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Chronic Disease, Public Health, Research, Technology

More evidence that text message programs can help in managing diabetes

mobile_phone_6.16.14Previous research has shown that automated daily text messages can increase medication adherence among diabetic patients and reduce their repeated visits to the emergency room. Now new research offers more evidence that text-message-based programs are an effective tool in helping in those with type 2 diabetes improve their glycemic control.

For the study, researchers from the Scripps Whittier Diabetes Institute partnered with a San Diego-based community clinic providing care to a large percentage of Latino patients with type 2 diabetes. A group of 126 patients were randomly assigned to receive either standard care alone or standard care combined with frequent text messages. According to a release:

Standard care consisted of regular visits with a primary care physician and a brief computerized presentation conducted in English or Spanish that included; diabetes nutrition standards; desired targets for blood sugar, cholesterol and blood pressure; and medications recommended to achieve control.

For the text messaging group, the same standard care was provided but in addition messages were sent to their mobile devices at random times throughout the week. The messages focused on healthy nutrition tips, the benefits of physical activity and medication adherence, and requests to check blood sugar and send back results. Two to three messages were sent each day at the beginning of study enrollment, and the frequency tapered off over a six-month period.

“At the six-month mark, we found that the Dulce Digital [study] participants had a significantly larger decrease in hemoglobin A1c test levels than the control group,” said [Athena Philis-Tsimikas, MD, corporate vice president for the Scripps Whittier Diabetes Institute.]

Noting the promise of mobile phones to aide low-income populations in managing chronic diseases, Philis-Tsimikas said in the release, “We found that by using text messages we were able to circumvent many of the barriers these patients face, such as lack of transportation or childcare, while still being able to expand the reach of diabetes care and education.”

The findings were presented on Friday at the 74th Scientific Sessions of the American Diabetes Association in San Francisco.

Previously: Text message program helps smokers “stay focused on quitting”, Text message reminders shown effective in boosting flu shot rates among pregnant women and Texts may help people with diabetes manage care
Via HealthCanal
Photo by Wolfman-K

Chronic Disease, Patient Care, SMS Unplugged

High yield: Lessons from a 4-year-old

High yield: Lessons from a 4-year-old

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category

AlanIn two days, we take our last exam as first-year medical students. Sitting in the same library that I used to as a pre-medical student, I think about what it is, exactly, that has changed this year. For me, the point of transition from pre-med to med student really happened over Thanksgiving break a few months ago.

I had come home from my first term of medical school more ready for my mom’s hugs and homemade banana bread than ever. People say that the first few terms of medical school are like trying to drink out of a fire hose, because there’s so much information we are expected to learn and retain. On an average week, for example, we have 40 hours of class, not to mention the time we need to study.

Luckily, one of the hardest classes this term had its final the day before Thanksgiving break, so we could go home with some amount of stress alleviated. Biochemistry had been the hardest, least intuitive class for me, and I was relieved it was done – and I was happy to be with my family.

* * *

“So what have you learned in medical school?” my beloved step-dad, Dan, asks excitedly. We’re having our traditional family brunch, with my grandparents, parents and sister, and all the cousins that are around. I look down at my plate, thinking. I’ve learned that the vitamin B12 bottle I can see on our kitchen counter next to the leftover pie contains a unique vitamin because it’s only helpful to two enzymes. I’ve learned how the fatty food that we’re eating kills us, and what that food looks like in dead bodies.

“Diabetes,” I answer, smiling at Dan. “I’ve learned how the two types of diabetes happen.”

“Ah, sí?” my grandmother asks in Spanish. “Debemos invitarle a Bea para que nos enseñes.”

My little 7-year-old cousin, Aida, was diagnosed with type 1 diabetes two years ago. It’s caused quite a stir in my Hispanic family that we can’t feed her quesillo, bread or even fruit without worrying. Her mom, my Aunt Bea, has been plagued with guilt that she did something wrong ever since the diagnosis.

In every family there is that one cute little kid – usually the youngest – whose misbehavior makes all the other kids look like angels. Punishment doesn’t work because they don’t mind being yelled at, discipline doesn’t work because they’re stubborn, and praise doesn’t work because they’re so cute they get attention all the time anyway. If my siblings read this, they’ll nod their heads remembering me as a child. When I hear this description, though, I think of my 4-year-old cousin, Aida’s little brother. He is the most beautiful little child, with big brown eyes, tan skin and dark rusty red hair.

Alan was born when I was already away in college, so I don’t get to see him or his adorable older sisters very much. But here I am now, with Alan and the rest of my family, who gather on the couch after brunch and wait for me to explain to them what’s going on with Aida. I talk with Aida and Bibi, the two little girls, about clean-up cells that got the wrong message in Aida’s body.

I’m asking Aida and Bibi to explain to me what they understood from what I had said when I look over at my aunt to make sure she’s okay. It’s then that I realize that Alan is quiet. It’s the only time that I’ve ever seen him sit quietly, and I see his attention is on me, as well. There’s no way he understood what I was talking about with beta cells and the immune system, but he understands that this is important, and because everyone in his family is focused on it, so is he. In the dynamics of his family, diabetes trumps all other cards.

***

In that moment, my 4-year-old cousin taught me the two most important lessons that I’ve learned so far in medical school. First, that diseases – whether common and rather boring to learn about, or rare and still not understood – affect everyone in the patient’s family. Every family has someone with something, my own included. And, second, everyone whose life is influenced by such diseases looks to doctors more often for support, affirmation and solidarity than anything else. This moment on the couch with my precocious cousin listening to me, this was medicine. And I was becoming a doctor.

Natalia Birgisson is a first-year medical student at Stanford. She is half Icelandic, half Venezuelan and grew up moving internationally before coming to Stanford for college. She is interested in neurosurgery, global health, and ethics. Natalia loves running and baking; when she’s lucky the two activities even out.  

Photo of Alan Higuery by Beatriz Royo Higuerey

Chronic Disease, Parenting

“I’d rather bury my child than leave him behind”: Mother of developmentally disabled child on redefining parenthood

"I'd rather bury my child than leave him behind": Mother of developmentally disabled child on redefining parenthood

As a mom of two, I found myself doing a double-take when I came across a recent Huffington Post headline: “Bury My Son Before I Die.” In the moving, difficult-to-read (and, presumably difficult-to-write) piece, the mother of a boy with lissencephaly who is “developmentally… like an infant in a 15-year-old body” describes caring for him and worrying what might happen to him as he grows older. “It goes against everything we believe about motherhood, but I’d rather bury my child than leave him behind,” she writes, before going on to explain:

I used to worry about Benjamin dying, but now, 15 years in, I worry about him surviving beyond my husband and me. Only we have comforted Benjamin through daily seizures and seven surgeries. We are his one true voice. No one can understand Benjamin the way we do.

I have learned to embrace motherhood with brutal honesty. I don’t actually want to see my son take his last breath. I don’t want to know life without him. For as long as I live, I will do whatever I can to keep Benjamin healthy and give him the best possible quality of life. His happiness is my happiness. He is no less than anyone else, deserves every right and consideration. As Benjamin’s advocate I can guarantee a strong proactive force. When I’m gone, I can do no more.

Chronic Disease, Health Costs, Health Policy, Nutrition, Obesity, Stanford News

Study shows banning soda purchases using food stamps would reduce obesity and type-2 diabetes

Study shows banning soda purchases using food stamps would reduce obesity and type-2 diabetes

soda

In the late 1800s and early 1900s, carbonated beverages such as Coca-Cola, Dr Pepper and 7UP were sold as nerve tonics and health drinks. But, we now know that sugary sodas contribute to obesity, type-2 diabetes and cavities. Still, most Americans drink more soda than they like to admit.

Even though sugar-laden soft drinks have no nutritional value, they are still eligible for food stamps. Nutrition researchers and some politicians have advocated for a ban on buying sugar-sweetened drinks with food stamps but the U.S. Department of Agriculture, which runs the program, is under tremendous pressure from beverage company lobbyists to keep the existing regulations.

Sugary drinks are especially concerning because too many liquid calories put consumers at a higher risk of developing type-2 diabetes. Some nutrition experts are concerned that taxpayers are subsidizing an unhealthy diet, which will result in higher medical costs for Medicare and Medicaid down the road, when food stamp recipients experience the health problems associated with obesity and diabetes.

In a new study (subscription required) published in this month’s Health Affairs, Sanjay Basu, MD, PhD, an assistant professor of medicine at the Stanford Prevention Research Center, and his colleagues created a computer model to simulate the effects of a soda ban on the health of food stamp recipients. They found that obesity would drop by 1.12 percent for adults, and by 0.41 percent for children, affecting about 281,000 adults and 141,000 children. Type-2 diabetes would also drop by 2.3 percent.

The researchers also calculated the effects of reimbursing participants 30-cents for each dollar spent on fruits and vegetables. The subsidy did not affect obesity or diabetes rates, but doubled the number of people who ate the recommended number of fruits and vegetables each day. A county in Massachusetts tried the same reimbursement system as part of the USDA’s Healthy Incentives pilot study, and saw a similar increase in the fruit and vegetable purchases of food stamp recipients.

“It’s really hard to get people to eat their broccoli,” said Basu in a press release. “You have to make it really cheap, and even then, sometimes people don’t know what to do with it.” But, with one in seven Americans receiving food stamps, he points out that these small changes can have wide-ranging effects.

“It’s very rare that we can reach that many people with one policy change and just one program.”

Patricia Waldron is a science writing intern in the medical school’s Office of Communication & Public Affairs.

Previously: Food stamps and sodas: Stanford pediatrician weighs inCan food stamps help lighten America’s obesity epidemic? and Stanford’s Sanjay Basu named a Top Global Thinker of 2013
Photo by Andy Schultz

Chronic Disease

Living with Ehlers-Danlos Syndrome: “Sometimes I just don’t have it in me to be inspirational”

We’ve partnered with Inspire, a company that builds and manages online support communities for patients and caregivers, to launch a patient-focused series here on Scope. Once a month, patients affected by serious and often rare diseases share their unique stories; this month’s bonus column comes from previous contributor Michael Bihovsky.

I have a connective tissue disorder named Ehlers-Danlos Syndrome. It’s a genetic collagen defect that results in super lax ligaments and tendons, creating frequent joint dislocations, cartilage tears, chronic muscle spasms, and much more. May is Ehlers-Danlos Awareness Month.

Every EDS patient knows that one of the hardest parts of our day is the moment we open our eyes and waken into the reality of our bodies

Usually I take this opportunity to say something inspiring, about how my illness has changed me for the better and given me a clear purpose in life for both the work I do and the person I want to be. While all these things are true, the fact is that sometimes I’m in a physical state where I just don’t have it in me to be inspirational. And that’s all right – inspirational words are meaningless without the context of genuine human struggle. So, if you’re interested – and if you’ll bear with me – I’d like to take this opportunity to talk about EDS in its rawest sense, and to do my part to tell you about the very serious disease it is.

When I was a child, I got sick… and I never got better. And I never will. When I was finally diagnosed with EDS, it was made clear to me that there was no cure for my condition. The best we could do was try to manage and slow the symptoms – symptoms that were pretty much guaranteed, in the long run, to get worse. I have done the best I can with this knowledge. I’ve tried to make the most of the life I’ve been given, and whenever possible to keep a smile on my face and hope in my heart. But it’s been very hard. Every EDS patient knows that one of the hardest parts of our day is the moment we open our eyes and waken into the reality of our bodies, stirred from dreams of ourselves as we used to be, and the futures we imagined we’d have.

EDS is considered a rare disease, but every year the suspected percentage of those afflicted rises dramatically. The disease is notoriously underdiagnosed because doctors themselves don’t usually know about it, and are only able to start diagnosing patients when a textbook case (such as myself) walks into their office and physically demonstrates what it is. The devastating irony is that EDS is actually one of the simplest diseases to diagnose – all you really need is a protractor, and an online guide to a system of criteria known as the Beighton Scale. Then take this to your doctor for confirmation. When I performed these tests on myself a few years ago and then went to my doctors asking “What do you know about Ehlers-Danlos Syndrome?”, the deer-in-the-headlights look was as unanimous as it was unnerving.

So for anyone out there suffering from chronic pain, or other strange symptoms, please look into this. Or if you have a friend in physical distress, please pass on this information. EDS is a scary and challenging diagnosis, but the consequences of not knowing are far greater than that of a correct diagnosis. EDS symptoms can range from the very mild to the extremely severe. One thing is certain, though: If I had received a diagnosis back when my symptoms were mild, I would be living a very different life now. Every single day, in my struggle to actualize the person I still can be, I cannot help but mourn the person I could have been.

To the many people out there reading this who have EDS, or any other chronic illness, “invisible” or not – thank you for being my brothers and sisters. Take care of yourselves, and take care of each other. And remember that healing others may very well be the clearest path to healing ourselves.

Michael Bihovsky is a musical theater composer and performer, and an “invisible illness” advocate. He is best known for his viral YouTube video “One Grain More,” a musical parody of Les Miserables about the plight of the food allergy community. Michael has also written an original musical, “Fresh!,” which tells the semi-autobiographical story of a group of college freshmen overcoming physical and emotional adversity amidst the craziness of college, and he is currently writing a book titled “Live Because: The Philosophy of the Broken, and the Journey Toward Wholeness.” For more information, visit www.livebecause.com.

Previously: “Live Because:” Living a fuller life with chronic illness

Chronic Disease, Health Costs, Health Policy, Research, Stanford News

Keeping kidney failure patients out of the hospital

Keeping kidney failure patients out of the hospital

Keeping kidney patients healthy enough to stay out of the hospital certainly sounds like a good thing – both for the patients and the economy. Now there’s scientific evidence to show how this can be done.

Reducing hospital readmissions was a focus of the the Affordable Care Act, and Kevin Erickson, MD, an instructor in nephrology at Stanford, decided to study a group of patients who are often hospitalized. He and his colleagues examined whether an additional doctor’s visit in the month after hospital discharge would help keep kidney-failure patients on dialysis from being readmitted. He and his colleagues analyzed data collected between 2004-2009 by the United States Renal Data System, a national registry of nearly all end-stage renal disease patients in the country.

It’s nice to find something that may generate both cost savings and better health outcomes

Results showed that there was a significant reduction in hospital readmissions with that extra doctor’s visit in the month after hospital discharge. And while the percentage doesn’t sound all that significant – 3.5 percent -  in real numbers that translates to 31,370 fewer hospitalizations and $240 million per year saved, according to the study published this month in the Journal of the American Society of Nephrology.

“It’s nice to find something that may generate both cost savings and better health outcomes,” Erickson told me. “Patients with end-stage renal disease suffer from poor quality of life. Some of that I suspect is related to multiple trips in and out of the hospital.”

Patients with kidney failure are at a particularly high risk of hospital readmission: In 2009 patients getting dialysis were admitted to the hospital nearly two times per year, 36 percent of whom were rehospitalized within 30 days, according to the study.

Previously: Study shows higher Medicaid coverage leads to lower kidney failure rates; Study shows higher rates of untreated kidney failure among older adults; Study shows daily dialysis may boost patients’ heart function, physical health.

Chronic Disease, Health Policy, Nutrition, Obesity, Pediatrics, Videos

Fed Up: A documentary looks for answers about childhood obesity

Fed Up: A documentary looks for answers about childhood obesity

I can’t wait to see Fed Up, a new documentary about childhood obesity.

In the early 2000s, when I was earning a PhD in nutrition at UC Davis, I heard a lot of scientific debate about possible causes of the U.S. obesity epidemic. Was it too much fat in our diets? Too much sugar? Processed food? Junk food ads on TV? An “obesogenic environment” – one in which snacks are ubiquitous, adults drive everywhere and neighborhoods aren’t safe enough for kids to play outside?

Or was it something else?

“The message has been pushed on us: It’s your fault you’re fat,” says Mark Hyman, MD, chair of the Institute for Functional Medicine, in the Fed Up trailer above.

The movie assembles an impressive roster of experts in nutrition research, pediatric health and public advocacy to oppose that message. Michael Pollan, Mark Bittman, Robert Lustig, Marion Nestle, Harvey Karp, former President Bill Clinton and others say we should not be blaming individuals – especially kids – for struggles with their weight. Instead, they are taking a hard look for answers at the food environment.

“This is the first generation of American children expected to lead shorter lives than their parents,” says a voice-over in the Fed Up trailer. That definitely makes untangling the causes of the obesity epidemic worthy of the efforts of our best scientists. Like I said, I can’t wait to see it.

Previously: Childhood obesity a risk for imminent heart problems, research shows, Using hip hop to teach children about healthy habits and Sugar intake, diabetes and kids: Q&A with a pediatric obesity expert
Via Food Politics

Chronic Disease, Clinical Trials, Pediatrics, Research

New research shows how to keep diabetics safer during sleep

New research shows how to keep diabetics safer during sleep

sleeping girlLife with type 1 diabetes requires an astonishing number of health-related decisions – about 180 per day. But patients’ vigilant monitoring of their daytime blood sugar, food intake, insulin and activity levels is perhaps less exhausting than the worries they face about getting a safe night’s sleep. During sleep, diabetics often fail to sense when their blood glucose veers too low. Low blood sugar levels can cause seizures and even, in rare cases, death.

“At night you lose control,” said Bruce Buckingham, MD, a pediatric endocrinologist who treats children with diabetes at Lucile Packard Children’s Hospital Stanford. “It’s when things can happen.” Among children with diabetes, about 75 percent of hypoglycemic seizures occur at night, he said.

That’s why Buckingham and his colleagues across the United States and Canada have been testing various methods to automate blood sugar control during sleep. Our press release on their new research describes an approach that could make a big difference – automated shut-offs of patients’ insulin pumps to keep their sugar levels above the hypoglycemia danger zone:

The new study, which [appeared] online May 7 in Diabetes Care, coupled a glucose sensor worn under the skin to an insulin pump that was connected wirelessly to a computer at the bedside. The computer ran an algorithm that calculated when a low blood-sugar level might occur and then temporarily suspended insulin delivery until the sugar level was trending upward. This occurred without waking the patient. The shutoffs reduced the cumulative time patients spent with low blood sugars during sleep by 81 percent, with only a minimal increase in nighttime glucose levels.

“A system like this should dramatically decrease diabetics’ risk of having a seizure overnight,” said Bruce Buckingham, MD, professor of pediatric endocrinology at Stanford, who led the trial and is a co-author of the study. “Patients and parents will be able to have a better night’s sleep, knowing that there is a much lower risk of severe hypoglcyemia at night.”

During the study, the researchers monitored close to 2,000 nights of sleep in 45 people with type 1 diabetes. The patients, who were 15 to 45 years of age, slept in their own homes and didn’t know ahead of time which nights their insulin pumps could be shut off by the computer and which nights their pumps operated normally. Several measures of hypoglycemia indicated that patients were safer on treatment versus control nights. Morning blood sugar levels were slightly higher after treatment nights, but still within the healthy range.

To get a sense of what the results mean for patients and their families, I spoke with Jack Leguria, whose 14-year-old daughter, Rosa, has had type 1 diabetes for almost 10 years. Rosa participated in the second phase of Buckingham’s research, which is now testing whether the benefits his team documented for older teenagers and adults will extend to children as young as 3. Seeing the new technology in action was exciting for Rosa and her parents.

“This is going to be life-altering for us,” Leguria said. “In four years, Rosa will be ready for college. For a child with type 1 diabetes who is not able to recognize low blood sugar at night, that’s a very difficult prospect for us.”

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Chronic Disease, Orthopedics, Pain

Finding relief from lower back pain

lower back painIf you thought a pain in the neck was inconvenient, try on chronic lower back pain for size. (Just kidding – both sound uncomfortable.) In a recent article, Prevention magazine suggests easily administered treatments for the latter kind of pain. Tips include paying attention to your body by noticing if you pronate your feet, taking action by attending yoga classes, and winding down with massage or acupuncture sessions.

Recognizing that back pain’s sometimes intractable nature can cause stress in other forms, the piece continues:

No, the pain isn’t in your head. But what is in your head could be making it worse. “Fear, anxiety, and catastrophizing can amplify pain,” says [Stanford anesthesiologist Sean Mackey, MD, PhD]. “People often get swept up in thoughts like This will never get better.” Because brain circuits that process pain overlap dramatically with circuits involved with emotions, panic can translate into actual pain. Cognitive-behavioral therapy helps you recognize and reframe negative thoughts. Deep breathing can help, too, as can simply shining a light on dark thoughts. “Start by accepting that you have pain,” Mackey says. “Then say to yourself, It will get better.”

Previously: Stanford researchers address the complexities of chronic painExploring the mystery of painExploring the use of yoga to improve the health and strength of bones and Ask Stanford Med: Pain expert responds to questions on integrative medicine
Via @StanfordHosp
Photo by U.S. Army

Autoimmune Disease, Chronic Disease, Clinical Trials, Patient Care

Two decades with scleroderma: How I find answers to hard-to-solve questions

The day I was diagnosed with scleroderma 21 years ago was devastating for my parents and me, to say the least. I was 15 years old and I remember thinking: I have what? Scleroderma? What is that? Can you spell that?

Not much was known about the disease and, since the Internet was in its infancy, we couldn’t simply Google “scleroderma” to learn more about it or find support groups. There was no one to bounce off ideas with. My father, who was a diligent researcher, consulted medical textbooks. Meanwhile, my mother, who was born with the “gift of gab,” sought information from anyone and everyone who crossed her path. But ultimately we were forced to rely heavily on doctors’ recommendations, which sadly were pretty gloomy and a bit much for a teenager to handle.

Fast forward to today. When I have a question, I connect with my local chapter of the Scleroderma Foundation, either by e-mailing a board member or by attending a support group meeting. I also go online to the Raynauds Association, Scleroderma Foundation and Pulmonary Hypertension Association. Above all it’s important to find a rheumatologist who is not only knowledgeable about scleroderma, but has a good grasp of its complexities and is willing to help you get the results you need. Trust me – they are out there!

Back in 2004, I decided it was time to get a new rheumatologist. I asked around for recommendations from my personal network and a friend with rheumatoid arthritis suggested I see her physician. Before meeting the doctor, I looked at his online reviews from other patients and his curriculum vitae to get a sense of his academic and professional experience and achievements. When meeting with a new physician, it’s important to ask if she/he has treated other scleroderma patients, gauge their knowledge of clinical trials, find out if they are up to date on the medications being used to treat the different facets of the disease, and make sure they understand the importance of certain annual tests.

When I switched rheumatologists, I had a particular problem I needed to solve. For the most part my illness had become stable, but I had one pesky ulcer that was truly relentless! I tried various calcium channel blockers, ACE Inhibitors, and Vasodilators, and nothing worked. The infections were getting out of control, even though I did my best to stay on top of it. My frustration reached a point where I asked my doctor to “please, remove the first flange of my index finger.” Thankfully he refused and said, “No, we’re not going to give up.”

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