“Work is just really busy right now.”

“My kids have sports every night…plus tutoring and music lessons.”

“I have killer project deadlines and travel coming up.”

“The family room needs to be painted, and my garden is a mess.”

“I hate missing American Idol.”

Did you find yourself on this excuse list yet?  If not, please feel free to add your own. 

In the span of two generations we have gone from the culture that saved the world by winning World War II, put a man on the moon, and invented the personal computer, to one that simply cannot take care of itself.  Worse, we can’t stop making excuses about why we refuse to take care of ourselves.  My best guess is that the GIs who defeated the Nazis, and the NASA engineers who put Neil Armstrong on the lunar surface, probably also felt like they had better things to do, but they were undeterred.

Where is that attitude today?  Today, we concentrate on setting new records for excuses, all the while expecting someone else to deliver a magic bullet that will bail us out of a predicament that is largely of our own making.  No doubt that the mix of factors driving the tidal wave of sedentary lifestyles and overweight/obesity is volatile and complex; ultimately, however, it boils down to this – when faced with making a choice, what did you do?  Did you opt to sleep in and then eat a Danish upon arising? Or, did you opt to get up 30 minutes early, take a power walk with your dog, and then eat a bowl of oatmeal with sliced banana?  Did you forgo working out today, because it can wait until tomorrow?  Or, in a moment of clarity and maturity, did you take control of both your schedule and your emotions and get your workout done today, because that way you have room for another one tomorrow? 

The rhetoric of choice permeates American society: we want to choose our doctor; choose amongst a million options for every conceivable retail product; choose when we can telecommute instead of driving to work.  But when it comes to the fundamental choices that underlie our own health, welfare, and longevity, we devolve into a bundle of excuses and finger-pointing.  We blame McDonald’s, Coke, Microsoft, oil companies, and car companies. 

The irony about excuses is that they are easy to dispense and give a false sense of adequacy for a while, as though there is actual thought involved in making them.  This makes it easy to become scarily comfortable with them as a rationale for living.  However, like all houses of cards, a life built on excuses is remarkably easy to dissemble.  Your first episode of chest pain, the first bad blood test showing sky high blood glucose and cholesterol levels, your first bit of slurred speech (indicating a potential coming stroke); the employee or child who watches you never workout or make a sensible dietary choice all the while wondering why you implore that they do so.  These are all things that compel people to seriously considering making the healthier choices that were within their grasp all along and to bury the excuse-driven life.

The sad part, of course, is that some people still will not get the message.  Their moment of awakening will come when the ability to choose is as far from their grasp as possible.  After all, it is hard to make better choices when you are connected to a respirator being wheeled into an OR for open heart surgery because [fill in your favorite excuse here] was just too important…more important than doing everything within your power to preserve your own quality of life.  How is there any choice more important than that?

In the February 26, 2009 issue of the New England Journal of Medicine, Commomwealth Fund President Karen Davis, delivers an ideological, biased defense for increased federal intrusion into health care markets.  Not surprisingly, instead of informing readers by publishing a countervailing view in the same issue, the Journal’s editors left her numerous dubious assertions unchallenged.  So, I have decided to challenge them here, taking them one by one directly from the text of the essay.  The full text of the paper is available at this link: http://content.nejm.org/cgi/content/full/360/9/852.

Point: Medicare has lower administrative costs and provider payment rates than fee-for-service commercial insurers…a new public-private plan option could offer premiums…20% to 30% lower than commercial rates for similar benefits.

Counterpoint: Medicare has lower administrative expenses in part because the program farms out benefits administrations and claims adjudication to private health plans that operate on a regional basis.  Like many private firms that win government business, the plans have an incentive to keep expenses as low as possible, which results in a patchwork quilt of coverage and payment policies and claims administration processes that confuse and frustrate both providers and consumers.  Claims administration and electronic health records are all part of administration, and they are not cheap. 

Medicare’s below-market reimbursement rates give doctors an incentive to not participate with the program.  Dr. Davis does not broach the subject of contracting with providers; in her scheme, would hospitals and doctors have to contract with all health plans, including government ones, and accept whatever they paid?  Or, would providers have both discretion and the opportunity to negotiate payment rates? 

Point:  …correct overpayments for prescription drugs…Prices that are paid for prescription drugs in the United States continue to be well in excess of those paid in other countries. 

Counterpoint: Price alone is a paltry basis upon which to debate the value of prescription drugs.  In sum, prescription drugs consume only about 10¢ of every medical care dollar, and certain classes of drugs, such as anti-depressants and statins, have revolutionized care in their respective specialties (Roehrig C, Miller G, Lake C, Bryant J.  National health spending by medical condition, 1996-2005.  Health Affairs.  2009. 28; w358-w367).  More to the point, the growing sophistication of prescription drugs (for example, through pharmacogenomics), and the advent of new biologicals (such as epoiten), will help to further forestall hospitalizations or shorten them.  Hospitals consume nearly three times as much of every medical care dollar as do medicines.  A more obvious and helpful strategy would be to overhaul the process by which drugs and biologics eventually lose their patent protection and become marketable as generic products.  Punishing prescription drug innovators is completely inconsistent with her assertion that health plans and providers must work together to better manage chronic conditions and avert hospitalizations.  How can you possibly have it both ways? 

Point: [impose]…a new federal excise tax of 1¢ per 12 ounces on sugar-sweetened soft drinks…increasing the federal tax on beer by 5¢ per 12 ounce can and on other alcohol products by proportional amounts. 

Counterpoint: The obesity crisis is not the result of Coke and Pepsi.  Over the past 35 years, the average American’s daily caloric intake has increased by 24%, with nearly all of this excess from fats and refined starches, not just sugars (White, J, Straight talk about high-fructose corn syrup: what it is and what it ain’t.  American Journal of Clinical Nutrition.  Dec. 2008. 88;6:1716S-1721S).  Using the tax code in this manner perpetuates policy by demonization, and, in a uniquely un-American manner, punishes manufacturers for producing perfectly legal products that meet a market demand, which is particularly offensive because these products are safe when used in moderation and may even provide a modest health benefit, in the case of limited alcohol intake, and sweetened sports drinks for activity lasting longer than an hour.  A debate over taxing sugar-sweetened sodas would surely devolve into a legislative and regulatory food fight over what snack foods (can’t wait to see the health czar’s definition of that term) to tax.  Curiously, Davis offers no insight into what these kinds of taxes would do to the producers, but one can imagine job losses as demand declines, pushing more people into the hands of the public half of her public-private health care infrastructure.  A cynical observer might question whether such an outcome is not exactly the intended result.  Make people dependent on what you offer and you increase the likelihood of sustaining or enhancing your political power. 

Point: [the proposals]…would lead to near universal coverage, with only 1% of the US population uninsured. 

Counterpoint: Universal coverage, while a theoretically laudable goal, is not synonymous with universal care.  In universal coverage exemplar Canada, access problems are well documented (Armstrong D, Barkun A, Chen Y, et al.  Access to specialist gastroenterology care in Canada: the practice audit in gastroenterology (PAGE) wait times program.  Can J Gastroenterol.  2008; 22:155-160).  Wait times are also a problem in other universal coverage states, such as the United Kingdom.  Universal coverage will clearly extract a price, in terms of access to care (wait times, approval for marketof new drugs and devices), and provider participation.  Covering everyone and lowering costs means that someone will wait for services that they deem important and necessary, but that the federal czar determines are not urgent.  How long are you willing to wait for a joint replacement?  A non-emergent cardiac procedure?  Plastic surgery to repair the results of a traumatic injury?  A consultation with a pediatric allergist for your child? 

Point: Currently, the secretary of health and human services does not have sufficient flexibility to test and fine-tune savings strategies on a statewide or regional basis….perhaps with the advice of a council of independent experts.  

Counterpoint: This is code for concentrating power in the hands of a political appointee executive.  In our political system, this is simply opens the door to lobbying of heretofore unseen intensity by interest groups to ensure that their particular sacred cows are spared at the expense of someone else’s.

Missing pieces: Davis makes no mention of tort reform, how to deal with medical education costs, or how to encourage citizens to take better care of themselves through more conscientious personal health choices.  She ignores the fundamental demographic drivers of health costs: a population that is both growing and aging; the baby-boomers, still the wealthiest generation, is getting ready to retire and will rebel against any restriction on their access to the care they want, when they want it; and that her strategic approach to health care will politicize it even further. 

Her essay is a paean to the power of the state.  While health care markets undoubtedly require reform, it is not immediately clear that the path to succes  requires dismissing the role of private capital and innovation, which are critical to improve service delivery and rationalize a system that is a clinical, fiscal, and regulatory morass.  It is equally unlikely that the strategic success is achievable without getting every American to take greater responsibility for himself or herself.  The Centers for Disease Control and Prevention estimate that we spend 27% of every medical care dollar on problems that are preventable through better physical activity and nutrition choices (Anderson, L., et al.  Health care charges associated with physical inactivity, overweight, and obesity.  Preventing Chronic Disease.  October 2005.  2:4; 1-12).  Her facile claim that shifting health care costs on to government’s balance sheet will aid American business is a canard as long as government has unlimited power to tax and shift policy through penurious reimbursement that stifles innovation and growth.                                                                 

It is now fashionable amongst policy elitists to fantasize about the perfection of a state-based and state-controlled medical care system.  To those who feel warm and fuzzy about this concept, I leave you with the words of Thomas Jefferson: A government big enough to give you everything you want, is strong enough to take everything you have.

Regular physical activity is known to help protect against the likelihood of getting breast cancer.  A number of studies have shown that women who get regular physical activity are less likely to get the disease, and, if they do get it, they may do better.  Regular physical activity can also help with recovery.

This paper, from exercise scientists at the University of South Carolina, is the first paper to look at differences in fitness amongst women and their likelihood of dying from breast cancer.  Importantly, the researchers tested each woman in the study (over 14,000 in all) to learn her precise level of aerobic fitness.  Each woman underwent a complete exam, including a rigorous exercise stress test to determine whether she had a low, moderate, or high level of fitness. 

The women were followed for an average of 16 years.  On average, they were age 43 upon enrollment in the study and were able to complete 13.3 minutes of the exercise test on a treadmill.  The women with the highest levels of fitness also had the lowest body mass index (BMI), better blood lipids, lower blood pressure, smoked and drank less, were more active, and generally made better lifestyle choices. 

During the follow-up period, 68 women died of breast cancer.  After adjusting for all the lifestyle and medical factors noted above, the researchers concluded that a high level of fitness is strongly protective against dying from breast cancer.  Women with the highest level of fitness, based on their objective exercise treadmill test, had a risk of dying from breast cancer that was less than half the risk of death for women with the lowest level of fitness.  Of the 68 breast cancer deaths, only 17 happened in the highly fit group. 

In a related study, researchers from the National Institutes of Health (NIH) led a team looking the relationship between pancreatic cancer and lifestyle choices.  Pancreatic cancer, while relatively rare, is particularly frightening because it is very deadly and its risk factors are not well understood. 

Using survey data from more than 400,000 adults over age 50, researchers assessed how these lifestyle choices may affect the risk of pancreatic cancer: smoking, alcohol intake, eating a Mediterranean-style diet (heart healthy fats, fruits, vegetables, relatively little red meat), having a healthy body mass index (BMI of 18 to 25), and getting regular physical activity.  The assigned a score of 0 for each element that a person lacked (unhealthy pattern) or a score of 1 for each characteristic that the person had (healthy pattern).

There was a strong relationship between having a high score (5) and having a much lower risk of pancreatic cancer.  People who scored 5 cut their pancreatic cancer risk by nearly 60% compared to people who scored 0.  While the researchers scored physical activity independently, it is clearly related to body weight, because maintaining a healthy body weight is nearly impossible for middle-aged and older adults without regular physical activity.  While this kind of study cannot establish causality, it does demonstrate that lifestyle choices may be strongly associated with this deadly cancer.

The take-away from both these studies is that, as we have noted many times, physical activity is the trump card in a healthy lifestyle.  Never underestimate the power of physical fitness and the benefits that it may confer upon you.  Exercise causes a cascade of positive changes that may spillover quite dramatically from your cardiovascular system and muscles to other components of your body.  Aside from stopping smoking and not drinking excessively, it is a critically important hedge against cancer and other serious diseases.  

Sources: Peel, BJ, et al.  A prospective study of cardiorespiratory fitness and breast cancer mortality.  Medicine & Science in Sports & Exercise.  April 2009. 41:4; 742-748.3

Jiao, L., et al.  A combined healthy lifestyle score and risk of pancreatic cancer in a large cohort study.  Archives of Internal Medicine.  April 27, 2009.  169:8; 764-770.

A group of exercise scientists from Australia has just reported the first ever study of how regular exercise — both strength training and endurance activity — changes the way that your genes function.  Your genes, of course, are the code that determines how your body works.  Genes are either turned on (up-regulated) or turned off (down-regulated).  Up-regulated genes express certain proteins, which are the critical elements in how your body works.

In this study, the scientists looked for differences between athletes with more than eight years of regular training in long distance cycling or weight lifting.  They compared the genes in the muscles of these athletes to each other, as well as to the muscle genes of a control group made up of people with no history of endurance or strength training. 

The results of the study showed that there 263 genes were different between the athletes and the sedentary controls.  In addition, 21 genes were different between the men who strength trained and the men who cycled.  The up-regulated endurance genes were responsible for making better use of fats and carbohydrates for fuel and creating more mitochondria (the small parts of every skeletal muscle cell where energy is produced); the up-regulated strength genes improved use of proteins and building of both muscle mass and strength.  

The authors acknowledge that a limitation of their study is that it relies upon a small sample, and they did not assess what level of “de-training” would it take to shut these genes off or down-regulate them.  Regardless, this study shows persuasively that the regular physical activity can actually change the biochemical building blocks that make you who you are – your genes.  This also argues for doing both strength and endurance activity, because they clearly effect different genes, and, consequently, produce different results.  And, just think, if you can change your genes, you may also eventually be able to change your jeans…into a smaller size, that is. And won’t that be a gratifying and satisfying kind of downregulation?

Source: Stepto, NK, et al.  Global gene expression in skeletal muscle from well-trained strength and endurance athletes.  Medicine & Science in Sports & Exercise.  March 2009.  41:3; 546-565.

Galileo Health Partners, LLC  was founded in 2006 as a Maryland limited liability company. Galileo Health Partners succeeds State Health Policy Solutions, LLC, which Vik Khanna directed from 1995 through 2005.

We chose the name Galileo for a very important reason. Galileo Galilei was a pre-eminent Italian scientist who lived from 1564-1642. Many people mistakenly believe that Galileo proved that the earth revolved around the sun. In fact, credit for that seminal discovery goes to Copernicus, who died around the time of Galileo’s birth. However, it was Galileo whose courage and persistence eventually convinced people that Copernicus was right.

Like Galileo, we are not primary researchers engaged in the processes of experimentation and discovery. Rather, we are experts in translation, helping make technical and scientific information in the realms of Medicare, exercise science, and nutrition accessible and understandable to a broad audience. Our philosophy is to teach, teach, and then teach some more, helping to ensure both acceptance and a high level of comprehension by our clients and their stakeholders.

Galileo Health Partners, LLC is a health consulting firm that provides innovative and creative consulting services to a wide range of corporate and government clients.

Health and wellness consulting. We advise small and mid-sized businesses and major foundations on the development and implementation of scientifically sound and medically safe health and wellness programs. Our services include strategic advice, seminars for employee groups, briefings for management, and the production and delivery of attractive health education materials to employees.

Medicare information strategies. We are experts in Medicare managed care information, particularly critical aspects of the new prescription drug benefit. Galileo Vice President Teri Deutsch has been on the cutting edge of developing the managed care benefits data collection (PBP) and marketing information (SB), which are both critical to success of Medicare Rx.

Our partners, Vik Khanna and Teri Deutsch, are experienced thought leaders in their respective fields. See Contact Us to find out how to get in reach us.