Popularizing Prescription Drugs

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rx-bottle-and-cashLaura Ries was moved to action when she saw a TV commercial portraying a woman happily sharing time with her grandchildren after taking Lyrica, a prescription medication, for diabetic nerve pain of which her elderly mother suffers.

“The ad showed someone who was enjoying life again,” said Ries, president of a marketing strategy firm in Atlanta, who then researched the drug and spoke with her mother’s doctor. “This was very related to what my mom was experiencing.”

Her reaction was precisely the aim of ‘direct-to-consumer’ advertising: getting patients or their family members to remember a drug’s name and ask the doctor for a prescription.

Spending on such commercials has grown 62 percent since 2012, even as ad spending for most other product types was flat.

“Pharmaceutical advertising has grown more in the past four years than any other leading ad category,” said Jon Swallen, chief research officer at Kantar Media, a consulting firm that tracks multimedia advertising. It exceeded $6 billion last year, with television picking up the lion’s share, according to Kantar data. Major network evening news and daytime drama programs are heavy with drug ads.

But the increase of drug advertisements has generated new controversy, in part because the ads inevitably promote high-priced drugs, some of which doctors say have limited practical utility for the average patient-viewer. For example, 60 capsules of Lyrica costs about $400 [the drug Ries asked about for her mother].

Critics, including the American Medical Association who called a ban in 2015, say ‘direct-to-consumer’ advertising inflates demand for new, more expensive drugs and encourages patients to ask their doctors for often marginal — and sometimes inappropriate — drugs that are stimulating high health care costs.

Such prohibition is unlikely. Previous efforts to push such an outcome have stalled, generally on free-speech arguments by the powerful drug lobby who declare that such ads provide valuable information to patients about treatment options.

Spending Zooms

One thing is certain: ‘direct-to-consumer’ advertising is big. And, as nearly everyone who watches TV knows, it’s getting bigger.

Some programs — the nightly news and sitcoms aimed at older Americans — get most of their advertising from drug companies. A Kantar analysis shows 72 percent of commercial breaks on the “CBS Evening News” have at least one pharmaceutical advertisement. Commonly, the ads target a range of conditions that generally affect this demographic. Sixty-two percent of commercial breaks during “General Hospital” include a drug ad.

“A lot of these ads target the caregivers and the children of older people,” said consultant Tom Lom, a former managing partner of Saatchi & Saatchi Consumer Healthcare, which has created ads for pharmaceutical giants.

Drug companies were on track to spend an estimated $6.4 billion on ‘direct-to-consumer’ advertising in the U.S. last year, up 5 percent from 2015, according to Kantar. In 2012, spending for pharmaceutical TV ads was the 12th-largest category. By last year, drug ads were sixth.

While substantial, the spending was less than the amount spent by automakers, retail and restaurants. Networks — ABC, CBS, NBC — along with cable channels like CNN — draw a lot of the pharmaceutical advertising.

According to Swallen, the effect of the ban on networks would be a daunting, 8 percent loss of total ad revenue, and its impact would be most evident for programming popular with viewers older than 60 ­— for instance, evening news shows. Similarly, cable networks such as the Hallmark Channel, which draw viewers from this demographic, would feel the pinch because they work on lower budgets.

Why Some Drugs Are Advertised

For years, the ‘direct-to-consumer’ industry was mostly focused on drugs that relieved chronic, typically non-fatal afflictions like heartburn (Nexium), allergies (Claritin) and high cholesterol (Lipitor).

More recently, Lom said, advertising has focused on more serious illnesses affecting seniors, such as Alzheimer’s disease. Ads for drugs that target constipation caused by other drugs — opioids — hit the scene last year, reflecting the large numbers of people taking painkillers.

In 2016, the top three ads based on total spending were Lyrica, $313 million; Humira, $303 million; and Eliquis, $186 million, according to Kantar Media.

The reasons why some drugs are advertised more than others vary, with drug companies evaluating which products are most likely to bring them the most revenue.

Drugmakers do not care “whether it’s a rare, expensive drug or a popular cheap drug,” said Amanda Starc, associate professor of strategy at Northwestern’s Kellogg School of Management. “They’re looking at the marginal return on advertising. A small number of customers spending a lot or a big number spending a little.”

How Advertising Plays To Consumers

The United States is one of two countries — the other is New Zealand — that allows ‘direct-to-consumer’ advertising, a long-standing practice that became more common in the mid-1980s after the FDA issued new rules. Most advertising was in print. But more television advertising began appearing when some of the rules were relaxed a decade later.

Lom said the ads give consumers a “head start” on knowing about drugs that might be available for their ailments, speeding up the consumer education process.

Surprisingly, 62 percent of physicians, for instance, said they would or might prescribe a harmless, even placebo, treatment to a patient who does not need it but demands it, according to a 2016 poll conducted by Medscape, an online physician education website.

Current rules require that if a drug is named in an ad, information must be included about side effects and adverse reactions. That makes it even more important that drug advertising be visually captivating — if not surprising, say consultants.

Meanwhile, the side effects are glossed over. “The ads describe the risks and at the same time play pleasant music — or show happy images — which helps to distract people from getting the message,” says Dr. Aaron Kesselheim, associate professor of medicine at Harvard Medical School.

Those that do advertise, however, appear to have a handle on the market. Ries, the brand consultant, says it wasn’t just the ad that helped her to remember Lyrica, but the name, too, which was easy to spell and pronounce.

Reis said her mother did take the Lyrica “and it’s helped.” That’s a good thing, says the brand guru who takes pride in looking out for her mother. “The ad spurred the conversation.”

But whether the advertising empowers patients or leaves them vulnerable is debatable.

The Secret to Chronic Happiness

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Lady with cookiesBy all rights, Fletcher Hale should not be happy. At 76, the retired trade association manager has endured three heart attacks and eight heart bypass operations. He’s had four stents and a balloon inserted in his heart. He has diabetes, glaucoma, osteoarthritis in both knees and diabetic neuropathy in both legs. He can’t drive. He can’t travel much. He can’t see very well. And his heart condition severely limits his ability to exercise. On a good day, he can walk about 10 yards before needing to rest.

Yet the Brooklandville, Md., resident insists he’s a genuinely happy guy — in part, because he appreciates what he can do. “There’s no question that as age impinges on your life, you do have ‘black dog’ days,” said Hale. “I fight aging every day. But I never, ever give up. You have to work at keeping happy.”

Hale focuses on the things that bring him joy: writing and listening to music and audiobooks. By juggling those pastimes throughout the day — every day — he ultimately feels a sense of contentment. “Every one of those things requires that I use my mind — which is a good thing.”

Geriatric experts agree that Hale has pretty much figured out the right formula. “You have to be willing to accept your new reality — and move forward,” said Dr. Susan Lehmann, director of the geriatric psychiatry day program at Johns Hopkins University School of Medicine. “Aim to have the best life you can at where you are right now.”

Living with chronic disease often complicates life. The majority of adults 65 and over have multiple chronic conditions that contribute to frailty and disability, according to a 2013-14 report from the Centers for Disease Control and Prevention. The percentage of chronic conditions among people 65 and over has increased over time, too. The percentage of people reporting hypertension, asthma, cancer and diabetes was higher in 2013-14 than in 1997-98, reports the CDC.

Chronic conditions can have a devastating impact on both men and women, according to the CDC report. About 57 percent of women and 55 percent of men age 65 and up reported hypertension. Another 54 percent of women and 43 percent of men reported arthritis. And a full 35 percent of men and 25 percent of women reported dealing with heart disease. At the same time, older women were more likely to report clinically relevant depressive symptoms than were older men. In 2014, 15 percent of women 65 and older reported depressive symptoms, compared with 10 percent of men.

Chronic pain, in fact, more frequently leads to depression than does anxiety, said Dr. Kathleen Franco, associate dean at the Cleveland Clinic Lerner College of Medicine. That depression then leads to additional pain and suffering, she said. “So you have an emotional and physical component.”

That’s why Hale clings dearly to his greatest passion: writing. When he retired at 65, his original plan was to travel with his wife, Tracey. His physical limitations curbed those goals, so he circled back to what has brought him the most happiness. He stays engaged in daily news by writing for two blogs — including one at-large column in which he espouses what he calls his “compassionate conservative” values.

Hale also adores reading, even though glaucoma has made it all but impossible. Not one to give up, he uses his Amazon Echo smart speaker to order audiobooks. He loves sitting on his balcony in the sunshine and listening to books like The Guns of August. Similarly, he enjoys streaming both classical and country music, especially the Oak Ridge Boys and the country rock group Alabama.

Hale also has learned to use Alexa, the Echo’s built-in digital assistant, to help with seemingly simple tasks that are difficult with poor eyesight. To tell time, he simply asks Alexa.

Beyond that, he avoids getting trapped in any frustration loops, such as trying to troubleshoot computer issues. During a recent technological tussle, he simply shut down the machine and turned on PBS and Charlie Rose. “Watching that show keeps my mind active,” he said. After taking time to de-stress, he was able to solve the tech issue.

Hale finds some excuse to get out of his house every day. Sometimes he runs an errand. Or he’ll meet a friend for lunch. As a bird lover, he might just sit in a park listening to birds singing. “If I can combine a pleasant venue with the sound of bird symphonies, I’m a happy camper,” he said.

This is Hale’s version of what some experts call “mindfulness.” Mindfulness, which often involves deep, slow breathing that’s aimed at lowering your heart rate and calming you down, can be highly effective on older, ailing people, said Franco. “It’s simple. It doesn’t cost anything. You can do it and no one even knows you’re doing it.”

One other thing often works like magic: helping others. “Once you start giving to others, you tend not to get stuck in your own aches and pains,” said Franco.

Anne McKinley knows this firsthand. Even at 85, she still volunteers for an aging advocacy group and sits on its board of directors.

McKinley copes with the debilitating effects of lifelong scoliosis. She, too, battles glaucoma, and her visual perception difficulties affect her balance. She’s had both knees replaced and more recently needed emergency surgery for an infection she contracted in the hospital following parathyroid surgery, which also affected her vocal cords.

The Evergreen, Colo., resident said that keeping a very positive attitude — and constantly reaching out to family and friends — keeps her content.

“Feeling like I have control of my life is very important,” she said. “The key is not to feel rushed. I can accomplish one thing in a day and feel good about it.”

It’s been a tough road since her husband, Cameron, died four years ago after 59 years of marriage. But with her master’s degree in social work and experience as a social worker, she knew how to utilize social services for older people in her community. That includes one service that performs housekeeping and other chores for a modest fee.

McKinley still visits family in Florida — though she must use a cane or walker to get around. Her grandchildren frequently come to visit, “and we feast whenever they do,” she added, typically on the cookies and pies she loves to bake. Above all, she said, she’s always getting out of the house. She gets her hair cut every week. “It’s my best remaining feature,” she said.

Then, there’s her Siamese cat, Frankie, who joins McKinley every evening at 6 p.m. to watch the evening news while McKinley makes herself a snack and a martini. “My favorite part is the olives,” she said.

And, yes, she expresses how particularly grateful she is for what she has — including a home with a 20-foot-high ceiling on an 18-acre site, where she can look out any window and see the surrounding beauty.

The real key to happiness at every age and stage — particularly old age — is not material things, but gratitude for life’s simple blessings, like laughter among friends or watching a sunset with a loved one, said Lehmann, the Johns Hopkins doctor. “It’s the small things in life that end up mattering most of all.”

Perhaps Think Before You Eat?

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Diets designed to boost brain health, targeted largely at older adults, are a new, noteworthy development in the field of nutrition.

The latest version is the Canadian Brain Health Food Guide, created by scientists in Toronto. Another, the MIND diet, comes from experts at Rush University Medical Center in Chicago and Harvard T.H. Chan School of Public Health.

Both diets draw from a growing body of research suggesting that certain nutrients — mostly found in plant-based foods, whole grains, beans, nuts, vegetable oils and fish — help protect cells in the brain while fighting harmful inflammation and oxidation.

Both have yielded preliminary, promising results in observational studies. The Canadian version — similar to the Mediterranean diet but adapted to Western eating habits — is associated with a 36 percent reduction in the risk of developing Alzheimer’s disease. The MIND diet — a hybrid of the Mediterranean diet and the DASH diet (Dietary Approaches to Stop Hypertension) — lowered the risk of Alzheimer’s by 53 percent.

Researchers responsible for both regimens continue to study them further in rigorous clinical trials launched this year.

Still, the diets differ in several respects, reflecting varying interpretations of research regarding nutrition’s impact on the aging brain.

A few examples: The MIND diet recommends two servings of vegetables every day; the Canadian diet recommends five. The Canadian diet suggests that fish or seafood be eaten three times a week; the MIND diet says once is enough.

The MIND diet calls for at least three servings of whole grains a day; the Canadian diet doesn’t make a specific recommendation. The Canadian diet calls for four servings of fruit each day; the MIND diet says that five half-cup portions of berries a week is all that is needed.

Carol Greenwood, a professor of nutrition at the University of Toronto and a key force behind the Canadian diet, and Martha Clare Morris, a nutritional epidemiologist at Rush University Medical Center and originator of the MIND diet, elaborate on research findings about nutrition and aging and their implications for older adults.

Nutrition And The Brain

It’s not yet well understood precisely how nutrition affects the brains of older adults. Most studies to date have been with animals or younger adults.

What is clear: A poor diet can increase the risk of developing hypertension, cardiovascular disease, obesity and diabetes, which in turn can end up compromising an individual’s cognitive function. The corollary: A good diet that reduces the risk of chronic illness is beneficial to the brain.

Also, what people eat appears to have an effect on brain cells and how they function.

“I don’t think we know enough yet to say that nutrients in themselves support neurogenesis (the growth of neurons) and synaptogenesis (the growth of neural connections),” Greenwood said. “But pathways that are needed for these processes can be supported or impaired by someone’s nutritional status.”

Essential Nutrients

“Several nutrients have been shown to have biological mechanisms related to neuropathology in the brain,” Morris said.

On that list is Vitamin E, a powerful antioxidant found in oils, nuts, seeds, whole grains and leafy green vegetables, which is associated with slower cognitive decline, a lower risk of dementia, and reduced accumulation of beta-amyloid proteins — a key culprit in Alzheimer’s disease.

“The brain is a site of great metabolic activity,” Morris said. “It uses an enormous amount of energy and in doing so generates a high level of free radical molecules, which are unstable and destructive. Vitamin E snatches up those free radicals and protects the brain from injury.”

Also on her list is vitamin B12 — found in animal products such as meat, eggs, cheese and fish — and vitamin B9 (folate), found in green leafy vegetables, grains, nuts and beans.

Because aging affects stomach acids that facilitate the absorption of B12, “everyone who gets to middle age should have a doctor check their B12 levels,” Morris said. A deficiency of this vitamin can lead to confusion and memory problems, while folate deficiency is associated with cognitive decline and an increased risk of dementia.

Omega-3 fatty acids found in fish and nut oils, especially DHA (docosahexaenoic acid), are highly concentrated in the brain, where they are incorporated in cell membranes and play a role in the transmission of signals between cells.

“A primary focus has to be maintaining healthy” blood vessels in the brain, Greenwood said. “So, heart health recommendations are similar in many ways to brain health recommendations, with this exception: The brain has higher levels of Omega-3s than any other tissue in the body, making adequate levels even more essential.”

Other studies point to calcium, zinc and vitamins A, C and D as having a positive impact on the brain, though findings are sometimes inconsistent.

Foods To Avoid

For the most part, the Canadian and MIND diets concur on foods to be avoided or limited to once-a-week servings, especially saturated fats found in pastries, sweets, butter, red meat and fried and processed foods.

As for dairy products, “there’s no evidence one way or another. If you like your yogurt, keep eating it,” Morris said. Greenwood adds a caveat: Make sure you consume low-fat dairy products as opposed to whole-fat versions.

Other Helpful Diets

Randomized clinical trials have demonstrated that both the Mediterranean diet and the DASH diet have a positive impact on various aspects of cognition, although neither was created specifically for that purpose.

“At the end of the day, our [Canadian] diet, the MIND diet, the Mediterranean diet and the DASH diet are not that different; they’re all likely to be helpful,” Greenwood said.

The Pattern Counts

Studies promoting the cognitive benefits of drinking tea or eating blueberries have recently garnered the headlines. But a focus on individual foods is misguided, both experts suggested. What matters instead are dietary patterns and how components of various foods interact to promote brain health.

The bottom line: Concentrate on eating an assortment of foods that are good for you. “As long as people are eating a healthful diet, they shouldn’t have to worry about individual nutrients,” Greenwood said.