Alcohol use biggest risk factor for dementia a study says

-By Centre for Addiction and Mental Health

Alcohol use disorders are the most important preventable risk factors for the onset of all types of dementia, especially early-onset dementia. This according to a nationwide observational study, published in The Lancet Public Health journal, of over one million adults diagnosed with dementia in France.

This study looked specifically at the effect of alcohol use disorders, and included people who had been diagnosed with mental and behavioural disorders or chronic diseases that were attributable to chronic harmful use of alcohol.

Of the 57,000 cases of early-onset dementia (before the age of 65), the majority (57%) were related to chronic heavy drinking.

The World Health Organization (WHO) defines chronic heavy drinking as consuming more than 60 grams pure alcohol on average per day for men (4-5 Canadian standard drinks) and 40 grams (about 3 standard drinks) per day for women.

As a result of the strong association found in this study, the authors suggest that screening, brief interventions for heavy drinking, and treatment for alcohol use disorders should be implemented to reduce the alcohol-attributable burden of dementia.

"The findings indicate that heavy drinking and alcohol use disorders are the most important risk factors for dementia, and especially important for those types of dementia which start before age 65, and which lead to premature deaths," says study co-author and Director of the CAMH Institute for Mental Health Policy Research Dr. Jürgen Rehm. "Alcohol-induced brain damage and dementia are preventable, and known-effective preventive and policy measures can make a dent into premature dementia deaths."

Dr. Rehm points out that on average, alcohol use disorders shorten life expectancy by more than 20 years, and dementia is one of the leading causes of death for these people.

For early-onset dementia, there was a significant gender split. While the overall majority of dementia patients were women, almost two-thirds of all early-onset dementia patients (64.9%) were men.

Alcohol use disorders were also associated with all other independent risk factors for dementia onset, such as tobacco smoking, high blood pressure, diabetes, lower education, depression, and hearing loss, among modifiable risk factors. It suggests that alcohol use disorders may contribute in many ways to the risk of dementia.

"As a geriatric psychiatrist, I frequently see the effects of alcohol use disorder on dementia, when unfortunately alcohol treatment interventions may be too late to improve cognition," says CAMH Vice-President of Research Dr. Bruce Pollock. "Screening for and reduction of problem drinking, and treatment for alcohol use disorders need to start much earlier in primary care." The authors also noted that only the most severe cases of alcohol use disorder -- ones involving hospitalization -- were included in the study. This could mean that, because of ongoing stigma regarding the reporting of alcohol-use disorders, the association between chronic heavy drinking and dementia may be even stronger.

Why Studying Gun Violence Matters

-By SHEILA KAPLAN - NYT

Federal officials and lawmakers debate whether to relax restrictions, backed by the National Rifle Association, on governmental research into gun violence. Credit Cengiz Yar, Jr./Agence France-Press — Getty Images

Guns in the home protect families.

For decades, that has been an essential part of the National Rifle Association’s mantra in defending firearms ownership, repeated at congressional hearings, in advertisements and on T-shirts.

Dr. Mark Rosenberg, who once headed research on firearm violence at the Centers for Disease Control and Prevention, wondered if there was any evidence backing the N.R.A.’s assertion.

“So we looked at the question, does having a gun at home protect your family or not?” Dr. Rosenberg recalled.

He was amazed by the answer. The landmark study in 1993 showed that bringing a gun into the home puts everyone at much greater risk.

“They were saying if you want to keep your family safe, if you are a real man, you will have a gun at home,” Dr. Rosenberg said. “Bringing the gun not only didn’t protect you, it put you at much, much greater risk.”

To this day, gun rights advocates dispute the study’s findings. The N.R.A. pushed Congress in 1995 to stop the C.D.C. from spending taxpayer money on research that advocated gun control. Congress then passed the Dickey Amendment in 1996, and cut funding that effectively ended the C.D.C.’s study of gun violence as a public health issue.

The result is that 22 years and more than 600,000 gunshot victims later, much of the federal government has largely abandoned efforts to learn why people shoot one another, or themselves, and what can be done to prevent gun violence.

After the Parkland school massacre in Florida last month, lawmakers and gun control experts have demanded that the agency take up the issue of studying gun violence again, arguing that the federal law doesn’t ban such research altogether but prohibits advocacy of gun control.

Alex M. Azar II, the secretary for health and human services, said at a congressional hearing that he believed the C.D.C. should resume the work. “We’re in the science business and the evidence-generating business,” Mr. Azar said, ”and so I will have our agency certainly working in this field, as they do across the broad spectrum of disease control and prevention.’’

Alex M. Azar II, now the secretary of health and human services, at his confirmation hearing in January. He told lawmakers recently he believed the C.D.C. should resume work into gun violence. Credit Win Mcnamee/Getty Images

At a meeting with reporters last week, Mr. Azar said that other priorities, like fighting the flu and Ebola, also competed for funds. He did not specify which subjects would be a priority, how much money he might ask Congress to allocate to gun violence research, or whether he will transfer money from other health agency programs.

There is no shortage of ideas — or criticism of the time lost in studying gun violence.

“We have repeatedly and consciously turned our back on the problem,” said Garen Wintemute, a professor of emergency medicine who in July started the Firearm Violence Research Center at the University of California, Davis, with funding from the state. “How many thousands of people are dead today who might have been alive if that research effort had been put in place and we had answered critical questions and set prevention measures in motion?”

It’s a question that haunts researchers. In the aftermath of the Sandy Hook school shooting in 2012, President Obama directed the C.D.C. to reconsider gun violence research. The agency commissioned a report from the Institute of Medicine outlining priorities, but never followed up.

The most pressing questions cited by the institute, now known as the National Academy of Medicine, still have no answers. Who is most likely to use a gun in a crime, and where does the gun come from? How often are guns used in domestic violence cases? How often are the people who are arrested for gun crimes the same individuals who actually bought the weapons?

Then there is a separate set of questions about what kind of policy changes or prevention efforts actually reduce gun-related deaths and injuries.

Andrew R. Morral, a senior behavioral scientist at the RAND Corporation, directed a recent study that found moderate evidence that background checks do reduce both firearm suicides and homicides. The report also said there is moderate evidence that stand-your-ground laws, which allow people to use guns to defend themselves without first trying to retreat, may increase the murder rate.

“In many cases, we’ve been having arguments about factual matters for decades,” Mr. Morral said. As an example, he cited laws that seek to prevent children from killing themselves or others with guns.

“The N.R.A. has argued that such laws make it tough for people to defend themselves in a crisis,” Mr. Morral said. “But there’s no research on that. We’ve argued and argued and argued, and we have not invested in the research needed to answer the question: What is the trade-off between childhood deaths and self-defense?’’

The new set of proposals by President Trump calls for a commission to examine whether to raise the age to 21 from 18 for young people to buy certain firearms. Just after the Parkland killings, Mr. Trump repeatedly supported raising the age, but the latest proposals do not include such a measure — one that the N.R.A. opposes.

Students protesting in favor of gun control legislation in Washington on Feb. 21. Credit Evan Vucci/Associated Press

Dr. Thomas R. Frieden, who was director of the C.D.C. from 2009 to 2017, said in an email that he believed the study of firearms-related violence was important even though little was conducted during his tenure.

“That’s why year after year I asked Congress to fund C.D.C. to do research in this area,” Dr. Frieden said. ”We need to know which interventions are most effective and how they can best be implemented to save the most lives.”

But Congress refused to include funding for those proposals, he said. The National Institutes of Health has continued to fund some gun violence research, including violent crimes related to drug and alcohol consumption, and parental roles in preventing injury from firearms.

N.I.H. is also assessing ways to reduce suicides and accidental deaths among children and adolescents and war veterans. More than 60 percent of all gun deaths in the United States are suicides.

The Justice Department also studies gun violence, but the budget for that research is a small fraction of what the federal government spends on looking at other high-mortality hazards, like car accidents or smoking — money that has led to actions that greatly reduced deaths in both categories.

Private foundations have stepped up to fill the gap. But there is another congressional roadblock that private money cannot circumvent — the Tiahrt Amendments, which prevent the Bureau of Alcohol, Tobacco, Firearms and Explosives from sharing its firearms-tracking database with anyone outside of law enforcement.

Those records, Mr. Morral and other experts say, are crucial to analyze the flow of guns used in crimes over state borders, from places where guns are easy to buy to places where it is tougher.

The Dickey Amendment technically did not ban gun research, only advocacy. Its real goal — one it easily achieved, according to public health officials in place at the time — was to scare federal agencies into thinking twice about even collecting data that might reflect badly on gun ownership.

Since the Parkland murders, there have been signs of change. Several Republican lawmakers said they would support the C.D.C. taking on the issue.

“There’s a tremendous misunderstanding here and maybe an overabundance of caution on the part of C.D.C. and N.I.H.,” said Representative Tom Cole, of Oklahoma, chairman of a House appropriations subcommittee that oversees funding for the health and human services department.

In an interview, Mr. Cole also said he expected there would be money available for such work at both N.I.H. and C.D.C., but not until next year’s appropriations.

Some Democrats are pressing to take advantage of the new mood on Capitol Hill. Senator Patty Murray, of Washington, the ranking Democrat on the health committee, and Senator Edward J. Markey, Democrat of Massachusetts, have both pressed Mr. Azar for details, but as of Friday neither had received a response.

“From fighting cancer to decreasing road traffic fatalities, public health research has played a critical role in saving lives,” Ms. Murray wrote to Mr. Azar. ‘‘It is immoral and unacceptable to treat gun violence any differently.”

In the House of Representatives, Democratic members of the Committee on Energy and Commerce have called for a hearing on the adequacy of federal research into gun violence.

Jennifer Baker, a spokeswoman for the N.R.A., said the group continues to support the Dickey Amendment. “We oppose taxpayer dollars being spent to advocate for gun control,” Ms. Baker said.

Asked if there is any type of research the group would support, she said the N.R.A. would like to see a study of how often firearms are used in self-defense.

The Institute of Medicine report, published with the National Research Council, is still considered a road map by the C.D.C. The report proposed research on issues like motivations for gun ownership and use; the relationship between poverty and gun use; risk factors that lead youths to carry guns; and dozens of other questions.

The C.D.C. did ask for and receive money to expand its National Violent Death Reporting System, which tracks homicides and suicides in 40 states, the District of Columbia and Puerto Rico. The project aims to help state health departments develop strategies to reduce violent deaths, but some critics say the database lacks sufficient detail to be very useful.

Research proponents want to make sure that new studies don’t serve as an excuse for a lack of action on gun control.

“Although more gun research is needed,” Dr. Frieden said, “there are proven means to reduce gun violence, including better background checks, getting guns away from domestic abusers and people convicted of violent crimes, and safe storage. More research can help. But this is no excuse for inaction.”

New prostate cancer risk model could better guide treatment

-Michigan Medicine - University of Michigan

A new model could change treatment guidelines for nearly two-thirds of men with localized prostate cancer.

One of the biggest challenges in treating prostate cancer is distinguishing men who have aggressive and potentially lethal disease from men whose cancer is slow-growing and unlikely to metastasize.

For years, prostate-specific antigen (PSA) level, cancer grade and tumor stage have been used to sort prostate cancer patients into risk groups established by the National Comprehensive Cancer Network. These risk groups help determine treatment course.

But the longtime practice has shortcomings.

"These risk groups were developed decades ago and were optimized for what is called biochemical recurrence, which simply means that a man's PSA level rises again sometime after treatment," says Daniel Spratt, M.D., associate chair of research and assistant professor in the Department of Radiation Oncology at Michigan Medicine.

"It was not optimized for more meaningful outcomes like identifying which men will ultimately develop metastases or die of prostate cancer."

That means men with prostate cancer are being left behind in the era of precision medicine, Spratt says.

The good news? Technology has advanced to the point where genetic information derived from tissue biopsied at diagnosis can much more accurately predict which men have aggressive prostate cancer. A genomic classifier score is assigned based on tests run on 22 genes known to increase the risk of developing metastatic disease.

The bad news? There has been no way to integrate these new gene expression biomarker risk scores into the NCCN risk groups that have traditionally been used to guide treatment.

"So what we did is basically say: We've got a flawed model," says Spratt. "We've got these new biomarkers, but we don't really know how to integrate them. Let's see if we can merge them together to create a new, integrated system that is simple and easy to use, and standardize the use of these biomarkers."

The study was reported in the Journal of Clinical Oncology.

New reporting methods

Four multicenter, retrospective cohorts of nearly 7,000 men, all of whom had gene expression biomarker scores, were used to design, test and validate a new model for assigning risk groups. Two new clinical-genomic systems were created: a simple three-tiered system and a more granular six-tiered system.

When the researchers tested the new risk group models against conventional NCCN risk groups for the development of metastatic disease and death from prostate cancer, they found that the new clinical-genomic groups were much more accurate predictors than the traditional NCCN risk groups.

The team also found some noticeable differences.

"What our new system does is not only more accurately identify men who have either indolent disease or aggressive disease, but it reclassifies almost 67 percent of men, potentially changing recommendations for their treatment," says Spratt.

Implications for care

For men with a lower-risk, slow-growing disease who are much more likely to die of something other than prostate cancer, active surveillance is typically recommended. Through careful monitoring of the condition, they are able to defer treatment.

"It's great because you spare the cost and side effects of treatment," says Spratt. "However, in the community setting, only about 50 percent or less of men who we would normally say should go on active surveillance actually go on it. That's because clinicians don't have great confidence in the old NCCN risk grouping system."

This new system creates a much larger pool of low-risk men eligible for active surveillance, and it gives more accuracy and confidence to doctors prescribing treatment.

On the other hand, the new risk group classification also identifies a much larger pool of high-risk men who, if left untreated, are likely to die of prostate cancer. This group would receive more intensive treatment, possibly including radiation, hormone therapy or clinical trials.

"This is similar to what the oncotype recurrence score is for breast cancer," Spratt says. "Women who have a high oncotype score are told they have a large chance of absolute benefit from adding chemotherapy, while those with a low oncotype score may have a very small benefit -- but the absolute benefit is so small, it's not worth the side effects and cost of the therapy."

Spratt says this new clinical-genomic risk grouping system for prostate cancer is ready to be used today.

"This could radically change the way we perceive and treat localized prostate cancer," he says.

A lifetime of regular exercise slows down aging, study finds

-University of Birmingham

A group of older people who have exercised all of their lives, were compared to a group of similarly aged adults and younger adults who do not exercise regularly. The results showed that those who have exercised regularly have defied the aging process, having the immunity, muscle mass, and cholesterol levels of a young person.

Researchers at the University of Birmingham and King's College London have found that staying active keeps the body young and healthy.

The researchers set out to assess the health of older adults who had exercised most of their adult lives to see if this could slow down ageing.

The study recruited 125 amateur cyclists aged 55 to 79, 84 of which were male and 41 were female. The men had to be able to cycle 100 km in under 6.5 hours, while the women had to be able to cycle 60 km in 5.5 hours. Smokers, heavy drinkers and those with high blood pressure or other health conditions were excluded from the study.

The participants underwent a series of tests in the laboratory and were compared to a group of adults who do not partake in regular physical activity. This group consisted of 75 healthy people aged 57 to 80 and 55 healthy young adults aged 20 to 36.

The study showed that loss of muscle mass and strength did not occur in those who exercise regularly. The cyclists also did not increase their body fat or cholesterol levels with age and the men's testosterone levels also remained high, suggesting that they may have avoided most of the male menopause.

More surprisingly, the study also revealed that the benefits of exercise extend beyond muscle as the cyclists also had an immune system that did not seem to have aged either.

An organ called the thymus, which makes immune cells called T cells, starts to shrink from the age of 20 and makes less T cells. In this study, however, the cyclists' thymuses were making as many T cells as those of a young person.

The findings come as figures show that less than half of over 65s do enough exercise to stay healthy and more than half of those aged over 65 suffer from at least two diseases.* Professor Janet Lord, Director of the Institute of Inflammation and Ageing at the University of Birmingham, said: "Hippocrates in 400 BC said that exercise is man's best medicine, but his message has been lost over time and we are an increasingly sedentary society.

"However, importantly, our findings debunk the assumption that ageing automatically makes us more frail.

"Our research means we now have strong evidence that encouraging people to commit to regular exercise throughout their lives is a viable solution to the problem that we are living longer but not healthier."

Dr Niharika Arora Duggal, also of the University of Birmingham, said: "We hope these findings prevent the danger that, as a society, we accept that old age and disease are normal bedfellows and that the third age of man is something to be endured and not enjoyed."

Professor Stephen Harridge, Director of the Centre of Human & Aerospace Physiological Sciences at King's College London, said: "The findings emphasise the fact that the cyclists do not exercise because they are healthy, but that they are healthy because they have been exercising for such a large proportion of their lives.

"Their bodies have been allowed to age optimally, free from the problems usually caused by inactivity. Remove the activity and their health would likely deteriorate."

Norman Lazarus, Emeritus Professor at King's College London and also a master cyclist and Dr Ross Pollock, who undertook the muscle study, both agreed that: "Most of us who exercise have nowhere near the physiological capacities of elite athletes.

"We exercise mainly to enjoy ourselves. Nearly everybody can partake in an exercise that is in keeping with their own physiological capabilities.

"Find an exercise that you enjoy in whatever environment that suits you and make a habit of physical activity. You will reap the rewards in later life by enjoying an independent and productive old age."

The research findings are detailed in two papers published today in Aging Cell and are the result of an ongoing joint study by the two universities, funded by the BUPA foundation.

The researchers hope to continue to assess the cyclists to see if they continue to cycle and stay young.

The enemy within: Gut bacteria drive autoimmune disease

-Yale University

Bacteria found in the small intestines of mice and humans can travel to other organs and trigger an autoimmune response, according to a new study. The researchers also found that the autoimmune reaction can be suppressed with an antibiotic or vaccine designed to target the bacteria, they said.

Orange dots represent the gut bacterium E. gallinarum in liver tissue.

The findings, published in Science, suggest promising new approaches for treating chronic autoimmune conditions, including systemic lupus and autoimmune liver disease, the researchers said.

Gut bacteria have been linked to a range of diseases, including autoimmune conditions characterized by immune system attack of healthy tissue. To shed light on this link, a Yale research team focused on Enterococcus gallinarum, a bacterium they discovered is able to spontaneously "translocate" outside of the gut to lymph nodes, the liver, and spleen.

In models of genetically susceptible mice, the researchers observed that in tissues outside the gut, E. gallinarum initiated the production of auto-antibodies and inflammation -- hallmarks of the autoimmune response. They confirmed the same mechanism of inflammation in cultured liver cells of healthy people, and the presence of this bacterium in livers of patients with autoimmune disease.

Through further experiments, the research team found that they could suppress autoimmunity in mice with an antibiotic or a vaccine aimed at E. gallinarum. With either approach, the researchers were able to suppress growth of the bacterium in the tissues and blunt its effects on the immune system.

"When we blocked the pathway leading to inflammation, we could reverse the effect of this bug on autoimmunity," said senior author Martin Kriegel, M.D.

"The vaccine against E. gallinarum was a specific approach, as vaccinations against other bacteria we investigated did not prevent mortality and autoimmunity," he noted. The vaccine was delivered through injection in muscle to avoid targeting other bacteria that reside in the gut.

While Kriegel and his colleagues plan further research on E. gallinarum and its mechanisms, the findings have relevance for systemic lupus and autoimmune liver disease, they said.

"Treatment with an antibiotic and other approaches such as vaccination are promising ways to improve the lives of patients with autoimmune disease," he said.

Study Shows, Holding Hands Can sync Brainwaves, Ease Pain.

-University of Colorado at Boulder

A new study by a pain researcher shows that when a romantic partner holds hands with a partner in pain, their brain waves sync and her pain subsides.

Reach for the hand of a loved one in pain and not only will your breathing and heart rate synchronize with theirs, your brain wave patterns will couple up too, according to a study published this week in the Proceedings of the National Academy of Sciences (PNAS).

The study, by researchers with the University of Colorado Boulder and University of Haifa, also found that the more empathy a comforting partner feels for a partner in pain, the more their brainwaves fall into sync. And the more those brain waves sync, the more the pain goes away.

"We have developed a lot of ways to communicate in the modern world and we have fewer physical interactions," said lead author Pavel Goldstein, a postdoctoral pain researcher in the Cognitive and Affective Neuroscience Lab at CU Boulder. "This paper illustrates the power and importance of human touch."

The study is the latest in a growing body of research exploring a phenomenon known as "interpersonal synchronization," in which people physiologically mirror the people they are with. It is the first to look at brain wave synchronization in the context of pain, and offers new insight into the role brain-to-brain coupling may play in touch-induced analgesia, or healing touch.

Goldstein came up with the experiment after, during the delivery of his daughter, he discovered that when he held his wife's hand, it eased her pain.

"I wanted to test it out in the lab: Can one really decrease pain with touch, and if so, how?"

He and his colleagues at University of Haifa recruited 22 heterosexual couples, age 23 to 32 who had been together for at least one year and put them through several two-minute scenarios as electroencephalography (EEG) caps measured their brainwave activity. The scenarios included sitting together not touching; sitting together holding hands; and sitting in separate rooms. Then they repeated the scenarios as the woman was subjected to mild heat pain on her arm.

Merely being in each other's presence, with or without touch, was associated with some brain wave synchronicity in the alpha mu band, a wavelength associated with focused attention. If they held hands while she was in pain, the coupling increased the most.

Researchers also found that when she was in pain and he couldn't touch her, the coupling of their brain waves diminished. This matched the findings from a previously published paper from the same experiment which found that heart rate and respiratory synchronization disappeared when the male study participant couldn't hold her hand to ease her pain.

"It appears that pain totally interrupts this interpersonal synchronization between couples and touch brings it back," says Goldstein.

Subsequent tests of the male partner's level of empathy revealed that the more empathetic he was to her pain the more their brain activity synced. The more synchronized their brains, the more her pain subsided.

How exactly could coupling of brain activity with an empathetic partner kill pain?

More studies are needed to find out, stressed Goldstein. But he and his co-authors offer a few possible explanations. Empathetic touch can make a person feel understood, which in turn according to previous studies could activate pain-killing reward mechanisms in the brain.

"Interpersonal touch may blur the borders between self and other," the researchers wrote.

The study did not explore whether the same effect would occur with same-sex couples, or what happens in other kinds of relationships. The takeaway for now, Pavel said: Don't underestimate the power of a hand-hold.

"You may express empathy for a partner's pain, but without touch it may not be fully communicated," he said.

Exercise may decrease heart drug's effectiveness

-Simon Fraser University

Health care experts are quick to remind us that a healthy lifestyle includes regular exercise. But what if certain, potentially life-saving medications don't perform as well during exercise?

Peter Ruben and his team of researchers have spent years studying why seemingly healthy patients with inherited cardiac arrhythmias can sometimes suddenly die during exercise. (2017, 2016, 2015) His past research has shown that exercising can trigger a perfect storm of events, unmasking an arrhythmia: high heart rate, elevated body temperature, and elevated acid in the blood.

Now the team has dug deeper and discovered that some of these physiological changes accompanying exercise, particularly elevated body temperature and elevated heart rate, might also decrease the ability of Ranolazine to maintain a healthy heart rhythm during exercise.

Ranolazine is a second-line therapeutic agent prescribed for angina pectoris, for which chest pain is the main symptom. It works to improve blood flow to help the heart work more effectively and also has been effective in treating those with some inherited arrhythmias.

Knowing that external triggers can affect drug-channel interaction, Ruben's team was keen to test Ranolazine's efficacy under various physiological states.

They discovered that increased body temperature and heart rate reduce the potential effectiveness of Ranolazine to exert its anti-arrhythmic effects in one of the most common forms of inherited arrhythmia.

Ruben advises physicians to caution patients who take Ranolazine for this form of inherited arrhythmia (and perhaps others yet to be tested) that it may work well while the patient is resting, but could lose its effectiveness during exercise. "This is important because exercise can trigger a catastrophic arrhythmia in these patients, and Ranolazine could not be expected to control the arrhythmia in those patients during exercise." says Ruben.

Do You Know How Much Protein Really Need Your Body?

Everyone needs protein in their diet. But, what your body requires can be different than your friends and family.

Protein is an essential macro-nutrient in a healthy, balanced diet. That's nothing new or surprising. Most people think of strong muscles or building muscles when they think of protein, and that is true. However, this nutrient does more than just build muscle tissue. Proteins are essential for cell function and also are integral in the structure, function, and regulation of tissues and organs in your body. They can carry messages throughout the body, and help fight infections. Where things get confusing is when it comes to how much protein you should consume. Let's break it down.

General Recommendations

The RDA, or recommended daily allowance, to meet minimum health requirements is to consume 0.8 grams of protein per kilogram of body weight. So, if you weigh 150 pounds, divide that by 2.2 to get your weight in kilograms — about 68 kilograms. Multiply 68 by 0.8 and you'll get a recommendation of 55 grams of protein per day. However, understand that the RDA is designed to meet minimum health requirements, and is probably not enough if you are even moderately active in your daily life, let alone an avid exerciser. Think of the RDA as the minimum amount of protein you should be consuming each day.

Recent Findings

In general, there is a belief that people consume too much protein, and don't need to add more to their diets. However, a summit was held in Washington, D.C. where 40 nutrition scientists gathered to discuss protein in depth. Their findings suggested that the RDA was only about 10 percent of your daily caloric intake. Many people consume closer to 16 percent of their total calories from protein daily, and that is just fine. Their research suggests that a range of 15 to 25 percent is actually more in line with good health and function. So, for that 150-pound person, 83 to 138 grams of protein per day is a healthy range.

Takeaway Message

Figure out what your RDA is for your body weight. Divide that by 10. Then multiply the result by 15 to get your low-end recommendation and the result by 25 to get the high end. Keep a food log for a few days with accurate measurements of your food to determine how much protein you are eating each day. Is it in that range? If so, you are probably doing okay in the protein department.

If you're concerned about your diet or are an avid exerciser or athlete, you may want to meet with a registered dietitian. An RD can look over your diet and help you eat according to your health, goals, and needs.

Need to Know about the Volumetrics Diet

The Volumetrics diet is more of an eating pattern that a strict diet, but you do have to pay attention to what you eat.

Have you heard of the Volumetrics diet? It’s not a hard-and-fast “diet” that restricts entire food groups, requires you to fast, or do any ridiculous “cleanses.” The Volumetrics diet came from the theory that you eat the same weight of food each day without regard to how many calories you take in or the breakdown of how much fat, carbohydrates, and protein in your diet. Research has shown that most people eat the same amount, the same volume, the same weight of food, every day. The Volumetrics diet centers on this fact.

Will you lose weight on the Volumetrics eating style? Most likely, yes. Is it an overall healthy diet, though? Also yes. In fact, U.S. News & World Report ranked the Volumetrics diet as number 5 in Best Diets Overall out of forty diets that were analyzed by a panel of health and nutrition experts.

The Volumetrics diet was created by Barbara Rolls, PhD., as a healthy eating approach that focuses on helping people feel full while concentrating on choosing a wide variety of nutrient-dense, but not calorie-dense, foods. The key component of this diet is to fill up on a larger volume of food that is low in calories, meaning you are physically eating more. It’s not a “quick fix diet” that will have you dropping weight incredibly fast. It’s more of a long-term eating pattern that lets you eat more and still lose weight. You feel fuller with fewer calories but a physically larger amount of food.

One excellent attribute of this diet is that no foods are off-limits. You do have to think about energy density when you make your food choices, but this is an easy concept to grasp and put into action. Energy density is the amount of energy (measured in calories) in a certain portion of food. Energy-dense foods are items that have a lot of calories in a very small amount of food (think calories per bite). Foods that have low energy-density provide fewer calories in a large volume. An example: a fun-size Snickers bar contains 80 calories and can be eaten in two bites, whereas you could eat two large cucumbers for about 90 calories. Another example: you could eat four whole cups of asparagus for 107 calories or only 1/2 a small order of french fries from McDonald’s for about 112 calories (without ketchup).

The Volumetrics diet also centers on foods that contain a lot of water, like most vegetables and fruits because they make you feel full on fewer calories since water adds weight to food but no calories. Experts also say that you feel fuller and more satisfied off of solid foods than liquids. So, downing a lot of H2O just won’t be enough to make you feel full, but consuming a great deal of water-rich foods will.

The Volumetrics diet creator Barbara Rolls established four food categories, described here:

Category 1: Very-low-density foods (also called “anytime” foods) — non-starchy vegetables and fruits (basically all vegetables except potatoes, sweet potatoes, corn, peas, and winter squash), broth-based soups, and nonfat milk.

Category 2: Low-density foods, including reasonably-sized portions of starchy vegetables and fruits, cereals, whole grains, legumes, lean proteins, low-fat dairy, and some low-fat mixed dishes (think chili or enchiladas).

Category 3: Medium-density foods — small portions of higher-fat meats, full-fat cheeses, refined breads, desserts, baked goods and pastries, pizza, pretzels, salad dressing, and ice cream.

Category 4: High-density foods — sparing portions of fried foods, candy, cookies, crackers, chips, nuts, and fats (such as butter and oil).

The idea is to eat a lot from categories one and two, eat small amounts of category three, and try to keep choices in category four to a minimum. Each day you eat three meals, two snacks, and dessert. You decide how strictly you want to adhere to the diet, so its flexibility is a benefit.

The Bottom Line

This eating pattern is easy to follow, encourages you to eat lots of fruits and vegetables that are full of beneficial nutrients, lets you eat intuitively, and keeps you full and satisfied.

You Need to Know About Ayahuasca

Ayahuasca is an Amazonian plant mixture. It is used for a variety of reasons and has become popular in Silicon Valley and Brooklyn societies for its ability to bring a heightened sense of consciousness.

Western society reportedly first encountered ayahuasca in 1851. It is a combination of various plants and commonly consumed as a tea. It had a resurgence in popularity in the 1970s and is once again coming into vogue, despite being an illegal substance.

Ayahuasca creates a psychedelic, visionary state of mind and is traditionally used by shaman and medicine men to help diagnose patients and to commune with nature. More recently, psychotherapy academics have become interested in using ayahuasca to treat health issues. And there are also people that use ayahuasca recreationally, to help discover a deeper meaning.

The potent blend of herbs is not without side effects. It causes diarrhea and vomiting, which is commonly known as “the purge,” amongst fans. Despite the side effects and unpleasant trips, ayahuasca remains popular amongst those that use it as they seek to experience new things with each visit.

In cities ranging from Hawaii to New York to California and others around the world, ayahuasca ceremonies are commonly held as group activities known as circles. The way that the ayahuasca rituals and experiences are described frequently rely on modern language and even technological terms as people strive to let go of unwanted emotions like anger.

Many circles include filling out a health questionnaire ahead of time as certain health conditions, including high blood pressure or taking antidepressants, means that ayahuasca.

Circles and ceremonies are closely monitored by experienced facilitators as some people become violent with the blend and there have been incidents of women being molested and others physically harmed or killed while under the influence.

WHY ARE PEOPLE USING AYAHUASCA?

Ayahuasca induces a psychedelic, visionary state of mind and this effect is employed by various people for various reasons.

Shamans or medicine men take ayahuasca to communicate with nature or to see what is causing a patient’s illness on a spiritual level. In Brazil several religions can be found that pivot around gatherings where ayahuasca is taken by all participants. Drinking ayahuasca and singing together takes them into a healing and inspiring kind of trance.

In the past few decades ayahuasca is slowly gaining interest from Western society as well. Not only academic researchers in the field of psychotherapy have shown an increased interest. Psychonauts, i.e. people who practice responsible and conscious use of mind-altering substances, use ayahuasca to confront themselves with the richness of the mind, the infinity of the universe, and their deepest fears, so as to experience ecstasy resulting from facing and overcoming these fears.

One effect of ayahuasca is that it makes a lot of people vomit and many drinkers get diarrhea. One tribe calls ayahuasca ‘kamarampi’, which stems from ‘kamarank’: to vomit. It is also called ‘la purga’, as it purges the body through this physical effect, and purifies the mind through the meaningful psychological experiences or visions. You usually feel totally refreshed and reborn after a strong experience.

WHAT MAKES AYAHUASCA SO INTERESTING?

Although not unique to ayahuasca, there are many fascinating reports about people who have been healed from comprehensive problems, like addiction or depression, during one or more sessions. This, however, can also be achieved using LSD, psilocybin mushrooms, iboga, other psychedelics or various breathing and meditation techniques, and always involves heavy psychological work.

Ayahuasca is not a miracle cure in the sense that you drink the brew and all your troubles have vanished within a couple of hours. It is a miracle cure though, in the sense that it brings unconscious and seemingly other-worldly processes to surface, which enables you to work with it while the effects last.

What is more unique about ayahuasca, is that the effects rely on a specific combination of two plants: Banisteriopsis caapi and chacruna (or chagropanga, depending on the region). How and when exactly the discovery of combining these two plants was made by native Americans remains unclear, although many tribes and shamans have their own mythical tales explaining this event.

Second, the primary ingredient of chacruna and chagropanga is also a neurotransmitter found in all human beings and plays a key role in all kinds of extraordinary states of awareness. This neurotransmitter is called dimethyltryptamine, or DMT for short, and is found in the brain, blood, lungs and other parts of the human body. There is strong evidence pointing towards the pineal gland (“the third eye” in esoteric traditions), located in the center of the brain, as the main factory of human DMT. Apart from human beings, DMT can be found in every mammal and in a variety of plants.

Kids’ social media time ‘could be cut to a few hours’ to improve mental health

Sites like Facebook and Instagram would be legally obliged to boot off teenagers after set period under government plans

-By John Lucas and Harry Cole - The Sun

TEENS could be blocked from social media sites after a few hours under government plans to improve their mental health.

Youngsters would have to prove they are over 13 to join sites such as Facebook and Instagram, which would then have a legal requirement to boot them off after a set period.

Sites such as Facebook and Instagram would have a legal requirement to boot kids off after a set time

It comes as a new law making it compulsory for porn sites to check users are over 18 starts next month.

However critics say the move could expose kids and parents to identity fraudsters.

Matt Hancock, secretary of state for digital, culture, media and sport, told The Times the cut-off points could vary by age.

He said: “There is a genuine concern about the amount of screen time young people are clocking up and the negative impact it could have on their lives.

Matt Hancock, Secretary of State for Digital, Culture, Media and Sport said there is concern about the amount of screen time young people are clocking up

“It is right that we think about what more we could do in this area.”

Mr Hancock gave no details of how the scheme could work, but ministers have discussed setting up a one stop shop website for parents to register their children.

Facebook, Instagram and Twitter specify a minimum age of 13, but children only have to enter their date of birth and no checks are made.

Mr Hancock added: “It is not beyond the wit of man to develop an age-verification system; people have their age in their passport. Much more needs to be done.”

An age verification scheme has been proposed in a plan to safeguard youngsters' mental health

From April, the new Digital Economy Act will mean anyone wanting to view porn must register a credit card with websites.

Firms ignoring the law could be fined up to £250,000 or blocked by service providers.

Matt Kilcoyne, of the pro-freedom Adam Smith Institute, said last night: “Ministers could be opening up taxpayers to fraud and abuse here.

“Credit card crime is already far too hard to police - so why make it any easier for criminals?

“Young people will always try to access these sites - so why expose their parents to online fraudsters?

“Nanny often says she knows best, but she hasn’t had her illegally identity cloned by crooks yet.”

Children aged 12 to 15 spend more than 20 hours a week online, according to Anne Longfield, the children’s commissioner, and a third of internet users are under 18.

How One Child’s Sickle Cell Mutation Helped Protect the World From Malaria

The genetic mutation arose 7,300 years ago in just one person in West Africa, scientists reported on Thursday. Its advantage: a shield against rampant malaria.

-By Carl Zimmer - NYT

A false-color image of healthy red blood cells with some sickle cells, the defective cells that die quickly and cause sickle cell anemia. Sickle cells are the result of a mutation that scientists say arose in a single person in West Africa more than 7,000 years ago. Credit Eye of Science/Science Source

Thousands of years ago, a special child was born in the Sahara. At the time, this was not a desert; it was a green belt of savannas, woodlands, lakes and rivers. Bands of hunter-gatherers thrived there, catching fish and spearing hippos.

A genetic mutation had altered the child’s hemoglobin, the molecule in red blood cells that ferries oxygen through the body. It was not harmful; there are two copies of every gene, and the child’s other hemoglobin gene was normal. The child survived, had a family and passed down the mutation to future generations.

As the greenery turned to desert, the descendants of the hunter-gatherers became cattle-herders and farmers, and moved to other parts of Africa. The mutation endured over generations, and for good reason. People who carried one mutated gene were protected against one of the biggest threats to humans in the region: malaria.

There was just one problem with this genetic advantage: From time to time, two descendants of that child would meet and start a family. Some of their children inherited two copies of the mutant hemoglobin gene instead of one.

These children could no longer produce normal hemoglobin. As a result, their red cells became defective and clogged their blood vessels. The condition, now known as sickle cell anemia, leads to extreme pain, difficulty with breathing, kidney failure and even strokes.

In early human societies, most children with sickle cell anemia likely died by age 5. Yet the protection afforded by a single copy of the sickle cell mutation against malaria kept fueling its spread.

Today, over 250 generations later, the sickle cell mutation has been inherited by millions of people. While the majority of carriers live in Africa, many others live in southern Europe, the Near East and India. Those carriers have about 300,000 children each year with sickle cell anemia.

A colored scanning electron micrograph of a female Anopheles gambiae mosquito, a carrier of malaria. People with the sickle cell mutation are more resistant to malaria. Credit Dennis Kunkel Microscopy/Science Source

How humans got the sickle cell mutation is a sprawling saga that emerges from new research carried out at the Center for Research on Genomics and Global Health, part of the National Institutes of Health, by Daniel Shriner, a staff scientist, and Charles N. Rotimi, the center’s director. Their study was published on Thursday in the American Journal of Human Genetics.

Dr. Shriner and Dr. Rotimi analyzed the genomes of nearly 3,000 people to reconstruct the genetic history of the disease. They conclude that the mutation arose roughly 7,300 years ago in West Africa.

Later, migrants spread the mutation across much of Africa and then to other parts of the world. Wherever people suffered from malaria, the protective gene thrived but brought sickle cell anemia with it.

Today, sickle cell anemia remains a heavy burden on public health. In many poor countries, most children with the disease still die young. In the United States, the average life span of sufferers has been extended into the early 40s.

Dr. Rotimi said that an improved understanding of the history of sickle cell anemia could lead to better medical care. It might allow researchers to predict who will suffer severe symptoms and who will only experience mild ones.

“It would definitely help physicians to treat patients at a global level,” he said.

Doctors in the United States first noticed sickle cell anemia in the early 1900s. The disease got its name from the way it changed the shape of red blood cells from healthy disks to abnormal curves.

Most cases turned up in African-Americans, doctors found. But 8 percent of African-Americans had at least some sickle-shaped blood cells, even though the vast majority had no symptoms at all.

By 1950, researchers had resolved this paradox, discovering the difference between carrying one mutated copy of the hemoglobin gene and carrying two copies. By then it had also become clear that sickle cell anemia was not unique to the United States.

In Africa, researchers found sickle-shaped red blood cells in people across a broad belt, from Nigeria in West Africa to Tanzania in the east. The cells also turned up at high rates in people in parts of the Near East and India, and in southern European countries such as Greece.

Genetically speaking, this made no sense. Because inheriting two copies of the gene is so deadly, the mutation should have become rarer with passing generations, not more common.

In 1954, a South African-born geneticist named Anthony C. Allison observed that people in Uganda who carried a copy of the sickle cell mutation suffered fewer malaria infections than people with normal hemoglobin.

Later research confirmed Dr. Allison’s finding. The sickle cell mutation seemed to defend against malaria by starving the single-celled parasite that causes the disease. The parasite feeds on hemoglobin, and so it’s possible that it can’t grow on the sickle cell version of the molecule.

“Sickle cell is a rare example of human evolution where we have a good idea of what happened and why,” said Bridget Penman, a malaria expert at the University of Warwick in England.

Early genetic studies suggested that five different kinds of DNA, known as haplotypes, surround the mutation. These are named for the places where they were most common: Arabian/Indian, Benin, Cameroon, Central African Republic and Senegal.

These haplotypes became important for diagnosing sickle cell anemia, because some appeared to cause more severe disease than others. But the haplotypes also gave scientists a chance to explore the history of the mutation.

“It has been an open question as to whether the actual sickle cell mutation itself emerged several times or just once,” said Dr. Penman.

Some researchers saw the five haplotypes as evidence that the mutation arose on five separate occasions in five different places. Other researchers thought it unlikely that genetic lightning could strike so many times.

“We said, ‘How do we jump into this forty-year debate?” said Dr. Rotimi.

He and Dr. Shriner examined the genomes of 2,932 people from around the world. They found that 156 of the subjects mostly from Africa, but also from Barbados, the United States, Colombia and Qatar carried a copy of the sickle cell mutation.

The researchers scanned the DNA surrounding the mutation in those people. While most of it was identical from person to person, in some spots it differed.

Combining their findings, the researchers concluded that all 156 people inherited the same mutation from a single person who lived roughly 7,300 years ago. “This alone is a big contribution to our understanding,” said Dr. Penman.

The new study also offers hints as to how the mutation spread to millions of descendants.

The oldest version of the sickle cell mutation is found in people from western and central Africa. They may have inherited it from an ancestor in the green Sahara.

The mutation might have spread to other parts of Africa with the expansion of a people called the Bantu. Arising about 5,000 years ago around what is now Cameroon and Nigeria, they converted woodlands to farm fields on a massive scale.

As they cleared land for agriculture, they may have promoted the spread of malaria by mosquitoes. The insects thrived by laying eggs in standing water around the farms and feeding on the growing population of farmers. The intensification of malaria in human populations may also have accelerated the spread of the protective sickle cell mutation.

Over the next few thousand years, the Bantu carried the mutation across much of eastern, central and southern Africa, Dr. Shriner and Dr. Rotimi conclude. In places where malaria was prevalent, the mutation offered protection. But malaria is rarer in southern Africa, and there the sickle cell mutation became rarer, too.

Later, the study suggests, Africans carried the mutation to other parts of the world. Waves of migrants made their way to the Near East. As people from different ancestries interbred, the mutation made its way further afield, into Europe and India.

Some West Africans captured in the slave trade brought the sickle cell mutation to the Americas. But in places like the United States, where malaria was uncommon or nonexistent, the mutation offered less of an evolutionary advantage. As a result, African-Americans have a lower rate of sickle cell anemia than Africans today.

Frederick B. Piel, an epidemiologist at Imperial College London, said he looked forward to bigger genome-based studies on the sickle cell mutation. It remains to be seen if these patterns can be found in thousands of carriers, instead of just 156, he said.

Dr. Penman said that scientists also should study the different genetic variations identified in the new research. These may help explain why the sickle cell mutation leads to deadly symptoms in some people and only mild ones in others — something that scientists still can’t explain.

“This knowledge might inspire treatments in itself,” she said.

Women are five times more likely to donate a kidney to their spouse than men, a study reveals

Experts suggested altruism could be the cause, though men are also more likely to have kidney problems in the first place

-By Nick McDermott - The Sun

Experts said the likely reason is that wives are simply less selfish.

Men were five times less likely to donate a kidney to their spouse than women, but is selfishness the reason?

European donor figures that includes British data reveal that 36 per cent of women that are clinically suitable go on to donate a kidney to their husband.

However, only seven per cent of suitable men go on to donate a kidney for their wife.

International Society of Nephrology Past President Professor Adeera Levin, from the University of British Colombia, Canada, said: “Although it is hard to pinpoint a specific reason for higher numbers of wives being donors than husbands, the evidence suggests women are motivated by reasons such as altruism and the desire to help their family continue to survive.”

The research, published in the journal Visceral Medicine, was released to mark World Kidney Day.

Professor Adeera Levin of the University of British Colombia hinted higher altruism in women could explain the figures

It shows two-thirds of all living kidney donors in Europe were women in 2014.

And 36 per cent of wives but only 6.5 per cent of suitable husbands donated their kidney.

NHS Blood and Transplant confirmed women make up 54 per cent of the UK organ donor register.

Lisa Burnapp, NHSBT Lead Nurse for Living Donation, said: “Whilst a higher proportion of female to male donors may be attributed to different choices between women and men, there are other factors that contribute when drawing a comparison.

“For example, if a couple have had children together and the man wishes to donate to his female partner, she may have antibodies against him from her pregnancies which would make him an unsuitable donor for her.

“However, if the situation was reversed, the woman would be able to donate to her male partner.” NHS data shows there were 990 living kidney donors in 2017. It is a 10 per cent decline on 2013, the highest ever year.

If a couple have had children together, the man may be an unsuitable donor for the woman due to antibodies against him left over from the pregnancy, said Lisa Burnapp, NHSBT Lead Nurse for Living Donation

Living donation accounts for one in three kidney transplants, and officials said 261 people died waiting for one.

Fiona Loud, Policy Director of Kidney Care UK, received a kidney from her husband 11 years ago.

She said: “Giving a kidney to a loved one is an incredible gift and last year around a third of all kidney transplants were from living donors.

The decision to donate a kidney is a difficult, but potentially life-saving one. 261 people died last year waiting for a living kidney transplant, while 990 living transplants took place in the UK

“Deciding to give a kidney is a very personal and emotional decision so more research is needed in order to understand the reasons why women are more likely to become living donors.

“If we are to reverse the current downward trend in the number of living kidney donations in the UK we need to ensure that both men and women know about living kidney donation and are supported in their decision to do so.”

It Will Pass On Rebates From Drug Companies to Consumers, UnitedHealthcare Says

-By REED ABELSON - NYT

A UnitedHealthcare branch in Brooklyn. Credit Christopher Lee for The New York Times

In response to growing consumer frustration over drug prices, UnitedHealthcare, one of the nation’s largest health insurers, said on Tuesday that it would stop keeping millions of dollars in discounts it gets from drug companies and share them with its customers.

Dan Schumacher, the president of UnitedHealthcare, said the new policy will apply to more than seven million people who are enrolled in the company’s fully insured plans, beginning next year.

“The benefit could range from a few dollars to hundreds of dollars to over a thousand,” Mr. Schumacher said.

Not all drugs come with rebates that are paid to the health plan. People in plans with high deductibles who buy drugs that carry large rebates will see the greatest savings, Mr. Schumacher said.

Insurers like UnitedHealthcare, whose parent company also owns a large pharmacy benefit manager, OptumRx, have come under increasing public pressure as drug prices — especially for brand-name drugs continue to rise, angering consumers and lawmakers. The decision by UnitedHealthcare is the latest in a series of steps taken by drug makers and health plans to try to lessen public discontent over drug prices, even as the companies spar over who is to blame.

Aiming to deflect criticism, the pharmaceutical industry has increasingly pointed the finger at both insurers and pharmacy managers for not sharing the rebates with customers filling prescriptions. The Pharmaceutical Research and Manufacturers of America, the industry trade group, rolled out an advertising campaign, “Share the Savings,” last year to make the case that by passing on the discounts, plans could significantly lower patients’ out-of-pocket bills. The group called UnitedHealthcare’s decision “a step in the right direction.”

Insurers, including UnitedHealthcare, contend that they already use the money from discounts to lower premiums for all their customers, and argue the real issue is the high cost of so many drugs. 

But UnitedHealthcare seems to have blinked, signaling what could be a coming shift away from the system of convoluted deals struck between the drug companies and these middlemen, said Adam J. Fein, president of Pembroke Consulting, a research firm. Although the new policy will only affect a fraction of the company’s customers, “it’s one more step on the path of creating a more transparent pharmacy supply chain,” Mr. Fein said.

The amount of rebates can vary widely, with some drugs, like Humira and Enbrel that treat rheumatoid arthritis, being deeply discounted. Others, like medicines for rare conditions where there is no significant competition, have little to no rebates. Patients, employers and the public have little information on what any one drug costs and whether the discounts ultimately flow back to customers.

“The industry is taking criticism from a lot of different people,” said Erik Gordon, a business professor at the University of Michigan. It is significant that UnitedHealthcare “felt compelled to do something,” he said.

The Trump administration recently floated the idea of requiring private drug plans under Medicare to pass on the savings to consumers at the pharmacy counter. On Tuesday, Alex M. Azar II, a former executive at Eli Lilly and the new secretary of health and human services, called UnitedHealthcare’s move “a prime example of the type of movement toward transparency and lower drug prices for millions of patients that the Trump administration is championing.”

But insurers have resisted the idea that they be forced to pass on the savings in Medicare drug plans, arguing that it would result in significantly higher premiums for everyone. Federal officials estimate that consumers buying the drugs would save, on average, from $45 to $132 a month under the proposal. But then premiums for all Medicare beneficiaries would increase anywhere from an estimated $14 to $44 a month.

UnitedHealth Group, UnitedHealthcare’s parent, opposes the Medicare proposal because it would raise premiums sharply for older people.

By contrast, the company’s plans offered through private employers would have a minimal effect on premiums, Mr. Schumacher said. “The benefit to the individual is meaningful.”

Employers who self-insure already have the option of passing the discounts onto customers, Mr. Schumacher said. CVS Health, a large pharmacy benefit manager, allows employers to share the discount with their workers and has offered rebates to its own employees since 2013. OptumRx also offers the option of sharing the discount directly with consumers.

But while some employers seem interested, it has not taken off, Mr. Schumacher said. “We have some customer interest,” he said. “It’s in the early innings.”

While some employers want to keep the savings, more are becoming concerned about how these large rebates affect people taking expensive medicines who are in high-deductible plans or pay a significant percentage of every prescription they fill, said Edward A. Kaplan, a senior vice president at Segal Consulting. The rebate “is such a big number,” he said.

The shift to choosing to share those savings with the employees filling these prescriptions “is beginning to happen slowly,” he said.