A Doctor’s Vision of the Future of Medicine

It's June 2018. Sally picks up a handheld device and holds it to her finger. With a tiny pinprick, it draws off a fraction of a droplet of blood, makes 2,000 different measurements and sends the data wirelessly to a distant computer for analysis. A few minutes later, Sally gets the results via e-mail, and a copy goes to her physician. All of Sally's organs are fine, and her physician advises her to do another home medical checkup in six months.

This is what the not-so-distant future of medicine will look like. Over the next two decades, medicine will change from its current reactive mode, in which doctors wait for people to get sick, to a mode that is far more preventive and rational. I like to call it P4 medicine—predictive, personalized, preventive and participatory. What's driving this change are powerful new measurement technologies and the so-called systems approach to medicine. Whereas medical researchers in the past studied disease by analyzing the effects of one gene at a time, the systems approach will give them the ability to analyze all your genes at once. The average doctor's office visit today might involve blood work and a few measurements, such as blood pressure and temperature; in the near future physicians will collect billions of bytes of information about each individual—genes, blood proteins, cells and historical data. They will use this data to assess whether your cell's biological information-handling circuits have become perturbed by disease, whether from defective genes, exposure to bad things in the environment or both.

Several emerging technologies are making this holistic, molecular approach to disease possible. Nano-size devices will measure thousands of blood elements, and DNA sequencers will decode individual human genomes rapidly, accurately and inexpensively. New computers will sort through huge amounts of data gathered annually on each individual and boil down this information to clear results about health and disease.

Medicine will begin to get more predictive and personalized (the first two aspects of P4 medicine) over the next five to 10 years. First, doctors will be able to sequence the genome of each patient, which together with other data will yield useful predictions about his or her future health; it will be able to tell you, for example, that you have a 30 percent chance of developing ovarian cancer before age 30. Second, a biannual assessment of your blood will make it possible to get an update on the current state of your health for each of your 50 or so organ systems. These steps will place the focus of medicine on individual patients and on assessing the impact that genes and their interactions with the environment have in determining health or disease.

In preventive medicine (the third P), researchers will use systems medicine to develop drugs that help prevent disease. If, say, you have a 50 percent chance of developing prostate cancer by the time you're 50, you may be able to start taking a drug when you're 30 that would reduce substantially reduce that probability. In the next 10 to 20 years the focus of health care will shift from dealing with disease to maintaining wellness.

Participatory medicine acknowledges the unparalleled opportunities that patients will have to take control of their health care. To participate effectively, though, they will have to be educated as to the basic principles of P4 medicine. New companies that can analyze human genome variation, like 23andMe and Navigenics, are already planning to provide patients with genetic information that may be useful in modifying their behavior to avoid future health problems. In the future, patients will need not just genetic data but insight into how the environment is turning genes on and off to cause disease—just as smoking often causes lung cancer and exposure to sunlight can cause skin cancer.

By Leroy Hood (NEWSWEEK)

Ethical, Legal, and Social Issues in Genetic Testing

Information from genetic testing can affect the lives of individuals and their families. In addition to personal and family issues, genetic disease or susceptibility may have implications for employment and insurance. Therefore, careful consideration in the handling of this information is very important. Critical issues include:

• Privacy - the rights of individuals to maintain privacy. Some genetic tests are required or strongly encouraged for developing fetuses and newborn babies. If an infant is found to be a carrier or likely to develop or be affected by an inherited disease, these findings may affect the future employability or insurability of the individual.

• Informed consent - obtaining permission to do genetic testing. One must have knowledge of the risks, benefits, effectiveness, and alternatives to testing in order to understand the implications of genetic testing.

• Confidentiality - acknowledgment that genetic information is sensitive and access should to limited to those authorized to receive it. Future access to a person's genetic information also should be limited.

The TLC Diet - Lowering Your Cholesterol

There are a number of ways your health care provider can help you to lower your LDL level enough to decrease your risk of developing heart disease or having a heart attack including Therapeutic Lifestyle Changes (TLC) which is a special cholesterol lowering diet that includes physical activity and weight management. 

Some patients may require cholesterol-lowering drug treatment in addition to TLC.

The TLC diet is a low-saturated-fat, low-cholesterol diet that includes less than seven percent of calories from saturated fat and less than 200 mg of dietary cholesterol daily. The number of calories allowed on the TLC diet is individualized based on the number of calories needed to lose weight or maintain weight while avoiding weight gain. Sometimes reducing saturated fats and dietary cholesterol is not enough to lower your LDL enough and increasing the amount of soluble fiber may be necessary. Other foods that contain plant stanols or plant sterols such as cholesterol-lowering margarines and salad dressings can be added to the TLC diet to further help boost the effectiveness of the TLC diet.

Foods low in saturated fats include:

fat free or one percent dairy products
lean meats
fish
poultry with the skin removed
fruits 
vegetables
soft margarines either liquid or in tubs--read the labels to find the ones that are low in saturated fats, as well as ones that contain little or no trans fat

Foods, high in cholesterol, that should be limited include:

liver and other organ meats
egg yolks
full-fat dairy products

Sources of soluble fiber include:

oats
fruits such as oranges and pears
vegetables such as brussel sprouts and carrots
dried peas and beans

High Blood Cholesterol - what you need to know

According to the American Heart Association approximately 102.3 million American adults have total blood cholesterol values of 200 mg/dL and higher, and of these about 41.3 million American adults have levels of 240 or above. In adults, total cholesterol levels of 240 mg/dL or higher are considered high risk, and levels from 200 to 239 mg/dL are considered borderline-high risk.

Cholesterol is important because your blood cholesterol level is a major factor in determining your risk of developing heart disease. The higher your blood cholesterol, the higher your risk of developing heart disease or having a heart attack. Heart disease is the number one cause of death among both women and men in the United States. Every year more than one million U.S. residents have heart attacks and about half of those heart attacks are fatal.

Cholesterol is a waxy, fat-like, substance in your blood that builds up in the walls of the arteries; eventually, this build up of cholesterol causes a narrowing of the arteries and restriction of blood flow to the heart can become slow or blocked. Oxygen is carried through the blood to your heart; if your heart does not receive enough blood or oxygen you may experience chest pain. If there is a complete blockage in your arteries then a heart attack occurs.

If you have high blood cholesterol, you may not be aware of the potential problem since high blood cholesterol alone does not cause symptoms. This lack of symptoms makes it imperative that everyone (recommendations are for those 20 and over) is tested and knows their blood cholesterol numbers. If you have high blood cholesterol, lowering your numbers will significantly reduce your risk of heart disease and heart attack. High cholesterol can affect both males and females of all ages; my teenage son has very high (over 400) cholesterol levels, as well as triglycerides, which is quite scary for a parent.

To find out what your blood cholesterol numbers are you need to have a blood test called a "lipoprotein profile." You must fast for nine to 12 hours before your test. The lipoprotein profile provides information about your:

total cholesterol 

LDL or bad cholesterol -- LDL cholesterol is the primary source of cholesterol build up and blockage in your arteries.
HDL or good cholesterol -- HDL cholesterol helps to keep LDL cholesterol from building up in your arteries.
triglycerides -- Triglycerides are another type of fat in your blood.

Total cholesterol levels that are under 200 mg/dL are the most desirable; blood cholesterol levels from 200 to 239 mg/dL are indicative of borderline high cholesterol; levels of 240 mg/dL and above indicate high blood cholesterol levels.

FYI: Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood. 

What LDL cholesterol category am I in? 

Less than 100 mg/dL = Optimal 
100-129mg/dL = Near optimal/above optimal
130-159 mg/dL = Borderline high
160-189 mg/dL= High
190 mg/dL and above= Very high

The good HDL cholesterol provides protection against heart disease; the higher your HDL number is, the lower your risk of developing heart disease or having a heart attack. However, if your HDL cholesterol number is lower than 40 mg/dL your risk is considerably higher than someone whose HDL is 60 mg/dL or higher.

Heart disease risk also increases in people who have high triglyceride levels. Some people may need treatment for high triglycerides if their level is borderline high (150-199 mg/dL) or high (200 mg/dL or more).

More Than Just Diet - Your Cholesterol Factors

Many factors affect your cholesterol level; some are under your control, while others such as age, gender, and heredity are not. Things that you can control include:Your diet. While saturated fat in your diet is the main source that may cause your blood cholesterol levels to raise, cholesterol in food sources is also important; reducing theses dietary sources of cholesterol can help to lower your blood cholesterol levels.

Your weight. If you are overweight, your risk for heart disease and high blood cholesterol is greatly increased. If you lose weight you can lower your LDL and total cholesterol levels and help to increase your HDL and reduce your triglyceride levels.

Being physically inactive. Another risk factor for heart disease, as well as a contributing factor in being overweight is a lack of regular physical activity. Regular physical activity helps to lower LDL and raise HDL cholesterol. According to a report on a new study of diet and exercise by the National Academy of Sciences, Institute of Medicine one hour of physical activity is now recommended to reduce health risks.Because other factors such as age, gender, and heredity are things you cannot change, controlling your diet, weight, and amount of physical activity are even more important. The fact is that the older we get the higher blood cholesterol levels will rise. Women are particularly susceptible to the age factor since before menopause total cholesterol levels are lower than men of the same age; however, post menopausal women often see an increase in LDL levels. You may also be genetically predisposed to high blood cholesterol levels since high cholesterol can run in families.Your risk for developing heart disease or having a heart attack depends on the number of risk factors you have in addition to high blood cholesterol; generally, the higher your LDL level the higher your risk of developing heart disease or having a heart attack. If you already have heart disease, your risk is significantly higher than someone who does not have heart disease. If you have diabetes, you risk is greater as well. Other major risk factors that have an impact on your LDL levels include:Smoking cigarettes. If you smoke, stop; if you don't smoke, don't start!

High blood pressure. If your blood pressure is 140/90 mmHg or higher or if you are already taking blood pressure medication, you are at increased risk for heart disease or heart attack.

Low HDL cholesterol. HDL levels of less than 40 mg/dL increase your risk; while HDL levels of 60o mg/dL or higher do not increase your risk of heart disease or heart attack.

Family history. If your family history includes heart disease in your father or brother before age 55 or heart disease in mother or sister before age 65, your risk is increased.

Age. Men who are 45 and older and women who are 55 and older face significant risk of developing heart disease or heart attack if their cholesterol levels are high.Although being overweight and/or physically inactive are not included in this list they are factors which must be considered and corrected.