Dodging Alzheimer’s

A recent Lancet Neurology paper concludes:

around a third of Alzheimer’s diseases cases worldwide might be attributable to potentially modifiable risk factors.

That is, education, physical inactivity, smoking, hypertension, obesity, diabetes and depression.

Dementia is a frightening matter, and one quite familiar to many people in our aging society, either through personal experience or the media. Should the grim prospect of Alzheimer’s disease – and the possibility of avoiding it – be more heavily utilized in public health messaging?

Generally speaking, coercing people into healthy behavior through threatening them with terrible complications unless they change may not be the best tactic to promote wellbeing.

But people do need to realize the consequences of their lifestyle choices, and while heart attacks and strokes should be concrete enough menaces, the idea of losing grip of the cognitive processes that constitute the very you might be what’s needed to propel somebody out of, say, smoking.

A greater chance of surviving into old age with your wits intact – consider adding this to your phrasebook of health promotion.

New data on alcohol-cardiovascular health link

Souvenir from Dahab. Never had the courage to touch the contents.

Souvenir from Dahab, 2009. Never had the courage to touch the contents.

Is alcohol healthy when consumed in moderate amounts?

The topic is controversial. Observational studies have found light to moderate drinking to be associated with less cardiovascular illness, but a recent research article in BMJ tips the scale in favor of ”probably not”.

In many previous studies, alcohol consumption and mortality have appeared to have a ”J”-shaped relationship: while heavy drinkers have a high risk of cardiovascular illness and mortality, light and moderate drinkers seem to enjoy smaller risk than teetotals (see e.g. these two much-quoted papers, and a more recent meta-analysis).

(The definition of moderate drinking, in case you were wondering, depends on who wrote the recommendations but generally means something like 1 or 2 drinks a day. Contrary to popular belief, red wine has not been proven superior to beer or spirits; in the studies mentioned above, only the amount of pure alcohol had significance.)

The way the J-shaped curve has traditionally been interpreted is that moderate alcohol consumption would prevent cardiovascular illness and prolong one’s life span. Biological mechanisms for how this might take place have also been proposed (see e.g. here).

But in the end it’s a correlation-causation thing: we only know there seems to be a connection but cannot tell if one really causes the other. (For entertaining examples of bizarre correlations, see here – movie appearances by Nicolas Cage vs. drowning deaths is my favorite.) Maybe the teetotals are abstinent because their underlying illnesses keep them from drinking alcohol? Maybe the people with “civilized” drinking patterns also have higher education, better incomes and more healthy behavior in general? The only way to find out for sure would be to run a randomized controlled trial, and this is unlikely to ever happen.

What the BMJ authors Holmes and Dale (and a lengthy list of collaborators) did was to look at a gene (a particular allele of alcohol dehydrogenase) that is known to be associated with lower alcohol consumption. While not a substitute for a clinical trial, this is quite a smart method really: gene alleles are randomly assigned to individuals (kind of), people cannot falsify them (like they might downplay their actual consumption of alcohol) and cannot be changed by lifestyle (so there is no possibility of the causation working two ways).

They conclude:

From the U shaped association seen in observational studies, we would expect that for drinkers below the nadir (12-25 units/week), a reduction of 17.2% in alcohol consumption — would lead to a small increase in the risk of coronary heart disease — Contrary to these expectations, however, we found that individuals below the nadir with a genetic predisposition to consume less alcohol had lower odds of developing coronary heart disease at all categories of alcohol consumption — bringing the hypothesised cardioprotective effect of alcohol into question.

So is moderate drinking healthy or not? The only really accurate answer at present is, we still don’t know. The new BMJ paper does not present definite evidence of alcohol’s causal effect because it uses a gene as a proxy and there may be confounding factors. However, it gets closer to proving causation than the older ”J-curve” studies.

The new study is welcome because it challenges the popular (but scientifically poorly founded) belief that moderate drinking is good for you. We need more info. The health effect of moderate drinking – be it positive or negative – may not be big from individual point of view – but given the very large alcohol-consuming population of the world, knowing the true answer to the question would have great importance to health policy.

Meanwhile, there is a lot we do know about the health effects of too much booze (it remains among the three leading risk factors for death and disability worldwide) and the practical advice regarding drinking stays largely the same.

If you’re an abstainer, there is no reason to start drinking because 1) there is no real proof that alcohol is beneficial; 2) even if it were, the gains would most likely be small, plus 3) you would risk drifting into the “heavy drinker” sector, which is unambiguously harmful. If you’re a moderate drinker, that’s probably OK; what the new BMJ paper hints, though, is that you might still be better off consuming less. I find it credible.

Opposing gay marriage is simply bad thinking

The bill to legalize same-sex marriage in Finland was rejected yesterday by the Legal Affairs Committee of the Parliament. (There will still be a full parliamentary vote in the autumn.)

That Finland will not (yet) allow same-sex marriage is a human rights issue, but also a case of bad thinking and bad politics.

In economist terms, allowing gays to marry would be a Pareto improvement over the present situation, i.e. a change that makes at least somebody (in this case, gays) better off without harming anyone.

It is intellectually very difficult not to support a Pareto improvement where somebody wins and nobody loses

For those suspecting that same-sex marriage would affect the society in some negative way, I’ll only refer to these two pie charts: English, Finnish.

Considering that 54 to 65 % of population support gay marriage, a change should be a matter of time.

Would you trust this bird?

A cup of coffee at the town square while waiting for a train in Mikkeli. This little fellow hops casually closer. He wobbles on the back of a chair and observes the town life in a nonchalant manner, casting only occasional side-glances at my donut. Surely he’s just enjoying the nice summer day like me?

Sheesh. He’s no first-timer.

The Lost City of N

There would have been plenty of job opportunities in and around the capital city but I guess had to see something different. Now, three months post graduation, I find myself employed in the small town of N in Eastern Finland.

In Finnish standards, N is in the middle of nowhere. Not many public transport connections. Some 100 km to the closest hospital. When I got off the bus, the driver warned me about a bear that had been sighted nearby.

The population is falling, and the age pyramid is diamond-shaped. The unemployment rate is around 20%. N has received media attention because of its many social problems and violence.

Visiting the town center, which has been laid out around one or two major roads, is telling. Empty office spaces. Few daycare centers, disproportionally many bars. Looks like everybody who was able to escape has done exactly that, and those who couldn’t…

What the heck did I sign up for?

It has become obvious that there is a lot of work. Cardiovascular mortality is high, obesity and diabetes are rampant, alcohol is a problem, and the prevalence of schizophrenia is higher than in the rest of the country. My new colleagues are kind and knowledgeable but they, too, seem quite busy.

I’m feeling cautiously positive anyway. The town is surrounded by gorgeous forests and lakes. My apartment comes with a rocking chair. The natives are friendly, and by all accounts, there is some real doctor’s work to be done.


I remain in gratitude to the friend who gave me a yoga gift card for Christmas. I’ve been going to hatha lessons for some months now and enjoyed immensely the gentle, relaxing exercises (after which you somehow still feel like you’ve done some serious sports).

Naturally, I’ve tried to find out if there are any health benefits to yoga. It seems there may well be, although good RCTs are lacking so the truth is yet uncertain (see e.g. this Cochrane review about yoga for primary prevention of cardiovascular illness).

Yoga does have some plausibility in this regard: it comprises both physical exercise and stress management, both of which can be good for you.

Any health benefits are very unlikely, however, to be attributable to the flow of prana, or opening of meridians, or whatever.

See, the only thing that bothers me about my yoga studio is that some instructors will tell me a specific asana will “massage my kidneys” and thus help cleanse my body, while another will “open up my ankles” and release all the unspecified bad stuff that tends to accumulate there (I can only hope they aren’t referring to thrombi).

I haven’t confronted these instructors: that hasn’t felt appropriate, and I doubt such a discussion would change things much. I’ve though about voting with my feet and taking my money elsewhere, but I probably won’t. Despite the dubious health claims, I simply like my new hobby too much, and there are other, very professional instructors who give great yoga lessons without referring to prescientific concepts.

But just as I can enjoy a tall, healthy glass of orange juice without pretending it is a magic potion, I would prefer my yoga as it is: invigorating, fun and free of superstition.

(P.S. In any case, there will be a break from yoga lessons. I may still need to fully grasp I’m a doctor now, but two months ago I received my degree from the university, and two days ago I took the physician’s oath. Next, I will move to work in a remote Eastern Finnish town. Updates will follow.)

Until proven otherwise

There are many rules of thumb in medicine (think MIDAS for instance). One popular formula goes: [insert symptom] is a sign of [insert disease], until proven otherwise.

When still studying, I ran into these so often I decided to write down each one I heard. Here are some I found in my notebook.

  • Fever in a traveler is malaria – until proven otherwise.
  • Any liquid in a trauma patient’s abdominal cavity is blood – until proven otherwise.
  • A case of tuberculosis from an XDR-TB-prevalent area is XDR – until proven otherwise.
  • An infection in a neutropenic patient is bacterial – until proven otherwise.
  • A smoker’s hemoptysis signifies lung cancer – until proven otherwise.
  • Petechiae and ecchymoses mark meningococcal disease – until proven otherwise.
  • Osteomyelitis is caused by S. aureus – until proven otherwise.
  • Simultaneous anemia, leukopenia and trombosytopenia signify acute leukaemia – until proven otherwise.
  • A hot, red foot in a diabetic patient means Charcot’s foot – until proven otherwise.
  • A III cranial nerve palsy that affects the pupil means there is a cerebral artery aneurysm – until proven otherwise.

Anything else in this fascinating genre of mnemonics?