J: Hi I'm John Green!

A: I'm Aaron Carroll.

J: And we're here today to do Healthcare Triage Q&A. I'm gonna ask your questions of Dr. Carroll. I'm also might ask some of my questions, uh, most of which will revolve around my own mortality. Aaron, am I gonna die?

A: nnnnnnn...yes.

J: Damn it!

A: Some day! Some day! Not now. 

J: (Sigh) What's my chances next five years?

A: Very, very low. Really low.

J: Yeah but not nil, not zero. 

A: Yeah, not zero. Really low. 

Q1....
J: We're going to start with a question from Little Lionflower: "How long does it take to process food into stored fat or muscle energy? If I eat fewer calories today, will I see the difference tomorrow or the next day?" 

A: Not in terms of fat. Um, so there's no chance that if you eat fewer calories today is going to reduce in fat reduction tomorrow. But there will be changes in your water weight, and eating less salt or less certain nutrients may make you diurese, or pee off some of the water so that it would not be immediate weight reduction. But it would be a fat reduction that would be consistent. 

J: So if I'm looking to lose 13 pounds in the next 24 hours what would you recommend?

A: I don't know if there's any way, short of amputating a leg (laughter), that you could probably pull that off. Or have a baby! Women could do that - have a baby. 

J: so I just need to have a baby

A: Have a baby! Tomorrow
 
J: (laughs more) 


Q2....
J: Sakowski asks: "Do you think there are specific health benefits to weight training? Metabolic, cognitive, or hormones?"

A: Well certainly if it gets you to exercise it would be, yes, because of course, if you, in fact, some of the recommendations for exercise are always 150 minutes a week or five days a week at 30 [minutes] or moderate, or vigorous for two 30-minute periods and I think three periods of weight training instead. So, if you want to figure it out so that you're still getting the recommended amount, weight training is perfectly fine. Some people also argue too that if you put on more muscle mass that that helps you increase your metabolic rate or how many calories you're burning and that it could help with long-term management. Iiiiii'm not totally convinced of that. 

J: What are the supposed cognitive benefits of weight training?

A: So again, I think that's more exercise than it is weight training. So there are definitely cognitive benefits with respect to anxiety and depression, everything else that I've- we even did this discussion in an episode of exercise. But I don't think that would specifically be weight training. 

J: So I'm good to continue with my, uh, 30 minutes a day of jogging?

A: Yeah.

J: Slash fast-walking.

A: That's perfectly... you see 30 to 35 minutes a day is the weekly recommended amount. You have done the recommended amount. 

Q3:
J: James asks: "My parents are saying Obamacare has caused their premiums to rise, but I'm not convinced that's the reason (they're in TX). What causes premiums to rise? How can I help them find better rates/plans?" Can I answer this question first?

A: Sure! Go ahead.

J: ...and then you tell me if I'm right.

A: Yeah. 

J: No, Obamacare has not caused your parents' premiums to go up. And the way to find them better rates or plans is to have a drastic overhaul of our healthcare system so that we have one that is more like countries in Europe. 

A: Okay, so since that's NOT gonna happen, I'm going to give you realistic advice. So first of all, it's healthcare premiums that rise when healthcare spending goes up. I mean, you know as much as we demonize health insurance companies, their profit margins are on the thin-side, so what happens is that each year they have to guess how much they're going to spend on healthcare. If they wind up spending more on their risk pool than they thought, then the next year, they raise the premiums in order to sort-of compensate for that. So, the reason the premiums likely went up for your parents is that that health insurance company wound up spending more money than they did the year before. The way to fix it is if they're getting a plan from the exchanges, go shop for a cheaper plan. It's very likely that if that plan went up, then other plans may be cheaper because they weren't covering such a sick pool. So you need to shop around every year. And it is easy or common these days to scapegoat Obamacare and just blame it for every little problem. Healthcare spending and premiums have been rising really fast since forever, and in fact they have been in the past few years rising so much more slowly than ever before. You can also credit that to Obamacare, but nobody does. But you know these days it's just like anything: "Did you hear the new drugs have side-effects? 

Now it's because of Obamacare!" It's just... It's not all Obamacare's fault.

J: Is there any truth to the talk that Obamacare is in a sort of death spiral, where the pools are getting sicker and sicker?

A: No. So what they've seen is that some of the co-ops have gone under and those are specifically some non-profits that they tried to hold together, but it turns out it's hard to start up a health insurance plan from scratch, especially if it's small, 'cause when you cover a very small risk pool, it's dangerous.  You've also heard about some companies saying that they might, and it's might, exit the exchanges, but those companies have a rather small share of the entire private insurance market and the exchanges, they don't comprise the big players and those people are hanging in and there's nothing about it which isn't a death spiral.

J: This question's from Jeanine, who asks, "What does current research say about eggs?  My grandparents' generation were told that eggs were bad because of cholesterol.  My mother was told not to eat egg substitutes.  What is being told to my generation?"

A: Um, that eggs are fine, and we even have a whole Healthcare Triage episode on this topic, you should go watch it, but the gist of it is that most people are what we would call hyporesponders to dietary cholesterol, that the amount of cholesterol that they eat does not have any real relationship to their serum cholesterol, or what's in their blood.  The vast majority of your cholesterol is made by your liver and it's not what you're eating.  The eating doesn't matter.  They've done studies where they give people with diabetes like three eggs a day every day for months, no impact whatsoever, so it turns out dietary cholesterol, not really related to serum cholesterol, so the idea that we need to watch how much cholesterol we're eating is sort of out of vogue.

J: Alright, Aaron, littletriptoheaven asks, "Pros and cons of donating my eggs?"  I don't think she's referring to chicken eggs.

A: I hope not.

J: In which case, I think it's all pros, except that, you know, they don't keep that well if you donate them to a food pantry.  

A: Eggs are delicious.  You can give them away.  

J: I think it's great.  I think it's--we're in favor of it.  

A: Yes.  Yes.

J: But when it comes to the eggs that are inside of one's body?

A: So the, you know, the cons are that there are some, you know, potential downsides.  You can ovarian hyperstimulatio.  

You can have, you know, an infection or an abcess.  The long-term outcomes aren't really well-known.  There's pain, obviously.  You know, some women might react to the hormones, so there are some downsides.  The upsides are sometimes you're helping somebody out, so there's that benefit, and a lot of people often do and unfortunately because there's a lot of money and so, unfortunately, sometimes the companies that are into this prey on students and you know, younger women who really do need money, and then it gets questionable, 'cause we're talking about a lot of money involved, and so you should really talk about that with your doctor, and you should really think about whether it's worth it for you.  If you're helping out somebody that you love, of course, there's a real upside and even helping out somebody you don't know, there could be a real upside, too.

J: Michelle asks, "I've been getting a lot of conflicting info about Lyme disease, some of it from different doctors (chronic Lyme vs. post-treatment Lyme syndrome, ideal length of antibiotic treatment, etc.)  What's the deal?

A: So, you know, you get bitten by certain types of ticks, they give you Lyme Disease, first thing you do is you get a localized rash and usually it's like it gets red, it gets indurated, and sometimes you wind up getting sort of a bullseye around it.  Sometimes it just sort of like, diffusely red all the way out.  Later, that will start to spread and you'll start getting that rash in other parts of your body.  That's like this delayed infection and anytime during this, you want to treat it with antibiotics and you can take care of it.  The first reactions are easy to treat with like, oral antibiotics.  As it gets more spread, they're gonna use IV antibiotics.  If you don't get the infection in time, it sorta goes into chronic mode and then you wind up having some pretty severe problems that can be neurologic, that can be muscular, that can be joint-related, and they can last for a long time and some percentage of people get that.  At that point, antibiotics don't do much.  People think it's almost too late, which is why you wanna really catch Lyme Disease as early as possible.

J: Hannah asks, "Is there a difference in hand cleanliness," Oh!  Near and dear to my heart, Hannah.  This is one of my favorite kinds of questions.  "What's the best way to wash my hands if you use soap before wetting your hands?"

A: Yeah, ironically enough,--

J: Fascinating.  

A: People worry about the soap far too much.  The biggest and most important part of hand cleanliness is that you have water and that you literally are using a lot of contact and scrubbing.  That is much more important than the type of soap you use, when you put the soap on, or how much soap you use.  It is the scrubbing under the water, so I don't know, put the soap on before, put the soap on after.  I would put it on, to be honest, after, 'cause it's really important--don't forget, the water, the water and the scrubbing.  That's what makes a difference.

J; Alright.  Follow up question.  If I am in a situation where I don't have any Purell and I don't have access to water, does this do anything?

A: I--not between your two hands, because you're rubbing them on yourself, but technically, I think if you took a towel--

J: Yeah.

A: --and you rubbed, like something that didn't have--that was clean, and you rubbed, you would likely be taking off some of the dirt.  

J: Can I just rub it on--

A: Probably no, 'cause I bet your shirt is dirty.  Anything (?~8:54)

J: It's even dirtier.

A: That's a thing.  It's like, you need something clean.  That's why the water theoretically is cleaner than you, but if you just rub your hands together, all you're doing is rubbing (?~9:02) together.

J: I was kinda hoping that I was killing the bacteria--

A: No.  No.

J: By the force of my hands.

A: No.  And in fact, there have been some studies out that show that the paper towels are probably better than the hand--the hand dryers because first of all, the hand dryers inside are often filthy, and so they're just blowing germs onto you.

J: Sure.

A: But when you take the paper towel, the actual rubbing again, takes some stuff off of you.

J: thepurplemaneater asks, "I know that a causal link between knuckle cracking and arthritis has been disproved, but do these results also apply to other joints that people can crack, like their necks and ankles and wrists?"

A: No.  No, you're fine with all of it.  It doesn't do anything.  Although it can make you like, socially unacceptable.  It might not make people--make people not like you, but it doesn't matter.  You know that when you crack it, what you're hearing is actually the gas boiling out of your joints because you're creating a vacuum and then like, the gas can actually theoretically boil so, you know, I don't know.  It's really unpleasant for a lot of people, but it's not gonna hurt you.

J: Amanda asks, "What are your thoughts on the mixed research or lack of research on helmeting babies for plagiocephaly?"

A: You got it.  Plagiocephaly.

J: Nailed it!

A: Plagiocephaly.  Plagiocephaly is like, when one half of the back of your head is flat and brachiocephaly is when both halves are flat.

J: Okay.

A: Since we've done sort of the Back to Sleep campaigns with babies now.

J: Yeah.

A: If you don't pick 'em up and they spend a lot of times, you get more and more flat.  There are a lot of people that think you need to put those kids in helmets, like really rigid helmets that like, make their heads grow into them.  It's incredibly unpleasant, it can be expensive.  Where I trained, they did a lot of this and they developed it and they swore by it.  There's no good evidence that this stuff works and the only randomized controlled trial that I know has been done was published in the BMJ, it showed no difference.  It's like, 26% of kids in helmets had fully resolved, 23% of kids who never got the helmets fully resolved.  This is like, you know, most of us, we have no idea if our heads are flat in the back or not, 'cause your hair grows in and you grow up, so it's like, I don't know.

J: Sarah asks, "Is yoga or a form of cardio better for managing anxiety?"

A: Oh--

J: I've got a good answer for this question.

A: Go for it.

J: As somebody who does a lot of anxiety, but not a lot of either cardio or yoga, just whatever works for you is better and you can do both, like, do your own randomized controlled trial and then whatever works for you.

A: Yoga gives me anxiety, so I, I can't endorse it.

J: I feel so--the reason I feel anxious when I do yoga is because I'm usually in a classroom setting and there are lots of people around me who are better at yoga so it's essentially like asking me to go to a calculus class but where I have to publicly perform calculus.

A: I think it's almost even worse, it's like they're speaking another language, 'cause I don't even know what--they all just, they say a word and they all know what to do, and I'm like, I don't even know what the person just said.

J: Yeah.

A: I can't do any of it.  And it hurts.

J: I--even when I know what it is, it's hard, but yeah, I'll tell you what, lots of people swear by yoga.

A: I know, I'm not trying to dissuade you.

J: And they are probably right.

A: Yes.

J: Ethan asks, "Is the US treating MCR-1 containing bacteria--"  I don't even know what that is, Ethan.  Now I'm nervous.  "--as a serious threat and if not, should they be?"  What is that, Aaron?  Is it a serious threat.

A: I know--I know I shouldn't answer this question because it's only going to make your day really bad.

J: It is a serious threat.

A: It's like a bacteria which has been picked up more and more in other countries.  I think it's been in China, maybe in Denmark recently, and it's a bacteria that's pretty much resistant to every antibiotic we have, so it's not terribly common yet, but people are starting to get panicked about it.

J: Should we be panicked about it, because I feel like the bacteria that are completely drug resistant have a better chance of spreading through human populations almost by definition?

A: They do, but again, you're talking about a few isolated incidents.  It's like, you know, ebola is terrible, too, but it's not, you know, it's mostly contained.  It's not here, and so you can spend the rest of your life panicked about stuff that's overseas that can kill you and it absolutely exists and we should work on trying to combat it, but it's probably not worth a lot of everyone's brainpower all of the time.

J: You told me not to worry about ebola.  I didn't worry about ebola.  

A: That turned out fine.

J: I didn't get ebola.

A: Right.

J: YET.  

A: No.  It's not gonna--you're not gonna get ebola.  

J: I didn't get it yet.  

A: You're not gonna get ebola.  

J: Well, I mean, I'll tell you what, if I get ebola--

A: If, okay, this, there will be video evidence.

J: I want, I want to hear you say--

A: I will publicly apologize to you on tape if you get ebola.

J: On tape.  Notice he didn't say in person.  Yenmano asks, "What is the evidence for implementing Nurse Practitioners as primary care?  Are the outcomes different from family physicians?"

A: No, the outcomes are not different.  Of course, my wife Aimee is a Nurse Practicioner, so I'm biased in this answer, but no, they're phenomenal.  She's a much better primary care healthcare provider than I am.  Any day of the week.  You know, certainly providing primary care for specific tests, they're excellent and we use them in many parts of the healthcare system.  A lot of times regulations are fought by the AMA and other groups that want to, of course, you know, keep the market small so that there are more demand, but there is no evidence that they provide inferior care in any way.

J: Okay, this question is from Andrew Hart, who asks, "Are sugar substitutes safe to consume in high amounts, like 10-15 packets per day, equivalent to 2 tablespoons of sugar according to the packet?"

A: So if we're going by science, ironically enough, and this is gonna scare a lot of you, that's not considered high use.  If you look at sort of what the FDA says is the maximal amount that they know or they believe is safe, for a lifetime of use, I think for aspartame, it's the equivalent of like, 75 packets a day, so if you used more than 75 packets a day every day, that would be where they would say you're out of the safety zone.  For saccharine, it's less.  I think it's like, just under 25, but still.

J: That's still a lot.

A: Still, that's a ton and 10-15 is way less than that.  Now, if you're asking me is like, you know, on a personal level, that's--I--10-15 seems like a lot.  Like, I think anything in, you know, that amount is probably too much.  I have maybe like one or two packets a day in my coffee.  Some people still think that's crazy and that they're unsafe, but you know, we did a whole episode on artificial sweeteners.  You can go watch that, but still, like, even at that level, that's still not considered unsafe.

J: So the FDA basically thinks I can have 40 Coke Zeros a day?  

A: Is that the aspartame or is that Ace-K?  I can't remember these days.

J: Uhh, I think--

A: Coke Zero is still aspartame, yeah, yeah, yeah.

J: No, no, no, Coke Zero is not aspartame.  Diet Coke is aspartame.  Coke Zero is the other one.

A: Right, right.  Oh, Ace-K.  I think Ace-K is, if I remember correctly, Ace-K is, well, it's at least 25, because I know saccharine is the lowest.

J: Alright.

A: I think Ace-K is at 75 with aspartame, so yeah, you're still fine.

J: It's really hard for me--

A: 40 is a lot (?~15:26)

J: --to drink a case of Diet--of Coke Zero a day.

A: But that's like, 24, so it's like, you're still fine.

J: I know.  

A: Now, that's a lot of soda.  I wouldn't drink that much.  I  I w

J: Thanks.  Thank you for that advice that I shouldn't drink 40 sodas a day.

A: I wouldn't.  

J: I don't think I should drink four--

A: I wouldn't even drink 24 a day.  I don't know.  I'm gonna go way less.

J: Mike Hutchings asks, "Will you do a video on SSRIs?  How effective are they?  How common are they?  Are they suitable for children and teenagers?  Side effects, etc?"

A: Yeah, in fact, our last Healthcare Triage live, we said we're doing that video.  We'll do it in probably February, 'cause I think January is already pretty much written, but that's a great answer.  It's--SSRIs are sorta controversial still how much they actually do work, so we'll do an episode on that.

J: Aaron, this is our last question for today.  Joey Karp asks, "Is drinking out of disposable plastic water bottles bad for your health?"

A: No.  It--it's probably, you know, we said this before, it's probably not great for the environment.

J: Right.

A: No, it's not great for the environment.  I (?~16:15) I'm gonna say 'probably'.  Not great for the environment.

J: Yeah.

A: But if you have one and you're using it over and over and over again, unless there's something really wrong with it, no.  I mean, a lot of the stuff you hear about leaking out and (?~16:23) and all that, it's overblown and it's not real.  The amounts that you have to get are huge and you really just can't get it from plastic water bottles, so for the most part, no, it's not dangerous to you.

J: It's only a public health concern--

A: Yes.

J: --because it's bad for the public.

A: Which also, long-term, is bad for you, so yeah--

J: Right.

A: Limit it, but it's like, but don't freak out that if you drink like, a glass or a bottle of water that you're gonna get sick.  It's not gonna happen.

J: Well, Aaron, thank you for introducing me to the new super-resistant bacteria that I didn't know about and for answering all of our questions.

A: And Lyme disease, don't forget about Lyme disease.

J: Oh yeah, Lyme disease, thanks.

A: Anytime.

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation.  Your support makes this show bigger and better.  We'd especially like to thank our research associate, Joe Sevits, and our surgeon admiral, Sam.  Thanks Joe, thanks Sam.  More information can be found at patreon.com/healthcaretriage.

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