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Health care part 2

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I previously posted on how we in the U.S. could save perhaps half of our health care costs by eliminating useless treatments that are given only because of the urge to "do something":

http://psychohist.livejournal.com/42141.html#cutid1

I still owed a post on the other half of the solution: how to improve health care substantially without significant additional costs. Unfortunately, this is not that post, because I haven't had time to write it yet. However, I can at least provide a couple of tidbits that won't take as long to post.

First, a result on cancer. There was a recent experiment that gave 1179 women aged 55 or over either a placebo, or 1400-1500 mg/d of calcium supplement, or the calcium supplement plus 1100 IU of vitamin D3. Statistically significant results were found only with the group that got vitamin D. How significant? Cancer incidence after the first year was reduced by 77%, with a highly significant P < 0.005.

Unfortunately, there was no group that took the vitamin D only, so we don't really know if the calcium is important here. We also don't know if vitamin D helps prevent cancer in men or in premenopausal women, though there are some indications that it might. Still, 77% of cancers in women 55 and up amounts to 27% of all cancers in the U.S., even without any benefits to any other groups.

The second is an epidemiological study, and so less conclusive, but since it found a factor of two difference rather than the normal single digit percentage differences for a simple macronutrient change, I think it's significant and worth paying attention to. It's again a result on women, and it found that in a group of 32,578 Italian women, the 25% that ate the most carbohydrate were twice as likely to get coronary heart disease - basically, heart attacks - as the 25% of women that ate the least carbohydrate, with P < 0.04. Reducing carbohydrate intake of all women to that of the lowest 25% should reduce heart attacks in women by about a third. Since women suffer about 46% of all coronary heart disease, That amounts to a total population reduction of about 15%.

So, cutting cancer by 27% and heart attacks by 15% - not a bad start, eh? Sorry I have nothing for the men, though.

"Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial"
http://www.ajcn.org/content/85/6/1586.full

Statistics on cancer incidence by sex and age:
http://apps.nccd.cdc.gov/uscs/cancersbyraceandethnicity.aspx

"Dietary Glycemic Load and Index and Risk of Coronary Heart Disease in a Large Italian Cohort"
http://archinte.ama-assn.org/cgi/content/abstract/170/7/640

Statistics on coronary heart disease by sex:
http://www.cdc.gov/mmwr/preview/mmwrhtml/su6001a13.htm?s_cid=su6001a13_x

Later post on the topic of vitamin D preventing cancer:
http://psychohist.livejournal.com/67372.html
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On January 20th, 2011 06:06 pm (UTC), izmirian commented:
The calcium and vitamin D study looks very interesting. Is anyone doing further studies on this. Seems like a huge benefit.
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On January 20th, 2011 07:59 pm (UTC), psychohist replied:
It does seem pretty huge, doesn't it? From a scientific and medical standpoint, we ought to be doing major new trials on (a) separating the vitamin D effect from the calcium effect, (b) determining whether the effect applies to men and to younger women, and (c) doing bigger trials to reduce the somewhat large uncertainty band. Compliance might also be worth looking at, since the 77% reduction was achieved even with only 86% compliance with the vitamin D and 74% with the calcium.

I don't know how one figures out whether any such follow ups are actually being done, but unfortunately I wouldn't be surprised if they weren't. Based on the author affiliations and the study design - it was primarily looking for osteoporosis benefits, and only secondarily for cancer effects - it seems likely that most of the funding for this study came from the dairy industry. They might have an incentive to look at men, but they'd have a positive disincentive for separating the vitamin D and calcium effects.

It used to be that health insurance companies would have had an incentive to look at things like this to reduce their costs. Unfortunately, that's no longer the case with the new health care laws; limitation of administrative costs and profits to a percent of medical expenses now gives them a strong disincentive for reducing health care costs. Now, more cancers means more money, not just for the medical industry, but also for the health insurance industry.
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On January 20th, 2011 08:51 pm (UTC), izmirian replied:
Yeah, after reading the article I immediately went to look at the amount of vitamin D in the milk that I drink. I drink a fair bit of milk but not enough to get the levels of vitamin D that they had in the study.

It's certainly true with the insurance companies having really no incentive to look at this kind of thing (not that I think they really ever did). Possibly an HMO like Kaiser might at least follow up on that type of research. It also makes sense for a national health service to investigate further.
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On January 21st, 2011 12:59 am (UTC), izmirian replied:
Interestingly, I searched for vitamin D references in the NHS and did find this article from 2009. Unfortunately it only mentions two other studies, neither of which appears to be as good. Clearly the information isn't propagating well which seems a little strange.

http://www.nhs.uk/news/2009/09September/Pages/Vitamin-D-and-cancer-prognosis.aspx
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On January 21st, 2011 02:03 am (UTC), psychohist replied:
Answering both your comments at once....

Most HMOs are now just insurance companies with preferred providers; I know that wasn't the original idea behind the HMO movement, but it turned out to be too difficult to get the scale needed to support a full set of medical infrastructure. Kaiser fulfills both the insurance company role and also owns a bunch of hospitals, but the new health care law still gives them at least some disincentive to do this kind of research - plus Kaiser appears to specialize in charging extra for gold plated service anyway. Prior to last year, insurance companies did have the incentive, but generally did not have the scale, to fund this kind of study. They lacked the scale because they couldn't really operate across state lines - there are advantages to allowing states regulatory authority over health insurance, but this was one of the disadvantages.

National health services don't really have an incentive to pursue this kind of thing either, because they lack profit motive. That may change when there's a budget crunch, but at that point they are looking for quick fixes rather than trials that take years to run. This is really the kind of thing NIH ought to be doing, but they're subject to political pressures as well.

It's also to be pointed out that trials of this sort are quite expensive and usually only run for new, patentable drugs. Offhand the only nondrug trials I can think of with this level of significance are this one and the Byelorussian breast feeding one.

I think there are two reasons this trial isn't getting the attention it deserves. First, there are a zillion papers on associations between various cancers and various supplements and dietary and lifestyle factors; to people who don't distinguish between associational studies and double blind trials, this one may not stand out. Second, there was another trial done somewhat before this one that found no significant effect from 400 IU of vitamin D per day, I think with a smaller number of subjects, and people who don't distinguish between "fails to prove" and "disproves" may already have decided that vitamin D doesn't help based on that earlier trial.

Of course, if there was a follow up trial, it probably wouldn't be completed and published until several years from now. We can always hope these researchers came up with funding from somewhere.
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On January 21st, 2011 01:06 am (UTC), mjperson replied:
There's a series of commercials lately along the lines of, "My doctors tell me that I can't usefully absorb calcium if I don't take it with food... so I buy these expensive calcium and vitamin-D tablets to solve the problem."

I often shout at the TV. "Or you could just take them with food!"
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On January 21st, 2011 02:04 am (UTC), psychohist replied:
I admit I try to take my vitamin D with food, and that results in me forgetting completely a couple times a week. Time release tablets would be worth some extra money to me.
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On January 26th, 2011 08:49 am (UTC), (Anonymous) commented:
claim insurance
Wow - this is the best article i’ve read in ages!
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