Tuesday, August 7, 2012

Gun Mathematics

James Holmes went to the movies and shot 142 people. Wade Page entered a Sikh temple and gunned down 9 citizens. 31,513 people were killed by firearms in 2010 in the United States. (1) It remains remarkably easy to obtain firearms in most states.

One man, Richard Reid, boarded flight 63 from Paris to Miami on December 22, 2001 with plastic explosives in his shoe. The fuse failed to ignite. Reid is serving a life sentence in a supermax prison that houses the most dangerous prisoners in the federal system. All airline passengers since Reid’s attempt must remove their shoes so they can be scanned for bombs.  

How do we make sense of the different responses?
To put the question another way, how do we compare the association of shoes with bombs vs. the association of firearms with mortality? What would the equivalent of the new transportation safety regulations be for guns?

Is this simply a matter of the relative impotence of the shoe lobby compared to the gun lobby?

A brief review of the statistics lends some clarity to this uniquely American situation.

Firearms are one of the top 10 causes of death in the US. (1) In a 2003 World Health Organization study, the US was compared to 20 other high-income countries (Australia, Austria, Canada, Czech Republic, Finland, France, Germany, Hungary, Iceland, Japan, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Slovenia, Spain, Sweden, Scotland, and the United Kingdom). The US population at that time was 290.8 million and the combined population of the other countries was 563.5 million. There were 29,791 firearm deaths in the US that year and a total of 7,653 firearm deaths in the other 20 countries. (2)

We Americans are not more violent. But American violence is often lethal violence. And there is one reason for this fact; access to guns. We humans are an emotional lot, prone to impulsive behavior. Most violence is impulsive and the consequences limited by what’s at hand.

Another set of statistics helps frame a rational approach to gun legislation. Firearm deaths fall into three categories, suicides, homicides, and accidents. Most people are unaware of the fact that suicides represent the largest category, followed by homicides. (1)

It is fair to say that the majority of individuals who commit suicide are mentally ill or temporarily out of their minds. Most suicide deaths are accomplished with firearms. Between 2003 and 2007, an average of 46 Americans committed suicide with guns each day. (3)

Studies attempting to explain why some regions have higher suicide rates repeatedly find a strong significant positive association between gun ownership and rates of suicide. (4) Simply put, states with more guns have more suicides.

Public health concerns legitimately include gun control.

Similarly, preventable accidents fall under the purview of public health. Many fatal firearm accidents occur in children. In the U.S., children between the ages of 5 and 14 are 11 times more likely to be killed accidentally by a gun compared with the same aged children in other developed countries. (5) If we can perfect the child-proof medicine bottle, we should be able to protect children from guns.

It took one shoe to change the way Americans travel.
What will it take to change our way with guns?  


1.     U.S. Department of Health and Human Services, CDC, National Center for Health Statistics, National Vital Statistics Reports Jan 11 2012 Vol.60, 4
2.     Richardson EG, Hemenway D, J Trauma 2011 Jan; 70 (1):283-43
3.     Hemenway D. Amer J Lifestyle Med 2011 5:502
4.     Miller M, Lippman S, Azrael D, Hemenway D. Household firearm ownership and rates of suicide across the 50 U.S. states J Trauma. 2007;62:1029-1035
5.     Richardson EG, Hemenway D. Homicide, suicide, and unintentional firearm fatality: comparing the United States with other high-income countries, 2003 J Trauma. Doi: 10.1097/TA.


Friday, August 3, 2012

The New Elixir - A Cup of Joe

The world’s most widely used pick-me-up reduces your risk of neurodegeneration, depression, cancer and cardiovascular disease, and that’s just the beginning of the story.  Yes, I’m talking about that legal, over-the-counter beverage now available every other block. You know, brain juice, brew, liquid energy, morning mud, rocket fuel, wakey juice.

It may even be an ingredient in that fountain of youth we’re still searching for. According to a recent study in the New England Journal of Medicine, coffee lowered all-cause mortality by over 10% after 13 years of follow-up. (1)

Before I summarize the remarkable medicinal properties this plant-based beverage has recently been shown to possess, let me flag the potential negative effects. They are few in number and undoubtedly the positive dwarfs the negative. However if you happen to suffer from one of these conditions, you might want to consult your doctor before changing your coffee consumption.

Coffee can increase blood pressure and intraocular pressure (a potential concern if you have glaucoma), make the anxious more anxious, and worsen tremors and insomnia. (2) There, that’s it. Makes you wonder why it’s gotten such bad press in the past.

While it is true that caffeine transiently increases blood pressure, it appears that when consumed in  coffee, the increase is small and offset by protective effects. For instance, coffee beans are rich in antioxidants that decrease LDL and markers of inflammation (3-8). Inflammation occurs early in the development of cardiovascular disease and is most commonly triggered by a sedentary lifestyle, stress, and processed foods.

Overall coffee appears remarkably heart friendly. It has been shown to substantially decrease the risk for coronary heart disease (4) and as little as 2 cups per day decreases the risk of heart failure. (9)

Recent research has demonstrated coffee’s capacity to protect the brain as well. Investigators found that 1-6 cups per day reduce the risk for stroke by 17% (3) A well designed Swedish study followed female coffee drinkers for an average of 10 years and found a 22%-25% reduction on stroke risk. (11)

Well that’s great you say, but can it help me loose weight? Yes, indeed. By decreasing glucose absorption, coffee can facilitate weight loss, especially when combined with other measures. (15) It also improves glucose metabolism and insulin sensitivity, thereby decreasing one’s risk for Type 2 Diabetes. (12-14)

Coffee also appears to provide protection from a number of cancers through its antimutagenic and antioxidant effects. (16,18) Studies suggest different quantities are necessary to affect different cancers; prostate cancer – 6 cups/day (17), estrogen receptor-negative breast cancer - > 5 cups/day (21), endometrial cancer - > 4 cups/day (16)

When it comes to protecting your brain, studies have shown coffee to be a potent agent. Recent investigation demonstrated a protective effect in subjects with mild cognitive impairment, a condition that usually progresses to dementia. Those who consumed 3-5 cups of coffee per day attained blood caffeine levels of > 1200 ng/ml showed no progression of their condition during the 2 to 4 years of follow-up. (22)

Coffee drinkers also appear to be at lower risk for Parkinson’s disease. Recent research presented at annual meeting of the American Academy of Neurology demonstrated that as little as 3 cups of coffee per day may block the formation of Lewy bodies, an early diagnostic sign of the development of Parkinson disease. (23)

The other remarkable brain benefit relates to mood.
Just last year researchers found that women who consumed 2 to 3 cups of coffee per day lowered their risk for depression by 15% compared to women who drank less than 1 cup per week. And more coffee afforded more protection. Those drinking 4 or more cups per day lowered their risk by 20%. (24) The investigators speculated that this antidepressant effect stemmed from coffee’s antioxidant and anti-inflammatory qualities. (25-27)

If all that isn’t a sufficiently broad spectrum to convince you that coffee might be the most exciting “new” gun in medicine’s armamentarium, the list goes on.

What type of pathology remains? “Can it fight infection?” you ask. Yes, and not just any wimpy intruder. Coffee has also proven itself a potent force against one of the scariest bacteria, methicillin-resistant Staphylococcus aureus, known as MRSA. The mechanism of this effect remains a mystery. However, subjects reduced the likelihood of having MRSA in their nasal airways by almost 50% by drinking coffee regularly, regardless of quantity. (28)

So bottoms up.

For once a simple pleasure is the perfect prescription.

1. Freedman ND, Park Y, Abnet CC, et al. Association of coffee drinking with total and cause-specific mortality. N Engl J Med. 2012;366:1891-1904
2. Pasquale L. Program and abstracts of the American Glaucoma Society 22nd Annual Meeting; March 1-4, 2012; New York, New York. Abstracts 23 and 83.
3. Larsson SC, Orsini N. Coffee consumption and risk of stroke: a dose-response meta-analysis of prospective studies. Am J Epidemiol. 2011;174:993-1001.
4. Wu JN, Ho SC, Zhou C, et al. Coffee consumption and risk of coronary heart diseases: a meta-analysis of 21 prospective cohort studies. Int J Cardiol. 2009;137:216-225.
5. Natella F, Nardini M, Belelli F, et al. Coffee drinking induces incorporation of phenolic acids into LDL and increases the resistance of LDL to ex vivo oxidation in humans. Am J Clin Nutr. 2007;86:604-609.
6. Gómez-Ruiz JA, Leake DS, Ames JM. In vitro antioxidant activity of coffee compounds and their metabolites. J Agric Food Chem. 2007;55:6962-6969.
7. Nardini M, D'Aquino M, Tomassi G, et al. Inhibition of human low-density lipoprotein oxidation by caffeic acid and other hydroxycinnamic acid derivatives.  Radic Biol Med. 1995;19:541-552.
8. Montagnana M, Favaloro EJ, Lippi G. Coffee intake and cardiovascular disease: virtue does not take center stage. Semin Thromb Hemost. 2012;38:164-177.
9. Mostofsky E, Rice MS, Levitan EB, Mittleman MA. Habitual coffee consumption and risk of heart failure: a dose response meta-analysis. Circ Heart Fail. 2012;DOI:10.1161/CIRCHEARTFAILURE.112.967299.
10. Larsson SC, Orsini N. Coffee consumption and risk of stroke: a dose-response meta-analysis of prospective studies. Am J Epidemiol. 2011;174:993-1001.
11. Larsson SC, Virtamo J, Wolk A. Coffee consumption and risk of stroke in women. Stroke. 2011;42:908-912.
12. Huxley R, Lee CM, Barzi F, et al. Coffee, decaffeinated coffee, and tea consumption in relation to incident type 2 diabetes mellitus: a systematic review with meta-analysis. Arch Intern Med. 2009;169:2053-2063.
13. Sartorelli DS, Fagherazzi G, Balkau B, et al. Differential effects of coffee on the risk of type 2 diabetes according to meal consumption in a French cohort of women: the E3N/EPIC cohort study. Am J Clin Nutr. 2010;91:1002-112.
14. Floegel A, Pischon T, Bermann MM, et al. Coffee consumption and risk of chronic disease in the European Prospective Investigation into Cancer and Nutrition (EPIC)–Germany study. Am J Clin Nutr. 2012;95:901-908
15. Vinson JA, Burnham B, Nagendran MV, et al. Randomized double-blind placebo-controlled crossover study to evaluate the efficacy and safety of a green coffee bean extract in overweight subjects. Program and abstracts of the 243rd American Chemical Society National Meeting and Exposition; March 25-29, 2012; San Diego, California. Abstract 92.
16. Je Y, Hankison SE, Tworoger SS, et al. A prospective cohort study of coffee consumption and risk of endometrial cancer over a 26-year follow-up. Cancer Epidemiol Biomarkers Prev. 2011;20:1-9.
17. Wilson KM, Kasperzyk JL, Rider JR, et al. Coffee consumption and prostate cancer risk and progression in the Health Professionals Follow-up Study. J Natl Cancer Inst. 2011;8;103:876-884.
18. Turati F, Galeone C, La Vecchia C, et al. Coffee and cancers of the upper digestive and respiratory tracts: meta-analyses of observational studies. Ann Oncol. 2011;22:536-544.
19. Galeone C, Tavani A, Pelucchi C, et al. Coffee and tea intake and risk of head and neck cancer: pooled analysis in the international head and neck cancer epidemiology consortium. Cancer Epidemiol Biomarkers Prev. 2010;19:1723-1736.
20. Song F, Qureshi AA, Han J. Increased caffeine intake is associated with reduced risk of Basal cell carcinoma of the skin. Cancer Res. 2012;72:3282-3289.
21. Li J, Seibold P, Chang-Claude J, et al. Coffee consumption modifies risk of estrogen-receptor negative breast cancer. Breast Cancer Res. 2011;13:R49.
22. Cao C, Loewenstein DA, Lin X, et al. High blood caffeine levels in MCI linked to lack of progression to dementia. J Alzheimer Dis.           2012;30:559-572.
23. Ross W, Duda J, Abbott R, et al. Association of coffee caffeine consumption with brain Lewy pathology in the Honolulu-Asia Aging Study. Program and abstracts of the 64th Annual Meeting of the American Academy of Neurology; April 21-28, 2012; New Orleans, Louisiana. Abstract #S42.005.
24. Lucas M, Mirzaei F, Pan A, et al. Coffee, caffeine, and risk of depression among women. Arch Intern Med. 2011;171:1571-1578.
25. Pasco JA, Nicholson GC, Williams LJ, et al. Association of high-sensitivity C-reactive protein with de novo major depression. Br J Psychiatry. 2010;197:372-377.
26. Ng F, Berk M, Dean O, Bush AI. Oxidative stress in psychiatric disorders: evidence base and therapeutic implications. Int J Neuropsychopharmacol. 2008;11:851-876.
27. O'Connor A. Coffee drinking linked to less depression in women. New York Times. February 13, 2012. http://well.blogs.nytimes.com/2011/09/26/coffee-drinking-linked-to-less-depression-in-women/ Accessed January 11, 2012.
28. Matheson EM, Mainous AG, Everett CJ, King DE. Tea and coffee consumption and MRSA nasal carriage. Ann Fam Med. 2011;9:299-304.