Aaron: Hi, I'm Aaron Carroll.

John: I'm John Green.

Aaron: And this is Healthcare Triage.

John: And today we're going to answer some of your questions.

(Intro Music)

John: Alright Aaron, this question comes from Roseperson; What policy change could have the biggest benefit for US health?

Aaron: Well we're starting off easy, aren't we?  Um, I guess if I had to pick one thing to do it would be is if we could somehow transition the way that we reimburse care from sort of doing anything and how much volume it is, to sort of trying to pay for things perhaps that work versus not work.  Though I think the likelihood of that happening anytime soon is pretty small, but that would do a lot.

John: What kind of daily exercise is best long-term, walking, running, short versus long distance, cycling, etc.?

Aaron: You know, people ask that kind of question all the time, and the simple answer is whatever you will do for a long period of time, meaning whatever you will do consistently.  The same thing has been shown with diet.  You know, people will wonder what's the best kind of diet.  The truth of the matter is whatever will work for you and whatever will stick so that you keep doing it over a period of time.

John: And how long should I - how, how much exercise should I be getting a day?

Aaron: Uh, people are act- I think most people would say thirty secon- oh God, thirty minutes of activity a day.  Thirty seconds is too short, too short.

John: He said thirty seconds

Aaron: Nope

John: I'm in

Aaron: Nope, too short, thirty minutes

John: Go, go, go, go, go, I'm almost there, I'm almost there

Aaron: You want your - heart elevated, thirty minutes.

John: Alright, thirty minutes a day.  What if I want to do, like, two hours a day, is that a problem?

Aaron: No, as long as you can handle it; but the problem that most people do is they push too hard and then they get sore, or they get tired, or they can't sustain it over a period of time, and then they stop, and stopping is what we want to avoid.

John: Like that day that I ran eight miles, and then the next day... I couldn't walk.

Aaron: Exactly.  When I tried P90X for a while, and it's like, it took me half an hour to get out of my car.

John: [laughs]

John: Ben asks, "Hey, you're a doctor.  Can you take a look at my rash?"

Aaron: Sure!  Yeah, looks fine.

John: Yeah. Yeah, I think you're alright. Yeah. I'm not a doctor, but, that's, that's no big deal

Aaron: That looks fine.

John: njnerdymom asks, "Why are some hospitals more prestigious, like the Mayo Clinic?  And, are they better?"

Aaron: Well, some are prestigious cause they have very good PR departments and very good advertising; some are prestigious cause they make a lot of money and some are prestigious just because they have high quality people that work there.  Uh, but,  uh it's not like every hospital is prestigious in everything, so some may be good in some things and not as good as other things, some may be good at everything.  Uh, but, there's no great evidence that necessarily the prestige translates into quality or better care.

John: onceuponA asks, "Will you please use Healthcare Triage to tell my dad that soda isn't leaching calcium from my bones?"

Aaron: Yeah this is a myth. Um, it's actually related to the fact that in early evidence they showed that carbonated beverages slightly increased how much calcium will be in your urine. Uh, but what they didn't tell you is that on the back side is that your body quickly readjusts to retain more calcium so that you don't lose any of the aggregate. And studies that have been done over long periods of time with different kinds of carbonated beverages have shown that people don't have problems with relationship to their bones or breaking them.

I happen to know onceuponA and I know that this is a question from her dad, so I'm telling Adriana's dad "Don't worry about this."

John:  Emily asks, "What are the actual risks and benefits of home birth vs birth center vs hospital?"

Aaron: That's a great question and unfortunately it's not terribly easy.  I mean of course you go to the hospital for sort of insurance purposes.  Not insurance of health insurance but just of in case something goes wrong, you're there.  Uh, But the truth of the matter is that the vast majority of births are gonna do just fine and probably would be great at home.  And don't really need that.  But I think most people go to the hospital for the "what if?"

John: This is helpful to me because as you know I am a massive hypochondriac.  Um, so I would be asking all of that.

Aaron: Well that's good.

John: What you don't know is that I ask Aaron of these questions what the camera isn't on.

Aaron: But I give you the same answers.

John: I know, you do.  Consistently the same answers.

Aaron: Very consistent.

John: psionedge asks, "Does privatizing Medicare/Medicaid have any evidence of saving money while actually working?"

Aaron: Yes.  Uh, in the sense that when they look at sort of Medicare Advantage programs, which are private companies which are administering Medicare across the country, if you look at it in a county-to-county basis, there are places in the country where Medicare Advantage is actually providing the Medicare benefits for less money.  Those are much rarer however than the times when Medicare Advantage is costing much more money.

So if you're asking me is there any evidence that in some markets, private insurance can provide Medicare benefits more cheaply than Medicare can, yes. But holistically overall, the government is probably more efficient at providing those benefits.

John: Does improving patient satisfaction scores affect other outcomes?

Aaron: Oh wow.  See questions like this sound simple but are just not.  Because the question is what is satisfaction and what are the outcomes? And there are studies that show that patients who are more satisfied and have a better relationship with their doctor actually might adhere to recommended therapy more closely and therefore get a better benefit.

John: That's definitely true for me.

Aaron: But there are also studies that show that trying to please patients in an effort just to get better satisfaction often can lead to increased costs and less good outcomes.  And that was actually shown in a study published a couple years ago that got a lot of press because they were showing that satisfaction actually cost more and even lead to higher mortality.  But that's cause sometimes doctors go overboard in an effort to please patients do the wrong thing. That's not good.  But building a good relationship in order to improve satisfaction, that's a good thing.

John: So this is one of those places where actually sometimes satisfied customers are not, um, healthy, the healthiest possible customers.

Aaron: No. Correct, and often what people want is not what is best for them. And sometimes you have to explain and do things that might make them more upset in the short term.  But you try to do it in a manner that builds a bond that hopefully increases that quality of the relationship in the long term.

John: I have been asking my doctor, who you recommended to me, to give me Botox, uh, for months because I'm becoming an older gentleman and I'm on YouTube, and there's no room on YouTube for wrinkles.

Aaron: Right.

John: He just is completely unsympathetic to my position.

Aaron: As would I be.

John: And so I give him very low patient satisfaction scores.

Aaron: That may be.  But see, I think he's probably doing you a service in the long run.

John: [laughs] Okay this question is from James. What's the #1 thing you can do to help you live longer?

Aaron: I would need to know James to answer that question.

John: I can show you a picture of him; he looks like that.

Aaron: It depends, you know, if you smoke the #1 thing to do is stop smoking.  If you are eating unhealthily, the #1 thing you can do is eat better.  If you don't exercise, the #1 thing you can probably do is exercise. 

John: Let me ask you this: Is, this is a totally personal hypochondriac question, um, if I'm choosing between changing my diet so that it's heavy in fruits and vegetables, lower in fat OR exercising which of those is more important to me living a longer healthier life?

Aaron: I, looking at you and knowing you I would say probably exercising.  Cause I would imagine, you're not obese, your diet is probably decent to begin with and any changes... 

John: (whispers)  It's not great.

Aaron: Well any changes you're making are at the edges.  You're not talking about probably eating multiple servings of meat a day or eating so much that you're really unhealthy.  So in that case, probably getting good exercise you'd be better off. 

John: That's helpful.  Alright I've got a few more questions for you.  How effective is stretching for preventing sports-related injury?

Aaron: Not at all.

John: In fact isn't it bad?

Aaron: Not at all.  This is one of those that blows people minds but there have been systematic reviews, there was one in like I think 2004 and they looked at hundreds of trials.  There were six good studies and none of them showed that stretching prevented injury.  There have been other studies to show that you know warming up and everything else, it doesn't actually make you perform better and in fact, some studies show that when they randomize people to stretch or not they don't run as fast, jump as high.  In other words they don't even perform as well.  So you're not preventing injury and you're potentially making yourself not play as well.  So I don't know why we still do this.

John: Um, is it true that you should stretch after you exercise to minimize, you know, soreness the next day or whatever?

Aaron: I've seen no good evidence about the stretching.  What I have seen people push is that you should just, you know, walk perhaps.  Or just try to work your muscles through and the idea is that you're trying to get the lactic acid out.  I've not seen any good studies to say whether that's true or not but that at least makes a little bit of sense.

John: Have there been studies that conclude that food dye does or does not negatively affect children's behavior?

Aaron: This is, I wish this one as clean as like sugar is where it's, like, so clear that there have been huge randomized controlled trials that show that it doesn't.  But there are some randomized controlled trials of kids who already have hyperactive behavior, like who have ADHD, pretty severe ADHD, where eating a lot of foods with some dyes could lead to slightly worse behavior in parent's eyes.

John: Wow.

Aaron: So, having said that, if you have a child with severe ADHD and you're concerned about this and you want to try no dyes, okay.  But the problem is that people extrapolate this to say "Oh if my normal child gets dye then somehow he's gonna be a bad kid". That there's no evidence for.  So the idea that we need to avoid these like the plague holistically, there's not much evidence for that.

John: There's no evidence for it, but like I mean it's possible, it sounds like.

Aaron: Well everything's possible!

John: Now I'm freaking out about food dye.

Aaron: No, no. And you need...

John: Nope, too late. I'm on the - I'm on the - I'm on the crazy train. I've already left the station. I'm removing all the dye from my child's life. He's already- he's already got a lot of energy. 

Aaron: Yeah but if you - But see if you go to those lengths then you could probably make him hate you and you're probably gonna you know not, you want to have a better relationship with your child that's more important.

John: Don't worry. He already hates me.

Aaron: Oh.

John: We're covered on that front.

John: Dietary cholesterol is not strongly linked to LDL blood levels.  True, false or in between? Also, what are LDL blood levels?

Aaron: LDL is the low density lipoproteins. See I knew that one.

John: Good or bad?

Aaron: Uh, that is the. . . 

John: Oh boy

Aaron: Oh my god, see this is the danger.  

John: HDL is bad, right? 

Aaron: HDL is bad, LDL is good.  So this is a great question because it's a 

John: Who's the doctor now?

Aaron: Right, well this is where it gets . . I rarely get asked this question with respect to LDL levels.  It's always HDL levels, but they're, they're sort of linked. The truth of the matter's that the vast majority of people actually are what we call hyporesponders, meaning that they don't actually respond with respect to their blood cholesterol levels to what they're eating in their diet.  So you could actually change what you eat - eat tons of eggs, don't [eat] eggs.

They did a study where they gave regular people three eggs a day every day for a long time - no change in their dietary cholesterol.  I mean, in their actual blood cholesterol.  About 30% of people are what we call hyperresponders, meaning their levels do change with respect to food, but it's much less than you'd think.  Changing your diet by something like 100 milligrams of cholesterol a day might bump it by 2, which is almost inconsequential.

John: Two points out of like?

Aaron: Two points out of, when we talk about like 200 or more.  
John: We're talking about hundreds, yeah.

Aaron: Right.  So you would actually have to change your, the amount of cholesterol you take massively to truly change how much cholesterol, to get yourself from an unsafe to a safe level.  Which is why medications are recommended for people who truly are at unsafe levels.

John: Is sitting as harmful as smoking? Please say no, please say no, please say no, please say no.

Aaron: No!

John: Thank you.

Aaron: This is one of those, this is one of those, they, this was in the news a lot and - the study basically said that people who sit for eight hours a day or more are more likely to have cardiovascular disease than people who sit for less than eight hours a day.  But what they really meant was that people who don't exercise are going to have a higher cardiovascular risk than people that do exercise.  

But there is no question that smoking is just bad.  And if I had to say which of these would I be more concerned about, if you're a smoker stop smoking.  I mean that is by far the worst thing that you can do in respect to all of this stuff.  Having said that, if you're not smoking, yeah, be less sedentary. It's only going to improve your life.

John: But in that study didn't they say that like, even people who exercise 30 minutes a day, if they have a very sedentary lifestyle, there's still an increased risk?

Aaron: It is increased risk, but it's like "increased risk." You know, how much more so? Smoking is going to be so much worse for you over the long term, in the risk that you could die, uh, than, than, than the sitting.  Uh, having said that, if you have a choice do both.  If you have, you know if you're not smoking I would absolutely encourage you to be more active.  But if, but if, if somebody was presenting to me with both and said, "I sit for eight hours a day and I smoke." Unequivocally I would say stop smoking.  That would be number one.  

John: Is sugar as addictive as cocaine?

Aaron: No, but you know, the reason this was in the news so much - there was this crazy study, and I don't remember whether it was by high school students or college students, but what they did was they basically got all these rats to run through a maze. And for like some of the rats at the end of the race - at the end of the maze - they gave them a cookie, an Oreo. And in other rats when they got to the end of the maze, they gave them cocaine.  

And so they found that the rats were just as eager to get through the maze whether they got cocaine or a cookie.  That does not mean that Oreos are as addictive as cocaine.  And I don't know why anyone would think that that's the case. It means that rats like both?

John: Okay, discuss the evidence for nutritional supplements.

Aaron: None. It's great for making really expensive urine, that's about it. They just don't work. I mean, the truth of the matter is most Americans have a totally well balanced diet are getting the vitamins they need. If you have to, take a multivitamin that's going to supplement you and probably put you over the edge. But the human body is just not meant to take in any excess vitamins or any kinds of supplements, your body doesn't process them, it just pees them out. And so you're really not doing much at all.

If there was some kind of nutritional benefit to eating more of this stuff, evolution. would have pushed us, and other animals, to eat more of the stuff. We basically are conditioned to eat about the right amount of the stuff, some people don't get enough, multivitamins fine. Some people get a bit too much, that's fine too, they're just gonna pee it out. But the idea that we're gonna massively supplement ourselves with any one vitamin or any one supplement and that's going to drastically change our health, there's really almost no evidence for that at all.

John: Last question, from me. You just said that nutritional supplements only make for expensive urine. I have, as you may notice, medium-sized guns. Um, I was thinking of developing gigantic guns.

Aaron: Okay.

John: Wouldn't nutritional supplements potentially help me with my gigantic guns development project?

Aaron: There's really not much evidence for that at all. Having said that... 

John: Devastating! 

Aaron: I know. Well, the thing is if this stuff was easy and it actually worked, it would work for regular people. It only seems to work for really extreme bodybuilders who were working so hard anyway that they were gonna get massive muscle build up. For the vast majority of people it's just not going to make any difference at all. There is some evidence that recovery beverages like some of the protein shakes, or really there have been great studies that show that, you know, chocolate milk is just as good of a recovery beverage as the super expensive ones you buy in stores.

John: Oh so now who likes milk?

Aaron: Well but [both laughs] Darn it! The milk is always on to me! But that would be a small... [bangs table repetitively] Anyway.

John: Aaron Carroll, pro-milk. You heard it here first.

Aaron: Anyway, there's some evidence that that actually recovery but again you're talking about really intense high-performance athletes, not us, or at least not me, maybe you.

John: Well probably also not me.

Aaron: Okay, but so then none of the supplements are really gonna make a difference at all.

John: Alright, well thank you Aaron so much this has been tremendously educational as it always is and thanks for all your work on Healthcare Triage.

Aaron: Thank you. Oh, my pleasure, thank you.

John: Alright, bye everybody!