Making Breakfast a Priority to Fight Serious Health Issues

The traditional bacon-egg-toast breakfast may not be so bad for you after all. It’s just possible that increasing the fat in the first meal of the day may prevent metabolic syndrome, a cluster of risk factors that occur together, which can increase your tendency to develop coronary artery disease, stroke, and type 2 diabetes.

"Studies have looked at the type and quantity of food intake, but nobody has undertaken the question of whether the timing of what you eat and when you eat it influences body weight, even though we know sleep and altered circadian rhythms influence body weight," according to lead author Molly Bray Ph.D.

Researchers at the University of Alabama at Birmingham examined the timing of different foods in contributing to metabolic syndrome in mice. The results, being published online today in the International Journal of Obesity, showed that mice starting the day with a high fat meal and ending the day with a low-fat meal had normal metabolic profiles, while those reversing meals had an increase in weight, glucose intolerance and several other factors present in metabolic syndrome.

Precursors to metabolic syndrome, which affects over 50 million Americans, are tubby tummy (excess belly fat) and insulin resistance. High cholesterol, high blood pressure, and high triglycerides are also factors in the disease.

“The first meal you have appears to program your metabolism for the rest of the day,” Dr. Bray said. “(Having) a fat-rich breakfast, you have metabolic plasticity to transfer your energy utilization between carbohydrates and fat.”

Overall, the mice were fed the same amount of calories, just in different combinations. The end result being that the timing of your dietary intake is just as important as the quality and quantity. What this means is that swapping out the higher fat proteins from dinner to breakfast might be a better option. Having that piece of ham, a couple of sausage or bacon strips with an egg or two in the morning, along with a whole grain pasta and veggies at night could keep your waist from expanding and stave off serious health problems associated with metabolic syndrome.

Obese Children as Young as Three Show Signs of Future Heart Disease

Being at risk for developing heart disease or having a stroke was once something only adults had to worry about. But now children are being added to the meld, many of them as young as three years old. In fact, a recent study found that about twice as many obese 3-to-5-year old children had elevated levels of C-reactive protein (CRP)—an inflammatory marker that experts say has been shown to predict the risk of heart disease, stroke and death under certain conditions—compared to those at healthy weights. And that difference grew to more than four times the frequency in teenagers from 15 to 17 years old.

The study, conducted by researchers from the University of North Carolina, involved 16,000 children and adolescents aged 1 to 17; nearly 70 percent of which were a healthy weight, 15 percent were overweight, 11 percent were obese, and 3.5 percent were severely obese. Overall, 40 percent of obese children aged 3-5 had increased levels of CRP, compared with 17 percent of those at healthy weights. By age 15-17, 83 percent of the severely obese had increased levels of CRP, compared with 18 percent of the healthy weight adolescents.  

High levels of CRP are an indication of inflammation in the body. Because the damage seen in heart disease is caused by inflammation in arterial walls, it follows that CRP could be used as a general marker for the risk of heart disease. Previous studies have linked high levels of CRP in overweight and obese adults with an increased risk of heart disease, but less has been known about CRP levels in children. “We’re seeing a relationship between weight status and elevated inflammatory markers much earlier than we expected,” said study lead Dr. Asheley Cockrell Skinner, an assistant professor of pediatrics at the UNC School of Medicine.  

The researchers observed a similar pattern of elevation when they check two other inflammation markers, although one wasn’t elevated in obese children under six. Levels of one were higher in obese children from the age of six and the other from age nine. “In this study we were unable to tease apart whether the inflammation or the obesity came first but one theory is that obesity leads to inflammation, which then leads to heart and vessel disease later on,” said study co-author Dr. Eliana Perrin, who is with the Department of Pediatrics at the University of North Carolina Medical School. “A lot more work needs to be done before we figure out the full implication of these findings, but this study tells us that very young, obese children already have more inflammation than children who are not obese—and that’s very concerning.”

The concern of finding elevated CRP in such young children is that its effects could be cumulative. Dr. Skinner says future research is needed to see if that is the case and whether losing weight could reduce the inflammatory response in children. “It’s really important to be concerned about childhood obesity and to even be concerned when they are quite young,” she said. “We can’t wait until they’re adolescents or adults.”

In the U.S., 14 percent of 2-to-5-year-olds are considered overweight or obese. There are no medications to treat these young children. The only way to help them overcome obesity is to increase their activity and change the type of food that the entire family eats. Dr. Stephen Daniels, professor of pediatrics and environmental health at Cincinnati Children’s Hospital Medical Center, recommends at least an hour of active play each day for children 3 to 4 years old, along with a healthy diet that includes five fruits and vegetables. He notes that toddler-hood is “a time when dietary patterns may become more like those of adults, and also when many children develop physical activity patterns both good and bad.”

The study was funded by the National Institutes of Health and published in the journal Pediatrics.

A Little Less Salt In Your Diet Could Improve Health and Preserve Life

Although everyone needs a healthy amount of salt intake, consuming too much can be deadly. Salt is critical to life, as it helps to maintain the water content in our blood, balances the blood’s acids and bases, and is essential for the movement of electrical charges in the nerves that move our muscles. However, the consumption of too much salt can lead to high blood pressure and heart disease. In addition, a diet high in salt content is often associated with weight gain.

According to results of a new analysis performed by Dr. Kirsten Bibbins-Domingo of the University of California, San Francisco and colleagues, a reduction in salt consumption would be a very healthy move for Americans. If the U.S. population decreased its daily salt intake by just one-half teaspoon, the health benefits would be almost equivalent to a substantial decrease in obesity rates, the prevention of heart attacks through treating practically everyone with cholesterol drugs, and a smoking reduction in the amount of 50 percent.

Individuals who choose to avoid high-calorie, low-fiber, and processed foods, such as those found in fast food restaurant meals and on supermarket shelves, can achieve a healthy level of salt intake. A low-salt diet is one that normally consists of the lower calorie, healthier foods associated with weight loss. For some helpful and healthful diet information, check out the HealthNews diet reviews.

In the report on the latest analysis that was published in the New England Journal of Medicine, the researchers stated that cutting salt consumption by a small amount is an easily attainable goal that would prevent between 11,000 and 23,000 strokes, 18,000 to 35,000 heart attacks, and from 15,000 to 32,000 deaths resulting from any cause. On the average, American men consume 10.4 grams of salt, while American women average a salt intake of 7.3 grams daily. These numbers continue to rise, with 75 to 80 percent of all salt consumed coming from processed food. The researchers wrote, “Even if the federal government were to bear the entire cost of a regulatory program designed to reduce salt consumption, the government would still be expected to realize cost savings for Medicare, saving $6 to $12 in health expenditures for each dollar spent on the regulatory program.”

The study used a computerized model to analyze data from prior studies to determine an estimation of the blood pressure-lowering benefits associated with a decrease in salt consumption, and the impact of lower blood pressure on the reduction of heart disease, stroke and heart attacks. Findings revealed a benefit for everyone who consumed less salt, however, the greatest benefit was found among people having a high risk for heart problems, including blacks, people suffering from hypertension, and seniors over the age of 65.

A panel appointed by the independent research arm of the National Academies of Science, known as the Institute of Medicine, is expected to issue a report making recommendations as to actions that can be taken by the government as well as manufacturers for reducing the intake of salt. In addition, Dr. Bibbins-Domingo said the U.S. Food and Drug Administration deliberating as to whether or not to re-categorize salt, currently designated as a safe food additive, to one that would require product labeling that would warn consumers about high levels of salt contained in food. Dr. Bibbins-Domingo also said that California is contemplating placing restrictions on salt content of food purchased by the state for public institutions, such as schools and prisons.

Alcohol's Hidden Effects Revealed In New NHS Campaign

A new 6 million pound NHS campaign to reveal alcohol's hidden effects warns people of the unseen damage caused by regularly drinking more than the advised limits and highlights drinkers' affected organs while they sup their drink in the pub or at home.

The campaign was launched recently by Public Health Minister, Gillian Merron. It forms part of a government-wide strategy to tackle the harmful effects of alcohol and is backed by major health charities.

Merron said in a press statement that:

"Many of us enjoy a drink - drinking sensibly isn't a problem." But, she warned that:

"If you're regularly drinking more than the NHS recommended limits, you're more likely to get cancer, have a stroke or have a heart attack."

The Department of Health developed the campaign with Cancer Research UK, the British Heart Foundation and the Stroke Association. Part of it entails showing a series of strong messages on TV, in the press and outdoor posters, showing how much harm drinking more than the NHS advised daily limit can do to your body.

In the TV campaign, one advert of three men drinking in a pub, shows one of them with a semi-transparent body, and as he sups his beer, different organs are highlighted to show which parts the narrator, who is explaining the risks of drinking alcohol, is talking about (for example, when high blood pressure is mentioned, the heart becomes more visible).

The NHS advises that women should drink no more than 2 to 3 units of alcohol a day (about 2 small glasses of wine) and men should drink no more than 3 to 4 a day(about two pints of lager).

In the UK, a unit of alcohol is 10 millilitres of ethanol (ethyl alcohol) and the strength of an alcoholic drink (the amount of ethyl alcohol it contains) is shown in percentage ABV (alcohol by volume). So every increase of 1% ABV adds another unit of alcohol to a litre: one litre of a drink of 1% ABV contains one unit of alcohol, one litre of 2% per cent ABV drink is 2 units, one litre of 3% ABV is 3 units, and so on.

However, most alcoholic drinks are stronger than 1 or 2% ABV and you don't have to drink a litre to consume several units. For instance, one pint (just over half a litre) of beer at 4% ABV contains 2.3 units, and half a 0.75 litre bottle of wine at 13% ABV contains 4.9 units.

A recent YouGov poll of more than 2,000 adults showed that more than half (55 per cent) of drinkers in England mistakenly believe that alcohol only does harm if you regularly binge or get drunk.

The survey also revealed that 83 per cent of adults who drank more than the NHS advised daily limit don't believe their drinking is putting their long- term health at risk.

This suggests that 8.3 of the 10 million adults in England who regularly drink above the recommended limit are probably unaware of how much damage their drinking is doing to their bodies, said the NHS.

Although the vast majority of those surveyed realised that alcohol consumption is linked to liver disease, few realised it is also linked to throat cancer, mouth cancer, breast cancer, stroke and heart disease.

This is in spite of evidence from research that shows, for example:

    * A man who regularly drinks more than two pints of lager a day is three times more likely to have a stroke or mouth cancer.
    * A woman who regularly drinks more than two glasses of wine a day is 50 per cent more likely to get breast cancer, and twice as likely to have high blood pressure (which could lead to a heart attack).

According to figures from the Department of Health, over 9,000 people in the UK die from alcohol-related causes every year. Estimates from the World Health Organization (WHO) suggest that 20 per cent of alcohol-related deaths are from cancer, 15 per cent are from cardiovascular conditions like heart disease and stroke, and 13 per cent are from liver disease.

Chief Medical Officer for England, Professor Sir Liam Donaldson, said that it was important for people to "realise the harm they, unknowingly, can cause to their health by regularly drinking more than the recommended daily limits."

"This campaign gives people the facts about the effect alcohol can have on their body and provides support for people who choose to drink less," he added.

Director of Communications for The Stroke Association, Joe Korner, said:

"We are pleased to be involved in this campaign because it alerts people to the long term health risks of regular heavy drinking."

Korner said that stroke is the biggest cause of severe disability in adults and affects about 150,000 people every year in the UK, so it is vital that people understand that regularly drinking above the recommended daily limit means they are more likely to have high blood pressure, the single biggest risk factor for stroke.

The British Heart Foundation's Associate Medical Director, Dr Mike Knapton, urged that while there is some evidence that sensible drinking in moderation appears to offer some protection against heart disease, this should not be seen as a reason to take up drinking:

"There are better ways to protect yourself from heart disease," he said.

"The evidence is clear, regularly drinking above the recommended daily limits harms the heart as well as causing a host of other harmful effects," said Knapton.

Sara Hiom, director of health information for Cancer Research UK said that decades of research has shown that alcohol can raise the risk of several cancers, including cancer of the bowel, breast, liver, mouth, foodpipe (oesophagus), voicebox (larynx) and throat.

"Our bodies convert alcohol into a toxic chemical called acetaldehyde which can lead to cancer by damaging DNA and stopping our cells from repairing this damage," explained Hiom, adding that another side effect of alcohol consumption is raised levels of estrogen which increases the risk of breast cancer.

"The simple message is that the more you drink the greater your cancer risk but the more you cut down the more you reduce that risk," said Hiom.

Electronic Prescriptions Reduce Errors By Seven-Fold

Should doctors around the country use e-prescribing to decrease prescription errors? A study led by physician-scientists from Weill Cornell Medical College found that health care providers using an electronic system to write prescriptions were seven times less likely to make errors than those writing their prescriptions by hand. The study appears today in the online edition of the Journal of General Internal Medicine.

There is currently a strong push in the United States to encourage doctors to write electronic prescriptions in the ambulatory setting, where an estimated 2.6 billion drugs are provided, prescribed or continued. According to the study's authors, demonstrating improvements in safety with electronic prescribing is important to encourage its use, especially among community providers in solo and small group practices who mostly write prescriptions by hand.

"We found nearly two in five handwritten prescriptions in these community practices had errors," says Dr. Rainu Kaushal, the study's lead author and associate professor of pediatrics, medicine and public health, and chief of the Division of Quality and Medical Informatics at Weill Cornell Medical College. "Examples of the types of errors we found included incomplete directions and prescribing a medication but omitting the quantity. A small number of errors were more serious, such as prescribing incorrect dosages."

"Although most of the errors we found would not cause serious harm to patients, they could result in callbacks from pharmacies and loss of time for doctors, patients and pharmacists," says senior author Dr. Erika Abramson, assistant professor of pediatrics at Weill Cornell Medical College and a pediatrician at the Komansky Center for Children's Health at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. "On the plus side, we found that by writing prescriptions electronically, doctors can dramatically reduce these errors and therefore these inefficiencies."

"At a time when the federal government and many state governments, led by New York state, are pushing for increased use of information technology to improve the delivery of health care, it is important that physicians are aware of how technology like electronic prescribing systems can improve the safety and value of care they give patients," says Dr. Kaushal, who is also director of pediatric quality and safety for the Komansky Center for Children's Health at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. "It is also important that electronic prescribing systems are easy for health care providers to use, fit well into their workflow, and that providers have technical assistance to help them install and maintain these systems."

To evaluate the effects of e-prescribing on medication safety, researchers looked at prescriptions written by health care providers at 12 community practices in the Hudson Valley region of New York. The authors compared the number and severity of prescription errors between 15 health care providers who adopted e-prescribing and 15 who continued to write prescriptions by hand.

The providers who adopted e-prescribing used a commercial, stand-alone system that provides dosing recommendations and checks for drug-allergy interactions, drug-drug interactions and duplicate drugs. All the practices that adopted e-prescribing received technical assistance from MedAllies, a health information technology service provider. The study noted that, without extensive technical support, it is difficult for physician practices to achieve high rates of use of electronic prescribing and subsequent improvements in medication safety.

In total, the authors reviewed 3,684 paper-based prescriptions at the start of the study and 3,848 paper-based and electronic prescriptions written one year later. After one year, the percentage of errors dropped from 42.5 percent to 6.6 percent for the providers using the electronic system. For those writing prescriptions by hand, the percentage of errors increased slightly from 37.3 percent to 38.4 percent. Illegibility problems were completely eliminated by e-prescribing.

Additional co-authors were Drs. Lisa Kern (assistant professor of public health and medicine at Weill Cornell Medical College and a physician at NewYork-Presbyterian Hospital/Weill Cornell Medical Center), Yolanda Barrón (research associate in biostatistics at Weill Cornell Medical College), and Jill Quaresimo, R.N., J.D., of Taconic IPA, Fishkill, N.Y. The study was supported by funding from the Agency for Healthcare Research and Quality.

Source
Weill Cornell Medical College

The Mathematics Behind A Good Night's Sleep

Why can't I fall asleep? Will this new medication keep me up all night? Can I sleep off this cold? Despite decades of research, answers to these basic questions about one of our most essential bodily functions remain exceptionally difficult to answer. In fact, researchers still don't fully understand why we even sleep at all. In an effort to better understand the sleep-wake cycle and how it can go awry, researchers at Rensselaer Polytechnic Institute are taking a different approach than the traditional brain scans and sleep studies. They are using mathematics.

Professor of Mathematics Mark Holmes and his graduate student Lisa Rogers are using math to develop a new computer model that can be easily manipulated by other scientists and doctors to predict how different environmental, medical, or physical changes to a person's body will affect their sleep. Their model will also provide clues to the most basic dynamics of the sleep-wake cycle.

"We wanted to create a very interdisciplinary tool to understand the sleep-wake cycle," Holmes said. "We based the model on the best and most recent biological findings developed by neurobiologists on the various phases of the cycle and built our mathematical equations from that foundation. This has created a model that is both mathematically and biologically accurate and useful to a variety of scientists.

"This is also an important example of how applied mathematics can be used to solve real issues in science and medicine," Holmes continued.

To create the model, the researchers literally rolled up their sleeves and took to the laboratory before they put pencil to paper on the mathematical equations. Rogers spent last summer with neurobiologists at Harvard Medical School to learn about the biology of the brain. She investigated the role of specific neurotransmitters within the brain at various points in the sleep-wake cycle. The work taught the budding mathematician how to read EEG (electroencephalography) and EMG (electromyography) data on the brainwaves and muscle activity that occur during the sleep cycle. This biologic data would form the foundation of their mathematic calculations.

This research foundation allowed the team to develop a massive 11-equation model of the sleep-wake cycle. They are now working to input those differential equations into an easy-to-use graphic computer model for biologists and doctors to study.

"We have developed a model that can serve other researchers as a benchmark of the ideal, healthy sleep-wake cycle," Holmes said. "Scientists will be able to take this ideal model and predict how different disturbances such as caffeine or jet lag will impact that ideal cycle. This is a very non-invasive way to study the brain and sleep that will provide important clues on how to overcome these disturbances and allow patients to have better and more undisturbed sleep."

Rogers will continue her work on the program after receiving her doctoral degree in applied mathematics from Rensselaer this spring. Her work on the mathematics of the sleep-wake cycle has already garnered attention within the scientific community, earning her a postdoctoral research fellowship from the National Science Foundation (NSF). With the fellowship, Rogers will continue her work at New York University and begin to incorporate other aspects of the sleep-wake cycle in the model such as the impacts of circadian rhythms.

Source:
Gabrielle DeMarco
Rensselaer Polytechnic Institute

Cognitive Behavioral Therapy: Beneficial And Low Cost Treatment For Back Pain

 group cognitive behavioral therapy (CBT) can reduce low-back pain at a low cost to the health-care provider. Furthermore, one year after the start of treatment, the improvement was sustained.

Ranked as one of the top three most disabling conditions in the developed World, persistent low-back pain is increasingly common. It can be very debilitating. Because it is so widespread, back pain is also costly to treat.

A randomized controlled trial was undertaken by Professor Sarah E Lamb, at the Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK, and colleagues. It included a total of 701 patients with troublesome subacute or chronic low-back pain from general practices across England. The researchers aimed to determine whether group cognitive behavioral therapy would offer any added benefit to best practice advice in primary care. This advice included recommendations on staying active and correct use of pain medication.

The patients were then randomly assigned to two groups:
• 468 participants were given up to six sessions of group CBT
• 233 controls were given no additional treatment

In each group, 85 percent of participants completed the study. Primary outcomes were the change at one year from baseline in Roland Morris disability questionnaire and modified Von Korff scores. Both are tools to measure pain and disability.

After one year, results indicate that CBT had significantly improved both disability scores. The change from baseline in the Roland Morris questionnaire was 2.4 points in the CBT group compared with 1.1 points in controls. The Von Korff score changed by 13.8 percent in the CBT group and 5.4 percent in controls. Importantly, the treatment was cost-effective. The cost per quality-adjusted life-year was about half that of competing treatments such as acupuncture.

The authors comment: "Effective treatments that result in sustained improvements in low-back pain are elusive. This trial shows that a bespoke cognitive behavioural intervention package, BeST, is effective in managing subacute and chronic low-back pain in primary care. The short-term effects (4 months) are similar to those seen in high-quality studies and systematic reviews of manipulation, exercise, acupuncture, and postural approaches in primary care."

Because the participants were representative of the ethnic mix of the UK and came from a mix of rural and urban areas, the authors consider that the treatment could have a broad applicability. They also observe that 95 percent of the CBT session time was intended towards achieving psychological goals rather than on supervised exercise.

They write in conclusion: "A bespoke cognitive behavioural intervention package for low-back pain has an important and sustained effect at 1 year on disability from low-back pain at a low cost to the health-care provider."

In an associated note, Dr Laxmaiah Manchikanti, Pain Management Center of Paducah, Paducah, KY, USA, comments that Lamb and colleagues' study "showed rather impressive results."

Manchikanti warns about the routine availability of group CBT for low-back pain in primary care. It "might be feasible in countries with national health-care systems, but not in a country like the USA."

He says in closing that "the results suggest that cognitive behavioural therapy is an excellent option for primary care physicians before they seek specialty consultations for their patients."

Researchers: Most `test tube' kids are healthy

More than 30 years after the world greeted its first "test-tube" baby with a mixture of awe, elation and concern, researchers say they are finding only a few medical differences between these children and kids conceived in the traditional way.

More than 3 million children have been born worldwide as a result of what is called assisted reproductive technology, and injecting sperm into the egg outside the human body now accounts for about 4 percent of live births, researchers reported Sunday at the annual meeting of the American Association for the Advancement of Science.

The majority of assisted reproduction children are healthy and normal, according to researchers who have studied them. Some of these children do face an increased risk of birth defects, such as neural tube defects, and of low birth weight, which is associated with obesity, hypertension and Type 2 diabetes later in life, the researchers said.

"Overall, these children do well," said Andre Van Steirteghem of the Brussels Free University Center for Reproductive Medicine in Belgium. "It is a reassuring message, but we must continue to follow up."

Carmen Sapienza, a geneticist at Temple University School of Medicine in Philadelphia, noted that few of these test tube children are older than 30, so it's not known if they will be obese or have hypertension or other health problems at age 50 or older.

Sapienza said researchers found differences in 5 percent to 10 percent of chromosome activity levels between assisted reproduction children and other kids.

What's not clear is whether these differences result in some way from assisted reproduction techniques or if they stem from other factors, perhaps ones that caused the couple's infertility in the first place.

Only a small fraction of the assisted reproduction children were outside the normal range of gene expression, Sapienza reported. "However, because some of the genes found to be affected are involved in the development of fat tissue and the metabolism of glucose, it will be interesting to monitor these children, long term to determine whether they have higher rates of obesity or diabetes."

"There are genetic causes of infertility that you can bypass now," Van Steirteghem said. "But this may mean that the next generation will be infertile, and that is something that all clinics should mention."

One factor in low birth weight may be that in many cases assisted fertility results in multiple births, which tend to be early and of lower weight.

"We must reduce the epidemic of multiple births," Van Steirteghem said, noting that in Sweden the rate had been cut from around 30 percent in the early 1990s to about 5 percent today.

In the United States, the Society for Assisted Reproductive Technology reported that the use of single-embryo transfers is increasing, and the frequency of triplet births is down to below 2 percent.

Sapienza noted that women seeking assisted reproduction tend to be older than those who conceive naturally, but said that had been controlled for in the studies comparing the two groups of children.

Dolores J. Lamb of the Baylor College of Medicine in Houston urged more testing of males for the reason for infertility.

"There are correctable causes of male infertility and a couple can then have children the natural way," she said. Also, infertility can be the first symptom of diseases such as testicular cancer, Lamb said.

As of 2008, the most recent data available, the United States reported that 361 clinics did 140,795 treatment cycles leading to the birth of 56,790 babies.

H1N1: Pandemic was emotional as well as physical

Last spring, U.S. doctors' offices were barraged with phone calls and worried patients packed into hospitals. Schools closed. Face masks and Tamiflu were suddenly in short supply. The country verged on an H1N1 panic.

The new flu virus, first widely reported in Mexico, was infecting the young and healthy, rather than those usually most at risk, the elderly and infirm. Beginning in April 2009, H1N1 flu fanned across the globe. The World Health Organization declared it a global pandemic in June.

Hand sanitizer was suddenly seen everywhere, and, heeding the often-repeated advice of top U.S. health officials, many people began coughing into their shoulders or elbows rather than covering their mouths with their hands.

"My patients were so anxious," recalled Dr. Danielle Ofri, an internist at Bellevue Hospital in New York. "They were so agitated. They wanted to know about that swine flu vaccine and when they're going to get it.

"It was another variation of the flu. Yet for our patients, it seemed so different, so unusual, so scary -- that the emotions took off well out of proportion of the disease."

The toll, while devastating to the families of those who died of H1N1, has not matched early projections of as many as 90,000 flu-related fatalities in the U.S.

H1N1 may have killed as many as 17,000 Americans, according to the Centers for Disease Control and Prevention. In an average year, about 36,000 people die from seasonal flu-related causes, according to the CDC.

Today, the visible signs of fear have ebbed. Many vaccination clinics report low turnout and have cut back their hours, according to local news reports. A recent health poll by the Harvard School of Public Health reported that nearly half of those surveyed believed the outbreak was over.

On Tuesday, a committee of the World Health Organization is scheduled to convene to review the H1N1 situation and possibly begin the process of officially downgrading the pandemic.

However, Dr. Keiji Fukuda, the special adviser on pandemic influenza to the director-general of the WHO, warned the change does not mean H1N1 is no longer a concern.

"The ending of a pandemic is not an on-and-off phenomenon," he said at a press briefing last week. "We really expected it to be more of a tailing-off phenomenon."

Although it seems that H1N1 has receded from the public consciousness, Fukuda said, "It is expected that it will continue to be a significant virus, circulating around the world as we head into the winter or the coming winter in 2010 and 2011."

Last week, the WHO recommended that the pandemic H1N1 influenza strain be included in the flu vaccine for the coming fall and winter. A Food and Drug Administration committee took similar steps Monday, which means there will not be a separate H1N1 vaccine this fall.

Paging Dr. Gupta blog: 2009 H1N1 flu strain will be in next season flu vaccine

Although some people may think that including H1N1 in the regular seasonal vaccine is a sign that it's a reduced threat, Dr. Michael Osterholm, director of the University of Minnesota's Center for Infectious Disease Research and Policy, said the risks should not be discounted.

"I don't think there is any reason to minimize what's yet ahead, just because it's in the seasonal flu vaccine.

"This virus does do damage differently than seasonal flu," Osterholm said. "We're talking about a disease that causes severe disease and deaths in a much younger population where you don't expect to see that."

Public health agencies have been criticized for sounding alarmist about H1N1. But Ira Longini, a professor of biostatistics at the University of Washington School of Public Health and Community Medicine, said not much was known in the spring of 2009 when the virus began sickening and killing people.

"It is difficult when you're dealing with a potentially extremely dangerous virus," said Longini. "You err on the side of caution. It could've been really bad -- it wasn't. It's much better than not reacting and having a public health disaster."

Initially, H1N1 elicited an extraordinary response, described as an emotional epidemiology by Bellevue's Ofri, who is also an associate professor at the New York University School of Medicine and author of "Medicine in Translation."

"The diseases themselves have their own epidemiology, related to biological environmental factors," she said. "Our perception of illness runs its own independent course from the actual epidemiology of an illness. H1N1 is a perfect example."

One reason that the pandemic struck a chord was that it fit an "outbreak narrative." These types of diseases often originate from developing countries and spread throughout the world.

"It feels like the world is being overtaken," she said. "Ebola, HIV, SARS were examples of how the pattern of disease development fit this narrative arc and struck our emotion."

Nowadays, she said, her patients barely mention swine flu.

"Once this was out of headlines, once the drama of the narrative arc is gone, it's no longer this unknown, evil, dark illness," she said. "Now it's kind of mundane, prosaic and so it doesn't make an interesting movie any longer. So it doesn't concern people anymore."

That's reflected in comments from Christopher Gower, an iReport contributor who lives in Henderson, Kentucky.

"I think it was overblown, " he said of H1N1. "They scared the public pretty bad."

Gower didn't get the vaccine, because he distrusts drug companies and fears side effects. He considered H1N1 just like a seasonal flu.

Watch Gower's iReport submission.

But for Egberto Williams, H1N1 posed an imminent danger for his family.

His wife has lupus, an autoimmune disorder.

"It was extremely frightening," said Williams, who lives in Kingwood, Texas. "I usually don't get scared but this hit home because you could see the reality of young people dying from getting something that looked like a cold. When it came to my wife, it was affecting people who are immunosuppressed. She was flying blind."

Watch Williams' iReport submission

His wife was able to get the vaccine early.

And advances in public health enabled fast, effective response, said Longini, the biostatistician.

"Through surveillance and modern microbiology and disease control methods, we've learned, we're able to react quite quickly," he said. "We know a lot, we're able to deal with threats if we're organized quite well."

Body dysmorphic disorder patients see details, not whole face

Some people check their appearance in any mirror, window or computer screen they can find, but not out of vanity. It's because they hate the way they look so much.

An obsession with one or more bodily features, normally in the face, indicates a condition called body dysmorphic disorder. This mental illness, which leads some patients to seek multiple plastic surgeries, is not uncommon; 1 to 2 percent of the population is thought to have it. But most people who have the disorder don't get a diagnosis; they just think they are ugly, said Dr. Jamie Feusner psychiatrist at the University of California, Los Angeles.

Some celebrities have BDD, but few have been public about it, Feusner said. He and colleagues have treated celebrities at UCLA, but cannot disclose which ones.

"Everyone else would consider them attractive -- they don't consider themselves attractive," he said.

It turns out that people with this condition have abnormal brain function when it comes to looking at pictures of their own faces, according to a new study led by Feusner and published in the Archives of General Psychiatry.

When viewing themselves in photographs, patients with BDD underutilize parts of the brain used in seeing the face's overall shape and size, he said.

"If you just see the pieces of your face, and not seeing how they fit into the whole, then it's going to look distorted," he said. "That's how we interpret the findings."

Researchers used functional magnetic resonance imaging to look at the brains of participants as they viewed photographs of their own faces and familiar faces. Subjects viewed pictures that were high spatial resolution (showing details such as skin blemishes), and low spatial resolution (showing the general shape of the face), and unaltered.

The findings showed that when the BDD patients viewed normal and low-resolution photos of themselves, they had abnormal brain activity in visual processing systems. Also, the part of the brain that helps guide behavior and maintain emotional flexibility, the frontostriatal systems, had unusual activation patterns.

"What we think may be happening is that they may be seeing details, perhaps even seeing details normally, but that they're not able to contextualize it," he said.

Although the sample size is small -- 17 patients with BDD and 16 healthy people participated -- for a functional imaging study a 32-person subject group is reasonable, experts say.

The study is "groundbreaking" in its demonstration that patients with BDD are too focused on the details aren't able to see the whole picture when they see themselves, said Sabine Wilhelm, director of the BDD Clinic and Research Unit at Massachusetts General Hospital, who was not involved in the study. This can be observed anecdotally in treatment, but this study confirms it at the level of brain processing, she said.

Feusner's previous research found that when BDD patients viewed the faces of other people -- not their own faces -- the brain's left hemisphere, associated with categorization and details, was more more active. Healthy individuals used the right hemisphere, the part of brain that processes more holistically.

It is too early to directly apply the findings to treatment, but one possibility is that patients with BDD could be retrained to see their own faces, he said.

Treatments available today for BDD include medications called selective serotonin reuptake inhibitors, also used for depression and anxiety disorders, and cognitive behavioral therapy, Wilhelm said. She also sees implications for treatment in the study's findings.

"What we need to do in cognitive behavioral therapy treatment development is to really enhance efforts at teaching patients how to see the big picture," she said.

Many people with BDD will try to have what they perceive as flaws -- pimples, scars, birthmarks, or other features -- surgically or dermatologically removed. But plastic surgery almost never fixes their unhappiness about their appearance: 81 percent are dissatisfied with results of cosmetic treatments, Wilhelm said.

"The problem is really on the inside, it's not what they really look like," Wilhelm said.

Besides seeking surgeries, other symptoms include frequent camouflage with makeup, compulsive picking of skin, and asking for reassurance from others, she said. People with BDD may also check their reflection to the point of endangering themselves while driving while looking at themselves in the rearview mirror, she said.

The likelihood of attempting suicide or being hospitalized is high among BDD patients. Not enough research has been done on the subject to determine whether BDD is the results of genes, environment, or some combination thereof. It is unclear which of these pathways led to the brain abnormalities found in the study, Feusner said.

Some brain patterns seen in BDD are also associated with obsessive compulsive disorder, although BDD is probably not a form of it, Feusner said. People with OCD tend to recognize that their fears and behaviors are excessive, whereas BDD patients are more delusional and are convinced that the ugliness they perceive in themselves in real.

BDD is also different than eating disorders because it is purely about an imagined appearance and not eating habits, Wilhelm said.

But Feusner does suspect a connection between BDD and anorexia, and his next project is a brain imaging study comparing patients with the two conditions. If you are interested in participating in this study,