Category Archives: Well-Being – PersonaL

Well-Being, Personal Well-Being, Health, Obesity, Chronic Disease, Healthy eating, healthy drinking, healthy cooking, physical exercise, Prevention, Predictive Medicine, Genomics, Personalization, Forecasting, Public Policy, Assessment, Diagnostics, Adaptive Health Systems Design, Medicare, Obamacare, Active, Healthy Living

SmartWatch Technology Reliably Detects Afib

The quantified self movement strikes again!

CREDIT: Cleveland Clinic Article on Detection of Afib via SmartWatch

Smartwatch Technology Reliably Detects Afib Prior to Cardioversion
Study suggests a role for KardiaBand when paired with physician review

A newly FDA-approved smartwatch accessory can record heart rhythm and successfully differentiate atrial fibrillation (AF) from normal sinus rhythm (SR) through an automated algorithm, according to a Cleveland Clinic investigation. The study, which will be presented March 11 at the American College of Cardiology’s 67th Scientific Session, also showed that the accuracy of interpretation gets even better when the accessory is supported by physician review.
The findings suggest that the wearable technology, known as KardiaBand™, can help screen patients before presentation for elective cardioversion to avoid unnecessary procedures, among other potential uses.
KardiaBand, which consists of a software app for an Apple Watch® and a sensor band that replaces one of the watch’s straps, provides a 30-second recording of an ECG rhythm strip when the wearer places a thumb on the sensor band. The app contains an algorithm for automated detection of AF.
“Our objective was to determine how accurately KardiaBand and its algorithm can differentiate AF from sinus rhythm compared with physician-interpreted 12-lead ECGs,” says senior author Khaldoun Tarakji, MD, MPH, a Cleveland Clinic electrophysiologist. In November 2017, the device became the first smartwatch healthcare accessory to be approved by the FDA, “but we wanted to test it ourselves to determine how well it would perform in clinical practice,” Dr. Tarakji explains.
Study essentials
To that end, he and Cleveland Clinic colleagues prospectively enrolled 100 consecutive patients (mean age, 68 ± 11 years) with chronic AF who were scheduled to undergo cardioversion. Upon presenting for the cardioversion procedure, all patients were given a KardiaBand-equipped smartwatch and trained in its use, after which they underwent traditional ECG assessment and a 30-second KardiaBand recording. If cardioversion was still indicated, they underwent ECG and KardiaBand testing after the procedure. KardiaBand recordings were then compared with the physician-reviewed ECGs and also reviewed by two blinded electrophysiologists, with these readings compared to ECG interpretations.
Eight patients did not undergo cardioversion because they presented in SR; these patients were excluded. Among the remaining patients, a total of 169 pairs of ECG and KardiaBand recordings were available for comparison (each patient had two before and two after cardioversion).
Key findings
• Of the 169 pre-cardioversion KardiaBand recordings, 57 fell out as “unclassified,” meaning that the KardiaBand algorithm did not draw a conclusion of either AF or SR.
• Among the remaining 112 pairs of recordings, the reviewing electrophysiologists determined that the KardiaBand algorithm correctly detected AF with 93 percent sensitivity and 84 percent specificity compared with ECG.
• When the blinded reviewers bypassed the automated algorithm and interpreted each patient’s KardiaBand strips against his or her ECG, sensitivity rose to 99 percent and specificity was 83 percent. Further, in the 57 unclassified cases, the reviewers were able to use the strips to correctly diagnose AF versus SR with 100 percent sensitivity and 80 percent specificity.
“This study shows that KardiaBand provides excellent sensitivity and good specificity in identifying AF,” says Dr. Tarakji. “The numbers improve further with physician overview of these recordings, indicating that even unclassified KardiaBand strip recordings could be of value to reading physicians.”
Smart devices demand smart use
KardiaBand carries the benefit of enabling patients to record their rhythm at any time, as opposed to only when they are wearing a Holter monitor or at a physician’s office. “We can catch intermittent episodes when they happen, and we’re not limited to a specific duration of monitoring time,” Dr. Tarakji says. He adds that wearable devices like this can also reduce time spent responding to false alarms if a recording taken at the same time shows normal rhythm.
Yet many questions remain about how KardiaBand and similar products may ultimately be used in practice. Dr. Tarakji cites a few examples:
• Which patients are best suited to this technology? For many patients dealing with AF, KardiaBand can provide reassurance when they need it. But for others, having constant access to their ECG data may lead them to check their rhythm obsessively, raising anxiety. “In general, however, patients value the instant feedback they get,” Dr. Tarakji observes.
• Do physicians have the IT infrastructure in place to make these devices part of their practice? Wearable devices can mean a flood of event reports to clinicians’ email boxes. At Cleveland Clinic, information from patients’ KardiaBands bypasses the email system and feeds into a cloud-computing platform that physicians can access anytime.
• How should clinicians respond to short episodes, particularly in asymptomatic patients? “We currently have a gap in our clinical knowledge about whether brief, random episodes that are asymptomatic warrant anticoagulation or not,” Dr. Tarakji explains, adding that ongoing studies are trying to address this important question.
“Future studies will focus on how we can use these smart devices intelligently to make sure they’re improving quality of care rather than just producing noise for physicians,” he observes.
A parallel goal, he says, is to ensure that the devices provide value by making care delivery more efficient. Noting that patients currently need to pay for KardiaBand out of pocket, Dr. Tarakji says that “developing a richer body of research evidence is the best way we can demonstrate cost-effectiveness to healthcare payers.”
Tech like this can’t be ignored
Indeed, KardiaBand could prove cost-effective by allowing patients who are in SR to avoid needless trips for elective procedures, such as in the case of the eight patients in the study who were found to be in SR when they presented for cardioversion and did not require the procedure. Other potential uses of KardiaBand for the longitudinal management of AF patients could well prove cost-effective too.
Regardless of how quickly such cost-effectiveness evidence may come, Dr. Tarakji says clinicians cannot be passive in the face of technologies like KardiaBand. “Patients will come to us with new products, and we can’t turn away,” he observes. “We need to test these products and find ways of responding to the information they deliver in a way that improves patient outcomes, all while remaining mindful of both patient and physician satisfaction.”
The researchers report that KardiaBand’s manufacturer, AliveCor, provided smartwatches for the study but was not involved in the study’s design, implementation, data analysis or interpretation.

Well-Being – Real Time Revisited

NOTE: This post revisits a post titled “Well-Being Real Time”. The original post was May, 2014, and can be found at: http://johncreid.com/2014/05/well-being-real-time/.

Well-Being – Real Time Revisited

Well-being is arguably the central mega-trend of the 21st century. As we look to the future, we have an obligation to “unpack” this dense concept, and find its essential component parts.

We describe these components here as “ACE” – ACT, CARE, and EAT. The wish we have for ourselves and for others is to be well. “Be Well” is our salutation and our call to actions.

How far out are we looking?

The future is now. ACE is here – together with real time measuring and monitoring. ACE is our pathway to greater and greater levels of personal well-being.

ACE measuring and monitoring will be supported by all elements of the quantified self movement. FitBit, Apple Watch, and so many other new monitoring devices will allow us to to bring personal well-being into a real-time modality.

ACE represents three pillars, each deceptively simple:

A – ACT: ACT is short for activity. The call to action is “stay active”. Well-being activity has physical activity at its center, but the pillar also embraces social activity, and activities of the mind. Staying active is a critical element of being well.
C – CARE: CARE is short for well-being care. The call to action is “care for yourself” and “care for others.”Well-being care of course has health care at its center, but there is so much more. e.g. genomics, massage, essential oils, acupuncture, etc. “Caring for myself” and “Caring for others” are elements of this pillar. “Preventive care” regular check-ups, colonoscopies after age 50, mammograms, pre-natal care for expecting mothers, etc.
E – EAT: EAT is short for eating and drinking. The call to action is “Eat well.” Well-being eating is the exploration of how what we eat and drink contributes to our well-being.

As simple as these pillars appear, each is complex: deep enough for a life-time of focus. Each represents bodies of research, skills, capabilities, and areas of professional endeavor. All together, these pillars represent pathway that each of us will follow as we attain greater and greater levels of personal well-being.

Discussion:

ACT

A – ACT (walking, running, calories burned etc)

Staying active is a critical element of being well. Well-being activity has physical activity at its center: sports, walking, lifting, climbing, yoga, and all of the other activities that light up a FitBit. The pillar also embraces activity of other kinds, e.g. social activity, and activities of the mind.

CARE

Well-being care is all about promoting health. Of course, it has health care at its center, but there is so much more. e.g. mental health, addictive behaviors, massage, genomics, essential oils, acupuncture, etc.

“Caring for myself” and “Caring for others” are elements of this pillar. “Preventive care”, eldercare and aging, palliative care are included, but so are regular check-ups, colonoscopies after age 50, mammograms, pre-natal care for expecting mothers, etc.

The ability to routinely monitor vital signs at home or at the office will be a part of this pillar. Lab work – including saliva, blood, and stool samples, will be more real time, more regular and less expensive. These trends will be one of the keys to progress in the care pillar. On the innovation side of this pillar will be many technologies, but breakthroughs in genomics will certainly be high on the list. Telemedicine is another innovation that will alter access to well-being care.

Predictive modeling will be more relevant than never. Am I headed for pre-diabetes? If so, what evidence shows me a path to avoid that condition?

CARE-MMEDS (what MEDS I take, what compliance I have, etc)

CARE-RResting Metabolic Rate (calories burned at rest)

CARE-VVITALS (pulse, BP, etc)

CARE-LLABS (blood testing, etc)

CARE-SSleep (duration, deep sleep, etc)

EAT

EAT is short for eating and drinking. The call to action is “Eat well.”

Well-being eating is the exploration of how what we eat and drink contributes to our well-being. Naturally, there is a social element, where eating and drinking together makes the experience more fulfilling. There is a physiological element, having to do with ingestion, osmosis, calories, glucose and glycogen, enzymes, etc. There is a psychological element, related to the feelings of satiety, or hunger, or thirst, and their related cravings. There is a sensory element, where sweet and sour contrasts, aromas, and their related metaphorical associations, play a part.

Eating delicious food and drink with friends is certainly a component. But achieving a balanced diet, with moderation as a central tenant,

On the one hand, this pillar is ancient. For thousands of years, elders have taught daughters and sons how to cook well. and cooking techniques have evolved

On the other hand, this pillar is ripe for innovation. The new breakthrough science related to the micro-biome is a part.

EATS (what I eat and drink, especially calories)

Implications

Monitoring all components of ACE (MEDS, Activity, Resting Metabolism,VITALS, EATS, LABS, Sleep) is now going to accelerate at an exponential rate.

There will be three settings where ACE monitoring will accelerate:

Employees in Workplaces: Employers will offer employees routine monitoring as part of employee benefits and/or health insurance.
Residents in Communities: Communities will offer residents routine monitoring as one of their amenities. Wellbeing facilities and programs will become as important as golf courses and swimming pools. Look for HOA’s,Condo and Coop associations, and subdivision developers to increasingly view MARVELS as critical to “place-making”.
Clients of service-providers: Hotels, spas, assisted-living centers, nursing homes, and many others will increasingly offer MARVELS monitoring as one of their base services.

The Privacy Imperative will be the critical success factor for all of these pushes into the future. It is foundational.

Without it, there will be no progress.

With it, personalized, real-time care will flourish. Each individual will be able to opt-in to his care-coaching community (and to opt-out whenever they choose), and get the extraordinary benefits that such a community can provide.

Want to talk to your well-being coach? FaceTime them, and they – with your permission – will help you sort out what’s going on with you.

Feel like you might need a check-in with a doctor? Send them an email – with your ACE history embedded in it, or get them on the phone or FaceTime, and see if they need you to come in.

The future is now.

BEWELL Centers will be everywhere. Look for:

DWELL CENTERS (part of BEWELL Centers) – for community ACE measuring and monitoring support. Target population is neighbors in the community.

Employee BEWELL CENTERS (part of BEWELL Centers) – for employees in workplaces ACE measuring and monitoring support. Target population is employees in the workplace.

CLIENT BEWELL CENTERS (Part of BEWELL Centers – for service-providers ACE measuring and monitoring support.Target population is clients of the service provider.
(Walgreens and CVS are already moving aggressively in this direction>

References:
The Privacy Imperative
LABS revolution
LABS By Disease
Quantified Self Movement

Amazon, BH, JPMorgan

With 1.2 million employees, Amazon, Berkshire Hathaway, and JP Morgan have decided to venture together into health care for their employees.

Following in the grand tradition of Henry Ford, who set up Henry Ford Hospital in Detroit, these three giants are stepping in too.

They have no illusions about how difficult it will be. But with premiums rising 19% per year, its clear that Congress is doing nothing, and someone has to do something.

“Planning for the new company is being led by Marvelle Sullivan Berchtold, a JPMorgan managing director who was previously head of the Swiss drugmaker Novartis’s mergers and acquisitions strategy; Mr. Combs; and Beth Galetti, a senior vice president at Amazon.”

The article points out that there are others working on this.

“Robert Andrews, chief executive of the Healthcare Transformation Alliance, a group of 46 companies, including Coca-Cola and American Express, that have banded together to lower health care costs.”

“Walmart contracted with groups like the Cleveland Clinic, Mayo and Geisinger, among others, to take care of employees who need organ transplants and heart and spine care.”

“Caterpillar, the construction equipment manufacturer, sets its own rules for drug coverage, which it has said saves it millions of dollars per year, even though it still uses a pharmacy benefit manager to process its claims.”

Suzanne Delbanco, the executive director for the Catalyst for Payment Reform, a nonprofit group that mainly represents employers”

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CREDIT: https://www.nytimes.com/2018/01/30/technology/amazon-berkshire-hathaway-jpmorgan-health-care.html?smid=nytcore-ipad-share&smprod=nytcore-ipad

TECHNOLOGY
Amazon, Berkshire Hathaway and JPMorgan Team Up to Try to Disrupt Health Care

By NICK WINGFIELD, KATIE THOMAS and REED ABELSON
JAN. 30, 2018
SEATTLE — Three corporate behemoths — Amazon, Berkshire Hathaway and JPMorgan Chase — announced on Tuesday that they would form an independent health care company for their employees in the United States.

The alliance was a sign of just how frustrated American businesses are with the state of the nation’s health care system and the rapidly spiraling cost of medical treatment. It also caused further turmoil in an industry reeling from attempts by new players to attack a notoriously inefficient, intractable web of doctors, hospitals, insurers and pharmaceutical companies.
It was unclear how extensively the three partners would overhaul their employees’ existing health coverage — whether they would simply help workers find a local doctor, steer employees to online medical advice or use their muscle to negotiate lower prices for drugs and procedures. While the alliance will apply only to their employees, these corporations are so closely watched that whatever successes they have could become models for other businesses.

Major employers, from Walmart to Caterpillar, have tried for years to tackle the high costs and complexity of health care, and have grown increasingly frustrated as Congress has deadlocked over the issue, leaving many of the thorniest issues to private industry. About 151 million Americans get their health insurance from an employer.
(Why will health care be so difficult for these companies to untangle? Analysis from The Upshot.)
But Tuesday’s announcement landed like a thunderclap — sending stocks for insurers and other major health companies tumbling. Shares of health care companies like UnitedHealth Group and Anthem plunged on Tuesday, dragging down the broader stock market.

That weakness reflects the strength of the new entrants. The partnership brings together Amazon, the online retail giant known for disrupting major industries; Berkshire Hathaway, the holding company led by the billionaire investor Warren E. Buffett; and JPMorgan Chase, the largest bank in the United States by assets.

They are moving into an industry where the lines between traditionally distinct areas, such as pharmacies, insurers and providers, are increasingly blurry. CVS Health’s deal last month to buy the health insurer Aetna for about $69 billion is just one example of the changes underway. Separately, Amazon’s potential entry into the pharmacy business continues to rattle major drug companies and distributors.
(Here’s a look at how the even the threat of Amazon’s entry into an industry can rattle stocks.)

The companies said the initiative, which is in its early stages, would be “free from profit-making incentives and constraints,” but did not specify whether that meant they would create a nonprofit organization. The tax implications were also unclear because so few details were released.
Jamie Dimon, the chief executive of JPMorgan Chase, said in a statement that the effort could eventually be expanded to benefit all Americans.

“The health care system is complex, and we enter into this challenge open-eyed about the degree of difficulty,” Jeff Bezos, Amazon’s founder and chief executive, said in a statement. “Hard as it might be, reducing health care’s burden on the economy while improving outcomes for employees and their families would be worth the effort.”

The announcement touched off a wave of speculation about what the new company might do, especially given Amazon’s extensive reach into the daily lives of Americans — from where they buy their paper towels to what they watch on television. It follows speculation that the company, which recently purchased the grocery chain Whole Foods, might use its stores as locations for pharmacies or clinics.
(We asked health care experts to imagine what the three corporations might do.)

“It could be big,” Ed Kaplan, who negotiates health coverage on behalf of large employers as the national health practice leader for the Segal Group, said of the announcement. “Those are three big players, and I think if they get into health care insurance or the health care coverage space, they are going to make a big impact.”

TAKING ON ‘THE HUNGRY TAPEWORM’
A look at the three companies that announced a joint health care initiative on Tuesday.

Total employees: 1.2 million 
Amazon: 540,000 
Berkshire Hathaway: 367,000
JPMorgan Chase: 252,000.
Individual strengths 
Amazon: logistics and technology
Berkshire Hathaway: insurance
JPMorgan Chase: finance.

Jeff Bezos of Amazon:
“The healthcare system is complex, and we enter into this challenge open-eyed about the degree of difficulty.”
Warren E. Buffett of Berkshire Hathaway:
“The ballooning costs of healthcare act as a hungry tapeworm on the American economy. Our group does not come to this problem with answers. But we also do not accept it as inevitable.”
Jamie Dimon of JPMorgan Chase:
“The three of our companies have extraordinary resources, and our goal is to create solutions that benefit our U.S. employees, their families and, potentially, all Americans.”

But others were less sure, noting that the three companies — which, combined, employ more than one million people — might still hold little sway over the largest insurers and pharmacy benefit managers, who oversee the benefits of tens of millions of Americans.

“This is not news in terms of jumbo employers being frustrated with what they can get through the traditional system,” said Sam Glick of the management consulting firm Oliver Wyman in San Francisco. He played down the notion that the three partners would have more success getting lower prices from hospitals and doctors. “The idea that they could have any sort of negotiation leverage with unit cost is a pretty far stretch.”

Even the three companies don’t seem to be sure of how to shake up health care. People briefed on the plan, who asked for anonymity because the discussions were private, said the executives decided to announce the initiative while still a concept in part so they can begin hiring staff for the new company.

Three people familiar with the partnership said it took shape as Mr. Bezos, Mr. Buffett, and Mr. Dimon, who are friends, discussed the challenges of providing insurance to their employees. They decided their combined access to data about how consumers make choices, along with an understanding of the intricacies of health insurance, would inevitably lead to some kind of new efficiency — whatever it might turn out to be.

“The ballooning costs of health care act as a hungry tapeworm on the American economy,” Mr. Buffett said in the statement. “Our group does not come to this problem with answers. But we also do not accept it as inevitable.”

Over the past several months, the three had met formally — along with Todd Combs, an investment officer at Berkshire Hathaway who is also on JPMorgan’s board — to discuss the idea, according to a person familiar with Mr. Buffett’s thinking.

The three chief executives saw one another at the Alfalfa Club dinner in Washington on Saturday, but by then each had already had dozens of conversations with the small in-house teams they had assembled. The plan was set.

Mr. Buffett’s motivation stems in part from conversations he has had with two people close to him who have been diagnosed with multiple sclerosis, according to the person. Mr. Buffett, the person said, believes the condition of the country’s health care system is a root cause of economic inequality, with wealthier people enjoying better, longer lives because they can afford good coverage As Mr. Buffett himself has aged — he is 87 — the contrast between his moneyed friends and others has grown starker, the person said.

The companies said they would initially focus on using technology to simplify care, but did not elaborate on how they intended to do that or bring down costs. One of the people briefed on the alliance said the new company wouldn’t replace existing health insurers or hospitals.

Planning for the new company is being led by Marvelle Sullivan Berchtold, a JPMorgan managing director who was previously head of the Swiss drugmaker Novartis’s mergers and acquisitions strategy; Mr. Combs; and Beth Galetti, a senior vice president at Amazon.

One potential avenue for the partnership might be an online health care dashboard that connects employees with the closest and best doctor specializing in whatever ailment they select from a drop-down menu. Perhaps the companies would strike deals to offer employee discounts with service providers like medical testing facilities.

“Each of those companies has extensive experience using transformative technology in their own businesses,” said John Sculley, the former chief executive of Apple who is now chairman of a health care start-up, RxAdvance. “I think it’s a great counterweight to what government leadership hasn’t done, which is to focus on how do we make this health care system sustainable.”

How Amazon Rattles Other Companies
The e-commerce giant’s actions – some big, like buying Whole Foods Markets; some smaller, like Amazon meal kits – have led to stock sell-offs for a wide range of businesses.

Erik Gordon, a professor at the University of Michigan’s Ross School of Business, predicted that the companies would attempt to modernize the cumbersome process of doctor appointments by making it more like booking a restaurant reservation on OpenTable, while eliminating the need to regularly fill out paper forms on clipboards.

“I think they will bring the customer-facing, patient-facing thing into your smartphone,” he said.

Amazon has long been mentioned by health care analysts and industry executives as a potential new player in the sector. While the company has remained quiet about its plans, some analysts noted that companies often use their own employees as a testing ground for future initiatives.

The entry of Amazon and its partners adds to the upheaval in an industry where much is changing, from government programs after the overhaul of the tax law to the uncertain future of the Affordable Care Act. All the while, medical costs have persistently been on the rise.

Nationwide, average premiums for family coverage for employees rose to $18,764 last year, an increase of 19 percent since 2012, according to the Kaiser Family Foundation. Workers are increasingly paying a greater share of those costs — they now pay 30 percent of the premium, in addition to high deductibles and growing co-payments.
“Our members’ balance sheets speak for themselves — health care is a growing cost at a time when other costs are either not rising or falling,” said Robert Andrews, chief executive of the Healthcare Transformation Alliance, a group of 46 companies, including Coca-Cola and American Express, that have banded together to lower health care costs.

Other major employers have also sought more direct control over their employees’ health care. Walmart contracted with groups like the Cleveland Clinic, Mayo and Geisinger, among others, to take care of employees who need organ transplants and heart and spine care. Caterpillar, the construction equipment manufacturer, sets its own rules for drug coverage, which it has said saves it millions of dollars per year, even though it still uses a pharmacy benefit manager to process its claims.

Suzanne Delbanco, the executive director for the Catalyst for Payment Reform, a nonprofit group that mainly represents employers, said controlling rising prices is especially hard in markets where a local hospital or medical group dominates. While some have tried to tackle the issue in different ways, like sending employees with heart conditions to a specific group, “it’s piecemeal,” she said.

She added, “There are so many opportunities to do this better.”

The issue is not solely a 21st-century concern: In 1915, Henry Ford became increasingly worried about the quality of health care available to his growing work force in Detroit, so he opened the Henry Ford Hospital. It is still in existence today.

Nick Wingfield reported from Seattle, Katie Thomas from Chicago and Reed Abelson from San Francisco. Michael J. de la Merced contributed reporting from London, and Emily Flitter from New York.

A version of this article appears in print on January 31, 2018, on Page A1 of the New York edition with the headline: 3 Giants Form Health Alliance, Rocking Insurers. Order Reprints| Today’s Paper|Subscribe

Prevention Revisited

The essay below is an argument for the quality of life benefits of prevention. But its conclusions about whether prevention saves money? Those conclusions are depressing.

But I want to consider it. If prevention doesn’t save money, this goes against every intuition I have ever had on the subject.

The source of this essay is worth considering. If you look below, Dr. Aaron just published a book arguing that bad foods are not so bad – in moderation. This is a conclusion I happen to agree with. I agree with “all things in moderation”.
 
For example, a primary conclusion is that insuring people makes them more, rather than less, likely to use the emergency room. But this conclusion is about insurance, not prevention, and speaks to people’s need for convenient access to health care.

Or a second example used: anti-smoking. The essay’s conclusion is outrageous: it says that society will pay more because people who stop smoking will live longer! So, if society wishes to reduce costs, a mass euthanasia program, at, say, age 67, will really do the trick!
 
I publish but do not endorse…..

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CREDIT: Essay in the New York Times

THE NEW HEALTH CARE

The essay below is depressing. But I want to consider it. If prevention doesn’t save money, this goes against every intuition I have ever had on the subject.

I definitely don’t trust the source of this essay, or its conclusions.

For example, a primary conclusion is that insuring people makes them more, rather than less, likely to use the emergency room. But this conclusion is about insurance, not prevention, and speaks to people’s need for convenient access to health care.

Or a second example used: anti-smoking. The essay’s conclusion is outrageous: it says that society will pay more because people who stop smoking will live longer! So, if society wishes to reduce costs, a mass euthanasia program, at, say, age 67, will really do the trick!

I publish but do not in any way endorse…..

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CREDIT: New York Times Essay

THE NEW HEALTH CARE

Preventive Care Saves Money Sorry, It’s Too Good to Be True

Contrary to conventional wisdom, it tends to cost money, but it improves quality of life at a very reasonable price.

By Aaron E. Carroll
Jan. 29, 2018

The idea that spending more on preventive care will reduce overall health care spending is widely believed and often promoted as a reason to support reform. It’s thought that too many people with chronic illnesses wait until they are truly ill before seeking care, often in emergency rooms, where it costs more. It should follow then that treating diseases earlier, or screening for them before they become more serious, would wind up saving money in the long run.
Unfortunately, almost none of this is true.

Let’s begin with emergency rooms, which many people believed would get less use after passage of the Affordable Care Act. The opposite occurred. It’s not just the A.C.A. The Oregon Medicaid Health Insurance experiment, which randomly chose some uninsured people to get Medicaid before the A.C.A. went into effect, also found that insurance led to increased use of emergency medicine. Massachusetts saw the same effect after it introduced a program to increase the number of insured residents.

Emergency room care is not free, after all. People didn’t always choose it because they couldn’t afford to go to a doctor’s office. They often went there because it was more convenient. When we decreased the cost for people to use that care, many used it more.
Wellness programs, based on the idea that we can save money on health care by giving people incentives to be healthy, don’t actually work this way. As my colleague Austin Frakt and I have found from reviewing the research in detail, these programs don’t decrease costs — at least not without being discriminatory.

Accountable care organizations rely on the premise that improving outpatient and preventive care, perhaps with improved management and coordination of services for those with chronic conditions, will save money. But a recent study in Health Affairs showed that care coordination and management initiatives in the outpatient setting haven’t been drivers of savings in the Medicare Shared Savings Program.

There’s little reason to believe that even more preventive care in general is going to save a fortune. A study published in Health Affairs in 2010 looked at 20 proven preventive services, all of them recommended by the United States Preventive Services Task Force. These included immunizations, counseling, and screening for disease. Researchers modeled what would happen if up to 90 percent of these services were used, which is much higher than we currently see.

They found that this probably would have saved about $3.7 billion in 2006. That might sound like a lot, until you realize that this was about 0.2 percent of personal health care spending that year. It’s a pittance — and that was with almost complete compliance with recommendations.

One reason for this is that all prevention is not the same. The task force doesn’t model costs in its calculations; it models effectiveness and a preponderance of benefits and harms. When something works, and its positive effects outweigh its adverse ones, a recommendation is made.

This doesn’t mean it saves money.

In 2009, as part of the Robert Wood Johnson Foundation’s Synthesis Project, Sarah Goodell, Joshua Cohen and Peter Neumann exhaustively explored the evidence. They examined more than 500 peer-reviewed studies that looked at primary (stopping something from happening in the first place) or secondary (stopping something from getting worse) prevention. Of all the interventions they looked at, only two were truly cost-saving: childhood immunizations (a no-brainer) and the counseling of adults on the use of low-dose aspirin. An additional 15 preventive services were cost-effective, meaning that they cost less than $50,000 to $100,000 per quality adjusted life-year gained.

But all of these analyses looked within the health care system only. If we really want to know whether prevention saves money, maybe we should take a wider perspective. Does spending on prevention save the country money over all?

A recent report from the Congressional Budget Office in the New England Journal of Medicine suggests the answer is no. The budget office modeled how a policy to reduce smoking through higher cigarette taxes might affect federal spending. It found that such a tax would cause many people to quit smoking — the desired result. In the short term, less smoking would lead to decreased spending because of reductions in health care spending for those who had smoked.
But in the long run, all of those people living longer would lead to increases in spending in many programs, including health care. The more people who quit smoking, the higher the deficit — even with the increased revenue from taxing cigarettes.

But money doesn’t have to be saved to make something worthwhile. Prevention improves outcomes. It makes people healthier. It improves quality of life. It often does so for a very reasonable price.
There are many good arguments for increasing our focus on prevention. Almost all have to do with improving quality, though, not reducing spending. We would do well to admit that and move forward.
Sometimes good things cost money.

Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine who blogs on health research and policy at The Incidental Economist and makes videos at Healthcare Triage. He is the author of The Bad Food Bible: How and Why to Eat Sinfully.

====================APPENDIX================

CREDIT: https://www.npr.org/sections/thesalt/2017/11/19/564879018/the-bad-food-bible-says-your-eating-might-not-be-so-sinful-after-all

The Bad Food Bible
How and Why to Eat Sinfully
by Aaron, M.D. Carroll and Nina Teicholz
Hardcover, 272 pages

There are some surprises in your book, like milk isn’t as nutritious as some might think?

This is one of those where, if you just look at nature, we’re the only animal that consumes milk outside of the infant period. Now there’s no need for it. Part of that is politics, and the fact that the United States got involved in promoting dairy and the whole dairy industry. But there’s really no good evidence outside of the childhood period that milk is necessary. One of the things that I tried to state in the book, and this is true of all beverages with calories, you should treat them like you treat alcohol. I mean, what else are you going to do with a good chocolate chip cookie? Of course you need a glass of milk with that. That’s like dessert — it’s something you should have because you want it, not because you need it.

Raw eggs often get a bad reputation, particularly when it comes to cookie dough. How bad are they, really?

The raw egg is another one where of course there is a risk. But you have to weigh that against joy again. The truth of the matter is that if you committed to eating raw eggs in cookie dough once a week every week for the rest of your life, you’d almost never come into contact with salmonella. If you did, you’d almost never get sick. If you got sick, you’d almost never notice. Even if you noticed, it would almost never result in something serious. The chance of you actually getting seriously ill is infinitesimal. … The joy of doing those kinds of things with your kids or enjoying the process of baking is much more satisfying and will lead to greater increases in quality of life than the infinitesimal risk that you’re hurting your health in some way.
So, it sounds like there’s a lot of misinformation surrounding what food is bad for us. What’s your eating advice then?

So I think you know, in general, one thing you can do is limit your heavily processed food as much as possible. Nature intended you to get the appley goodness from an apple, not from apple juice. But the more we can do to smile, to cook for ourselves, to know where our food is coming from, to be mindful of it, the better. But we shouldn’t be so panicked and fearful and constantly believing that if we don’t do what we’ve heard from the latest expert, that we’re going to get sick and die. That is just not true.

Of course, we are staring down the barrel of Thanksgiving, which for many of us can be a moment that produces a lot of anxiety, especially food anxiety nowadays. It just feels like it’s all so fraught. I’m evil if I eat meat. I’m bad if I like Diet Coke. Food is loaded.
It’s also really important, it’s one day a year! Your health and your eating habits are not established by one day a year. It’s perfectly fine to enjoy yourself and to live! You need to weigh — in all your health decisions — the benefits and the harms. And too often we only focus on the latter. And included in benefits are joy, and quality of life and happiness. There are times when it’s a perfectly rational decision to allow yourself to be happy and to enjoy yourself. I’m not sort of giving a license for people to eat whatever they want, anytime they want. Yes, the Diet Coke, the pie, these are all processed foods. So you should think about how much you’re eating them in relation to everything else. But on the other hand, a piece of pie on Thanksgiving is not going to erase everything else you’ve done the rest of the year. Thanksgiving is easily my favorite holiday and it’s not just because of the food, but also because of the meal and the fact that you get to enjoy it with family and friends.

I’ve got to ask you, what are you having for Thanksgiving?

As much as I can cram into my body on that day. But, I love turkey, really well-done turkey. I love mashed potatoes, and stuffing and gravy, and I think pie is the greatest dessert that exists, so I’m sure I’ll be having too much of that as well.

Producer Adelina Lancianese contributed to this report.

Homeostasis

One of the smartest guys in the room, Antonio Damasio, give his views about neuroscience and its relationship to pain, pleasure, and feelings. He points out that they all play a giant role in one of life’s most important concepts: homeostasis.

CREDIT: http://nautil.us/issue/56/perspective/antonio-damasio-tells-us-why-pain-is-necessary

Antonio Damasio Tells Us Why Pain Is Necessary
The neuroscientist explains why feelings evolved.

BY KEVIN BERGER
JANUARY 18, 2018

Following Oliver Sacks, Antonio Damasio may be the neuroscientist whose popular books have done the most to inform readers about the biological machinery in our heads, how it generates thoughts and emotions, creates a self to cling to, and a sense of transcendence to escape by. But since he published Descartes’ Error in 1994, Damasio has been concerned that a central thesis in his books, that brains don’t define us, has been muted by research that states how much they do. To Damasio’s dismay, the view of the human brain as a computer, the command center of the body, has become lodged in popular culture.

In his new book, The Strange Order of Things, Damasio, a professor of neuroscience and the director of the Brain and Creativity Institute at the University of Southern California, mounts his boldest argument yet for the egalitarian role of the brain. In “Why Your Biology Runs on Feelings,” another article in this chapter of Nautilus, drawn from his new book, Damasio tells us “mind and brain influence the body proper just as much as the body proper can influence the brain and the mind. They are merely two aspects of the very same being.”

BEYOND SCIENCE: Antonio Damasio, director of the Brain and Creativity Institute at USC, sings the glories of the arts in his new book, The Strange Order of Things: “The sciences alone cannot illuminate the entirety of human experience without the light that comes from art and humanities.”

The Strange Order of Things offers a sharp and uncommon focus on feelings, on how their biological evolution fueled our prosperity as a species, spurred science and medicine, religion and art. “When I look back on Descartes’ Error, it was completely timid compared to what I’m saying now,” Damasio says. He knows his new book may rile believers in the brain as emperor of all. “I was entirely open with my ideas,” he says. “If people don’t like it, they don’t like it. They can criticize it, of course, which is fair, but I want to tell them, because it’s so interesting, this is why you have feelings.”
In this interview with Nautilus, Damasio, in high spirits, explains why feelings deserve a starring role in human culture, what the real problem with consciousness studies are, and why Shakespeare is the finest cognitive scientist of them all.

One thing I like about The Strange Order of Things is it counters the idea that we are just our brains.

Oh, that idea is absolutely wrong.

Not long ago I was watching a PBS series on the brain, in which host and neurologist David Eagleman, referring to our brain, declares, “What we feel, what matters to us, our beliefs and our hopes, everything we are happens in here.”

That’s not the whole story. Of course, we couldn’t have minds with all of their enormous complexity without nervous systems. That goes without saying. But minds are not the result of nervous systems alone. The statement you quote reminds me of Francis Crick, someone whom I admired immensely and was a great friend. Francis was quite opposed to my views on this issue. We would have huge discussions because he was the one who said that everything you are, your thoughts, your feelings, your mental this and that, are nothing but your neurons. This is a big mistake, in my view, because we are mentally and behaviorally far more than our neurons. We cannot have feelings arising from neurons alone. The nervous systems are in constant interaction and cooperation with the rest of the organism. The reason why nervous systems exist in the first place is to assist the rest of the organism. That fact is constantly missed.

The concept of “homeostasis” is critical in your new book. What is homeostasis?

It’s the fundamental property of life that governs everything that living cells do, whether they’re living cells alone, or living cells as part of a tissue or an organ, or a complex system such as ourselves. Most of the time, when people hear the word homeostasis, they think of balance, they think of equilibrium. That is incorrect because if we ever were in “equilibrium,” we would be dead. Thermodynamically, equilibrium means zero thermal differences and death. Equilibrium is the last thing that nature aims for.

The importance of feeling is that it makes you critically aware of what you are doing in moral terms.

What we must have is efficient functioning of a variety of components of an organism. We procure energy so that the organism can be perpetuated, but then we do something very important and almost always missed, which is hoard energy. We need to maintain positive energy balances, something that goes beyond what we need right now because that’s what ensures the future. What’s so beautiful about homeostasis is that it’s not just about sustaining life at the moment, but about having a sort of guarantee that it will continue into the future. Without those positive energy balances, we court death.

What’s a good example of homeostasis?

If you are at the edge of your energy reserves and you’re sick with the flu, you can easily tip over and die. That’s one of the reasons why there’s fat accumulation in our bodies. We need to maintain the possibility of meeting the extra needs that come from stress, in the broad sense of the term. I poetically describe this as a desire for permanence, but it’s not just poetic. I believe it’s reality.

You write homeostasis is maintained in complex creatures like us through a constant interplay of pleasure and pain. Are you giving a biological basis to Freud’s pleasure principle—life is governed by a drive for pleasure and avoidance of pain?

Yes, to a great extent. What’s so interesting is that for most of the existence of life on earth, all organisms have had this effective, automated machinery that operates for the purpose of maintenance and continuation of life. I like to call the organisms that only have that form of regulation, “living automata.” They can fight. They can cooperate. They can segregate. But there’s no evidence that they know that they’re doing so. There’s no evidence of anything we might call a mind. Obviously we have more than automatic regulation. We can control regulation in part, if we wish to. How did that come about?
Very late in the game of life there’s the appearance of nervous systems. Now you have the possibility of mapping the inside and outside world. When you map the inside world, guess what you get? You get feelings. Of necessity, the machinery of life is either in a state of reasonable efficiency or in a state of inefficiency, which is most often the case. Organisms with nervous systems can image these states. And when you start having imagery, you start having minds. Now you begin to have the possibility of responding in a way that you could call “knowledgeable.” That happens when organisms make images. A bad internal state would have been imaged as the first pains, the first malaises, the first sufferings. Now the organism has the possibility of knowingly avoiding whatever caused the pain or prefer a place or a thing or another animal that causes the opposite of that, which is well-being and pleasure.

Why would feelings have evolved?

Feelings triumphed in evolution because they were so helpful to the organisms that first had them. It’s important to understand that nervous systems serve the organism and not the other way around. We do not have brains controlling the entire operation. Brains adjust controls. They are the servants of a living organism. Brains triumphed because they provided something useful: coordination. Once organisms got to the point of being so complex that they had an endocrine system, immune system, circulation, and central metabolism, they needed a device to coordinate all that activity. They needed to have something that would simultaneously act on point A and point Z, across the entire organism, so that the parts would not be working at cross purposes. That’s what nervous systems first achieve: making things run smoothly.

Now, in the process of doing that, over millions of years, we have developed nervous systems that do plenty of other things that do not necessarily result in coordination of the organism’s interior, but happen to be very good at coordinating the internal world in relation to the outside world. This is what the higher reaches of our nervous system, namely the cerebral cortex, does. It gives us the possibilities of perceiving, of memorizing, of reasoning over the knowledge that we memorize, of manipulating all of that and even translating it into language. That is all very beautiful, and it is also homeostatic, in the sense that all of it is convenient to maintain life. It if were not, it would just have been discarded by evolution.

How does your thesis square with the hard problem of consciousness, how the physical tissue in our heads produces immaterial sensations?

Some philosophers of mind will say, “Well, we face this gigantic problem. How does consciousness emerge out of these nerve cells?” Well, it doesn’t. You’re not dealing with the brain alone. You have to think in terms of the whole organism. And you have to think in evolutionary terms.

The critical problem of consciousness is subjectivity. You need to have a “subject.” You can call it an I or a self. Not only are you aware right now that you are listening to my words, which are in the panorama of your consciousness, but you are aware of being alive, you realize that you’re there, you’re ticking. We are so distracted by what is going on around us that we forget sometimes that we are, A-R-E in capitals. But actually you are watching what you are, and so you need to have a mechanism in the brain that allows you to fabricate that part of the mind that is the watcher.
You do that with a number of devices that have to do, for example, with mapping the movements of your eyes, the position of your head, and the musculature of your body. This allows you to literally construct images of yourself making images. And you also have a layer of consciousness that is made by your perception of the outside world; and another layer that is made of appreciating the feelings that are being generated inside of you. Once you have this stack of processes, you have a fighting chance of creating consciousness.

Why do you object to comparing the brain to a computer?

In the early days of neuroscience, one of our mentors was Warren McCulloch. He was a gigantic figure of neuroscience, one of the originators of what is today computational neuroscience. When you go back to the ’40s and ’50s, you find this amazing discovery that neurons can be either active or inactive, in a way that can be described mathematically as zeroes and ones. Combine that with Alan Turing and you get this idea that the brain is like a computer and that it produces minds using that same simple method.

Religions have been one of the great causes of violence throughout history. But you can’t blame Christ for it.

That has been a very useful idea. And true enough, it explains a good part of the complex operations, that our brains produce such as language. Those operations require a lot of precision and are being carried out by cerebral cortex, with enormous detail, and probably in a basic computational mode. All the great successes of artificial intelligence used this idea and have been concerned with high-level reasoning. That is why A.I. has been so successful with games such as chess or Go. They use large memories and powerful reasoning.

Are you saying neural codes or algorithms don’t blend with living systems?

Well, they match very well with things that are high on the scale of the mental operations and behaviors, such as those we require for our conversation. But they don’t match well with the basic systems that organize life, that regulate, for example, the degree of mental energy and excitation or with how you emote and feel. The reason is that the operations of the nervous system responsible for such regulation relies less on synaptic signaling, the one that can be described in terms of zeroes and ones, and far more on non-synaptic messaging, which lends itself less to a rigid all or none operation.
Perhaps more importantly, computers are machines invented by us, made of durable materials. None of those materials has the vulnerability of the cells in our body, all of which are at risk of defective homeostasis, disease, and death. In fact, computers lack most of the characteristics that are key to a living system. A living system is maintained in operation, against all odds, thanks to a complicated mechanism that can fall apart as a result of minimal amounts of malfunction. We are extremely vulnerable creatures. People often forget that. Which is one of the reasons why our culture, or Western cultures in general, are a bit too calm and complacent about the threats to our lives. I think we are becoming less sensitive to the idea that life is what dictates what we should do or not do with ourselves and with others.

What is love for?

To protect, to cause flourishing, to give and receive pleasure, to procreate, to soothe. Endless great uses, as you can see.

How do emotions such as anger or sadness serve homeostasis?

At individual levels, both anger and sadness are protective. Anger lets your adversary know that you mean business and that there may be costs to attacking you. These days anger is an expression of sociopolitical conflicts. It is overused and has largely become ineffectual. Sadness is a prelude to mental hibernation. It lets you retreat and lick your wounds. It lets you plan a strategy of response to the cause of the wounds.

You say feelings spurred the creation of cultures. How so?

Before I started The Strange Order of Things, I was asking friends and colleagues how they thought cultures had begun. Invariably what people said was, “Oh, we’re so smart. We’re so intellectually powerful. We have all this reasoning ability. On top of it all, we have language—and there you are.” To which I say, “Fine, that’s true. How would you invent anything if you were stupid?” You would not. But the issue is to recognize the motive behind what you do. Why is it that you did it in the first place? Why did Moses come down from the mountain with Ten Commandments? Well, the Ten Commandments are representative of homeostasis because they tell you not to kill, not to steal, not to lie, not to do a lot of bad things. It sounds trivial but it’s not. We fail to think about motivation and so we do not factor it into the process of invention. We do not factor in the motives behind science or technology or governance or religion.

How does consciousness emerge out of nerve cells? Well, it doesn’t. You’re not dealing with the brain alone.

And there’s one more thing: The importance of feeling is that it makes you critically aware of what you are doing in moral terms. It forces you to look back and realize that what people were doing historically, at the outset, at the moment of invention of a cultural instrument or a cultural practice, was an attempt to reduce the amount of suffering and to maximize the amount of wellbeing not only for the inventor, but for the community around them. One person alone can invent a painting or a musical composition, but it is not meant for that person alone. And you do not invent a moral system or a government system alone or for yourself alone. It requires a society, a community.

The assertion that intellect is governed by feelings can sound New Age-y. It seems to undermine the powers of reason. How should we understand reason if it’s always motivated by subjective feelings?

Subjective simply means that it has a personal point of view, that it pertains to the self. It is compatible with “objective” facts and with truth. It is not about relativism. The fact that feelings motivate the use of knowledge and reason do not make the knowledge and the reason any less truthful or valid. Feelings are simply a call to action.

If humans formed societies and cultures to avoid suffering and pain, why do we have violence and wars?

Your question is very important. Take developments of political systems. On the face of it, when you look at Marxist ideas, you say, “This is obviously homeostatic.” What Marx and others were trying to do in the 19th century is confront and modify a social arrangement that was not equitable, that had some people suffering too much and some profiting too much. So having a system that produced equality made a lot of sense. In a way that is something that biological systems have been trying to do, quite naturally, for a long time. And when the natural systems do not succeed at improved regulation, guess what? They are weeded out by evolution because they promote illness.
Biological evolution, through genetic selection, eliminates those mechanisms. At the cultural level something comparable occurs. Seen in retrospect, Marxism as applied in Russia resulted in one of the worst tragedies of humankind. But Russian communism was ultimately weeded out by cultural selection. It took around 70 years to do it, but cultural selection did operate in a homeostatic way. It led to the fall of the Berlin Wall and the Soviet empire. It was a homeostatic correction achieved by social means.
The same reasoning applies to religions. For example, we can claim that religions have been one of the great causes of violence throughout history. But you certainly can’t blame Christ for that violence. He preached compassion, and the pardoning of enemies, and love. It does not follow that good recommendations can be implemented correctly and always produce good results. These facts in no way deny the homeostatic intent of religions.

You write, “The increasing knowledge of biology from molecules to systems reinforces the humanist project.” How so?

This knowledge gives us a broader picture of who we are and where we are in the history of life on earth. We had modest beginnings, and we have incorporated an incredible amount of living wisdom that comes from as far down as bacteria. There are characteristics of our personal and cultural behavior that can be found in single-cell organisms or in social insects. They clearly do not have the kind of highly developed brains that we have. In some cases, they don’t have any brain at all. But by analyzing this strange order of developments we are confronted with the spectacle of life processes that are complex and rich in spite of their apparent modesty, so complex and rich that they can deliver the high level of behaviors that we normally, quite pretentiously, attribute only to our great human smarts. We should be far more humble. That’s one of my main messages. In general, connecting cultures to the life process makes apparent a link that we have ignored for far too long.


What would you be if you weren’t a scientist?

When I was an adolescent, I often thought that I might become a philosopher or perhaps a playwright or filmmaker. That’s because I so admired what philosophers and storytellers had found about the human mind. Today when people ask me, “Who’s your most admired cognitive scientist?” I say Shakespeare. He knew it all and knew it with enormous precision. He didn’t have the nice fMRI scanner and electrophysiology techniques we have in our Institute. But he knew human beings. Watch a good performance of Hamlet, King Lear, or Othello. All of our psychology is there, richly analyzed, ready for us to experience and appreciate.

Fiber’s Role in Diet

In this post, I discuss the role of the microbiome and the role of fiber in supporting a healthy microbiome. A healthy microbiome is related to the amount and diversity of the bacteria found within it.

If I had to summarize, I would say this: new research strongly confirms that high fiber diets are healthy diets. Because of this finding, eat 20-200 grams of fiber daily, by eating nuts, berries, whole grains, beans and vegetables.

The Role of the Microbiome
Bacteria in the gut – the “microbiome” – has been the subject of intense research interest over the last decade.

We now know that a healthy microbiome is essential to health and wellbeing.

On a scientific level, we now know that a healthy biome is one with billions of bacteria, of many kinds.

And specifically, we now know that a healthy biome has a layer of mucus along the walls of the intestine.

“The gut is coated with a layer of mucus, atop which sits a carpet of hundreds of species of bacteria, part of the human microbiome.”

If that mucus layer is thick, it is healthy. If it is thin, it is unhealthy (thin mucus layers have been linked to chronic inflammation). (“Their intestines got smaller, and its mucus layer thinner. As a result, bacteria wound up much closer to the intestinal wall, and that encroachment triggered an immune reaction.”)

The Role of Fiber in Supporting a Healthy Microbiome
“Fiber” refers to ruffage from fruits, vegetables, and beans that is hard to digest. If fiber is hard to digest, why are they so universally hailed as “good for you”?

That’s the subject of two newly-reported experiments.

The answer seems to lie in bacteria in the gut – the “microbiome”. Much has been written about their beneficial role in the body. But now it seems that some bacteria in the gut have an additional role: they digest fiber that human enzymes cannot digest.

So some bacteria thrive in the gut because of the fiber they eat. And, in an important natural chain, apparently there are some bacteria in the gut that that thrive because the waste of the bacteria that eats fiber. An ecosystem of bacteria tracing to fiber!

This speaks to one of the most-discussed subjects in science today: how and why is one microbiome populated with relatively few bacteria numbers and types, and why is another microbiome much more diverse – with many more bacteria and bacteria types?

One study, shown below, reports from Tanzania, after reviewing data from tribes that sustain themselves on high fiber foods. The results, reported in Science, clearly show that an ultra-high fiber diet results in ultra high bacteria counts and diversity.

Other findings suggest that fiber is the food of many bacteria types. Because of this, a diverse, healthy bacterial microbiome is dependent on a fiber-rich diet. (“On a low-fiber diet, they found, the population crashed, shrinking tenfold.”)

Indeed, it may well be true that many types of fibers support many types of bacteria.

Proof of this?

Researchers, including Dr. Gerwitz at Georgia State proved that more fiber seems to be better:

Bad: high, fat, low fiber (“On a low-fiber diet, they found, the population crashed, shrinking tenfold.” “Many common species became rare, and rare species became common.“)

Good: modest fiber
Better: high dose fiber (“Despite a high-fat diet, the mice had healthy populations of bacteria in their guts, their intestines were closer to normal, and they put on less weight.”)

Best: high dose of fiber-feeding bacteria
(“Once bacteria are done harvesting the energy in dietary fiber, they cast off the fragments as waste. That waste — in the form of short-chain fatty acids — is absorbed by intestinal cells, which use it as fuel.”

(“Research suggests that when bacteria break down dietary fiber down into short-chain fatty acids, some of them pass into the bloodstream and travel to other organs, where they act as signals to quiet down the immune system.”)

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This article documents rich-in-fiber foods:

CREDIT: http://www.todaysdietitian.com/newarchives/063008p28.shtml

In recognition of fiber’s benefits, Today’s Dietitian looks at some of the best ways to boost fiber intake,from whole to fortified foods,using data from the USDA National Nutrient Database for Standard Reference.

Top Fiber-Rich Foods
1. Get on the Bran Wagon (Oat bran, All-bran cereal, fiber-one chewy bars, etc)
One simple way to increase fiber intake is to power up on bran. Bran from many grains is very rich in dietary fiber. Oat bran is high in soluble fiber, which has been shown to lower blood cholesterol levels. Wheat, corn, and rice bran are high in insoluble fiber, which helps prevent constipation. Bran can be sprinkled into your favorite foods,from hot cereal and pancakes to muffins and cookies. Many popular high-fiber cereals and bars are also packed with bran.

2. Take a Trip to Bean Town (Limas, Pintos, Lentils, etc)
Beans really are the magical fruit. They are one of the most naturally rich sources of fiber, as well as protein, lysine, vitamins, and minerals, in the plant kingdom. It’s no wonder so many indigenous diets include a bean or two in the mix. Some people experience intestinal gas and discomfort associated with bean intake, so they may be better off slowly introducing beans into their diet. Encourage a variety of beans as an animal protein replacement in stews, side dishes, salads, soups, casseroles, and dips.

3. Go Berry Picking (especially blackberries and raspberries)
Jewel-like berries are in the spotlight due to their antioxidant power, but let’s not forget about their fiber bonus. Berries happen to yield one of the best fiber-per-calorie bargains on the planet. Since berries are packed with tiny seeds, their fiber content is typically higher than that of many fruits. Clients can enjoy berries year-round by making the most of local berries in the summer and eating frozen, preserved, and dried berries during the other seasons. Berries make great toppings for breakfast cereal, yogurt, salads, and desserts.

4. Wholesome Whole Grains (especially barley, oats, brown rice, rye wafers)
One of the easiest ways to up fiber intake is to focus on whole grains. A grain in nature is essentially the entire seed of the plant made up of the bran, germ, and endosperm. Refining the grain removes the germ and the bran; thus, fiber, protein, and other key nutrients are lost. The Whole Grains Council recognizes a variety of grains and defines whole grains or foods made from them as containing “all the essential parts and naturally-occurring nutrients of the entire grain seed. If the grain has been processed, the food product should deliver approximately the same rich balance of nutrients that are found in the original grain seed.â€‌ Have clients choose different whole grains as features in side dishes, pilafs, salads, breads, crackers, snacks, and desserts.

5. Sweet Peas (especially frozen green peas, black eyed peas)
Peas,from fresh green peas to dried peas,are naturally chock full of fiber. In fact, food technologists have been studying pea fiber as a functional food ingredient. Clients can make the most of peas by using fresh or frozen green peas and dried peas in soups, stews, side dishes, casseroles, salads, and dips.

6. Green, the Color of Fiber (Spinach, etc)
Deep green, leafy vegetables are notoriously rich in beta-carotene, vitamins, and minerals, but their fiber content isn’t too shabby either. There are more than 1,000 species of plants with edible leaves, many with similar nutritional attributes, including high-fiber content. While many leafy greens are fabulous tossed in salads, saut ©ing them in olive oil, garlic, lemon, and herbs brings out a rich flavor.

7. Squirrel Away Nuts and Seeds (especially flaxseed and sesame seed)
Go nuts to pack a fiber punch. One ounce of nuts and seeds can provide a hearty contribution to the day’s fiber recommendation, along with a bonus of healthy fats, protein, and phytochemicals. Sprinkling a handful of nuts or seeds over breakfast cereals, yogurt, salads, and desserts is a tasty way to do fiber.

8. Play Squash (especially acorn squash)
Dishing up squash,from summer to winter squash,all year is another way that clients can ratchet up their fiber intake. These nutritious gems are part of the gourd family and contribute a variety of flavors, textures, and colors, as well as fiber, vitamins, minerals, and carotenoids, to the dinner plate. Squash can be turned into soups, stews, side dishes, casseroles, salads, and crudit ©s. Brush squash with olive oil and grill it in the summertime for a healthy, flavorful accompaniment to grilled meats.

9. Brassica or Bust (broccoli, cauliflower, kale, cabbage, and Brussels sprouts)
Brassica vegetables have been studied for their cancer-protective effects associated with high levels of glucosinolates. But these brassy beauties, including broccoli, cauliflower, kale, cabbage, and Brussels sprouts, are also full of fiber. They can be enjoyed in stir-fries, casseroles, soups, and salads and steamed as a side dish.

10. Hot Potatoes
The humble spud, the top vegetable crop in the world, is plump with fiber. Since potatoes are so popular in America, they’re an easy way to help pump up people’s fiber potential. Why stop at Russets? There are numerous potatoes that can provide a rainbow of colors, nutrients, and flavors, and remind clients to eat the skins to reap the greatest fiber rewards. Try adding cooked potatoes with skins to salads, stews, soups, side dishes, stir-fries, and casseroles or simply enjoy baked potatoes more often.

11. Everyday Fruit Basket (especially pears and oranges)
Look no further than everyday fruits to realize your full fiber potential. Many are naturally packed with fiber, as well as other important vitamins and minerals. Maybe the doctor was right when he advised an apple a day, but he could have added pears, oranges, and bananas to the prescription as well. When between fruit seasons, clients can rely on dried fruits to further fortify their diet. Encourage including fruit at breakfast each morning instead of juice; mixing dried fruits into cereals, yogurts, and salads; and reaching for the fruit bowl at snack time. It’s a healthy habit all the way around.

12. Exotic Destinations (especially avocado)
Some of the plants with the highest fiber content in the world may be slightly out of your clients’ comfort zone and, for that matter, time zone. A rainbow of indigenous fruits and vegetables used in cultural food traditions around the globe are very high in fiber. Entice clients to introduce a few new plant foods into their diets to push up the flavor, as well as their fiber, quotient.

13. Fiber Fortification Power
More foods,from juice to yogurt,are including fiber fortification in their ingredient lineup. Such foods may help busy people achieve their fiber goals. As consumer interest in foods with functional benefits, such as digestive health and cardiovascular protection, continues to grow, expect to see an even greater supply of food products promoting fiber content on supermarket shelves.

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This article documents the newly-reported experiments:

CREDIT: NYT Article on Fiber Science

Fiber is Good for You. Now we Know Why

By Carl Zimmer
Jan. 1, 2018
A diet of fiber-rich foods, such as fruits and vegetables, reduces the risk of developing diabetes, heart disease and arthritis. Indeed, the evidence for fiber’s benefits extends beyond any particular ailment: Eating more fiber seems to lower people’s mortality rate, whatever the cause.

That’s why experts are always saying how good dietary fiber is for us. But while the benefits are clear, it’s not so clear why fiber is so great. “It’s an easy question to ask and a hard one to really answer,” said Fredrik Bäckhed, a biologist at the University of Gothenburg in Sweden.

He and other scientists are running experiments that are yielding some important new clues about fiber’s role in human health. Their research indicates that fiber doesn’t deliver many of its benefits directly to our bodies.

Instead, the fiber we eat feeds billions of bacteria in our guts. Keeping them happy means our intestines and immune systems remain in good working order.

In order to digest food, we need to bathe it in enzymes that break down its molecules. Those molecular fragments then pass through the gut wall and are absorbed in our intestines.
But our bodies make a limited range of enzymes, so that we cannot break down many of the tough compounds in plants. The term “dietary fiber” refers to those indigestible molecules.

But they are indigestible only to us. The gut is coated with a layer of mucus, atop which sits a carpet of hundreds of species of bacteria, part of the human microbiome. Some of these microbes carry the enzymes needed to break down various kinds of dietary fiber.

The ability of these bacteria to survive on fiber we can’t digest ourselves has led many experts to wonder if the microbes are somehow involved in the benefits of the fruits-and-vegetables diet. Two detailed studies published recently in the journal Cell Host and Microbe provide compelling evidence that the answer is yes.

In one experiment, Andrew T. Gewirtz of Georgia State University and his colleagues put mice on a low-fiber, high-fat diet. By examining fragments of bacterial DNA in the animals’ feces, the scientists were able to estimate the size of the gut bacterial population in each mouse.

On a low-fiber diet, they found, the population crashed, shrinking tenfold.

Dr. Bäckhed and his colleagues carried out a similar experiment, surveying the microbiome in mice as they were switched from fiber-rich food to a low-fiber diet. “It’s basically what you’d get at McDonald’s,” said Dr. Bäckhed said. “A lot of lard, a lot of sugar, and twenty percent protein.”

The scientists focused on the diversity of species that make up the mouse’s gut microbiome. Shifting the animals to a low-fiber diet had a dramatic effect, they found: Many common species became rare, and rare species became common.

Along with changes to the microbiome, both teams also observed rapid changes to the mice themselves. Their intestines got smaller, and its mucus layer thinner. As a result, bacteria wound up much closer to the intestinal wall, and that encroachment triggered an immune reaction.

After a few days on the low-fiber diet, mouse intestines developed chronic inflammation. After a few weeks, Dr. Gewirtz’s team observed that the mice began to change in other ways, putting on fat, for example, and developing higher blood sugar levels.

Dr. Bäckhed and his colleagues also fed another group of rodents the high-fat menu, along with a modest dose of a type of fiber called inulin. The mucus layer in their guts was healthier than in mice that didn’t get fiber, the scientists found, and intestinal bacteria were kept at a safer distance from their intestinal wall.

Dr. Gewirtz and his colleagues gave inulin to their mice as well, but at a much higher dose. The improvements were even more dramatic: Despite a high-fat diet, the mice had healthy populations of bacteria in their guts, their intestines were closer to normal, and they put on less weight.

Dr. Bäckhed and his colleagues ran one more interesting experiment: They spiked water given to mice on a high-fat diet with a species of fiber-feeding bacteria. The addition changed the mice for the better: Even on a high-fat diet, they produced more mucus in their guts, creating a healthy barrier to keep bacteria from the intestinal walls.

One way that fiber benefits health is by giving us, indirectly, another source of food, Dr. Gewirtz said. Once bacteria are done harvesting the energy in dietary fiber, they cast off the fragments as waste. That waste — in the form of short-chain fatty acids — is absorbed by intestinal cells, which use it as fuel.

But the gut’s microbes do more than just make energy. They also send messages. Intestinal cells rely on chemical signals from the bacteria to work properly, Dr. Gewirtz said. The cells respond to the signals by multiplying and making a healthy supply of mucus. They also release bacteria-killing molecules.
By generating these responses, gut bacteria help maintain a peaceful coexistence with the immune system. They rest atop the gut’s mucus layer at a safe distance from the intestinal wall. Any bacteria that wind up too close get wiped out by antimicrobial poisons.

While some species of gut bacteria feed directly on dietary fiber, they probably support other species that feed on their waste. A number of species in this ecosystem — all of it built on fiber — may be talking to our guts.

Going on a low-fiber diet disturbs this peaceful relationship, the new studies suggest. The species that depend on dietary fiber starve, as do the other species that depend on them. Some species may switch to feeding on the host’s own mucus.

With less fuel, intestinal cells grow more slowly. And without a steady stream of chemical signals from bacteria, the cells slow their production of mucus and bacteria-killing poisons.
As a result, bacteria edge closer to the intestinal wall, and the immune system kicks into high gear.

“The gut is always precariously balanced between trying to contain these organisms and not to overreact,” said Eric C. Martens, a microbiologist at the University of Michigan who was not involved in the new studies. “It could be a tipping point between health and disease.”

Inflammation can help fight infections, but if it becomes chronic, it can harm our bodies. Among other things, chronic inflammation may interfere with how the body uses the calories in food, storing more of it as fat rather than burning it for energy.

Justin L. Sonnenburg, a biologist at Stanford University who was not involved in the new studies, said that a low-fiber diet can cause low-level inflammation not only in the gut, but throughout the body.

His research suggests that when bacteria break down dietary fiber down into short-chain fatty acids, some of them pass into the bloodstream and travel to other organs, where they act as signals to quiet down the immune system.

“You can modulate what’s happening in your lung based on what you’re feeding your microbiome in your gut,” Dr. Sonnenburg said.
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Hannah D. Holscher, a nutrition scientist at the University of Illinois who was not involved in the new studies, said that the results on mice need to be put to the test in humans. But it’s much harder to run such studies on people.

In her own lab, Dr. Holscher acts as a round-the-clock personal chef. She and her colleagues provide volunteers with all their meals for two weeks. She can then give some of her volunteers an extra source of fiber — such as walnuts — and look for changes in both their microbiome and their levels of inflammation.

Dr. Holscher and other researchers hope that they will learn enough about how fiber influences the microbiome to use it as a way to treat disorders. Lowering inflammation with fiber may also help in the treatment of immune disorders such as inflammatory bowel disease.

Fiber may also help reverse obesity. Last month in the American Journal of Clinical Nutrition, Dr. Holscher and her colleagues reviewed a number of trials in which fiber was used to treat obesity. They found that fiber supplements helped obese people to lose about five pounds, on average.
But for those who want to stay healthy, simply adding one kind of fiber to a typical Western diet won’t be a panacea. Giving mice inulin in the new studies only partly restored them to health.

That’s probably because we depend on a number of different kinds of dietary fiber we get from plants. It’s possible that each type of fiber feeds a particular set of bacteria, which send their own important signals to our bodies.

“It points to the boring thing that we all know but no one does,” Dr. Bäckhed said. “If you eat more green veggies and less fries and sweets, you’ll probably be better off in the long term.”

=====================

CREDIT: https://www.npr.org/sections/goatsandsoda/2017/08/24/545631521/is-the-secret-to-a-healthier-microbiome-hidden-in-the-hadza-diet

Is The Secret To A Healthier Microbiome Hidden In The Hadza Diet?

August 24, 20176:11 PM ET
Heard on All Things Considered

MICHAELEEN DOUCLEFF
Twitter

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The words “endangered species” often conjure up images of big exotic creatures. Think elephants, leopards and polar bears.

But there’s another of type of extinction that may be occurring, right now, inside our bodies.

Yes, I’m talking about the microbiome — that collection of bacteria in our intestines that influences everything from metabolism and the immune system to moods and behavior.

For the past few years, scientists around the world have been accumulating evidence that the Western lifestyle is altering our microbiome. Some species of bacteria are even disappearing to undetectable levels.

“Over time we are losing valuable members of our community,” says Justin Sonnenburg, a microbiologist at Stanford University, who has been studying the microbiome for more than a decade.

Now Sonnenburg and his team have evidence for why this microbial die-off is happening — and hints about what we can possibly do to reverse it.

The study, published Thursday in the journal Science, focuses on a group of hunter-gatherers in Tanzania, called Hadza.
Their diet consists almost entirely of food they find in the forest, including wild berries, fiber-rich tubers, honey and wild meat. They basically eat no processed food — or even food that comes from farms.
“They are a very special group of people,” Sonnenburg says. “There are only about 2,200 left and really only about 200 that exclusively adhere to hunting and gathering.”

Sonnenberg and his colleagues analyzed 350 stool samples from Hadza people taken over the course of about a year. They then compared the bacteria found in Hadza with those found in 17 other cultures around the world, including other hunter-gatherer communities in Venezuela and Peru and subsistence farmers in Malawi and Cameroon.

The trend was clear: The further away people’s diets are from a Western diet, the greater the variety of microbes they tend to have in their guts. And that includes bacteria that are missing from American guts.

“So whether it’s people in Africa, Papua New Guinea or South America, communities that live a traditional lifestyle have common gut microbes — ones that we all lack in the industrialized world,” Sonnenburg says.

In a way, the Western diet — low in fiber and high in refined sugars — is basically wiping out species of bacteria from our intestines.

That’s the conclusion Sonnenburg and his team reached after analyzing the Hadza microbiome at one stage of the yearlong study. But when they checked several months later, they uncovered a surprising twist: The composition of the microbiome fluctuated over time, depending on the season and what people were eating. And at one point, the composition started to look surprisingly similar to that of Westerners’ microbiome.

During the dry season, Hadza eat a lot of more meat — kind of like Westerners do. And their microbiome shifted as their diet changed. Some of the bacterial species that had been prevalent disappeared to undetectable levels, similar to what’s been observed in Westerners’ guts.

But then in wet season — when Hadza eat more berries and honey — these missing microbes returned, although the researchers are not really sure what’s in these foods that bring the microbes back.

“I think this finding is really exciting,” says Lawrence David, who studies the microbiome at Duke University. “It suggests the shifts in the microbiome seen in industrialized nations might not be permanent — that they might be reversible by changes in people’s diets.

“The finding supports the idea that the microbiome is plastic, depending on diet,” David adds.

Now the big question is: What’s the key dietary change that could bring the missing microbes back?

Lawrence thinks it could be cutting down on fat. “At a high level, it sounds like that,” he says, “because what changed in the Hadza’s diet was whether or not they were hunting versus foraging for berries or honey,” he says.

But Sonnenburg is placing his bets on another dietary component: fiber — which is a vital food for the microbiome.
“We’re beginning to realize that people who eat more dietary fiber are actually feeding their gut microbiome,”
Sonnenburg says.

Hadza consume a huge amount of fiber because throughout the year, they eat fiber-rich tubers and fruit from baobab trees. These staples give them about 100 to 150 grams of fiber each day. That’s equivalent to the fiber in 50 bowls of Cheerios — and 10 times more than many Americans eat.

“Over the past few years, we’ve come to realize how important this gut community is for our health, and yet we’re eating a low-fiber diet that totally neglects them,” he says. “So we’re essentially starving our microbial selves.”

The Dying Algorithm

CREDIT: NYT Article on the Dying Algorithm

This Cat Sensed Death. What if Computers Could, Too
By Siddhartha Mukherjee
Jan. 3, 2018

Of the many small humiliations heaped on a young oncologist in his final year of fellowship, perhaps this one carried the oddest bite: A 2-year-old black-and-white cat named Oscar was apparently better than most doctors at predicting when a terminally ill patient was about to die. The story appeared, astonishingly, in The New England Journal of Medicine in the summer of 2007. Adopted as a kitten by the medical staff, Oscar reigned over one floor of the Steere House nursing home in Rhode Island. When the cat would sniff the air, crane his neck and curl up next to a man or woman, it was a sure sign of impending demise. The doctors would call the families to come in for their last visit. Over the course of several years, the cat had curled up next to 50 patients. Every one of them died shortly thereafter.
No one knows how the cat acquired his formidable death-sniffing skills. Perhaps Oscar’s nose learned to detect some unique whiff of death — chemicals released by dying cells, say. Perhaps there were other inscrutable signs. I didn’t quite believe it at first, but Oscar’s acumen was corroborated by other physicians who witnessed the prophetic cat in action. As the author of the article wrote: “No one dies on the third floor unless Oscar pays a visit and stays awhile.”
The story carried a particular resonance for me that summer, for I had been treating S., a 32-year-old plumber with esophageal cancer. He had responded well to chemotherapy and radiation, and we had surgically resected his esophagus, leaving no detectable trace of malignancy in his body. One afternoon, a few weeks after his treatment had been completed, I cautiously broached the topic of end-of-life care. We were going for a cure, of course, I told S., but there was always the small possibility of a relapse. He had a young wife and two children, and a mother who had brought him weekly to the chemo suite. Perhaps, I suggested, he might have a frank conversation with his family about his goals?

But S. demurred. He was regaining strength week by week. The conversation was bound to be “a bummah,” as he put it in his distinct Boston accent. His spirits were up. The cancer was out. Why rain on his celebration? I agreed reluctantly; it was unlikely that the cancer would return.

When the relapse appeared, it was a full-on deluge. Two months after he left the hospital, S. returned to see me with sprays of metastasis in his liver, his lungs and, unusually, in his bones. The pain from these lesions was so terrifying that only the highest doses of painkilling drugs would treat it, and S. spent the last weeks of his life in a state bordering on coma, unable to register the presence of his family around his bed. His mother pleaded with me at first to give him more chemo, then accused me of misleading the family about S.’s prognosis. I held my tongue in shame: Doctors, I knew, have an abysmal track record of predicting which of our patients are going to die. Death is our ultimate black box.

In a survey led by researchers at University College London of over 12,000 prognoses of the life span of terminally ill patients, the hits and misses were wide-ranging. Some doctors predicted deaths accurately. Others underestimated death by nearly three months; yet others overestimated it by an equal magnitude. Even within oncology, there were subcultures of the worst offenders: In one story, likely apocryphal, a leukemia doctor was found instilling chemotherapy into the veins of a man whose I.C.U. monitor said that his heart had long since stopped.

But what if an algorithm could predict death? In late 2016 a graduate student named Anand Avati at Stanford’s computer-science department, along with a small team from the medical school, tried to “teach” an algorithm to identify patients who were very likely to die within a defined time window. “The palliative-care team at the hospital had a challenge,” Avati told me. “How could we find patients who are within three to 12 months of dying?” This window was “the sweet spot of palliative care.” A lead time longer than 12 months can strain limited resources unnecessarily, providing too much, too soon; in contrast, if death came less than three months after the prediction, there would be no real preparatory time for dying — too little, too late. Identifying patients in the narrow, optimal time period, Avati knew, would allow doctors to use medical interventions more appropriately and more humanely. And if the algorithm worked, palliative-care teams would be relieved from having to manually scour charts, hunting for those most likely to benefit.

Avati and his team identified about 200,000 patients who could be studied. The patients had all sorts of illnesses — cancer, neurological diseases, heart and kidney failure. The team’s key insight was to use the hospital’s medical records as a proxy time machine. Say a man died in January 2017. What if you scrolled time back to the “sweet spot of palliative care” — the window between January and October 2016 when care would have been most effective? But to find that spot for a given patient, Avati knew, you’d presumably need to collect and analyze medical information before that window. Could you gather information about this man during this prewindow period that would enable a doctor to predict a demise in that three-to-12-month section of time? And what kinds of inputs might teach such an algorithm to make predictions?
Avati drew on medical information that had already been coded by doctors in the hospital: a patient’s diagnosis, the number of scans ordered, the number of days spent in the hospital, the kinds of procedures done, the medical prescriptions written. The information was admittedly limited — no questionnaires, no conversations, no sniffing of chemicals — but it was objective, and standardized across patients.

These inputs were fed into a so-called deep neural network — a kind of software architecture thus named because it’s thought to loosely mimic the way the brain’s neurons are organized. The task of the algorithm was to adjust the weights and strengths of each piece of information in order to generate a probability score that a given patient would die within three to 12 months.

The “dying algorithm,” as we might call it, digested and absorbed information from nearly 160,000 patients to train itself. Once it had ingested all the data, Avati’s team tested it on the remaining 40,000 patients. The algorithm performed surprisingly well. The false-alarm rate was low: Nine out of 10 patients predicted to die within three to 12 months did die within that window. And 95 percent of patients assigned low probabilities by the program survived longer than 12 months. (The data used by this algorithm can be vastly refined in the future. Lab values, scan results, a doctor’s note or a patient’s own assessment can be added to the mix, enhancing the predictive power.)

So what, exactly, did the algorithm “learn” about the process of dying? And what, in turn, can it teach oncologists? Here is the strange rub of such a deep learning system: It learns, but it cannot tell us why it has learned; it assigns probabilities, but it cannot easily express the reasoning behind the assignment. Like a child who learns to ride a bicycle by trial and error and, asked to articulate the rules that enable bicycle riding, simply shrugs her shoulders and sails away, the algorithm looks vacantly at us when we ask, “Why?” It is, like death, another black box.

Still, when you pry the box open to look at individual cases, you see expected and unexpected patterns. One man assigned a score of 0.946 died within a few months, as predicted. He had had bladder and prostate cancer, had undergone 21 scans, had been hospitalized for 60 days — all of which had been picked up by the algorithm as signs of impending death. But a surprising amount of weight was seemingly put on the fact that scans were made of his spine and that a catheter had been used in his spinal cord — features that I and my colleagues might not have recognized as predictors of dying (an M.R.I. of the spinal cord, I later realized, was most likely signaling cancer in the nervous system — a deadly site for metastasis).
It’s hard for me to read about the “dying algorithm” without thinking about my patient S. If a more sophisticated version of such an algorithm had been available, would I have used it in his case? Absolutely. Might that have enabled the end-of-life conversation S. never had with his family? Yes. But I cannot shake some inherent discomfort with the thought that an algorithm might understand patterns of mortality better than most humans. And why, I kept asking myself, would such a program seem so much more acceptable if it had come wrapped in a black-and-white fur box that, rather than emitting probabilistic outputs, curled up next to us with retracted claws?

Siddhartha Mukherjee is the author of “The Emperor of All Maladies: A Biography of Cancer” and, more recently, “The Gene: An Intimate History.”

Neo.Life

This beta site NeoLife link beyond the splash pagee is tracking the “neobiological revolution”. I wholeheartedly agree that some of our best and brightest are on the case. Here they are:

ABOUT
NEO.LIFE
Making Sense of the Neobiological Revolution
NOTE FROM THE EDITOR
Mapping the brain, sequencing the genome, decoding the microbiome, extending life, curing diseases, editing mutations. We live in a time of awe and possibility — and also enormous responsibility. Are you prepared?

EDITORS

FOUNDER

Jane Metcalfe
Founder of Neo.life. Entrepreneur in media (Wired) and food (TCHO). Lover of mountains, horses, roses, and kimchee, though not necessarily in that order.
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EDITOR
Brian Bergstein
Story seeker and story teller. Editor at NEO.LIFE. Former executive editor of MIT Technology Review; former technology & media editor at The Associated Press
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ART DIRECTOR
Nicholas Vokey
Los Angeles-based graphic designer and animator.
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CONSULTANT
Saul Carlin
founder @subcasthq. used to work here.

EDITOR
Rachel Lehmann-Haupt
Editor, www.theartandscienceoffamily.com & NEO.LIFE, author of In Her Own Sweet Time: Egg Freezing and the New Frontiers of Family

Laura Cochrane
“To oppose something is to maintain it.” — Ursula K. Le Guin

WRITERS

Amanda Schaffer
writes for the New Yorker and Neo.life, and is a former medical columnist for Slate. @abschaffer

Mallory Pickett
freelance journalist in Los Angeles

Karen Weintraub
Health/Science journalist passionate about human health, cool researcher and telling stories.

Anna Nowogrodzki
Science and tech journalist. Writing in Nature, National Geographic, Smithsonian, mental_floss, & others.
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Juan Enriquez
Best-selling author, Managing Director of Excel Venture Management.

Christina Farr
Tech and features writer. @Stanford grad.

NEO.LIFE
Making sense of the Neobiological Revolution. Get the email at www.neo.life.

Maria Finn
I’m an author and tell stories across multiple mediums including prose, food, gardens, technology & narrative mapping. www.mariafinn.com Instagram maria_finn1.

Stephanie Pappas
I write about science, technology and the things people do with them.

David Eagleman
Neuroscientist at Stanford, internationally bestselling author of fiction and non-fiction, creator and presenter of PBS’ The Brain.

Kristen V. Brown
Reporter @Gizmodo covering biotech.

Thomas Goetz

David Ewing Duncan
Life science journalist; bestselling author, 9 books; NY Times, Atlantic, Wired, Daily Beast, NPR, ABC News, more; Curator, Arc Fusion www.davidewingduncan.com

Dorothy Santos
writer, editor, curator, and educator based in the San Francisco Bay Area about.me/dorothysantos.com

Dr. Sophie Zaaijer
CEO of PlayDNA, Postdoctoral fellow at the New York Genome Center, Runway postdoc at Cornell Tech.

Andrew Rosenblum
I’m a freelance tech writer based in Oakland, CA. You can find my work at Neo.Life, the MIT Technology Review, Popular Science, and many other places.

Zoe Cormier

Diana Crow
Fledgling science journalist here, hoping to foster discussion about the ways science acts as a catalyst for social change #biology

Ashton Applewhite
Calling for a radical aging movement. Anti-ageism blog+talk+book

Grace Rubenstein
Journalist, editor, media producer. Social/bio science geek. Tweets on health science, journalism, immigration. Spanish speaker & dancing fool.

Science and other sundries.

Esther Dyson
Internet court jEsther — I occupy Esther Dyson. Founder @HICCup_co https://t.co/5dWfUSratQ http://t.co/a1Gmo3FTQv

Jessica Leber
Freelance science and technology journalist and editor, formerly on staff at Fast Company, Vocativ, MIT Technology Review, and ClimateWire.

Jessica Carew Kraft
An anthropologist, artist, and naturalist writing about health, education, and rewilding. Mother to two girls in San Francisco.

Corby Kummer
Senior editor, The Atlantic, five-time James Beard Journalism Award winner, restaurant reviewer for New York, Boston, and Atlanta magazines

K McGowan
Journalist. Reporting on health, medicine, science, other excellent things. T: @mcgowankat

Rob Waters
I’m a journalist living in Berkeley. I write about health, science, social justice and policy. Father of 1. From Detroit.
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Yiting Sun
writes for MIT Technology Review and Neo.life from Beijing, and was based in Accra, Ghana, in 2014 and 2015.
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Michael Hawley
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Richard Sprague
Curious amateur. Years of near-daily microbiome experiments. US CEO of AI healthcare startup http://airdoc.com
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Bob Parks ✂
Connoisseur of the slap dash . . . maker . . . runner . . . writer of Outside magazine’s Gear Guy blog . . . freelance writer and reporter.

CREDIT: https://medium.com/neodotlife/review-of-daytwo-microbiome-test-deacd5464cd5

Microbiome Apps Personalize EAT recommendations

Richard Sprague provides a useful update about the microbiome landscape below. Microbiome is exploding. Your gut can be measured, and your gut can influence your health and well-being. But now …. these gut measurements can offer people a first: personalized nutrition information.

Among the more relevant points:

– Israel’s Weitzman Institute is the global leader academically. Eran Elinav, a physician and immunologist at the Weizmann Institute and one of their lead investigators (see prior post).
– The older technology for measuring the gut is called “16S” sequencing. It tell you at a high level which kinds of microbes are present. It’s cheap and easy, but 16S can see only broad categories,
– The companies competing to measure your microbiome are uBiome, American Gut, Thryve, DayTwo and Viome. DayTwo and Viome offer more advanced technology (see below).
– The latest technology seems to be “metagenomic sequencing”. It is better because it is more specific and detailed.
– By combining “metagenomic sequencing” information with extensive research about how certain species interact with particular foods, machine-learning algorithms can recommend what you should eat.
– DayTwo offers a metagenomic sequencing for $299, and then combines that with all available research to offer personalized nutrition information.
– DayTwo recently completed a $12 million financing round from, among others, Mayo Clinic, which announced it would be validating the research in the U.S.
– DayTwo draws its academic understandings from Israel’s Weitzman Institute. The app is based on more than five years of highly cited research showing, for example, that while people on average respond similarly to white bread versus whole grain sourdough bread, the differences between individuals can be huge: what’s good for one specific person may be bad for another.

CREDIT: Article on Microbiome Advances

When a Double-Chocolate Brownie is Better for You Than Quinoa

A $299 microbiome test from DayTwo turns up some counterintuitive dietary advice.

Why do certain diets work well for some people but not others? Although several genetic tests try to answer that question and might help you craft ideal nutrition plans, your DNA reveals only part of the picture. A new generation of tests from DayTwo and Viome offer diet advice based on a more complete view: they look at your microbiome, the invisible world of bacteria that help you metabolize food, and, unlike your DNA, change constantly throughout your life.
These bugs are involved in the synthesis of vitamins and other compounds in food, and they even play a role in the digestion of gluten. Artificial sweeteners may not contain calories, but they do modify the bacteria in your gut, which may explain why some people continue to gain weight on diet soda. Everyone’s microbiome is different.

So how well do these new tests work?
Basic microbiome tests, long available from uBiome, American Gut, Thryve, and others, based on older “16S” sequencing, can tell you at a high level which kinds of microbes are present. It’s cheap and easy, but 16S can see only broad categories, the bacterial equivalent of, say, canines versus felines. But just as your life might depend on knowing the difference between a wolf and a Chihuahua, your body’s reaction to food often depends on distinctions that can be known only at the species level. The difference between a “good” microbe and a pathogen can be a single DNA base pair.

New tests use more precise “metagenomic” sequencing that can make those distinctions. And by combining that information with extensive research about how those species interact with particular foods, machine-learning algorithms can recommend what you should eat. (Disclosure: I am a former “citizen scientist in residence” at uBiome. But I have no current relationship with any of these companies; I’m just an enthusiast about the microbiome.)

I recently tested myself with DayTwo ($299) to see what it would recommend for me, and I was pleased that the advice was not always the standard “eat more vegetables” that you’ll get from other products claiming to help you eat healthily. DayTwo’s advice is much more specific and often refreshingly counterintuitive. It’s based on more than five years of highly cited research at Israel’s Weizmann Institute, showing, for example, that while people on average respond similarly to white bread versus whole grain sourdough bread, the differences between individuals can be huge: what’s good for one specific person may be bad for another.

In my case, whole grain breads all rate C-. French toast with challah bread: A.

The DayTwo test was pretty straightforward: you collect what comes out of your, ahem, gut, which involves mailing a sample from your time on the toilet. Unlike the other tests, which can analyze the DNA found in just a tiny swab from a stain on a piece of toilet paper, DayTwo requires more like a tablespoon. The extra amount is needed for DayTwo’s more comprehensive metagenomics sequencing.

Since you can get a microbiome test from other companies for under $100, does the additional metagenomic information from DayTwo justify its much higher price? Generally, I found the answer is yes.

About two months after I sent my sample, my iPhone lit up with my results in a handy app that gave me a personalized rating for most common foods, graded from A+ to C-. In my case, whole grain breads all rate C-. Slightly better are pasta and oatmeal, each ranked C+. Even “healthy” quinoa — a favorite of gluten-free diets — was a mere B-. Why? DayTwo’s algorithm can’t say precisely, but among the hundreds of thousands of gut microbe and meal combinations it was trained on, it finds that my microbiome doesn’t work well with these grains. They make my blood sugar rise too high.

So what kinds of bread are good for me? How about a butter croissant (B+) or cheese ravioli (A-)? The ultimate bread winner for me: French toast with challah bread (A). These recommendations are very different from the one-size-fits-all advice from the U.S. Department of Agriculture or the American Diabetes Association.

I was also pleased to learn that a Starbucks double chocolate brownie is an A- for me, while a 100-calorie pack of Snyder’s of Hanover pretzels gets a C-. That might go against general diet advice, but an algorithm determined that the thousands of bacterial species inside me tend to metabolize fatty foods in a way that results in healthier blood sugar levels than what I get from high-carb foods. Of course, that’s advice just for me; your mileage may vary.

Although the research behind DayTwo has been well-reviewed for more than five years, the app is new to the U.S., so the built-in food suggestions often seem skewed toward Middle Eastern eaters, perhaps the Israeli subjects who formed the original research cohort. That might explain why the app’s suggestions for me include lamb souvlaki with yogurt garlic dip for dinner (A+) and lamb kabob and a side of lentils (A) for lunch. They sound delicious, but to many American ears they might not have the ring of “pork ribs” or “ribeye steak,” which have the same A+ rating. Incidentally, DayTwo recently completed a $12 million financing round from, among others, Mayo Clinic, which announced it would be validating the research in the U.S., so I expect the menu to expand with more familiar fare.

Fortunately you’re not limited to the built-in menu choices. The app includes a “build a meal” function that lets you enter combinations of foods from a large database that includes packaged items from Trader Joe’s and Whole Foods.

There is much more to the product, such as a graphical rendering of where my microbiome fits on the spectrum of the rest of the population that eats a particular food. Since the microbiome changes constantly, this will help me see what is different when I do a retest and when I try Viome and other tests.

I’ve had my DayTwo results for only a few weeks, so it’s too soon to know what happens if I take the app’s advice over the long term. Thankfully I’m in good health and reasonably fit, but for now I’ll be eating more strawberries (A+) and blackberries (A-), and fewer apples (B-) and bananas (C+). And overall I’m looking forward to a future where each of us will insist on personalized nutritional information. We all have unique microbiomes, and an app like DayTwo lets us finally eat that way too.

Richard Sprague is a technology executive and quantified-self enthusiast who has worked at Apple, Microsoft, and other tech companies. He is now the U.S. CEO of an AI healthcare startup, Airdoc.

====================APPENDIX: Older Posts about the microbiome =========

Microbiome Update
CREDIT: https://www.wsj.com/articles/how-disrupting-your-guts-rhythm-affects-your-health-1488164400?mod=e2tw A healthy community of microbes in the gut maintains regular daily cycles of activities. A healthy community of microbes in the gut maintains regular daily cycles of activities.PHOTO: WEIZMANN INSTITUTE By LARRY M. GREENBERG Updated Feb. 27, 2017 3:33 p.m. ET 4 COMMENTS New research is helping to unravel the mystery of how […]

Vibrant Health measures microbiome

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Microbiome Update
My last research on this subject was in August, 2014. I looked at both microbiomes and proteomics. Today, the New York Times published a very comprehensive update on microbiome research: Link to New York Time Microbiome Article Here is the article itself: = = = = = = = ARTICLE BEGINS HERE = = = […]

Microbiomes
Science is advancing on microbiomes in the gut. The key to food is fiber, and the key to best fiber is long fibers, like cellulose, uncooked or slightly sauteed (cooking shortens fiber length). The best vegetable, in the view of Jeff Leach, is a leek. Eating Well Article on Microbiome = = = = = […]

Arivale Launches LABS company
“Arivale” Launched and Moving Fast. They launched last month. They have 19 people in the Company and a 107 person pilot – but their plans are way more ambitious than that. Moreover: “The founders said they couldn’t envision Arivale launching even two or three years ago.” Read on …. This is an important development: the […]

Precision Wellness at Mt Sinai
My Sinai announcement Mount Sinai to Establish Precision Wellness Center to Advance Personalized Healthcare Mount Sinai Health System Launches Telehealth Initiatives Joshua Harris, co-Founder of Apollo Global Management, and his wife, Marjorie has made a $5 million gift to the Icahn School of Medicine at Mount Sinai to establish the Harris Center for Precision Wellness. […]

Proteomics
“Systems biology…is about putting together rather than taking apart, integration rather than reduction. It requires that we develop ways of thinking about integration that are as rigorous as our reductionist programmes, but different….It means changing our philosophy, in the full sense of the term” (Denis Noble).[5] Proteomics From Wikipedia, the free encyclopedia For the journal […]