Hunger, Satiety and Obesity; what exactly regulates our appetite?

By Robert A. Shaffer M.D., Medical Director

Denise Biro, Weight Loss Coordinator

Shaffer Weight Loss Center at Gastroenterology Associates, N.A.P.C.

                                                                                                                 

     Our body naturally tells us when to eat and when to stop by hormones and neurons: ghrelen, neuropeptied Y, cholecystokinin, peptide YY, insulin, leptin and melanocortin. Problems begin when we do not listen to the signaling of our body. As we continue to consume more calories than needed without expending them, we start to develop excess fat and over time this can lead to health problems due to an erroneous message sent by the hormone leptin. Our appetite; hunger and satiety are regulated by the endocrine system that communicates with the hypothalamus and is controlled by a negative feedback system which can be disrupted by an improper diet leading to obesity.

   The stomach secretes a hunger hormone that sends a message to the brain to tell us it is time to eat. When our stomach is empty it produces the hormone ghrelin. Ghrelin sends a message from the epithelial cells of the the gastric fundus to the arcuate nucleus of the hypothalamous; the center for appetite regulation in the brain.  Ghrelin then stimulates the neuropeptide Y secreting neurons in the brain to increase hunger.

      Upon consuming food our stomach stretches and hormones start communicating with the appetite control center to signal satiety. Ghrelin concentrations decrease due to the release of the hormone cholecystokinin (CCK) from the enteroendocrine cells of the small intestine. Cholecystokinin then works together with another hormone called Peptide YY from the large and small intestine in a negative feedback cycle to control the appetite over a period of time.

      Another hormone that controls our appetite is insulin. Insulin is released from the beta cells of the pancreas to indicate that your body is metabolizing and not to consume anymore food.  Insulin regulates our fat stores by stimulating adiposytes (fat cells) to take up glucose and store as fat to use as energy at a later time.  As we eat, adiposcytes are stimulated to secrete leptin which stimulates melanocortin secretion in the arcuate nucleus of the hypothalamus signaling satiety; preventing the continued release of neuropeptide Y.

     Improper diet can lead the accumulation of excess adipose tissue and cause disruption in signaling of leptin secretion.  A person with a higher body fat mass will secrete an excess of leptin by the adipose cells. Here is the problem: over a long period of time this excess secretion of leptin can cause a disturbance in our negative feedback system. This causes our feedback system to become unresponsive to leptin or to have a receptor defect on the target cells in the hypothalamus.

     This disruptive signal of leptin signaling sends a message to the brain that we are hungry even after we just ate a big meal.  This could be a contributing factor that leads to obesity and other health disorders like fatty liver and insulin resistance. The best way to these issues is to follow a healthy nutrition plan and exercise. For more information on nutrition, exercise and diet please call 205-397-1448. 

       Shaffer Weight Loss Center at Gastroenterology Associates, N.A.P.C.

       100 Pilot Medical Drive

       Suite 250

       Birmingham AL 35235

      (p) 205 397 1448

      (w) gastrodocs.info

      (e) weightloss@ganapc.net                                                                           

      facebook.com/ shafferweightlosscenter.com

Resources:

http://www.ncbi.nlm.nih.gov/books/NBK22251/

http://www.jci.org/articles/view/36284

http://www.cdc.gov/pcd/issues/2009/jul/pdf/09_0011.pdf http://circres.ahajournals.org/content/101/6/545.full

WHY MAMMOGRAPHY IS NOT PERFECT

By Caroline A. Reich, MD, PhD

Women’s Imaging Associates

Birmingham, Alabama

Without a doubt, mammography is the most sensitive screening test developed for the early detection of breast cancer. Many lives have been saved because cancers have been caught when they are small and treatment is most likely to lead to a cure. However, like any screening test, the sensitivity (the ability to detect cancer) is not perfect. Some studies suggest that up to 20% of breast cancers may not be detected on mammography.

Several factors limit the sensitivity of mammography. First, not all breast cancers are the same. Some cancers like Ductal Carcinoma in Situ (DCIS) are often detected because of tiny, irregular calcifications that are deposited within the tumor and then seen on the mammographic images. Other cancers such as Invasive Ductal Carcinoma often cause distortion within the tissue, showing up as a mass with irregular margins.  Invasive Lobular Carcinoma is a particularly aggressive cancer that may grow quite large before distorting the normal tissue enough to be visible.

Just as breast cancers differ, the density of each woman’s breast tissue is variable and is a factor that can affect the sensitivity of the exam. Normal breast tissue ranges from being primarily fatty in composition to dense with fibroglandular elements. The density of the breast parenchyma will affect the appearance of the mammogram. A breast that is composed primarily of fat will be gray on the mammogram. A breast with dense tissue will be much whiter. Unfortunately, the signs of malignancy such as calcifications and tissue distortion are also white and can be obscured at times by the white tissue in a dense breast.

What can you do to increase your chances of detecting breast cancer as early as possible?

     1.       Most importantly, get a yearly mammogram once you turn forty! While mammography is not perfect, it remains the best screening tool we have, even in dense breasts. Tiny, irregular calcifications are a common sign of cancer. These suspicious calcifications are usually invisible on ultrasound or breast MRI.

      2.       Do NOT skip monthly breast self-exams! There are some cancers that are apparent as a breast lump before being visible on mammography. 

      3.       Know your breast density. Every mammography report includes a statement describing the relative density of the breast tissue. If you have dense breasts and have an increased risk for breast cancer such as a mother, sister or daughter with breast cancer, discuss with your healthcare provider your options for additional screening with breast ultrasound.

Be Strategic in Growing Your Medical Practice

By Matt Mettry, Director of Medical Professional Services

Brookwood Medical Center

If you’re involved in running a medical practice as a doctor, nurse or administrator, chances are that you know you need to think ahead. But do you know how important it is to be strategic about how you grow the practice?

There’s a lot of overhead when it comes to practicing medicine, and planning ahead will not only help your bottom line, but also help you provide high quality services to your patients.

You need to plan as far ahead as possible, which in most cases means 3-5 years. Look at the ages of your physicians and think about when they might retire. Succession planning is so important because it can take 12 months to 3 years to find physicians in certain specialties. The more time you have to interview candidates, find the right fit and get that new partner on board, the better.

Also think about whether or not aligning with a hospital is something you want to see in the practice’s future. Interests like autonomy, control, being part of a small organization and being your own boss are often reasons to start a private practice. Are you willing to give those up?

When you join forces with a hospital, you become part of a much bigger organization. You’ll still have control over the way you practice medicine, but there may be some changes, like requirements to use electronic health records and receiving input on hiring decisions.

Being a part of a hospital run medical practice will also introduce expectations of net revenue and volume. These are things you need to be comfortable with because it takes a lot of patient volume to have a really successful medical practice.

Whether aligning with a hospital is in your future or not, here are some action items you can take now to help grow your medical practice:

Introduce yourself to the community with speaking engagements and community education.

Consider opportunities to get involved in the community through business and civic clubs, church, social clubs, professional associations, chamber of commerce, rotary, etc.

Print welcome flyers and cards with name, photo, location, bio, availability and website.

Meet and greet other physician office staffs to create referral base.

Develop a list of targeted local schools and employers for introductions, screenings and events.

Create customized appointment cards, business cards, letterhead and envelopes.

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OIG and DOJ Take Increasingly Aggressive Fraud and Abuse Enforcement Posture

By Daniel Murphy

Bradley Arant Boult Cummings

If you have been following recent Department of Justice (DOJ) and Department of Health and Human Services (HHS) fraud and abuse enforcement efforts, you will be forgiven if you thought you had mistakenly tuned in to a 1980’s Chuck Norris film or an installment of professional wrestling’s Friday Night SmackDown.

Chuck Norris and Lee Marvin starred in the 1986 classic “The Delta Force”, while the DOJ and HHS jointly launched a “Medicare fraud strike force”, known as the “H.E.A.T. Task Force”, in 2009.  “H.E.A.T” stands for health care fraud prevention and enforcement action team.

In the 1980s, the World Wrestling Federation’s Jimmy “Superfly” Snuka and Junk Yard Dog delivered numerous smackdowns against their opponents, while the HEAT Task Force recently executed a large-scale, coordinated series of health care fraud and abuse charges against nearly one hundred individuals and billed it as a “takedown.”

On October 4, 2012, the DOJ and HHS announced that the HEAT Task Force had charged 91 individuals in seven cities with various criminal Medicare fraud violations that resulted in $429.2 million in improper Medicare payments.  The individuals charged in the task force operation included physicians, nurses and other licensed health care professionals.  The DOJ press release regarding this operation can be accessed here:  http://www.justice.gov/opa/pr/2012/October/12-ag-1205.html.

In addition to numerous individual charges and arrests, the HEAT Task Force has carried out other multi-jurisdictional, multi-agency raids like the most recent one on October 4.  In 2010, for example, the HEAT Task Force charged or arrested 94 physicians, health care company owners, and other for fraudulent Medicare claims worth $251 million.

The October HEAT Task Force raids came on the heels of a Government Accountability Office (GAO) report released in September 2012 (http://www.gao.gov/products/GAO-12-820) that detailed the scope and types of fraud identified by HHS and other agencies during the year 2010.  According to the GAO report, the DOJ and HHS investigated 10,187 cases of fraud against the Medicare, Medicaid and CHIP programs.  Of these cases, 7,848 involved criminal health care fraud and 2,339 were civil matters.  The cases described in the GAO involved every type of health care provider, located all across the country, and included a broad array of activity.

The GAO report is notable not only for the vast scale of fraudulent activity it documents, but also for the massive amount of government investigatory and prosecutorial resources that have been deployed to combat this activity.

One of the few areas of bipartisan agreement that existing during the policy debates leading up to the passage of the Affordable Care Act (ACA) was the need to reduce fraud, waste and abuse in Medicare and other federal health care programs.  Prior to the passage of the ACA, Congress passed the Fraud Enforcement and Recovery Act (FERA) in 2009.  In addition to many other enforcement tools FERA gave the federal government, the law included hundreds of millions of dollars in appropriations to fund fraud and abuse enforcement.

The developing track record of the HEAT Task Force and recent DOJ and HHS enforcement efforts suggests that these federal appropriations are now translating into action and large recoveries of improper federal health program payments.  With a continuing public appetite for federal deficit control, especially in the arena of health care spending, don’t expect the aggressive fraud and abuse enforcement stance of the DOJ and HHS to relax any time soon.

   

Important Upcoming Oral Argument and Decision for “Trinity on 280”

By Colin Luke
Bradley Arant Boult Cummings

Finally, the residents on the 280 corridor may get some relief and obtain their long-awaited medical center!  

The long-running battle by Brookwood and St. Vincents to stop a competing hospital from relocating to the half completed former HealthSouth Hospital on Highway 280 is in its final chapter. The Alabama Court of Civil Appeals has scheduled oral arguments on October 23 to hear the appeal by the State Health Planning & Development Agency (“SHPDA”) and Trinity Medical Center from Montgomery District Judge’s reversal of SHPDA’s unanimous decision approving this project. This appeal was joined by the Business Council of Alabama, Greystone Residential Association and the Shelby County Economic & Industrial Authority when they filed amicus briefs in support of Trinity and SHPDA’s position.

Trinity’s relocation efforts were approved by Administrative Law Judge James Hampton after the longest certificate of need hearing in Alabama’s history. Trinity received support from over 110 physicians (including many who work at Brookwood and St. Vincents) and numerous business leaders in and around the Birmingham, Jefferson County, and Shelby County areas. Importantly, many residents and emergency medical personnel testified about the dire need for a hospital on the 280 corridor and life-threatening drives down 280 past the proposed Trinity site to other hospitals. Trinity filed its CON application for this project in December of 2008.

Birmingham area contractors and subs are anxiously awaiting approval for this massive construction project which is described by noted economist Keivan Deravi as having the impact of a major automobile plant in the Birmingham area.  Completion of the 60% finished state-of-the art hospital for Trinity’s relocation will keep hundreds of construction workers busy for up to eighteen months. Trinity’s relocation will also cause the construction of a large professional office building next to the new hospital as well as an upscale hotel above the Cahaba Grand conference center.

Brookwood and St. Vincents oppose Trinity’s relocation for competitive reasons and are not confident in their ability to convince patients and physicians to choose Brookwood and St. Vincents after Trinity’s relocation. Brookwood has historically opposed any significant effort by Trinity (formerly Baptist Montclair) to update or relocate its current campus.

The Court of Civil Appeals has expedited its consideration of this important decision and should issue an opinion by the end of the year. 

State May Get Its First Freestanding Emergency Department

By Kelli F. Robinson, Sirote & Permutt, PC

In 2008, Brookwood Medical Center filed a Certificate of Need (CON) Application with the State Health Planning and Development Agency (SHPDA) to build a $19 million, 19,598-square foot freestanding emergency department on U.S. 280 in Shelby County. A freestanding emergency department is a fully functioning emergency department separately located from its hospital. Currently, there are no freestanding emergency departments in Alabama. The freestanding emergency department proposed by Brookwood will be located approximately eight miles from the hospital it owns and operates in Homewood.

Both Trinity and St. Vincent’s Health Systems intervened in opposition to Brookwood’s CON Application.  Trinity and St. Vincent’s requested a contested case hearing, and SHPDA appointed an administrative law judge (ALJ) to conduct the contested case hearing. Trinity moved the ALJ to dismiss Brookwood’s CON Application on the ground that Brookwood had failed to comply with SHPDA’s publication rule. Under SHPDA’s rules in effect at the time Brookwood’s CON Application was filed, an applicant was required to provide to SHPDA, within thirty days of filing the CON Application, proof of publication of notice of the CON Application for two consecutive weeks in a newspaper of general circulation in the areas affected.    

The ALJ denied Trinity’s motion to dismiss Brookwood’s CON Application and a contested case hearing was subsequently held. Following the hearing, the ALJ issued a recommended order concluding that Brookwood should be granted the CON. SHPDA’s CON Review Board adopted the ALJ’s recommended order and issued the CON to Brookwood. Trinity appealed to the Montgomery Circuit Court.

On June 3, 2011, the circuit court ruled that Brookwood committed a “fatal flaw” when it failed to comply with SHPDA’s publication rule and reversed the CON Review Board’s decision to issue Brookwood the CON. Brookwood appealed to the Alabama Court of Civil Appeals.  Trinity filed a cross-appeal, challenging the circuit court’s judgment insofar as it purported to affirm the CON Review Board’s decision “with respect to the merits” of the CON Application.

After hearing oral arguments in July 2012, the Court unanimously decided that Brookwood’s failure to publish notice of the CON Application in a newspaper of general circulation was harmless error. The Court found no indication that Brookwood’s noncompliance with the publication rule had the effect of silencing opposition to the CON Application from any member of the general public. The Court also concluded that Trinity was not prejudiced by Brookwood’s noncompliance because Trinity automatically received notice of Brookwood’s CON Application from SHPDA as an affected party providing similar services in the same area where the project was proposed to be located. 

Hence, the Court reversed the circuit court’s judgment reversing the CON Review Board’s decision to issue Brookwood the CON and remanded the case back to the circuit court for further consideration of Trinity’s appeal from the decision to issue the CON to Brookwood. The court also dismissed the cross-appeal filed by Trinity regarding the statement in the circuit court’s decision indicating that the Brookwood CON Application was valid on its merits. On remand, the circuit court was instructed to enter a judgment regarding the merits of the decision to issue Brookwood the CON. 

On September 12, 2012, the circuit court issued its opinion affirming the CON Review Board’s decision to issue Brookwood the CON which will allow Brookwood to build the first freestanding emergency department in Alabama. Trinity, however, could still appeal the circuit court’s ruling.

In addition, two more freestanding emergency department projects were approved by the CON Review Board on September 19, 2012. CON Applications filed by Princeton Baptist Medical Center and Medical West, an affiliate of UAB Health System, which would allow both hospitals to build freestanding emergency departments in Hoover, were approved despite an ALJ’s recommended order that only Princeton Baptist’s CON Application be approved. Both hospitals have until November 3, 2012, to appeal the rulings of the CON Review Board.

Let's stop heart disease!

By Andrew P. Miller, M.D., FACC, FAHA, FASH

Cardiovascular Associates

3980 Colonnade Parkway

Birmingham, Alabama 35242

Office (205) 510-5000

www.cvapc.com

From a study done across the world, 90% of your risk for a heart attack can be determined by a simple clinic visit and inventorying 6 common risk factors.

These are:

1.     Physical inactivity. Everyone should get 30 minutes of aerobic or symptom-limited activity 5 days a week or 150 minutes per week. If formal exercise is difficult, a pedometer can guage your activity level. The American Heart Association suggests 10,000 steps per day.

2.       Overweight/obesity. You should know where you stand with body mass index. This is your body weight divided by surface are of skin. The correct ratio is 25 or less. A body mass index over 30 qualifies as obese. It is predicted that in Alabama in 2030, 62% of our population will be obese. If you are in this category, a formal dietary intervention is worthwhile (such as weight watchers).

3.     Tobacco use. If you smoke or are around second-hand smoke then you are depleting your heart artery reserves and battering the artery walls with a risk factor that is most likely to take the young, productive members of this world from us. It is important to set a quit date. The number one indicator of whether you will quit is how many times you have tried. You must get smoking out of your environment. Then set a date that is at least 7 days away and not further than a month away and do your best. If you slip, you will have the experience of temporary success and it will be easier next time. Keep working on it.

4.         Hypertension. The ideal blood pressure is 115/75. For every 20 points on top and 10 points on bottom that you go up, your risk of stroke (and heart attack and death) is doubled. When you are over 50, it is the top number that is most important. So, when your blood pressure is 195 on top, your risk of stroke is 16-fold higher. The average number of pills it takes to control blood pressure in the US is 3.2. So, it might take some work, but simple medication for blood pressure might be the most important intervention we have to improve cardiovascular health in Alabama. You should have your blood pressure checked and get it controlled.

5.     High cholesterol. You should have yours tested and often treated with medications if it is high and you have other risk factors on this list or have had a prior heart attack or stroke.

6.     Diabetes. A fasting blood sugar can give you a good guage of your risk for it and diagnose it. Treating it is valuable for preventing heart attack, blindness, and the need for dialysis.

Each of these risk factors doubles or triples your risk for a heart attack. Unfortunately, together they are more potent at causing havoc, such that 3 wrong makes your risk 13-fold higher and 4 wrong makes your risk 42-fold higher.

It really takes a comprehensive strategy for inventorying and then controlling each of these risk factors to prevent heart disease and stroke, and keep you functionally able and independent for as long as possible.