Monthly Archives: March 2017

Vitamins D

Vitamins seem like something you can’t have too much of. Like too much ice cream on a sticky summer day—sure, you can technically go overboard, but the limit is so high, and what’s the worst thing that happens anyway? And unlike ice cream, we know that vitamins help keep us healthy.

But just like ice cream, vitamin D can have negative side effects when taken in large doses, the impacts can really sneak up on you, and obesity is a concern. Really.

The tricky thing about “medicines” like vitamin D is that you don’t immediately overdose on them. If you take too much Tylenol, you end up in the hospital pretty fast. That giant vitamin capsule isn’t likely to land you in the ER tomorrow or even a month from now. But vitamin D, unlike many of the other vitamins you may be taking, is fat soluble. That means that if you take too much of it, you won’t just pee it out like you would a water soluble vitamin. Instead of being carried out in your body’s wastewater, the vitamin will cling to your body fat for later use—which can compound the effects of daily overdosing. But it’s easy to think of supplements as harmless when you’re just popping a pill or two in your bathroom each morning.

More and more people are making that mistake. In fact, two vitamin D capsules a day (at 2000 international units each) adds up to 4000 IU—the daily limit. If you’re taking in any vitamin D at all otherwise (and you almost certainly are), you’re already over the safe dosage. And a new study in the Journal of the American Medical Association suggests that 3.2 percent of all Americans are doing just that. If 3.2 sounds tiny to you, keep in mind that back in 2007-2008 that number was only 0.2 percent.

The increase in vitamin D overdosing is a symptom of the general trend towards taking more vitamin D supplements. About 18 percent of U.S. adults are taking at least 1000 IU a day, which is well above the recommended daily dose of 600 IU. The question is: is that a problem?

A severe enough deficiency can give you osteomalacia, which you probably know better by the childhood version’s name: rickets. It’s basically a softening of the bone due to lack of calcium. Vitamin D helps your gut absorb all the calcium you need, so a lack of it causes similar problems to a calcium deficiency. Some people have also linked low vitamin D levels to everything from cancer to diabetes to asthma, but those are still just correlational—it’s not clear that a lack of vitamin D is causing those problems as opposed to just being associated with them. Because of this general association with vitamin D deficiency and poor health, some parents give their kids high-dose supplements to stave off things like the common cold. But a recent studypublished in the Journal of the American Medical Association shows that it has zero impact. Kids who were assigned to get 2000 IU of vitamin D didn’t get colds any less frequently than those assigned to get a low dose.

Here’s the rub, though: while it’s hard to know whether you’re vitamin D deficient, taking too much could be much worse. High doses have the potential to cause nausea, vomiting, constipation, and weakness. One double-blind clinical trialactually found that vitamin D supplements made elderly patients more likely to fall and fracture a bone, which flies right in the face of everything the supplements were thought to do. And since too much vitamin D can lead to too much calcium, you can also wind up with kidney stones and abnormal heart rhythms.

The flip side is that, unless you’re getting almost no vitamin D, you’re probably fine. There’s a reason that “rickets” sounds like an old-timey disease—because it is. It’s an exceedingly rare problem nowadays, in part because we started fortifying food. So between sun exposure and diet, you probably get enough vitamin D to function properly, even if you should maybe be getting a bit more. You certainly don’t need more than 1000 IU a day. There’s no evidence that taking vitamin D supplements can cure or prevent osteoporosis or bone fractures, improve bone density, or prevent infections. A better solution? Just eat more fish and eggs, and maybe venture outside once in awhile. It’s absolutely possible to get all the vitamin D you need from diet and sunshine. All three options would have multiple beneficial effects on your health and none are likely to make you puke. Win-win.

England’s Health Experiment

England is in the midst of a unique national experiment, the world’s most ambitious effort to treat depression, anxiety and other common mental illnesses.

The rapidly growing initiative, which has gotten little publicity outside the country, offers virtually open-ended talk therapy free of charge at clinics throughout the country: in remote farming villages, industrial suburbs, isolated immigrant communities and high-end enclaves. The goal is to eventually create a system of primary care for mental health not just for England but for all of Britain.

At a time when many nations are debating large-scale reforms to mental health care, researchers and policy makers are looking hard at England’s experience, sizing up both its popularity and its limitations. Mental health care systems vary widely across the Western world, but none have gone nearly so far to provide open-ended access to talk therapies backed by hard evidence. Experts say the English program is the first broad real-world test of treatments that have been studied mostly in carefully controlled lab conditions.

The demand in the first several years has been so strong it has strained the program’s resources. According to the latest figures, the program now screens nearly a million people a year, and the number of adults in England who have recently received some mental health treatment has jumped to one in three from one in four and is expected to continue to grow. Mental health professionals also say the program has gone a long way to shrink the stigma of psychotherapy in a nation culturally steeped in stoicism.

“You now actually hear young people say, ‘I might go and get some therapy for this,’” said Dr. Tim Kendall, the clinical director for mental health for the National Health Service. “You’d never, ever hear people in this country say that out in public before

A recent widely shared video of three popular royals — Prince William, Prince Harry and Kate, Dutchess of Cambridge — discussing the importance of mental health care and the princes’ struggles after their mother’s death is another sign of the country’s growing openness about treatment.

At 30, he was scrambling to manage a job and a young family — and unraveling fast. After nights out with friends, he would wake up the next morning with a visceral sense that he had done something awful.

“I knew I’d done nothing wrong, I knew it, but I would start to think, ‘O.K., I better check to make sure — that, like, I hadn’t hit somebody, or something,’” said Oliver, now 32 and a graphic designer outside London, who asked that his last name be omitted to protect his privacy. By the spring of 2015, after the birth of Oliver’s second child, the anxiety had so infiltrated his life that he had trouble leaving the house. “I was broken,” he said.

In 2005 David Clark, a professor of psychology at Oxford University, and the economist Richard Layard, a member of the House of Lords, concluded that providing therapy to people like Oliver made economic sense.

“We made the case that, just on lost work alone, the program would pay for itself,” Dr. Layard said in an interview in his office at the London School of Economics.

Dr. Clark, in his university office, said: “If someone has a broken leg, he or she immediately gets treatment. If the person has a broken soul, they usually do not.”

The program began three years later, in 2008, with $40 million from Gordon Brown’s Labour government. It set up 35 clinics covering about a fifth of England and trained 1,000 working therapists, social workers, graduates in psychology and others. The program has continued to expand through three governments, both ideologically left and right leaning, with a current budget of about $500 million that is expected to double over the coming few years.

Under the old system, Oliver might have gotten a drug and, possibly, some general psychological guidance and support. But he had never sought mental health treatment before, and he most likely would have gone years before getting any talk therapy because he had no idea it was available. The area where he lives had scores of practicing therapists but no centralized system for ensuring that people got scientifically backed approaches tailored to their specific problem.

Oliver learned from his doctor about Healthy Minds, the program’s local center, and he immediately called. He got a call back the next day.

The promptness of that initial reply appears to be crucially important, data collected by the program suggest. If patients don’t hear back in the first few days, many of them can be lost for good because the courage it took to make the call can dissipate fast.

Andrew Prinsloo, 43, a graphic designer living in Feltham who had anxieties similar to Oliver’s, said he got a call back minutes after sending an email to Healthy Minds in late 2015. “I was having these terrible thoughts about what I might do and, honestly, I was very reluctant to talk to anyone because I thought they’d lock me up,” he said in an interview.

Scrutinizing city sewage to study our health

Sewage offers a few advantages as a pool of information. For one thing, it’s anonymous. And yet it captures a little something from everyone. “You can pretty much guarantee that most people are going to be using the sewer system,” says Dan Burgard, an environmental analytical chemist at the University of Puget Sound in Tacoma, Washington.

And it’s fast. To find out about health and drug use, researchers typically rely on surveys and data collected by hospitals or during arrests. “There’s often a substantial lag time, as many as two or three years sometimes, before that data become available,” says Kevin Bisceglia, an environmental chemist at Hofstra University in Hempstead, New York. Besides, “If you ask someone about their illegal behavior they’re not necessarily going to tell you accurately.”

Sewage offers a more immediate—and honest—snapshot of what the city is up to. “Sometimes a million people or more are represented in a single 24-hour sample,” Halden says.

He and his colleagues have examined how chemicals in our waste can seep into the environment. In 2002, they found that triclocarban, an ingredient in antibacterial soaps, was not broken down during wastewater treatment. It showed up in sewage sludge, the solid muck left after treatment that is sometimes used to fertilize crops. “That opens a pathway for chemicals…potentially being taken up by plants and making it right back to our dinner plates,” Halden says.

A chemical that won’t break down during treatment and likes to collect in solids is worrying, he adds. “It’s actually the same chemistry that will persist in our bodies when we get exposed and will become sequestered…in body fat.”

Halden and his colleagues found that triclocarban and a similar chemical, triclosan, were persisting in sewage sludge at treatment plants across the nation and pollutingMinnesota’s freshwater lakes. There’s some evidence that these chemicals may disrupt the body’s hormonal activity. Plus they don’t seem to be more effective at preventing sickness than washing with regular soap and water.

Halden and his colleagues reported their concerns to multiple federal agencies and at a congressional briefing panel. In 2016, the U.S. Food and Drug Administration banned the chemicals from over-the-counter antibacterial washes and soaps.

“We used a million pounds per year of the chemical in the United States but there was no information about what happens to that million pounds once we wash our hands,” Halden says. “This is unfortunately not an isolated case; there are still a lot of chemicals where we need to understand better what happens to them.”

Sewage can also reveal what germs are brewing in a city. “When someone gets sick they shed a huge amount of bacteria or viruses,” Halden says. “Even a few sick individuals create a signal in the sewage, and we can measure that.” Those pathogens can serve as an early warning that an outbreak is at hand. Israel has been using its sewers to monitor polio virus for decades

With climate change and warming temperatures, different pathogens are expected to migrate away from the tropics. “We can actually follow the invasion of Zika virus and other viruses by looking at wastewater,” Halden says. Scientists could also track germs over time to watch for developing antibiotic resistance.

Waste may give a rough sense of a community’s overall health. “When you go to the doctors office you would never think twice about handing your specimen over,” Halden says. Sewage surveillance is a bit like taking a urine or stool sample from an entire city. Scientists could examine how often certain medicines are prescribed, or look for hormones and other chemicals our bodies make that can indicate stress or certain illnesses. Bisceglia and his team have measured cotinine, a breakdown product of nicotine, in Boston wastewater to calculate how many cigarettes the city’s smokers consume per day.

Illegal drugs also leave their mark in sewage. These traces can reveal patterns of use, the emergence of new drugs, or whether law enforcement strategies are working. “If they have a major drug seizure in a particular community, do they actually see that drop in use?” Bisceglia says.

For years, Europe has monitored drugs like cocaine and ecstasy in sewage. A continent-wide network has sampled urine and poop from more than 60 cities and towns. It has started to detect regional patterns—like how cocaine is more popular in southern and western Europe, and ecstasy and cocaine tend to be urban drugs.

Researchers are considering whether sewage might shed some light on the opioid epidemic. Unfortunately, this will be difficult. Heroin is quickly converted into morphine, and morphine in wastewater will be flowing from legal sources like hospitals too. “I can give you exactly how much morphine is in our samples, but telling you where it comes from is difficult,” Burgard says.

Then there’s fentanyl, a synthetic opioid that is 50 to 100 times more potent than morphine. That means people need to use less to get high, and it’s harder to find because the concentration is low. And other opioids can be difficult to pick out too.

Coffee drinkers seem to live longer

Coffe seems like one of those things that scientists can’t make up their minds about. Like chocolate, or whether koalas are cute or terrifying. To be fair, the way reporters cover coffee studies does make it feel like every coffee researcher out there changes their mind every few years. But the medical community has held pretty much the same position for years now: coffee is, if anything, good for you.

The question isn’t whether your caffeine habit is beneficial, the question is how much it actually helps you. And if we’re going by this latest study, published on Monday in the Annals of Internal Medicine, the answer is… not a ton. Yes, it does cut your risk of getting liver cancer. Yes, it seems to protect against various digestive diseases. Maybe it helps you fight cardiovascular disease or even cancer, though those connections are less clear. But the margins of improvement here are fairly tiny. And oh yeah, we’re talking about correlations here. Yes, people who drink coffee tend to live ever-so-slightly longer—but we don’t really know that it’s the coffee that does it. Coffee drinkers could have plenty of other things in common that contribute to health and longevity.

Let’s just give coffee the benefit of the doubt for a moment, though. Let’s say these studies do show a causal effect: drink coffee, live longer. Now we have to look at the size of that effect. In health studies, we do that by looking at something called the hazard ratio. Bear with me, here. It’s simpler than it sounds—and crucial to understanding studies like this one. Suddenly you’ll notice how few stories about superfoods and new health fads actually cite a hazard ratio, even though it’s the standard way to measure health impact. So just stick it out for the next paragraph—it’ll all be worth it.

The latest study features a lot of hazard ratios like that. Digestive diseases and liver cancer were the exceptions, which is why they ended up in headlines. And hey, it’s great that coffee seems to have some impact on those conditions. For liver cancer, the hazard ratio got down to an impressive 0.56 for the highest coffee consumer, with a confidence interval of 0.41–0.77, and the results were similar for digestive diseases. But how many people gets digestive diseases or liver cancer? They’re pretty rare already, and they’re definitely not the common causes of death that most of us have to worry about. And if you’re worried about liver cancer, you’d be better off kicking your alcohol habit than you would be drinking more coffee.

Oh and by the way, tea is pretty much the same story. So whatever your morning beverage of choice is, you’re all set to receive your marginal benefits. Just remember to not put sugar or cream in whatever you drink—the risks associated with obesitywill easily outweigh whatever small benefits you get from your caffeinated beverage.