they will think twice about attacking your products. That is why drug companies wine and and dine doctors. Because it works. It is why Roche flew in all these influential diabetes bloggers and laid out the high price spread for them.
Keep an eye on these "influential bloggers" over the next month and track how many mention the FDA's attempt to demand accountability from meter manufacturers. Track how many report research about the dangers of the drugs being forced on people with diabetes. Compare the ratio of feel good/cat blogging on their pages to information that might prevent one person from coming down with an unnecessary diabetic complication.
And if telling the truth will keep me from being "influential" as defined by meter companies, drug companies and the ADA, I'm just going to have to live with it. And console myself with the rate my blog traffic is growing at, which is currently a healthy 50% a year.
I recognized many of the attendees, who are indeed influential. But by no means all. In fact there were seven "influential" bloggers I had never before heard of including a recently diagnosed person with Type 2 who according to Google Reader has a whopping 38 subscribers.
Roche stated that they intend to publish materials for the newly diagnosed that will point them to these chosen people's blogs, which makes it more than an issue of wounded pride to me that this blog and its associated Blood Sugar 101 blog were ignored.
I have a lot more than 38 subscribers on Google News, folks. My latest Google Analytics report says that over the past month some 65,000 people visited my pages of whom almost 10,000 are returning visitors. Google makes these statistics available to advertisers. They aren't kept secret. I know for a fact that quite a few of the "influential bloggers" are not drawing anywhere near that kind of traffic and, in the case of the diabetes community sites invited, their retention levels--returning visitors month by month--are far lower than my 10,000.
So it does not take advanced paranoia to wonder if the reason I was excluded was that I blogged several times about the egregiously poor performance of Roche's Aviva meter. I have had three of them and all three were dangerously inaccurate, not matching lab results, and more importantly, not matching the meter's own results on closely repeated tests with the same blood draw.
Since the influential diabetes bloggers who were invited report that Roche's reps made it clear that opening a discussion about problems with their meters and strips were offensive, the reasons for my exclusion are clear.
Unfortunately, though, my exclusion means that Roche will finance the production of materials that doctors will give to the newly diagnosed pointing them to blogs full of feel-good posts about living with diabetes, enthusiastic endorsements of products the blogger has gotten for free, and no pointers to the vital information that could keep them from developing diabetic complications.
Because folks, whatever else you read on these pages, the central mission of this blog and the Blood Sugar 101 web site, is to let people know the truth about what blood sugar levels destroy their bodies and what the safe and effective strategies are that they can use to avoid this damage.
This message works. I hear on a regular basis from people who tell me they followed the advice given on the page about How To Get Your Blood Sugar Under Control and brought their A1cs down into the 5% range, even when they started with A1cs as high as 15%. And it isn't just the newly diagnosed. I heard recently heard from someone who brought a 15% A1c down into the normal range with these techniques who was a decade past diagnosis.
So Roche's decision to choose "feel good" diabetes bloggers as representatives of the "online diabetes community" and omit these pages from its list of recommended sites intended to be distributed to all newly diagnosed people with diabetes is not trivial.
It will also mean more people with Type 2 who blame themselves for causing their diabetes will not learn the truth about the real causes of Type 2 Diabetes. Blaming people for causing their Type 2 diabetes is a tragic trend, promoted by the media and all too many doctors.
Why is it tragic? Because guilt and self-hatred leads to denial. I cannot tell you how many people I have heard from who told me that until they learned that they did NOT cause their Type 2 diabetes by reckless overeating they could not bear to do the research it would take to conquer it. I have even heard a truly devastating story--from a local acquaintance--about a woman in her early 50s who refused a kidney transplant because she believed she had caused her diabetes and decided she didn't deserve the kidney.
Beyond that, Roche's move to define and support their choice of "influential diabetes bloggers" and to promote their selection of these bloggesr to the media should be a warning to all of us.
It illuminates the strategies used to control discourse that are employed by the commercial interests that profit mightily by exploiting those of us with diabetes of every type.
If they can't silence the bloggers who tell the truths that don't support their profits they can anoint other, less threatening bloggers, give them a high profile, and hope that by doing so they can herd the newly diagnosed people to bloggers who won't keep them from buying their inaccurate overpriced meters, expensive dangerous drugs, and deceptively promoted high carb "healthy" foods marketed by greedy corporations.
Because it's a simple fact, known to everyone in marketing, that if you give people free air fare, free premium hotel rooms, and expensive meals, they will think twice about attacking your products. That is why drug companies wine and and dine doctors. Because it works. It is why Roche flew in all these influential diabetes bloggers and laid out the high price spread for them.
Keep an eye on these "influential bloggers" over the next month and track how many mention the FDA's attempt to demand accountability from meter manufacturers. Track how many report research about the dangers of the drugs being forced on people with diabetes. Compare the ratio of feel good/cat blogging on their pages to information that might prevent one person from coming down with an unnecessary diabetic complication.
And if telling the truth will keep me from being "influential" as defined by meter companies, drug companies and the ADA, I'm just going to have to live with it. And console myself with the rate my blog traffic is growing at, which is currently a healthy 50% a year.
July 24, 2009
Phosphates in "Enhanced" Supermarket Meats
When we cut the carbs, a lot of use end up eating more meat. I have debunked quite a few poorly conducted studies that pretend to prove that eating meat raises mortality.
But a recent study raises an issue about meat that is important to people with diabetes.
Science Daily: Fresh Meats Often Contain Additives Harmful to Dialysis Patients
Supermarkets sell in the fresh meat department meats they label as "enhanced." These are meats that have been injected with solutions that are supposed to "enhance flavor" though of course, since they are mostly water, what they really do is enhance weight, allowing the supermarket to charge you more for the same piece of meat, since it has gained a couple ounces from being injected.
The study found that these enhanced meats contain levels of phosphate much higher than found in untreated meat. This can be extremely harmful to people on dialysis.
What the study did not mention is that phosphates can also be harmful to everyone else. Lifetime phosphate intake has been linked to the likelihood of developing kidney disease in everyone, not just people with diabetes.
I blogged about this a while ago here:
Coke Adds Death
and more recently here:
Avoid Phosphates and Preserve Your Kidneys
This research also points out that the labels on treated meat do not reveal the ingredients. My guess is that besides the phosphates, which were identified via lab analysis, these "enhanced" meats are also filled with MSG which, among other things, dysregulates appetite and contributes to weight gain.
Let your supermarket manager know that the store is selling a product that contains a dangerous chemical that could kill people on dialysis and which is NOT labeled to indicate this. Fear of lawsuits is a strong motivator for change. It's time that meat labels contained the same level of disclosure we find on other supermarket foods. Without disclosure we cannot know that what we are eating is not adulterated.
But a recent study raises an issue about meat that is important to people with diabetes.
Science Daily: Fresh Meats Often Contain Additives Harmful to Dialysis Patients
Supermarkets sell in the fresh meat department meats they label as "enhanced." These are meats that have been injected with solutions that are supposed to "enhance flavor" though of course, since they are mostly water, what they really do is enhance weight, allowing the supermarket to charge you more for the same piece of meat, since it has gained a couple ounces from being injected.
The study found that these enhanced meats contain levels of phosphate much higher than found in untreated meat. This can be extremely harmful to people on dialysis.
What the study did not mention is that phosphates can also be harmful to everyone else. Lifetime phosphate intake has been linked to the likelihood of developing kidney disease in everyone, not just people with diabetes.
I blogged about this a while ago here:
Coke Adds Death
and more recently here:
Avoid Phosphates and Preserve Your Kidneys
This research also points out that the labels on treated meat do not reveal the ingredients. My guess is that besides the phosphates, which were identified via lab analysis, these "enhanced" meats are also filled with MSG which, among other things, dysregulates appetite and contributes to weight gain.
Let your supermarket manager know that the store is selling a product that contains a dangerous chemical that could kill people on dialysis and which is NOT labeled to indicate this. Fear of lawsuits is a strong motivator for change. It's time that meat labels contained the same level of disclosure we find on other supermarket foods. Without disclosure we cannot know that what we are eating is not adulterated.
Subscribe to:
Posts (Atom)
