Friday, February 15, 2019

Ways to keep your child safe this summer

Over the July 4th weekend, my non-physician husband with a history of skin cancer tried to justify not wearing sunscreen in order to get some vitamin D. My husband, of course, has no idea how much vitamin D he needs or why, and I suspect he is not alone.
Why do we need vitamin D?

The easy answer is for bones. Vitamin D facilitates absorption of calcium and phosphate, which are needed for bone growth. Without sufficient vitamin D, bones become brittle (in children this is called rickets and in adults it is called osteomalacia) and break more easily. Vitamin D is likely beneficial for other parts of the body as well; studies suggest an overall decrease in death in addition to reductions in blood pressure, respiratory illnesses, cancer, heart disease, and depression. Adequate vitamin D during pregnancy also appears to reduce the chances of having a low-birthweight baby. However, most of the effects of vitamin D have not been studied in controlled settings. Studies looking at the benefits of vitamin D on various conditions are ongoing. A small study published earlier this month suggested that high-dose vitamin D could reduce redness and inflammation following sunburns, but the dose tested far exceeded the recommended daily dose of vitamin D.
How do I get the vitamin D I need?

Don’t run out to the drug store to buy vitamin D pills just yet. Your body produces vitamin D when the skin is exposed to sun, and it is estimated that most people need 1,000 to 1,500 hours of sun exposure throughout the spring, summer, and fall to obtain the necessary amount of vitamin D. Vitamin D deficiency is very common and on the rise. This is mostly due to vigilant sun protection, since sunscreen with SPF 30 reduces vitamin D production by 95%. Of course, as a dermatologist I am not advocating for prolonged sun exposure, but small amounts can go a long way, as the skin produces vitamin D that can last at least twice as long the vitamin D you take in through foods or supplements. Vitamin D can also be obtained through other sources, including fatty fish (such as tuna, mackerel, and salmon), foods fortified with vitamin D (such as dairy products, soy milk, and cereals), beef liver, cheese, and egg yolks. Of course, vitamin D supplements are needed for people most at risk for deficiency, including breastfed infants, older adults, people with limited sun exposure, darker skinned individuals, and overweight individuals.
Why shouldn’t everyone just take vitamin D supplements?

Too much vitamin D can be harmful, including (ironically) increasing fractures, falls, and kidney stones, and can be toxic by causing excessive levels of calcium. Although not proven, high vitamin D levels have been associated with prostate cancer, pancreatic cancer, and mortality. A recent study found that use of high-dose vitamin D supplements increased over a 15-year period.

So how much is too much? For adults, toxic effects increase above 4,000 IU per day. The recommended dietary dose of vitamin D is 600 IU each day for adults 70 and younger and 800 IU each day for adults over 70. To put this into perspective, 4 ounces of cooked salmon contains approximately 600 IU of vitamin D. There are exercise guidelines, of course. One of the most widely quoted physical activity recommendations comes from the US government’s Office of Disease Prevention and Health Promotion that recommends everyone exercise at a moderate or greater intensity for at least 150 minutes a week (or 30 to 45 minutes most days of the week). While this may sound reasonable enough, most people don’t follow it. The reasons are many and diverse, but a common one is that physical activity is not part of the daily routine. For example, increasingly we do not rely on walking or biking to get to work.
Two studies, one message

Two recent studies looked at the impact of different types of physical activity and came to similar conclusions. The first study compared rates of heart disease, cancer, and premature death over a five year period among more than 260,000 people who walked to work, cycled to work, or were sedentary during their commute. Compared to those who were sedentary:

    Those who biked had almost half the rate of heart disease, cancer, or premature death.
    Those who walked had lower rates of heart disease (by 27%) and lower rates of death due to heart disease (by 36%).

The other study was one performed as a follow-up to previous research that linked running for as little as five minutes a day (on average) with a longer lifespan. Further analysis found that runners (as compared with non-runners)

    experienced a 40% lower risk of premature death
    lived an additional three years
    were estimated to gain seven hours of added life for every hour they spent running.

In this study, the benefits of running were noted even for those who had cardiovascular risk factors, such as high blood pressure or smoking. Taken together, the researchers concluded that running might be unique in its health benefits among different types of exercise that have been studied. And while more running provided more health benefits, there did appear to be a limit: additional benefits were not seen with more than four hours of running per week, and three years of added life seemed to be the maximum gained. Cycling, walking, and other physical activity were also beneficial, though not as much as running.
Some caveats

These studies noted an association between certain physical activities (biking or running) and health benefits (lower risk of cancer, heart disease, or death). While it’s possible the physical activity directly caused these benefits, it’s also possible that there’s a different explanation. Perhaps cyclists and runners tend to eat healthier diets, smoke less, or inherit genes linked to longevity. While these studies attempted to account for these other factors, it’s impossible to completely eliminate other potential contributors. In addition, the study subjects may not be representative of the population at large. For example, the study of runners included subjects who were mostly white and middle-class; the results might have been different if others had enrolled.
Your mother was right

Getting up and getting some exercise is good for you. This is, of course, not a new idea. But these new studies are only the latest — and among the most compelling — to suggest that something as simple as walking, biking, or running could be a powerful way to improve your health and have a longer life. On a wet afternoon in early November of last year, I arrived 20 minutes early to an appointment with a new (to me) pain specialist. I had first scheduled the appointment in September. Since I had never visited this particular provider before, and because he was outside of the facility where I received most of my care, my health insurance required a referral from my primary care physician. This had taken nearly two months of bugging my PCP’s office, but two weeks before the appointment was scheduled I finally got the green light by them and was told everything was “all set.” Nevertheless, when I arrived at the appointment I was told I could not be seen because the referral had not, in fact, ever been received.

I was livid. I had taken time off from a tutoring job, foregoing a not-insignificant amount of pay for an appointment that now couldn’t be honored through no fault of my own. Despite doing my due diligence to ensure all the proper paperwork had been handled, the ball still got dropped somewhere out of my sight and I was paying for someone else’s mistake. When I got home I spent the next two hours that day, as well as hours each day for the next several days, trying to get to the bottom of what had happened. This included placing numerous calls to my primary care office and their referral department, as well as my insurance company. Each party evaded blame and pointed their fingers at the other, frustrating me even more. I kept asking the same question: why was I told I was all set when I wasn’t? In the end, I spent over 10 hours trying to settle this issue and ensure that the next referral to see this provider was actually processed and received well before my rescheduled appointment in January. Of course, no one offered to compensate me for the work I missed.

Unfortunately, this is not an unusual occurrence. While this was the most egregious example in my recent history, I can’t count the number of times I have had a referral lost regardless of being told it was processed, or showing up at the pharmacy to be told they never received the prescription my doctor said they called in.
A complicated job that doesn’t pay and does “cost”

Having a chronic health condition is its own part-time job that is equal parts administrative and detective work. What hours aren’t spent at actual medical appointments receiving much-needed care or diagnostic testing are usually devoted to requesting and tracking down referrals, prescription refills, trying to find out test results and what they mean, and soliciting follow-up medical advice from providers. As with the incident last November, I am often expected to be the conduit between my providers and my insurance company, instead of them communicating directly to each other. For most of us in the chronic illness community, this is an all-too-familiar story. As acknowledged in a Harvard Business Review article just this past May authored by medical doctors with Kaiser Permanente, the medical field is rife with inefficiencies that amount to a lot of wasted time for patients. In particular, the article recalls the blog posts of a chronically ill woman, Jess Jacobs (now deceased), who estimated less than one-tenth of 1% of the time she spent “getting care” was devoted to actually treating her conditions.

Another disillusioned patient, Sarah Kliff, also wrote about her experiences in an essay for Vox last year. Specifically, Kliff elaborates on the “…burden patients face in managing the health care system: a massive web of doctors, insurers, pharmacies, and other siloed actors that seem intent on not talking with one another.” As with me, Kliff notes this task falls to the patients, where it becomes akin to a part-time job where “the pay is lousy, the hours inconvenient, and the stakes incredibly high.”

Whether it’s ferrying medical records to different providers or being the one responsible for finding out why an insurance claim has been denied, patients have become the health care system’s “free labor.” Since most of this labor requires phone calls and visits during normal work hours, patients are often forced to interrupt or forego their professional duties in order to handle these aspects of their care. At least for me, this adds to my anxiety about the stability of my medical care and takes away from time I can and should be devoting to work and taking care of my health.
What would make a difference?

Establishing a more efficient and engaged health care system that fosters open communication and transparency between the entire network involved in patient care — health care facilities, insurance agents, physicians, and the patients themselves — will create a more positive outcome for everyone involved and a better outlook for patients, who can instead focus on their healing and health. In the meantime, there needs to be more education and awareness among employers and the general public regarding how time-consuming the health care system is for patients to navigate, so that more policies can be put in place to assist and accommodate people with chronic illness.

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