The top 10 health stories of 2009, Part 1

As we were putting together this year's top 10 list, uncertainty became a motif. Here at the beginning of the flu season, we don't really know if the H1N1 flu pandemic will stay controlled by public health measures, or take off in some unexpected way. Will the yearlong debate over health care reform result in something significant — or wind up being political sound and fury, signifying stalemate?

Many of the stories on this list are works in progress. More black-and-white answers would be nice, but learning to live with gray areas is, perhaps, the beginning of wisdom, and not just in health and medicine.

1. H1N1 flu

Most of the news about this year's H1N1 "swine flu" pandemic has been reassuring. While the H1N1 virus spreads easily and makes people sick, so far it's rarely life-threatening. A major reason for the calm has been the measured public health response. Plenty of information has been made available, and health officials gave us simple, concrete things to do to protect ourselves. A vaccine was developed and put into production, although shortages are a serious concern. We have months of flu season ahead of us and much could go wrong, but early indications show that this pandemic will stay manageable.

2. Health care reform

The final version was still taking shape as the Harvard Health Letter went to press, and the outcome is still in doubt, but some basic elements of health care reform looked to be in place: a mandate requiring individuals to buy health insurance, tighter regulation of health insurers, and the creation of computerized "exchanges" where people and small employers can shop for affordable policies. But chances are that legislation, if it does become law, won't do nearly enough to control costs.

3. Bad fat, good fat

In real estate, it's location, location, location. The same may be true for body fat — and color makes a big difference, too.

Fat location: The visceral fat in our abdomens churns out inflammatory factors and hormones. Subcutaneous fat, which lies under the skin, is metabolically sedate in comparison. Framingham Heart Study researchers reported that visceral, not subcutaneous, fat was associated with calcium deposits, a marker for atherosclerosis, in the body's main artery, the aorta. Visceral fat findings are shifting attention to waist size as a measure of obesity, although it's not so simple: subcutaneous fat also contributes to waist size, especially in women. Still, the notion that diet and other habits should be judged by their effect on waist circumference is gaining traction.

Fat color: White fat cells store fat, and most of the fat in our bodies — visceral and subcutaneous — is white fat. But there are also brown fat cells that actually burn fat. We have brown fat as newborns to help with the regulation of body heat, but it's long been believed that it soon disappears. A surprising trio of articles published in The New England Journal of Medicine used PET scans to show that we actually retain appreciable amounts of brown fat as adults in an area between the shoulder blades, and that the more brown fat an adult has, the more likely he or she is to be lean with healthy metabolic indicators. Researchers are now studying how brown fat cells can be increased or activated.

4. Curbing the doctor-industry relationship

Companies — particularly drug manufacturers — spend billions each year promoting their wares to doctors. In 2009, a wave of new rules and regulations went into effect to slow down the flow of gifts, free meals, and payments to physicians and eliminate conflicts of interest.

Large teaching hospitals barred their faculty from accepting gifts and meals and participating in speaker bureaus. Industry groups and professional societies revised their codes of conduct. Massachusetts and several other states stepped in with gift bans and disclosure requirements. And there is a good possibility that the health care reform legislation will include a requirement that drug and device makers report their payments to doctors on a public Web site.

Industry funding is important in medicine, especially when it comes to research. But it should be aboveboard, for all who are interested to see.

5. An alternative to warfarin?

Millions of people depend on the blood-thinning drug warfarin (Coumadin), especially those with atrial fibrillation. But warfarin interacts with dozens of drugs and herbs and some foods, and frequent blood tests are often necessary to make sure the blood's clotting capacity stays in a safe range. Patients and their doctors have accepted these drawbacks for lack of a good alternative. But this year, a good substitute might have been found. A new drug called dabigatran acts directly on thrombin, one of the key players in the formation of blood clots, and does not require blood monitoring. It has far fewer interactions with other drugs, herbs, and foods than warfarin. But the news isn't all good: in trials, heart attacks and gastrointestinal side effects were more common among those taking the new drug than they were among those taking warfarin. The FDA is expected to approve dabigatran in 2010.

To be continued in next week's issue of HEALTHbeat.