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Welcome to Functional Medicine Update for July 2012. Well, I'm very excited about this month in that it is a little bit like back to the future. We have the opportunity to visit with a clinician of the month who—I would say arguably—is at the head of his game, top of the class, and has done an incredible job in implementing functional medicine in his practice. I take some vicarious pride in that it was a little over 10 years ago that we had the opportunity to visit with this same clinician as he was moving his practice more and more into the functional medicine milieu, and over those 10 years Dr. Mark Hyman has become a leader in this field and has guided literally hundreds of other clinicians in the successful implementation of the functional medicine concept.
Dr. Mark Hyman: Ten Years of Leadership
I'm very, very pleased that in this ten-year span not only has Dr. Hyman had his career and his impact on patient management grow by exponential bounds, but also his impact on changing health care has started to become much more impactful as well through his work at the level of the executive and congressional branches of our government, and in the area of our armed services and some of the programs that are going to be applied over the years to come with our veterans. In these experiences, Dr. Hyman has started to understand the burden of chronic disease that's rising every day, the challenges that this family of diseases presents to our healthcare system, and some of the resistance there is to change within the system as a consequence of patterns of behavior and systems reimbursement policies. This resistance has retarded the integration of new concepts that would make chronic disease management more effective and efficient.
You're going to hear from Dr. Hyman about his personal journey, which we've all kind of shared in over this last 10 years within the growing and expanding domain of functional medicine, both at the individual practice level and at the societal level as it relates to the changing medical paradigm.
Clinician/Researcher of the Month
Mark Hyman, MD
The UltraWellness Center
45 Walker Street
Lenox, MA 01240
(413) 637-9991
July 2012
Here we are again. I feel like we're all in the living room, sitting in comfortable chairs and we're going to have a fireside chat with him in our Functional Medicine Update Clinician/Researcher/Educator of the Month interview. It's one of my great friends and colleagues. A person who has been a leader in our field for a number of years and continues to provide vision and guidance. I would call him a clinician's clinician: Dr. Mark Hyman.
Mark is a medical doctor who presently is in practice in Lenox, Massachusetts, with a very, very remarkable clinic that serves people with chronic illness across a wide range and spectrum of concerns using the functional medicine model. He's one of the aficionados and primary experts in the functional medicine model. Mark has broad-based interests, talents, and resources. He was a Chinese studies major in undergraduate school at Cornell. He went to China. He learned Chinese. He is involved in all sorts of different disciplines within the healing arts and brought them into primary care and family medicine. He and I met in an early stage of the evolution of the Institute for Functional Medicine. Mark went from student to teacher very rapidly. He integrated these concepts very successfully into his practice, and pioneered new ways of actually applying functional medicine. He was involved in the development of the Textbook of Functional Medicine, and the early days of teaching as faculty within the Applying Functional Medicine in Clinical Practice training program. From there, history has been written. Mark now is the Chairman of the Institute for Functional Medicine. He is a luminary/consultant/resource for all sorts of people who are looking for high-level understanding of the model, and has a list of patients that are extraordinarily grateful for the services that he has provided. We were very appreciative at the Institute for Functional Medicine annual symposium in Scottsdale in late May/early June, that the introduction to the symposium was provided by President Bill Clinton, who happens to be one of Mark's patients. Former President Clinton gave a wonderful salutation to the 850-plus delegates at the symposium, welcoming them and saying how much functional medicine meant to him and his family. Mark also has had a very strong relationship with Secretary of State Hillary Clinton. And he has recently been featured along with Mehmet Oz and Daniel Amen through this extraordinary project they've done at Saddleback Church in Orange County, California, called "The Daniel Plan."[1] So Mark has really been a leader and advocate for changing medicine, both how we do it and what we do in medicine.
Dr. Hyman, welcome to Functional Medicine Update. This is a re-visit for you, having graced us previously as a clinician of the month, but clearly a lot has been happening. You just got back from the Clinton Global Initiative, and lecturing for the second time at the TEDMED conference, and now this Daniel Plan and making it more well-recognized. Tell us how this all swirls about, plus your media tour on your book, and your public television educational series. I mean, that sounds like about four lives right there. Tell us a little bit about how it's going.
Functional Medicine in the National Spotlight: TEDMED, the Clinton Global Initiative, the Daniel Plan
MH: Yes, it is a lot, isn't it? Especially when you put it all together like that! I think: Wow, I don't have time for anything else. But actually right now I'm sitting out on my deck enjoying the sun. It's a beautiful summer day in the Berkshires, and I'm feeling really happy because at this moment in time there is this huge shift that is happening, and we can see it happening all over, where functional medicine is reaching prime time. It's getting recognition by President Clinton and Secretary Clinton; at the Clinton Global Initiative I spoke about it. It's been put into a mega-church in California with 30,000 members and we're seeking to expand.. People are looking at this as a mainstream solution to our chronic disease epidemic. My book became number one on the New York Times Bestseller List and the PBS show that went with it has been hugely successful because this message is the right message at the right time, and God knows we need a solution because we're in trouble.[2]
Awareness Happens: The Functional Medicine Movement
We look at this whole diabesity issue and the study that came out in Pediatrics a few weeks ago that showed teenagers went from nine to twenty-three percent pre-diabetes or type 2 diabetes from 2000 to 2008, which is frightening. And now we see even 37{56bf393340a09bbcd8c5d79756c8cbc94d8742c1127c19152f4230341a67fc36} of kids (teenagers) have one or more metabolic syndrome risk factors like dyslipidemia, high blood sugar, and hypertension, and they are metabolically obese even though they are thin because they are eating industrial toxic food.[3] This culture, this society, this shift happening—there is an awareness happening—and I think there is a movement starting to brew. We're getting sick and tired of the status quo. When I was at the Clinton Global Initiative, I met with Michelle Obama's director of the Let's Move program and another person who worked for the bipartisan policy center who were very knowledgeable about functional medicine. They were wanting to talk to me about how they can help support the growth of functional medicine, and they want to support the Institute for Functional Medicine's building of a nutrition curriculum for medical schools because that's one of the policy recommendations they made to change this conversation, so it is very, very exciting.
JB: Tell us a little bit…I mean, we all read the extraordinary article that reviewed the experience that you had with Dr. Oz and Dr. Amen with The Daniel Plan. Tell us a little bit about that, because I think there are some deeply embedded truths that are very important as it relates to how we can modify the healthcare system.
How the Daniel Plan Came to Be
MH: Yes. You know, when I think of the tagline for IFM–We Have to Change the Medicine We Do and the Way We Do Medicine–I think the medicine we do has to be germinated off of systems biology in medicine and functional medicine, but the way we do medicine has to change as well, and that's the delivery model. So we couldn't keep doing it in the way we were doing it, and I realized when I went to Haiti that Paul Farmer solved TB and AIDS not by finding medications, or better applications of surgery or interventions, but by using the community as a level to create behavior change, and that the social, economic, and political conditions were driving infectious disease in these countries. I realized that there was a parallel for this in the developed world, which was that the social, economic, and political conditions that exist in America and increasingly even in developing worlds are leading to obesity, and diabetes, and heart disease, and lifestyle-driven diseases, and that we have to deal with that through community-based intervention. I began to noodle on this, and I read a book Chelsea Clinton recommended, a book called Turning the World Upside Down by Nigel Crisp, the former head of the National Health Service.[4] It was basically saying that we have to shift our thinking and put patients and communities at the center of health care, not doctors and hospitals, and that really changing the conversation around chronic disease must be done in order for us to solve this, that's it's not going to happen one-by-one-by-one in the doctor's office but by the tens of millions in communities where people live, and work, and eat, and learn. That's where change happens. And I realized that that's really what could be done in this country. If we could take the functional medicine model and we could deliver it through small groups and communities, that just maybe something could happen that would show us a different way.
I met Rick Warren and I had this idea and I presented it to him over dinner one night. He said: Yes, let's do it. Because he had baptized 800 people one day, and they were all fat, and after the 500th one he thinks: Man, we're a fat church, and I'm fat, and we need to do something about this. So he was ready for it. We launched the Daniel Plan in January 2011. We had 15,000 people sign up the first week. The plan was basically a functional medicine lifestyle plan delivered through small groups in the community, and we also changed the culture of the church: we changed what was served, we changed the menus and the recipes, we got people active and exercising, so we changed the culture as well. Using that strategy–the small groups, changing the defaults in the community, and driving the right concepts through functional medicine–over the course of a year the church lost about 260,000 lbs. It was remarkable. People got rid of all sorts of chronic illnesses, because as we know in functional medicine, if you deal with the root causes, all of the other diseases go away downstream. People got rid of asthma, and migraines, and autoimmune disease, and irritable bowel, and reflux, as well as obvious things like diabetes and hypertension. People got off insulin (diabetes medication). We really saw that there was this potential for shifting the healthcare system through a wellness model in the faith-based communities.
It's sort of bizarre for me because I'm a Jewish guy from New York so what do I know about evangelical churches, but it was really clear to me that the community had to be the cure and that the group was the medicine. That was the insight that led me to move this forward. As I've been talking about this around the country, it's sort of a lightning rod. People are very excited about it. President Clinton asked me to speak about it at a conference called Health Matters in January and at the Clinton Global Initiative. I gave a talk at TEDMED about it. I think it is really an idea whose time has come—in fact, has to come because we can't solve this on a one-by-one level in the doctor's office. There are just too many patients.
Community-Based Programs May Be the Future of Treating Chronic Illness
JB: It's very interesting. I think you've done such a tremendous job of assembling a wide body of data information across many different disciplines into a very sensible kind of—as my father used to say—"rule of reasonableness" model. It just fulfills a rule of reasonableness. I reflect back to the interview I did a number of years ago on FMU with Dr. Halsted Holman. I know you know him by name if not the person. He's now at Stanford. He's 90-years-young. Still practicing. He is the guy who developed this concept of a community-based program for chronic illness that engaged patients in self-care. He authored that article "The Need for a New Clinical Education" that appeared in JAMA.[5] When I interviewed him on FMU, he talked about the power of small groups, and that people become their own teachers. And they are more effective when they are speaking to one another and guided by a professional than kind of getting lectured to by a professional in the absence of the group. I think you've hit on so many different points of connection: using the neural net as a behavior mod tool in the group process. It almost sounds like the psychobiology of this could be studied as it relates to this social networking approach that you use in the Daniel Plan.
MH: Absolutely. I think we all have a desire to be part of a tribe and a group. EO Wilson talked about this in his new book, The Social Conquest of the Earth.[6] There is a process called group selection. We're hard-wired to connect and link to each other for our survival. I just met a gentleman who is the head of the Center for Compassion Studies at Stanford, which is kind of surprising—he's a neurosurgeon—but really talking about the biology of compassion, and connection, and this is an underestimated medicine, I would say. Food is medicine, but community is also medicine. Leveraging those two things together is a combination that is uniquely suited to lifestyle disease. What is striking to me is when I review the literature on this (and there is a fair bit of literature), these interventions do work and they work better than conventional care, and they work both in developed and developing worlds. For example, there was a study recently in Health Affairs looking at comparison of lay interventions (lay groups) versus healthcare-professional-led groups for the diabetes prevention program, and there was no difference in outcomes; they both worked equally well.[7] So you don't have to be an expert to even do this. Peer support is adequate. . Even in developing worlds…Peers for Progress is an intervention that has been developed by the American Academy of Family Practice to look at peer-support models in the developing world. They looked at Thailand, Uganda, Cameroon, and South Africa, where diabetes is rampant. They taught villagers simple skills and knowledge, and then they helped them support each other, and through that self support and peer support (not led by a health profession but each other), they had dramatic reductions in their biomarkers: their hemoglobin A1C went from 9 to 6, and they had had better outcomes than any medical intervention, and there was a ten-fold reduction in healthcare costs.[8] So this is a very cost effective and actually more medically effective treatment. It's something that just has not been integrated in any way into medical care, and it's sort of surprising to me. It's like this big "a-ha."
JB: I think it's absolutely fantastic what you are kind of creating here. If we think of functional medicine as built on a systems biology framework or architecture, and that that systems biology has something to do with signals that come in and are translated by the individual into operative functions, which could be things like neuromuscular function, or gastrointestinal function, or cardiac function, that that signal systems biology matrix has never taken into account to the extent that you're having us recognize the signals that come from the social environment, from the social interaction. Yet we know, because there are many published papers that have demonstrated that the singular largest risk factor to cardiovascular disease is a feeling of being impoverished: low attribution, low sense of recognition, low sense of self-esteem, and low locus of control.[9],[10],[11] I think you are codifying, in a systems biology way, how social interaction is a signal so important in health. It's really quite remarkable, Mark—the way you are doing this.
Sociogenomics: How Our Social Connections Influence Gene Expression in Health and Disease
MH: Thank you. Well, you know, some of the insight I have—I've been following you and functional medicine, and I've been sort of focused for so many years on biological networks and really understanding at a very detailed molecular and genomic level what is going on with our biological networks. That's what functional medicine is: an understanding of how those biological networks are the determinants of illness. But I realize that there is another kind of network out there: our social networks. And, in fact, those networks and the social trends that connect us in the end may be more important than the genetic threads. I call this sociogenomics, which is how our social connections influence our gene expression in health and disease. The whole idea of sociogenomics is a very interesting insight for me because it has sort of been a natural flow for me from biological networks to social networks. I have always been involved in groups of different sorts and it is sort of how I live in my own life, but I never applied it to medicine, and now I realize that it actually may be the missing piece that can help really move this whole epidemic along.
JB: With that in mind, let's kind of just take a point/counterpoint view for a second. There is this sense of importance of individualization, or personalization, or what Roger Williams called biochemical individuality back in the late 40s/early 50s. A person might say: "Well, this sociogenomic model is great except doesn't it focus on the individual. Doesn't it tend to regress to the mean of the group and you lose personalization?" How would you respond to that?
MH: I think that's a fair statement and I think, you know, if you were to look at the basic principles of functional medicine, it's really the science of creating health. If you understand how to modulate those biological networks to create health, it works for most of the people, most of the time. It will—basically, without treating disease directly—ameliorate or improve or even resolve many conditions, as we found when we did this with 15,000 people in the church. However, there is probably going to be about 20 percent of people who still need extra help. In those cases, you can customize the program. I think you can even customize functional medicine using self-care models. I think this is the next step for functional medicine: creating models of self-care that can be decentralized and democratized, taking the veil back on the sort of secrecy of medicine and guiding people through self-diagnostics, questionnaires, and even self-testing—how they can adjust and modify their own lifestyle and diet and various interventions to help personalize the program. We actually have that as part of the Daniel Plan, so it's done as a self-care model. And then, of course, if people get stuck, then they have to go see a functional medicine doctor and get that extra level of intervention. It is sort of like if you reboot and restart the system a lot of problems will go away and then you see what you're left with. I once talked to my friend and he said he has people and he can't see them because his practice is so busy, and he takes his nurse practitioner and they put them on sort of an elimination diet and sort of basic supplementation, and then 30 days later they check in with them and they do an MSQ and most of their problems are gone and they haven't even seen a practitioner. And then those who still are stuck, you know, that's when they need expertise and the skillset of an experienced functional medicine doctor. I would say right now I do tertiary functional medicine. That's what I do, and it's people who really have complex chronic diseases and aren't amenable to simple changes, and that's fine—I mean, we'll always have a need for that—but most of the time we can actually create a basic plan and also a customized, personalized model that can be done through self-care.
JB: I know I'm getting into thorny questions but these are the kinds of things that I'm asked very frequently and I'm kind of going to the expert now to re-ask them to you. A person might say: "This is great. I spent 10 years getting training in medicine. I feel like I'm pretty skilled in the art. And now you're telling me that really I don't have much use because I can use a paraprofessional and I don't really need to see these people, so what good is my training and how can I make service?"
Doctors are Trained in Acute Care Rather than Basic Care of People with Everyday Problems
MH: I think, like most doctors who are listening, I went through my training in the hospital and became very skilled at acute care medicine, and was dealing with things in the extreme. And when I went into clinical medicine, it was a big jump. It wasn't actually what I was trained in. I wasn't trained in basic simple care of people with everyday problems. So our training is very sophisticated and very skilled and I think that's always going to be needed, but a lot of what we do is not at the level of our skillset, or training, or knowledge. That's unfortunate, and I think that can change. And I think doctors should be the ones who are dealing with things that are more complex and require more thinking and more evaluation and diagnostics. There will always be a need for that, but I think a lot of what we do, and particularly in primary care—even in a lot of specialty care—is just not up to what we were trained in, and I think that has to shift. What we are doing, and part of the reason our healthcare costs are so high, is we're using all these acute care interventions and diagnostics that we were trained in, and we're using them on things that aren't acute; we're using them on chronic illnesses. That's where the problem is.
JB: Yes, I think that's very well said. You said a couple of other things, there, that I believe are very important—like hot buttons—and that's diagnosis and disease, which we know are two words that really relate to the sine qua non of how docs are trained: to drive to the diagnosis, to get the definitive disease, and treat the disease as if it were a battle that is going to be won by medical therapeutics. Tell us a little bit of how your model fits into this disease diagnosis frame of reference paradigm.
MH: Your question is how does the diagnostic paradigm fit into this model?
JB: Or kind of juxtapose maybe the two, the way you have described, which I think is a beautiful way of describing a systems biology approach versus this kind of conceptual framework that most of us learn, memorize, and recite on demand, which is this diagnosis/disease model.
MH: We're mixing—or we are confusing—our approach, because we still need sort of a western diagnostic model that we're all trained in, but it's not sufficient to deal with multi-system, complex, multi-genome disorders that are being treated as if they are, you know, sort of the infectious disease, bug/drug model. For example, I had a patient the other day who has hyperaldosteronism. This is because of hypertrophy of her adrenal gland increasing the mineralocorticoids. To me, as a functional medicine doctor, I'm wondering why she's got this. I asked if she's having liquor issues, is she doing other things to trigger this, is this a hyperplasia of the adrenal gland or is it a tumor (an ectopic tumor)? Some things just happen that we don't completely understand that may not be completely amenable to the functional medicine approach. It may need to be cut out—she might have a tumor that needs surgery, she might need some medication to help shut down the aldosterone receptors, like Spironolactone. I think we have to be open to looking at people in the full spectrum of what's going on with them and understand how to distinguish between someone who just needs a hip replacement because her hip is destroyed and someone who needs a retuning of their systems biology.
JB: Yes, I think that's a beautiful model. You've kind of segued over into a very interesting point. I think a lot of our listeners would like to know: what is your practice like? What kind of patients do you have? What are the range of issues that you have to deal with? You've always called you're a "resort doctor"—the doctor of last resort. Tell us a little bit about that.
MH: I'm very excited because we've just moved into a brand new UltraWellness Center. We're 5000 square feet. We've got four doctors, a nurse practitioner, four nutritionists, two nurses (probably three soon), and we do a whole range of care that is everything from optimal health and aging and wellness care, to dealing with very complex chronic illnesses, along the age spectrum from autism to Alzheimer's, from diabetes to depression, from reflux to hormonal disorders and menopause. We do a lot of different chronic illnesses. It's pretty interesting. You never know what's going to walk in the door, but if you just stick your head down and you ask a lot of questions, you can use the matrix and come up with a roadmap even if you've never seen a problem before and begin to understand how to apply this model. That's what is so exciting about it. It doesn't matter what the condition is. My staff often gets asked: Do you treat this, or do you treat that? Yes, I treat everything. If it is something I don't know how to do, like a hip replacement, I'll refer them, but essentially most of the problems will be amenable to functional medicine, and you can know how to start by using the matrix. That's what we do, and it's very, very effective.
JB: Tell us a little bit about the matrix, for those who may be either new to the functional medicine model or just in early in kind of gaining of mastery of it. Tell us what the matrix is and how you find it useful.
Using the Functional Medicine Matrix
MH: This is something that has been evolved over the last 15 years by the faculty and by you and others in functional medicine. It's essentially a one-page sheet that we've summarized the model of functional medicine into, which is understanding how lifestyle factors and how predisposing both genetic and environmental factors influence your biological networks: your genetics, your early childhood influences, your prenatal environment, your early childhood development, stresses, traumas, various things, can trigger imbalances in your biological networks. And so can change in lifestyle, so what you eat, and what you think, and your social relationships and connections, how much you move—all of these things influence your biological networks. So when I see a patient, I want to know how do these factors influence their networks and how are those networks out of balance? There are nodes in your biological network, and those nodes really are the things that make up the matrix, which is your assimilation system, or we used to call it digestion, and how you assimilate and absorb nutrients; your defense and repair, which is how you manage your immune system and inflammation; how you make energy in your mitochondria, and the metabolism of energy in your body and your mitochondrial function; and then how that influences detoxification and biotransformation. And then we have transportation and circulation: how you move around blood and lymph fluid; and then communication, which involves all the cell signaling, and hormones, and our transmitter function; and then finally your structural integrity, which is all the way down from the cell membrane level and even nuclear receptors, all the way up to your biomechanical structure. All those are dynamically interacting all the time. Chronic disease is really a sign of imbalance in these basic nodes in your network, so my job as a doctor is to find out what are the things that triggered these imbalances? As Sidney Baker says: Is there too much of something or not enough of something? Is there too much of a toxin allergen, microbe, stress, poor diet, and not enough of something like good food, and rest, and movement, and sleep, and connection, and love, and meaning, and purpose? All of these things are really the raw materials for creating health. Where we work, mostly, is to restore those systems into balance through using lifestyle, and using nutrients, and using hormones, or sometimes even medication, but it is done with the understanding that we have to work to reset and restore these nodes in the network. When those are working, health happens. It's pretty extraordinary.
JB: I think you said so many extraordinary pearls, there. It's like a string of pearls, basically (a necklace). I want to go back and pick up a couple of them because I think they are very…you say them so easily because you're familiar with them and you are working with them successfully, but for the person that is kind of moving and gaining mastery maybe they need to stop a moment and just kind of take a deep breath—a cerebral oxygenation event—and say: Wow, that's a powerful concept.
Let's go to the term "nodes." I think nodes are really interesting as it relates to the clustering of events, and how there is convergence to certain regulatory command centers in our physiology, and how that relates to things like promoter regions of genes, and regulating assembly and expression of families of genes. It has now become fairly well-recognized that genes don't express themselves one at a time but rather as families that are regulated by these promoter regions that control a cassette of genes that are all interrelated. When you talk about nodes, you're really looking at where the convergence of these lay lines of metabolic control reside. How does a doc do that? Is it from experience and just asking the right questions and being a good listener, listening to the patient's story? Tell us how you gain this mastery.
Remodel Your Medical Paradigm
MH: It's sort of like building a house. It's like remodeling your paradigm (your medical paradigm). Instead of the IC9 codes and specialties, which is the original house structure, we have to remodel into different rooms, which are these basic core nodes in your biological networks that I just mentioned. And everything that happens to a patient in the course of their life gets sort of dumped into one of these areas. It's either an antecedent, a trigger, a mediator, a lifestyle factor, or it's some disturbance in one of these nodes. If someone, for example, has dysbiosis, or Lyme disease, or has mitochondrial dysfunction, or diabetes, these fall into different areas of those nodes, and often they cross over, right? Because diabetes is a mitochondrial dysfunction, it's an inflammatory issue, it's a hormonal problem, it can be related to microbes in the gut and micro-obesity. It can be related to structural integrity related to membrane function and receptors for essential fatty acid composition. So there's a whole series of different things in each node that can relate to any condition, but you can kind of categorize things in a rough way in these areas of the matrix, and then you can begin to see where the patterns lie—where in any particular person their story will sort of highlight. It will come up in bold relief. You don't even have to know what you're doing. I've been doing this for 15 years. I do this with every single patient. I have a detailed questionnaire which ferrets out a lot of these issues that are different than most medical questionnaires, and it's available for free on my website. People can download it. There is a practitioner button and they can get all these forms. Basically it's a way for me to collect data, and then once I collect that data then I categorize the data in these areas, and I can see on this one sheet of paper what things jump into relief. So if there is an immune/gut issue, well that's really clear. If it is more hormonal or toxic or nutritional factors, I can really identify what these are very quickly. And then based on that, I can begin to see: Where do I start? Where do we start with a patient? And you just sort of start to reset those systems. It's something that does take some training, and the Applying Functional Medicine in Clinical Practice and the certification program through IFM are really the pathways to understanding this new paradigm and to remodeling your medical house, so to speak.
JB: Let's first make sure our listeners can find your website: www.drhyman.com. Is that where you would direct them to?
MH: That's right. Yes.
JB: When you kind of boil this down to some of the big things that stick out from your experience, is there a short list of things that you have found that often are "a-has" related to the etiology of these chronic illnesses that produce these disturbances? Are there some things you say: "Wow, I never learned about these in medical school but these appear fairly frequently in the patients that I'm seeing?
Significant Lifestyle Changes Yield Better Results Than Incremental Changes
MH: I think there are a few things that I learned in functional medicine that work a lot. Nothing is going to work all the time for all the patients I have, but there are some few basic homeruns that if you follow these principles you're going to get great results with their patients. One is to work on the gut, and that's understanding it, how it becomes imbalanced, what things can go wrong, and what triggers it. Learning how to identify problems with the gut through a good history, through use of antibiotics, hormones, acid blockers, so forth, anti-inflammatories which can cause gut disturbance, early introduction of foods, for example (dairy, gluten, early antibiotics, early history of allergic or inflammatory disorders). We'll often pick up gut issues. And that's an important area to learn how to fix. And second is food. Elimination diets are very powerful, and often a hidden cause of many inflammatory and chronic diseases, even obesity, and gluten and dairy are probably the biggest factors. So those things can be enormously impactful when you change diets and see how they impact your patients. And then thirdly, just food as medicine in general. If you do incremental changes you'll often not see much. But if you do significant changes where you get people on a whole real-food diet that is gluten- and dairy-free, low glycemic load with dense phytonutrients, in a week or two you will see dramatic changes in a patient's health. They will see it in themselves and they will know that: "Boy, maybe diet does have something to do with how I feel." And they'll be willing to make those changes. If you do incremental changes, you might not get the results. In fact, I think that has been the key to my success. I build a close relationship with the patient quickly. I get them to engage and be willing to try something. I don't promise them that this is the answer to everything, but I say, "Look, this is something that is easy to do, is short term, the outcomes can be dramatic, and you have nothing to lose." If they buy into that, very quickly they can see that there are significant, significant changes in their health, and that clicks on with them very closely.
The other thing—I think, the big homerun—is really understanding metabolic syndrome, and understanding how to deal with that. It's really truly critical. If we do that, then we can really treat a lot of patients. There are other things like environmental toxins, and mercury, and chronic infections, but those are often the big homeruns in functional medicine.
JB: Let me, if I can, take that down to kind of a retrospective of the last few years of the focus of the Institute for Functional Medicine as indicated at its annual symposia. A couple of years ago at La Costa, the focus was on integrative functional approaches towards oncogenic conditions in the cancer realm. We've seen a focus on a functional medicine approach to autoimmune problems. And most recently (in 2012, now), a fantastic symposium focused on cardiometabolic syndromes. It seems that it's very interesting how this model, as you've described it, can cut across many different disciplines—what we might call medical siloes or areas of specialty. If you were to kind of get into your wonderful Mark Hyman philosophical chair and talk, at 50,000 feet, how is it this model can apply to such divergent states of pathology as cancer, autoimmune disease, and cardiometabolic disease? It seems like these are very different disease families, with different drugs to treat them, and different specialists who know them. How does that work?
MH: It works because at the very heart of systems biology medicine is the idea that most of the diseases that we see are rooted in the same fundamental imbalances, and that if we look at an individual they might manifest as a migraine, or as asthma, or as irritable bowel, or as cancer, or as diabetes, but in the end if you look really down to the root of it, there are disturbances in just a very few key systems. Those are the things we work on: immune system, digestive system, detoxification, energy, hormones, so forth. So these are the things that we really focus on, and if you focus on the root, then the branches take care of themselves. That was sort of the surprise at Saddleback when we did this. You know, it wasn't even with intervention. We just literally created a healthy living program and within a very short time people had dramatic changes in their health that were surprising even to me because we didn't really see them as patients, and as we just got them healthy, diseases went away as a side effect.
JB: I would call this a shifting huge paradigm in this time of great economic challenge to health care. You know, we're still trying to figure out a healthcare system out of a disease-care model, and we're still worrying about reimbursement and universal access, it seems, rather than talking about the type of system that we're going to put money into and provide access to. As you look forward, probably being in a very unique position having gone to the White House and been in discussion with policy makers about the future of health care, tell us what you see in your crystal ball. Where are we heading and what might we look forward to?
Change in Healthcare Will Come from the Bottom Up
MH: I think it's going to be a tough slog in terms of changing health care from the top down. I think we have to do it because it has to be done and I'll continue to work at it. Maybe we'll come up with some exciting new interventions, for example next week I'm going to New Orleans to work with the VA to create a functional medicine model within the VA in New Orleans because they have decimated their healthcare system, so it's an opportunity to create something from scratch, and using the group model with functional medicine. If we can create a pilot program like that, that shows dramatically increased improvement in outcomes and decreased costs, then maybe we'll catch on. But, it ultimately has to change reimbursement, otherwise things won't change. One of the other things I'm working on is changing the exams in medical education as required to provide teaching to the exams, like the national boards, and if you can change what's on those exams and make it more functional medicine, then the schools will have to change. So those kinds of interventions…there may be a few ninja interventions that could sort of shift the system from the top down. I believe it's got to happen from a grassroots model, and that's why I started at the church. If we create a huge change in the culture—if we change the way people think about their health and we help them understand what functional medicine is for themselves, then they will demand it, then doctors will be asked about it, then schools will want it, and it will shift. That's what I'm hoping we'll do, and so it is really moving multiple levers: education, reimbursement, demonstration projects, and grassroots movements around changing consumers' demands and values.
JB: I think that probably relates to the last question that I will burden you with. You're the leader of the functional medicine movement through the chairmanship of the Institute and being such a celebrated practitioner of this form of systems biology and health care. How do you see functional medicine as both a discipline and as an institute, changing or morphing to address this global increasing burden of chronic disease and trying to make a contribution to it?
MH: Well, the Institute has a five-year strategic plan that's to raise 20 million dollars to expand our educational platform, and to engage in pilot projects and research programs, as well as collaborate with other organizations that can help extend this model, and we're active in all those areas. I'm most excited about building a scalable e-learning platform, which we raised almost $300,000 dollars for at the last functional medicine conference, from our own community, in order to actually get this out there into a medical curriculum that can be used, and a nutrition curriculum, in medical schools and residency and postgraduate education, and it can be scaled internationally. IFM is increasingly being recognized as the leader in that field. Washington policy makers are coming to me saying, "We want to make functional medicine education part of the change that's got to happen in medicine." It's not us going out to try to recruit people to our way of thinking; it's people who have come to it and have now seen the light, and seen the value of it, and see how this needs to be what medicine is, and I'm very encouraged by that.
JB: Well, Mark, I want to tell you how privileged we are to have had this chance to visit with you and how really impressed and truly congratulatory I feel for what you've accomplished and how you have been a lightning rod for the functional medicine concept and the Institute for Functional Medicine. I'm so impressed by its faculty, by the quality of the people, the dedication, the intelligence, the wisdom, and the tireless work that goes into the Institute from its faculty and staff. I think what you are doing is leading a movement that cuts across a lot of boundaries. It really becomes a system in and of itself that exemplifies systems biology and medicine, so it's living its own model. I want to thank you on behalf of all of our listeners, and all I can say is keep the energy, take good care of yourself, we need leaders like you. I think the 21st century is going to have its challenges, which hopefully this model will provide some assistance in keeping a healthy population available to address the issues that we're going to deal with on a global basis in the environment, social structure, poverty, and others that I think we're going to have to find solutions to. Thank you very, very much.
MH: Thank you, Jeff. It's such a pleasure to be able to do this with you. In fact, how I learned functional medicine was by listening to every single Functional Medicine Update over the years. It has been a huge way for me to stay current and stay engaged and I've probably listened to thousands of hours of you. At first I had to keep hitting rewind until I finally started understanding the language.
JB: Well, I think you not only understand the language, you're creating the language now. That's the sign of a movement when you have really bright, capable, dedicated people picking up the flame. Thanks a million, and we're going to be traveling with you through your next journey. Be well.
MH: Thank you, Jeff. Thank you so much for what you do for all of us.
Bibliography[1] Kluger, Jeffrey and Elizabeth Dias. Does God Want You To Be Thin? Time. June 11, 2012. [2] Hyman, Mark. The Blood Sugar Solution: The UltraHealthy Program for Losing Weight, Preventing Disease, and Feeling Great Now! New York: Little, Brown and Company, 2012. [3] May AL, Kuklina EV, Yoon PW. Prevalence of cardiovascular disease risk factors among US adolescents, 1999-2008. Pediatrics. 2012;129(6):1035-1041. [4] Crisp, Nigel. Turning the World Upside Down: The Search for Global Health in the 21st Century. London: Hodder Arnold Publishers, 2010. [5] Holman H. Chronic disease—the need for a new clinical education. JAMA. 2004;292(9):1057-1059.
[6] Wilson Edward O. The Social Conquest of the Earth. New York: Liveright, 2012.
[7] Ali MK, Echouffo-Tcheugui J, Williamson DF. How effective were lifestyle interventions in real-world settings that were modeled on the Diabetes Prevention Program? Health Aff (Millwood). 2012;31(1):67-75.
[8] Fisher EB, Boothroyd RI, Coufal MM, et al. Peer support for self-management of diabetes improved outcomes in international settings. Health Aff (Millwood). 2012;31(1):130-139.
[9] Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA 1998;279(21):1703-1708.
[10] Abeyta IM, Tuitt NR, Byers TE, Sauaia A. Effect of community affluence on the association between individual socioeconomic status and cardiovascular disease risk factors, colorade, 2007-2008. Prev Chronic Dis. 2012;9:E115. Epub 2012 Jun 21.
[11] Alves L, Azevedo A, Silva S, Barros H. Socioeconomic inequalities in the prevalence of nine established cardiovascular risk factors in a southern European population. PLoS One. 2012;7(5):e37158. Epub 2012 May 29.
[12] Loscalzo J, Barabasi AL. Systems biology and the future of medicine. Wiley Interdiscip Rev Syst Biol Med. 2011;3(6):619-627.
[13] Liu YY, Slotine JJ, Barabasi AL. Controllability of complex networks. Nature. 2011;473(7346):167-173.
[14] Ridker PM, Danielson E, Fonseca FA, et al. Reduction in C-reactive protein and LDL cholesterol and cardiovascular event rates after initiation of rosuvastatin: a prospective study of the JUPITER trial. Lancet. 2009;373(9670):1175-1182.
[15] Gierman LM, van der Ham F, Koudijs A, et al. Metabolic stress-induced inflammation plays a major role in the development of osteoarthritis in mice. Arthritis Rheum. 2012;64(4):1172-1181.
[16] Aktas E, Sener E, Gocum PU. Mechanically induced experimental knee osteoarthritis benefits from anti-inflammatory and immunomodulatory properties of simvastatin via inhibition of matrix metalloproteinase-3. J Orthopaed Traumatol. 2011;12:145-151.
[17] Clockaerts S, Van Osch GJVM, Bastiaansen-Jenniskens YM, et al. Statin use is associated with reduced incidence and progression of knee osteoarthritis in the Rotterdam study. Ann Rheum Dis. 2012;71:642-647.
[18] Conaghan PG. The effects of statins on osteoarthritis structural progression: another glimpse of the Holy Grail? Ann Rheum Dis. 2012;71(5):633-634.
[19] Keiler AM, Papke A, Kretzschmar G, Zierau O, Vollmer G. Long-term effects of the rhapontic rhubarb extract ERr731® on estrogen-regulated targets in the uterus and on the bone in ovariectomized rats. J Steroid Biochem Mol Biol. 2012;128(1-2):62-68. [20] Qin X, Xu M, Zhang Y, et al. Effect of folic acid supplementation on the progression of carotid intima-media thickness: a meta-analysis of randomized controlled trials. Atherosclerosis. 2012;222:307-313.


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Apr 02
Happy Spring!
Spring is here and now it is time to do a liver detoxification! I started mine today! Although we did not have much of a winter here in much of Colorado, spring is the perfect time to clear out the liver and feel all the benefits such as increased energy and decreased inflammation. I have a gentle easy 3 week cleanse that I use and highly recommend. Contact me to get started right away. I can have them shipped to your door!

subset: commoncrawl


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Games for Kids with Autism & How to Start Teaching Games
Teaching kids with autism to play games is tricky. In 2008, I met a behavior analyst who changed my whole view on how to teach games. So today, I want to talk about Steve Ward and his book on this important topic.
Each week I provide you with some of my ideas about turning autism around, so if you haven't subscribed to my YouTube channel, you can do that now and join the thousands who already have.
A few months ago, I also started a weekly Turn Autism Around podcast and one of my guests was Steve Ward; he's featured in episode number 22. If you haven't heard the episode with Steve on Teaching Kids with Autism Games and Leisure Activities, I encourage you to listen to it.. So years ago, I met Steve Ward at a book signing. I was signing my book, The Verbal Behavior Approach and he was signing his new book, What You Need to Know About Motivation and Teaching Games.
I wrote a written blog on this topic, but now since I've interviewed Steve for my podcast and we talked about some other things, I wanted to hop back on here and do a video blog about Steve's book and Steve's work. Since then, it really has changed the way I teach games. I've recommended this book more times than I can count. Steve's book includes an analysis of how games help language. All that information is in the beginning.
Then there are 12 specific games such as Go Fish, Simon Says and Memory with data sheets and ways you could adapt the game based on functioning level and language. When I returned home from reading the book and meeting Steve, right away I wanted to implement these strategies with my son Lucas. I told his therapy team that since he was already playing Go Fish that I wanted to try to get that to be better.
When I really sat down and used the data sheets and Steve's book, the behavior analyst and I were able to see that we really didn't have him playing Go Fish very well at all. It was very prompt dependent and it wasn't really looking good. So we did use Steve's techniques to improve that game as well as other games. I was able to count errors and prompts and we were able to then make some changes to the game that we didn't think of prior to reading the book and meeting Steve.
The other thing that came up in addition to these kinds of card games and board games, is he also outlined some games such as Hotter, Colder and Red Light, Green Light, and he adapted them. Red Light, Green Light becomes stop and go, which are very functional, and Hotter, Colder becomes more like yes and no. We really talked on the podcast about how those sorts of games, which are also outlined in his book are excellent for teaching language, decision making, and problem-solving. Steve also told me, which I wasn't aware of, that he came out with a second advanced version called 21 More Games. I haven't checked out that book, but I'm sure that's awesome as well.
He has other books too. Steve has been in the ABA field for over 2 decades and is really quite an accomplished professional who really knows his stuff. So I highly recommend this book by Steve Ward, What You Need to Know About Motivation and Teaching Games and you can check out his other books through his website, wholechildconsulting.com. I hoped you liked this and you can check out the podcast interview as well, episode number 22. I'm sure you will love the book as much as I did. Wherever you're watching or reading this, I'd love it if you'd leave me a comment, give me a thumbs up and share this video/article with others who might benefit. And for more information, you can attend a free online workshop at marybarbera.com/workshop. I hope to see you right here next week.


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Books Helped Me Get Over My Middle Child Syndrome
I don't care what science or psychology says about the middle child syndrome, because I know first hand that being the middle child totally sucks. Stuck between two sisters myself, I know the struggle all too well, and while recent studies show birth order might not matter, it certainly didn't feel that way growing up. Luckily for me, I had good friends, a passion for journaling, and a love for reading that helped me survive as the middle child of my family.
Like Stephanie Tanner, Jan Brady, and the rest of the middle children of the world, when I was growing up, I constantly felt left our and ignored by my family, which in retrospect seems as ridiculous as my then favorite red leather jacket, and I was always fighting for the attention I felt I wasn't getting. I had a serious chip on my shoulder, and I remember complaining to my friends at school about how my family "just didn't get me" because after all, who was I to them? My older sister was the first, the special one, and my younger sister was the baby that everyone adored, but what was I? In truth, I was a grumpy little kid with a habit of being bored and jealous all at once. Luckily, I found books, and they were just what I needed.
On the most basic level, books were great company for the lonely days I usually spent brooding over all the attention my sisters were getting while I, the middle child, was usually shunned (OK, not really, but I was a pretty dramatic kid, and that's how it felt.) When I did feel left out or alienated from my family, I could always find refuge in a good story. Reading kept me busy and entertained, and helped me become more independent. I quickly learned being alone wasn't the worst thing in the world, as long as you had a good book to keep you company. Who needed an annoying family to ignore you when you have an adventure awaiting you at the turn of a page?
But books weren't only entertainment for me. They were my escape from sisterly drama, my companion when I felt no one else was paying attention, and my guide while I tried to figure out who exactly I was.
One of the biggest struggles I had as a middle child was finding where I fit in and what I wanted to be in a family where everyone else's roles were so clearly defined. My parents were, obviously, mom and dad, care givers, rule enforcers, and the heads of the house hold. As for my sisters, the older one was the leader and the protector, the bossy one who got to be in change when our parents were gone, and the younger one would always be the baby. But where did that leave me? I couldn't put a label on myself nearly as easily as I could my family members, but books helped me find a way around it.
Books like To Kill a Mockingbird, Bless Me,Ultima, and A Tree Grows in Brooklyn helped me shape my own stories and gave me the inspiration I needed to carve my own path and create my own identity.
While I was growing up, I read a lot of coming-of-age stories with young people just like me — alone, confused, and trying to figure out who they were. Books like To Kill a Mockingbird , Bless Me,Ultima, and A Tree Grows in Brooklyn helped me shape my own stories and gave me the inspiration I needed to carve my own path and create my own identity. These books about kids like me who could feel ignored and who could feel lonely but kids who ultimately found their own way, they helped give me the perspective I needed but couldn't get jammed in the middle of two other people. They taught me I could be anything I wanted to be, and I didn't have to fit into any kind of mold. Just because my older sister was the leader or my younger sister was the sweet one didn't mean I couldn't be those things, too.
But out of everything reading and books helped me with while I was growing up in the middle, I am most grateful for the way they helped me find my voice and speak up. As a middle child, I felt like my voice was constantly lost in the noise of everything on either side of me. I didn't feel like anyone listened when I talked, let alone cared what I had to say, but reading helped change all that. Brave characters like Nancy Drew, Hermione Granger, and Matilda, characters who spoke up when there was an injustice and girls who refused to let their own voices get drown out, were examples of the kind of girl I could be, and the kind of girl I should be. They taught me that what I had to say mattered, and if people weren't listening, I shouldn't keep quiet — I should just learn to talk louder.
If it wasn't for my love of reading and all of the great stories I've encountered along the way, being a middle child would have been a lot harder. Believe what you will about the middle child syndrome, but take it from me when I tell you that all that anxiety, all that fear of being ignored, it all feels real when it's happening to you. And yes, maybe you say that those things are a part of growing up no matter what your birth order is, but either way, books helped it all feel better. Books help make everything feel better.
Images: ABC; Giphy (2)


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Article Text
Background Self-reported diabetes has been found to be valid to evaluate people's diabetes status in the population of several countries. However, no such study has been conducted to assess the validity of self-reported diabetes in the Chinese population, the largest population with the highest rate of diabetes. The aim of our study is to evaluate the validity of self-reported diabetes among the middle-aged and older Chinese population.
Methods Data from 11 601 participants, aged ≥45, of the China Health and Retirement Longitudinal Study (CHARLS) during 2011–2012, were analysed. Prevalent self-reported diabetes was compared with reference definition defined by fasting glucose, glycated haemoglobin and medication use. Sensitivity, specificity, positive predicted value, negative predicted value and κ value were calculated overall, by 5-year age groups, by education levels and by living areas.
Results The sensitivity of prevalent self-reported diabetes was 41.5%, and the specificity was 98.6%. The sensitivity of self-reported diabetes increased with education levels, and was much higher among urban residents than rural residents (58.2% vs 35.0%). The specificity was above 98% among all age groups, in different education levels, and in rural and urban areas. Self-reported diabetes had substantial agreement with reference definition among participants with above vocational school education or those living in urban areas (κ=0.658 and 0.646, respectively).
Conclusions Although the sensitivity of self-reported diabetes was poor among middle-aged and older Chinese adults, the specificity and positive predictive values were fairly good. Furthermore, self-reported diabetes performed well among those with more than vocational school educations or those living in urban areas.
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Statistics from Altmetric.com
Strengths and limitations of this study
Study population was a representative sample of China's middle-aged and older population, which indicates high generalisability of the result of the current study.
We used fasting blood glucose and glycated haemoglobin levels instead of medical records to define diabetes, which eliminated undiagnosed cases of diabetes.
Stringent quality control and quality assurance measures were implemented in every stage of the China Health and Retirement Longitudinal Study (CHARLS) study, which guaranteed the quality of our study.
We included using traditional Chinese antidiabetic medication as one of the criteria for reference definitions of diabetes, which was different from the criteria that were generally accepted in studies outside China.
Self-reported diagnosis of diabetes is the major method for determining diabetes in large-scale epidemiological studies.1 ,2 Self-reported diabetes has been found to be a valid method to evaluate people's diabetes status in the populations of several countries, such as Britain,3 Spain,4 Brazil,5 Japan6 and the USA.7 ,8 However, no study has been conducted to examine the validity of self-reported diabetes in China, which has the largest number of people with diabetes in the world,9 particularly among the most vulnerable middle-aged and older Chinese population.
Diabetes is one of the leading causes of mortality and morbidity worldwide, which increases the risk for cardiovascular and kidney diseases.10 In China, approximately 114 million, or 11.6% of adults, had diabetes in 2010.9 However, less than one-third (30.1%) of these patients were aware of their disease condition,9 and this may affect the estimate of diabetes prevalence based on self-reports in large-scale epidemiological studies. The accuracy of self-reported information can be affected by respondents' age, gender, education, medical knowledge and frequency of contact with a physician.11 The inconsistency between self-reported diabetes and the reference standard can bias the results of studies using self-reported diabetes. Typical reference definitions of diabetes include fasting glucose level, random blood glucose test, haemoglobin A1c (HbA1c), oral glucose tolerance test and/or taking diabetes medications.8 ,12 Therefore, the purpose of this study was to assess the validity of prevalent self-reported diabetes by using reference definitions defined by fasting or random blood glucose levels, HbA1c and taking diabetes medication, in a representative sample of middle-aged and older Chinese population using baseline data from the China Health and Retirement Longitudinal Study (CHARLS).
Subjects and design
The CHARLS surveys a representative sample of more than 17 000 Chinese aged ≥45 from China's 28 provinces every 2 years to explore the dynamics of retirement and how retirement interacts with health, health insurance and economic well-being.13 Participants were selected using a four-staged, stratified, cluster sampling method.13 The baseline national survey was carried out from 2011 to 2012 through face-to-face household interviews, which collected detailed information on demographics, biomedical measurements, socioeconomic status and self-reported health status and functioning including diabetes.13 The CHARLS also collected data on fasting blood glucose and HbA1c. The comprehensive and multifaceted dataset provided by the CHARLS national baseline survey allows us to evaluate the validity of self-reported diabetes.
The response rate among eligible households was 80.51%.14 Overall, 17 314 individuals aged ≥45 within 10 257 households were investigated in the baseline survey.14 ,15 Blood samples were collected from 11 847 (67%) out of the 17 314 study individuals by medically trained staff. A total of 11 601 participants had blood samples and/or information on self-reported diabetes, insulin or diabetes medication, and were included in the current analysis. The current study was secondary analysis of the open-access dataset of the CHARLS.
Self-reported diabetes and reference definitions of diabetes
Participants were defined as having self-reported diabetes if they answered 'yes' to the questions: "Have you been diagnosed with diabetes or high blood sugar?". The reference definitions of diabetes were defined as: fasting blood glucose ≥126 mg/dL, or random blood glucose ≥200 mg/dL, or HbA1c ≥6.5%, or insulin use, or taking antidiabetic medications including traditional Chinese medicine and modern medicine. The cut-off points for diagnosis of diabetes were based on current recommendations from the American Diabetes Association.12
Measurement of blood glucose and HbA1c
Blood samples were collected by medically trained staff from the China Center for Disease Control and Prevention. Participants were asked to fast overnight. However, a small proportion (8%) of the blood samples was also drawn even if the participants did not fast.15 For those who did not fast, standards for random blood glucose level (≥200 mg/dL) and/or glycated haemoglobin (HbA1c) (≥6.5%) were used to define diabetes.
After collection, plasma for glucose assay was separated from blood samples and stored at −20°C,15 and whole blood for HbA1C assay was stored immediately and during shipment at 4°C.15 All the blood samples were transported within 2 weeks to the China Center for Disease Control and Prevention, where samples were placed at −80°C in a deep freezer before assay.15 Blood assays were performed at the Youanmen Center for Clinical Laboratory of Capital Medical University during February 2013 and June 2013.15 The laboratory used quality control samples daily during the testing of the CHARLS study samples, and all test results were within the target range (within two SDs of mean quality control concentrations). Glucose was measured using an enzymatic colorimetric test, and HbA1c was analysed using Boronate affinity chromatography.15
Demographic variables
Demographic variables including age, gender and educational level were collected using standardised questionnaires during the interview. Educational level was categorised as illiterate, less than primary school, primary school, middle school, high school and above vocational school.
Statistical analysis
We assessed the validity of self-reported diabetes by calculating sensitivity (proportion of people with diabetes who correctly self-reported having the condition), specificity (proportion of individuals without diabetes who correctly self-reported not having the condition), positive predictive value (proportion of individuals who self-reported having diabetes were diabetic based on reference definitions), negative predictive value (proportion of individuals who did not report having diabetes were not diabetic based on reference definitions) and κ value compared with the reference definitions of diabetes. The validity was evaluated overall, by 5-year age groups, education levels and by rural and urban areas. Sensitivity analysis using reference definitions excluding traditional Chinese antidiabetic medication was also performed. All analyses were performed in SAS V.9.3 (SAS Institute, Cary, North Carolina, USA).
Characteristics of the participants are shown in table 1. The participants had a mean age of 59.5 years old. Most had less than high school education and 28.6% were illiterate. The majority of the participants (80.2%) lived in rural areas. Overall, the participants had optimal fasting blood glucose, HbA1c and body mass index. A total of 7.8% of the participants reported physician-diagnosed diabetes, and most of them took modern medicine to treat diabetes; however, 22.6% of them did not treat their diabetes. Based on the reference definitions, 15.9% of the participants had diabetes.
The validity parameters of self-reported diabetes are presented in table 2. Self-reported diabetes had high specificity (98.6%), positive predicted value (84.7%) and negative predicted value (89.9%). However, the sensitivity of self-reported diabetes was only 41.5%. Overall, self-reported diabetes and the reference definitions had moderate agreement (κ=0.505). In different 5-year age groups, sensitivity varied from 33.2% to 47.1%, specificity was all above 98%, positive predicted values (PPV) ranged from 79.4% to 96.8%, and negative predicted values (NPV) were between 84.5% and 92.2%. In each age group, self-reported diabetes had moderate agreement with the reference definitions, with the 60–64 age group having the highest κ value (0.548). The sensitivity of self-reported diabetes increased with education levels. The specificities were also all above 98% among participants with different education levels. PPV and NPV ranged from 79.6–92.2% and 87.5–91.4%, respectively, in different education levels. Self-reported diabetes among participants with above vocational school education had substantial agreement (κ=0.658) with the reference definition. Furthermore, participants living in rural areas had much lower sensitivity and PPV compared to those living in urban areas. However, the specificity and NPV are similar between the two populations. Finally, urban residents had a much higher κ value than rural residents (0.646 vs 0.441).
The sensitivity analysis using the reference definitions including only modern antidiabetic medications (table 3) showed similar specificity (96.3%) and NPV (90.0%). However, the sensitivity (32.3%) and PPV (58.4%) of self-reported diabetes were much smaller, and the agreement between self-reported diabetes and the reference definitions was only fair (0.353).
To the best of our knowledge, this is the first study evaluating the validity of self-reported diabetes among the middle-aged and older Chinese population. We found that self-reported diabetes was 40.21% sensitive and 98.47% specific. In general, self-reported diabetes did not perform well in the middle-aged and older Chinese population. However, self-reported diabetes among participants with above vocational education or living in urban areas had high sensitivity and substantial agreement with the reference definitions.
In the current study, self-reported diabetes largely underestimated the prevalence of diabetes in the middle-aged and older Chinese population. This is different from studies reported in developed countries such as the USA, where self-reported diabetes was 55–80% sensitive.8 This difference is likely driven by the education level of the participants. The proportion of people who had received formal schooling higher than high school was only around 10% in the current study, which is much lower than that (above 81%) in the study conducted in the USA.8 On the contrary, sensitivity of self-reported diabetes from participants with high school or above vocational school education levels was similar to that in the USA.8 Our study indicates that blood glucose and/or HbA1c tests are necessary to accurately estimate the prevalence of diabetes in large nationwide diabetes studies.
Similar to studies in most countries, self-reported diabetes was highly specific in the current study.3–8 In addition, the PPV are very high in the current study. Hence, for studies with patients with diabetes, self-report is a useful tool to identify and recruit participants.
Self-reported diabetes performed much better among urban residents compared to rural residents in the current study. This may reflect differences in education and access to healthcare services between populations in these areas. Previous studies indicated that higher education and a recent health examination increased the sensitivity of self-reported diabetes.11 In China, urban residents had a higher education level and better access to medical services.16
Our study has several important strengths. First, the CHARLS participants were a representative sample of China's middle-aged and older population. So the findings can be generalised to all middle-aged and older Chinese adults. Second, most of the previous studies on the validity of self-reported diabetes used medical records as the 'gold standard', which may miss cases of undiagnosed diabetes, particularly for rural residents whose access to healthcare services is limited.16 The current study used fasting blood glucose and HbA1c levels to confirm diabetes, which eliminated cases of undiagnosed diabetes. Third, stringent quality control and quality assurance measures were implemented in every stage of the CHARLS study. Therefore, the quality of the current study can be guaranteed. Our study also has limitations. First, the response rate of blood samples collection was a bit low (67%), and according to the guideline of CHARLS, younger men were more likely to be missed in blood sample collection, mostly due to time conflict with their work. Since younger people have lower diabetes prevalence, lower response rate of this population will decrease the negative predictive values. Second, we included using traditional Chinese antidiabetic medication in the reference definitions, which was different from studies outside China. However, traditional Chinese medicine is an integral component of the healthcare system in China, where it is practiced side by side with conventional medicine in most hospitals and clinics.17 Many patients seek modern medicine and traditional Chinese medicine to manage diabetes. If not considering traditional Chinese medicine in the reference definitions, many cases would be missed. As in the current study, the prevalence of diabetes using the reference definitions including traditional Chinese medication was very close to that in a recent large scale national survey on diabetes in 2010.9 On the other hand, the diabetes prevalence using reference definitions excluding traditional Chinese medicine was much smaller than that in the national survey in 2010.9 We also performed sensitivity analyses for the validity of self-reported diabetes excluding participants only taking traditional Chinese medicine to manage their diabetes, as shown in the online supplementary table, and the validity of self-reported diabetes slightly decreased.
In conclusion, self-reported diabetes among the middle-aged and older Chinese population is 41.5% sensitive, indicating a low awareness rate of diabetes in this population. Public health efforts to increase the awareness of diabetes in this population are warranted. Self-reported diabetes is highly specific and the positive predictive values are fairly good. So self-reported diabetes can be used to identify and recruit diabetic participants. Furthermore, self-reported diabetes had substantial agreement with the reference definitions among urban residents and among participants with above vocational education. For large scale epidemiological studies among urban residents or participants with high education levels in China, self-reported diabetes is a useful tool to measure diabetes.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online table
XY and TL contributed equally.
Z-YZ and CL are co-corresponding authors.
Contributors CL and Z-YZ made substantial contributions to study design and data cleaning. XY and TL analysed the data in duplicate. XY, TL and LW interpreted the results and drafted the article. LW performed data analyses as suggested by the reviewers. All authors revised it critically for important intellectual content.
Funding The study was funded by National Natural Science Foundation of China (No. 81402692).
Competing interests None declared.
Ethics approval The original CHARLS was approved by the Ethical Review Committee of Peking University, and all participants signed informed consent at the time of participation.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The dataset used for current secondary analysis is publicly available on the CHARLS website (http://charls.ccer.edu.cn/en/page/data/2012-charls-pilot-wave2).
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DATU PIANG, 10 May 2010 (IRIN) – As Filipinos go to the polls on 10 May to elect a new president, Payuna Biano hopes the new government will help improve the plight of thousands of displaced people like her.Biano, 59, who has more than 20 children and grandchildren altogether, is among 300 people living hand-to-mouth in a 1m-high crawlspace under the Datu Gumbay elementary school in the town of Datu Piang in the southern Philippine province of Maguindanao.
They evacuated to the site at the height of fighting between Muslim separatist Moro Islamic Liberation Front (MILF) rebels and government troops in late 2008. More than 700,000 people were displaced by the violence across the troubled southern island of Mindanao.
"We have no money, no food. We hope the new set of leaders will help us rebuild our lives, but right now, they are all concerned with trying to win the elections," Biano said, as six of her young grandchildren, in threadbare clothes, played in the dirt.
"It's time the politicians found a solution to help us," she said.
Ancestral claims
Fighting erupted in August 2008, when the Supreme Court overturned a proposed deal that would have given the 12,000-strong MILF control over large areas of the southern Philippines they claim as ancestral land.
In protest, two of the MILF's most senior commanders launched deadly attacks across Mindanao, the southern third of the largely Catholic Philippines where they have been waging a bloody rebellion since 1978.
The fighting spilled over to agricultural communities, forcing an exodus from villages caught in the crossfire. Humanitarian agencies launched massive relief operations to help the displaced.
Nearly 400 people were killed, including soldiers and civilians who were caught in the fighting or fell ill in the overcrowded, disease-ridden evacuation camps, officials said.
Both sides agreed to a ceasefire in July, allowing a Malaysian-led peace monitoring mission to return to the area and to resume peace talks. The MILF, however, has already ruled out a final peace accord with the government of outgoing President Gloria Arroyo, who steps down on 30 June.
According to displaced housewife Farida Beding, the conflict can be resolved if voters elect local government officials who are neutral and whose agenda include forging adequate laws and safety nets to protect civilians from harm.
These officials, the 35-year-old says, should come up with a plan to relocate families still unable to return home.
"They should not be pro-MILF or pro-government. They should work to help us return and live normal lives," Beding said, as she herded her children away – they were told to keep a distance because their shelter is also a polling station. An estimated 50 million Filipinos will choose a successor to Arroyo and thousands of local and national officials.
Thousands homeless
In the past, conflict between the government and the MILF had flared up now and then, causing "relatively small-scale displacement", but after the 2008 conflict, displacement soared, with many staying in evacuation sites or with friends and family for longer periods, said Christophe Gillioz, former head of International Committee of the Red Cross (ICRC) in central Mindanao.
"People had never been displaced for so long," he said, noting that in the past, those displaced typically stayed away for only up to three months.
The ICRC said that based on its own monitoring, up to 60,000 were still displaced 18 months after the conflict.
The National Disaster Coordinating Council and the Department of Social Welfare and Development cited a higher estimate of about 100,000 still living in temporary shelters or with friends or relatives.


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Visit from the Jackson School of International Studies, University of Washington
- English
- Français
On Tuesday 16 February 2016, the NATO Defense College (NDC) was honoured to host a delegation from the Jackson School of International Studies, University of Washington (Seattle, WA). The delegation was led by Col (ret.) Frederick Lorenz, senior lecturer at the Jackson School of International Studies, and accompanied by NATO Senior Assistant Legal Adviser Ms Lone Kjelgaard. Among the twenty-five students in the group were participants from China, Ethiopia, Libya, Mongolia, Spain and Ukraine.
The aim of the visit was to give the visitors an overview of NDC activities and an introduction to current NATO priorities, as part of their course module on "The New European Security".
The group was warmly welcomed by Colonel James Huber (USA A), US Senior National Representative at the NDC.
A detailed briefing on the College and Research Division activities was given by Dr Jeffrey Larsen (USA C), Head Research Division. Following this, Dr Larsen spoke about "NATO and the Warsaw Summit". Dr Guillaume Lasconjarias (FRA C), Research Advisor, then gave a lecture on "NATO and A2/AD". These presentations were followed by challenging Q&A sessions.
During the course of the visit, the delegation gained first-hand insight into the College's unique contribution to strategic-level education and research for NATO and its Partners.


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Sassy Rags 3/4 sleeve turquoise linen Diana dress
- Brand: Classy Sassy Couture
- Product Code: Classy Sassy Couture
- Availability: 1
Our new "Dianna" dress is sure to be a customer favorite with its rounded and banded neckline, ruffled bottom, 3/4 sleeves, tucked front bodice and adorable floppy adjustable pockets. This is a new pattern we just recently created and are MORE than pleased with the fit and style. This listing is in a pretty turquoise color called "Ceramic" and perfect for layering with leggings, skinny jeans, slips or just wearing as is. Roomy fit. Heart leggings shown sold separately. Great fitting dress. Other colors coming soon.
Size Small is ready to ship. Other colors and sizes may be custom ordered.
Small (fits 6-10):
Bust - 40"
Length - 38"
Available Options


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02/24/2009, 08:24 PM (This post was last modified: 02/25/2009, 12:17 AM by sheldonison.)
sheldonison Wrote:....In this post, I will use this equation to derive the , accurate to five significant digits, using a linear approximation of sexp/slog. I haven't made any progress in proving the limit converges, but assuming it does, earlier in this thread I derived the error term of a linear approximation as the base approaches .
With a little additional algebra, this allows defining an sexp/slog extension to real numbers, for base e, by iterating the ln function "n" times. In practice, for base e, using n=5 will give approximately a million digits of precision. This also works for any other arbitrary base.
error term =~
relative error term =~
with m=, as b approaches ,
The error term uses the difference between a linear approximation, and a 3rd order approximation for the critical section. A linear approximation has a continuous 1st derivative, and a 3rd order approximation has a continuous 2nd derivative.
For this example, use a linear approximation to calculate sexp_e(-0.5), accurate to five significant digits. The relative error term required would be , which leads to m=~1/295. Use b=+(1/1500). As a comparison, the other results I used were +(1/25), but using a third order approximation. The base being used here is much closer to , and there are a lot more iterations.
Starting with the limit equation, I picked a value of n=5, for sexp_e(5). My excel spreadsheet can't handle sexp_e(5), but it can handle x=slog_b(slog_b(sexp_e(5)), which is x=10355300. Then, keep iterating x=log_b(x), another 65 times, for a total of 67 log_b iterations, until the value of x is less then log_b(e).
I stopped at x=2.71365. Now that x is in the linear region of the slog_b(x) curve, let x= sexp_b(slog_b(x)-0.5). For the slog_b function, I got a remainder term of 0.638016. Subtract 0.5, and use the linear approximation to begin the conversion back to the sexp_b, x=2.71194. The error term doubles to +/-0.000002 since two different linear approximations are required, one for the slog_b and another for the sexp_b.
Now iterate, taking x=b^x 66 times. I got x=5.36*10^77. One last exponentiation will be too large for the spread sheet, so I pair it up with the first ln. Let x= ln(ln(ln(ln(ln(b^x))))). The result I got was sexp(-0.5)=0.497818+/-0.00002.
Using the more accurate 3rd order approximation for the critical section, I got sexp(-0.5)=0.49783297. The delta between the two values was 1.5*10^-5 which is less than 2*10^-5.
The next thing I plan to do is to convert the base=e sexp function posted by Kouznetsov to another base, probably b=1.45, and graph the equations and derivatives to show that Kouznetsov's sexp function requires a 1-cyclic definition of sexp/slog base conversions, as the limit cannot converge to a constant, but instead wobbles. Jay noticed the same thing for Andy's sexp/slog extension to real numbers. I will also graph the sexp_e function converting from base=1.45. Any other suggestions?


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A small mammal from a mongoose family has one of the funniest and cutest ways of Sungazing. Until it faints in the heat.
Cuddly and sweet, ferocious and wild, regardless of their nature, cute animals have always been featured on favorite images, throughout the Internet and beyond. They adorn the covers of countless products, portraying the nature, appeal and user friendliness of the commodity, attracting potential buyers who cannot resist the adorable faces of their little furry friends.
Animals have been an inspiration for children' toys for ages, there's not a single grown up or a kid who doesn't have his/hers favorite Teddy bear, bunny or puppies from the early life, and this trend only seems to increase. As science evolves, so does the toys industry, producing the beany baby species we have never had before.
Animals have been symbols of nations, making us like a country just a little bit more. Who can resist the image of a panda, koala or a kangaroo, or not feel inspired looking at the majestic lion, or the proud giraffe. Each one of us has their own favorite animal we find the most cute, and each perception of cuteness is different. But, just like in the world of humans, cute baby animals are the most beloved, the most adored and the most sought after images or buddies in the world.
Animals are innocent on their own, regardless of their nature. We cannot really blame a tiger for his choices no more than a rabbit, although he is potentially deadly. But baby animals are all an equal portrayal of utter innocence, the purity in its cutest form, the spark that makes our hearts jump with joy. When they are cubs, a baby wolf can be freely put together with a bunny, we can see a kitten cuddle with dogs, or a kangaroo hold a baby wombat in its paws, gently of course. They are the perfect picture of naivete, the blameless, harmless creatures that represent the original and sublime state we were all at when we were born, and we all continue to seek throughout our lives.
Cute animals are not just bubbles of cuteness, but the means of, however short, return to the purest condition of goodness.
1. Lamb
Lamb is a young sheep. Although it is widely used for food, it's not as widely known that a lamb is one of the softest and cuddliest animals, attached to man and tame.
2. Cat
Cat is one of the favorite pets and an obsession by many cat lovers, artists and enthusiasts. There thousands of cat breeds throughout the world, all cute. The zoology branch dedicated to cats is called Felinology.
3. Dog
Probably the most favorite pet in the world and a man's best friend. Among many breeds, each one of us can find a perfect companion.
4. Kangaroo
Kangaroos are indigenous animals to the continent of Australia. This is a marsupial animal, meaning the female has a pouch where she keeps her young until they are old enough to run on their own.
5. Giant Panda
Panda may just be the most famous endangered animal in the world. Maybe it doesn't do kung-fu, but it sure is adorable.
6. Hedgehog
Hedgehog is not for petting! It's an easily frightened little critter, who rounds up in a ball, with its spiky hair sticking out to protect it. It's also one of the animals with the sweetest face ever!
7. Fennec Fox
This North African miniature fox has been officially proclaimed the most adorable animal in the world. Don't you agree?
8. Sloth
These slow and lazy anteaters have one of the most disarming facial expression in the whole animal kingdom.
9. Rabbit
Bunnies have always been related to kids. Although notorious in some countries, they are soft, cuddly and timid, they make great pets.
10. Elephant
They are usually not seen as cute, but anyone who has ever seen a baby elephant walk, drink or do just about anything will beg to differ.
11. Giraffe
Giraffe is one of the most reproduced animals in toy world. It's also one of the most emotional and easily stressed animals, so the watchers must never come to close, as it can be dangerous for both them, and the giraffe.
12. Squirrel
Playful and tiny, squirrel is common in the woods, but also city parks. It likes nuts, but it gets scared easily and runs very fast. Remember Chip n' Dale?
13. Polar bear
White and soft looking, polar bears are actually quite ferocious. Nevertheless, they look adorable.
14. Seal
Who can resist a seal with those big, round eyes? It's hard, but the seals are not pets!
15. Penguin
Funny, seemingly clumsy birds that don't fly, but actually great fish hunters and very socially conscious animals. Baby penguins are well taken care of by their parents until they grow up.
16. Orangutan
One of the most endangered species, losing its habitat on the islands of Borneo and Sumatra. They are gentle giants with friendly faces.
17. Baby deer
Beautiful animal, glorified by the iconic Bambi. The woodland creature that is the embodiment of freedom and cuteness.
18. Albino tiger
Tiger is officially proclaimed the most beautiful animal in the world. Looking at the albino tiger, this fact only confirms itself.
19. Duckling
Duckling is the young of a duck, not a swan. And it's not ugly, it's adorable!


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Please don't make me a joke.
captivating quotations from movies, television, literature and people - curated by actual geeks.
Hollywood's a place where they'll pay you a thousand dollars for a kiss, and fifty cents for your soul. I know, because I turned down the first offer often enough and held out for the fifty cents.
Husbands are chiefly good as lovers when they are betraying their wives.
It's not true I had nothing on. I had the radio on.
My work is the only ground I've ever had to stand on. I seem to have a whole superstructure with no foundation — but I'm working on the foundation.
When you're famous you kind of run into human nature in a raw kind of way. It stirs up envy, fame does. People you run into feel that, well, who does she think she is, Marilyn Monroe? They feel fame gives them some kind of privilege to walk up to you and say anything to you, of any kind of nature — and it won't hurt your feelings — like it's happening to your clothes not you.


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Brass single hilt, Duralumin butt, overall length 9 3/8 - 91/2 Leather handle, heavy sole leather, laminated with waterproof cement and tightly compressed between hilt and butt cap. Firmly fastened by means of special dome-shaped stainless steel nut on end of tang. Carefully shaped and highly polished. Based on the spec this looks like a Model 7 Fisherman - Hunter.
The item "Vintage USA Custom Hand Made, Randall Hunting Knife & Model A Sheath with stone" is in sale since Monday, September 24, 2018. This item is in the category "Collectibles\Knives, Swords & Blades\Collectible Fixed Blade Knives\Vintage Fixed Blade Knives\Custom & Handmade". The seller is "gdbrowerinc" and is located in Henrietta, New York. This item can be shipped to United States.


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Minneapolis, Minnesota
April 30, 2012 Adventure and Travel
Highlights from my first day in Minneapolis. I spent a few hours exploring the Walker Art Center. This was my first visit to the museum. The Walker has served as a huge source of inspiration over the years due to their leadership within the museum field. I've been especially inspired and challenged by their new media initiatives. The museum lived up to my expectations. Several great exhibits were on display, including Lifelike ("a close examination of artworks based on commonplaceRead More


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Bobby Roode is one of the most dominant names in the professional wrestling business. In a career spanning two decades, Roode has seen it all, be it hitting roadblocks time and again or standing tall on top of the world.
Roode is currently enjoying his RAW Tag Team Championship reign with Chad Gable. His stint with WWE has been successful so far.
During a recent interview with The Mirror, The Glorious Canadian wrestler revealed how important it is to utilize and maximize every opportunity as a WWE Superstar.
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"It's one of those things, everyone wants that opportunity to show what they can do."
"But there are so many hours of television… I have been very fortunate to be at the forefront of that and be in storylines on Raw and Smackdown now.
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"So it is competitive, but I think everybody has an understanding of how it works and how things are going – you have to be patient and stay positive."
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"If you aren't on TV one week, hopefully the next week you'll have that opportunity to go out there, whether it be a five minute match or a backstage promo.
"You just have to make the best of every opportunity you get and hope something sticks."
The former NXT Champion also talked about the exhausting road schedule that Superstars have to follow.
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"It's a grind. At the weekend alone, we traveled from Tallahassee, Florida to Fort Myers – that's over six and a half hours and 500 miles.
"So not only are we beating ourselves up in the ring, but we're in our cars driving 400 miles a night to get to the towns.
"It's a grind, but at least I get to do what I love to do. That's all part and parcel of the game.
"You get to travel around the world and enjoy new experiences… I've always said, your worst day in sports entertainment is still better than your best day digging ditches."


text: Sheila SandersHas been Painting and drawing since she was a young girl. Her love of animals has been an inspiration for many of her paintings. She works at her home studio in the Sierra foothills of California, where she has plenty of furry inspirations cats, dogs and horses.A variety of paintings and prints can be found here, oils, acrylics, chalk pastels, and water colors.


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One of the nicest things about a transcontinental crossing on Cunard's Queen Mary 2 is that the ship passes through five different times zones. So after our voyage from Southampton to New York, we arrived home feeling totally rested and restored.
See my recent article on CruiseVoyant about Crossing the Atlantic on Queen Mary 2.


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2019 sees the 10th Anniversary Grantchester Charity Runs being held on Sunday, September 29th. The first 10k was run by 30…
Category Archive: 2014
Grantchester Charity Runs: A brief history
As the popularity of the Grantchester Charity Runs has grown over the years, here are some of the changes we have made to make the event a more rewarding experience for everyone.
Sunday, September 30th 2018 New for 2018: Maggie's Centre Cambridge joins us as designated charity… … along with ACT- Addenbrooke's Charitable Trust …
Grantchester Runs in the News
First, some photos Cambridge Network Cambridge News WI Blogspot
Some photos ACT News Cambridge News Cambridge News 2
Grantchester Village
Grantchester Charity Runs on BBC Cambridgeshire Lunchtime Live with Sue Dougan, August 6th, sadly no longer available on iPlayer… Cambridge News
Three songs featuring the Grantchester Charity Runs on Cambridge …
Oct 13
3k and 10k Runners
Oct 08
Photos from the Grantchester Charity Runs
Oct 07
2014 Grantchester Charity Runs: Report and Results….
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2014 Grantchester Charity Runs: 10k Results
Aug 19