Friday, April 27, 2012

It's Getting Louder!

Can you hear it? From barely a whisper a year ago, the voices are getting louder. With drumsticks in hand, as the data continues to accumulate, more leading scientists are beginning to beat the drums of caution against dietary supplements.

"Emerging evidence has shown that high doses of certain supplements can actually increase the risk of cancer" wrote Maria Elena Martinez, PhD, of the University of California San Diego, and co-authors in a commentary just published online in the Journal of the National Cancer Institute.

Except for their value in treating a few uncommon nutrient deficiencies, Martinez and co-authors also wrote that "Dietary supplements have minimal supporting data for health benefits in disease prevention, particularly cancer. Despite this evidence [of potential harm], marketing claims by the supplement industry continue to imply anti-cancer benefits. Insufficient government regulation of the marketing of dietary supplement products may continue to result in unsound advice to consumers. Both the scientific community and government regulators need to provide clear guidance to the public about the use of dietary supplements to lower cancer risk."

One of the most notable comments emerging from the study related to the fact that even though "preclinical studies suggested that dietary antioxidants -- including beta-carotene, alpha-tocopherol, and vitamin C -- encouraged growth of normal cells and tissue and inhibited growth of abnormal tissue, clinical studies failed to support the favorable laboratory evidence." In layman's terms this means that animal studies cannot be relied upon to determine human usage."

Here are some excerpts from an article appearing in Medscape regarding some of the revealations:

"Several antioxidant trials have shown increased cancer risk with supplementation, the authors wrote. The most notable examples were two randomized trials of patients at high risk for lung cancer because of smoking or exposure to asbestos. Both trials showed an increased incidence of lung cancer in participants randomized to beta-carotene.

Laboratory and observational data had suggested a protective effect of folic acid against cancer, particularly colorectal cancer. However, a meta-analysis of randomized trials showed no effect of folic acid supplementation on development of colorectal adenomas (Int J Cancer 2011; 129: 192-203).

Two different randomized trials showed an increased risk of cancer (prostate) and precancerous lesions (colonic adenomas) in participants on long-term folic acid supplementation.

The Institute of Medicine recently updated its recommendations on vitamin D and calcium intake and found "there was not enough evidence to state that there is a causal association between low vitamin D intake and increased cancer risk."

Epidemiological studies have shown inverse associations between serum levels of 25-hydroxy (OH) vitamin D and several types of cancer. Three short-term randomized trials failed to demonstrate an effect of vitamin D supplementation on cancer incidence or mortality.

Observational studies have yielded conflicting data on the association between vitamin D concentrations and the risk of pancreatic cancer."

Time and again, a review of the evidence shows that supplements may not only lack clinical value, but may actually be harmful. The risk/benefit and the cost/benefit analyses therefore recommend against willy nilly usage.

Yet, modern day reincarnations of 19th century snake oil hucksters continue to thrive. Just yesterday, Dr. Oz on an episode of his show recommended no less than eight different supplements, all for weight loss or bloating. Suffice it to say, after researching each and every one, I could find no valid and reliable scientific support based on proper and sufficient studies to support seven out of eight the products, and only found mild support for one of them. I wish I had a drumstick. I know where I would want to bang it.

Yesterday morning, I did get to do a little noise-making of my own on a local Fox 29 morning news segment. The theme of the segment was how to best live to 100 and I was asked to discuss the value of natural foods over pills. With a colorful display in front of me of mostly unprocessed foods that included wild salmon, a variety of fruits and vegetables, and unsweetened almond milk, I described the benefits of each food over popular used supplements.  

There is no question that certain supplements, used selectively, may have benefit. Accordingly, we need to continue studying them to determine which fall into the usefulness category. In the interim, for the umpteenth time, don't use dietary supplements without the advice of a doctor and don't take advice from doctors who sell supplements.

At the same time, you may want to cover your ears because I suspect the noise is going to get much louder.

Wednesday, April 25, 2012

My Wife Is Smarter Than Me

I grew up on dietary supplements. As I've written before, my mother was a devout reader of Prevention Magazine in the 1960s and my supplementation experience began with cod liver oil some 50+ years ago and continued over many years with strong recommendations to take Vitamin C, beta-carotene, the B complex vitamins, etc. It was only within the past year or so that I realized my folly.

My wife, Yael, on the other hand, has always disdained supplement pills. We never really discussed her aversion to such pills and I just assumed she didn't like pills in general as she always tries to avoid medication whenever possible (another check-mark on her smart list).

Today, we got into a discussion about dietary supplements and she reminded me of her decision to abstain from them over all the years that I was popping them.  I finally asked her specifically for her reasoning. Her answer was so eloquent and pure that I had to write about it.

She explained that part of her childhood took place on a farm where she would pick eggs off the floor and fruits and vegetables from trees and fields.  It simply never made sense to her that somehow our health was dependent on taking little capsules that had been chemically synthesized and produced in some plant or laboratory as opposed to eating nature's own produce. She is so right and obviously much smarter than me because she realized the insanity years before I did.

Yet, it is reported that by some estimates, 80% of Americans now take some form of dietary supplementation. This is unfortunately the case despite a slew of recent studies beginning to form quite a unavoidable pile that have revealed that these pills instead of making us healthier may in fact be making us sicker.

A new patient of mine yesterday handed me Tuft University's Health and Nutrition Letter and asked my opinion if it was worth reading. She was on a dozen dietary supplements and admitted confusion on what she should take and had sought out such publications for affirmation of her choices. By the way, she was on many of the usual suspects with doubling and tripling of dosages across her various pills. Some dosages were 30 times the recommended daily allowance (RDA). I put her on a two week vacation from all her dietary supplements other than Aspirin to see if it would help with some of he medical issues.

Nevertheless, I promised to read Health and Nutrition Letter and report back to her on its value and reliability. After reading it, on first exposure, I give it a thumb's up. I thought it was well written, thoughtful, not attempting to be provocative; rather, I found the information to be factual and reported without apparent bias.

Articles included a report further debunking ginkgo biloba as effective in preventing heart attacks and strokes. It did report that ginkgo may have some mild benefit in preventing peripheral arterial disease (disease of blood vessels in arms and legs that prevents blood flow). Another article reported on yet another study that shows the benefits of a Mediterranean diet. There were articles on the FDA warning Cheerios about their bogus health claims and how Organic produce, contrary to widespread myth-making, has no nutritional benefit over conventionally raised produce. The study did not address the pesticide risks, just the nutritional value.

But my favorite article was titled "The Bad News About Products "Too Good to Be True."" It was a well presented argument against the false advertising perpetuated by a rapidly growing supplement industry. One key aspect of the article was discussion how Congress bowing to pressure from the ever-growing increasingly powerful dietary supplement industry, essentially sought to gut the 1990 Nutritional Labeling and Education Act (NLEA) by passing the Dietary Supplement Health and Education Act in 1994 (DSHEA) and the Food & Drug Admoinstration Modernization Act (FDAMA) in 1997.

While the NLEA "set a standard of "significant scientific agreement" for health related claims on product labels," both the DSHEA and FDAMA, according to a professor named Dr. James Tilloston at Tufts, marked a "return to snake oil. The FDA's hands are tied by unwise policy initiated by pressure groups to allow them to huckster. It's undermined all health claims."

I was recently interviewed by a reporter for The Globe Magazine on the deceptive practices of dietary supplement marketers. The reporter told me something that should give us all pause for thought. She told me that the reason there have been so few articles exposing the chicanery of the industry is because the dietary supplement industry represents a significant source of advertising dollars and no media outlet usually wants to bite the hand that feeds it. Nevertheless, I see this changing as the proverbial cat is out of the bag as the tsunami of recent studies showing harms from many such products simply can't be ignored.

 If this is any solace and it shouldn't be, I was invited to appear on the most popular morning TV show in Australia to discuss the problems with dietary supplements. I guess this growing public health problem is not confined to our borders and has become a world-wide phenomenon.

So warn your family, friends, neighbors, and even strangers: Don't take supplements without the advice of you doctor and even when doctors gives such advice, you should ask them what information they are relying upon as that information may now be outdated.

A word to the wise should be sufficient.

Tuesday, April 24, 2012

Polypills: Much Ado About Nothing

It is said that the body of medical knowledge is now doubling every five years. Unfortunately, no one said how much of that medical knowledge is useful. Today's blog will serve up a full dose of my deepening cynicism of the value of many medical studies being conducted around the world.

Here's one for fodder with a description excerpted from Medscape.

"April 19, 2012 (Dubai, United Arab Emirates) — A full-dose polypill strategy, combining aspirin, three antihypertensives, and a statin, not surprisingly produced greater drops in blood pressure and LDL cholesterol than those seen in the original half-dose combination pill, but with no significant differences in adverse effects, results of the TIPS2 trial show."

So here's the apparent takeaways from this study. First, that the included medications work in combination. That makes sense as they are often taken together. Second, drugs taken at their usual doasges work better than at half their dosages. Third, that once restored to their normal dosages, the combined drugs had no greater side effects than at half their dosages. Wasn't this known already from prior testing and popular usage of these drugs? Besides, this makes sense as they were used within their tested and FDA approved therapeutic ranges and therefore one would expect minimal side-effects for these commonly used drugs. This study followed a study that wanted to test the effectiveness of a combination pill at half the usual doses which worked but not as well as at regular dosages. 

Are you following the circular logic? They started with half dosages of popular drugs combined in one pill and got lesser results, so they doubled the dosages and got better results. So what?

But here's the real kicker from the article:

"Several key questions remain to be answered. Chief among them is whether a single-pill strategy not only will prove effective but will also actually increase compliance."

You see the problem is that no one wants to develop polypills because they can't be easily patented and they are apparently expensive to produce. Also, given the problem with medication compliance (taking pills as prescribed), it isn't even clear that one pill will get higher adherence than multiple pills do.

In the final analysis, a study shows that at half dosages of a combination of widely used medications you get lesser results. At regular prescribing dosages, you get better clinical results but no greater side effects than at half doses. Yet, no one wants to manufacture such pills because they first need regulatory approval and no one wants to sponsor the expensive studies needed to get such approval because they can't make money off the products because they can't easily patent them.  Most importantly, even if it was approved and produced, there is nothing to show that such polypills can be affordably sold and that they will even improve usage of such drugs.

Given all these facts, it sure seems like much ado about nothing.

Monday, April 23, 2012

More on Probiotics...

On March 10, 2012, I wrote a blog about probiotics and their limited usefulness. The original blog is below.

Here's an addendum:

According to comments made by Walter Coyle, MD, of the Scripps Clinic in La Jolla, Calif at the American College of Physicians' annual meeting and a report published by MedPageToday, "the science of the intestinal "microbiome" is still in its infancy and it remains unclear what changes to make, let alone how best to make them."

One of the primary reasons relatively little is known about intestinal bacteria is that the mix of gut flora varies greatly between individuals. For example, according to Coyle, a study of three members of the same household revealed that their intestinal bacterial composition differed markedly.

Also, it is believed that both environmental (outside) influences and host factors (the person's own internal activity) both play a role in how an intestinal bacterial community evolves, "host genetic influences [on the gut microbiome] remain unexplored," according to Coyle.

Host factors are considered important because during adulthood, individuals achieve a "characteristic "core" population of intestinal bacteria that remains stable even in the face of disruptions such as antibiotic treatment."

Here's some additional interesting information:

Two major categories of bacteria dominate in the intestine: Firmicutes and Bacteroidetes. Studies have found that obese people tend to have a higher ratio of the former to the latter. In fact, one clinical study of 12 people eating a calorie-restricted diet for one year found that there was no weight loss until the ratio of Firmacutes to Bacteroidetes shifted.

Unfortunately, it is not known if the ratio shifted as a result of metabolic changes or that metabolic changes resulted from a shift of the ratio. So if you are looking to lose weight, don't rush out and buy probiotics with  Bacteroidetes just yet because you may be wasting your money.

There is quite a bit of additional study needed before any reasonable conclusions and therapeutic applications can be derived for safe and effective medicinal use of probiotics. In the interim, probiotics appear to remain somewhat useful for irritable and inflammatory bowel syndromes and with antibiotic usage. Probiotics can also prevent yeast infections for women on antibiotics so I highly recommend their usage while on antibiotics. Remember, you need at least a billion (yes, "b") colonies (read more below). Otherwise, avoid them as you should any other unsubstantiated dietary supplements.

Blog from March 12, 2012:

What About Probiotics?

During my lectures on supplements, I am often asked "What about probiotics?" Before I share my common response with you here, let's first make sure we agree on the definition of a probiotic. According to the NIH's National Center for Complementary and Alternative Medicine, probiotics are defined as follows:

"Probiotics are live microorganisms (in most cases, bacteria) that are similar to beneficial microorganisms found in the human gut. They are also called “friendly bacteria” or “good bacteria.” Probiotics are available to consumers mainly in the form of dietary supplements and foods.

[(Prebiotics are non-digestible food ingredients, like oligofructose and inulin, which stimulate the growth and/or activity of "good bacteria" in the digestive system.)] 

The concept behind probiotics was introduced in the early 20th century, when Nobel laureate Elie Metchnikoff, known as the “father of probiotics,” proposed in The Prolongation of Life: Optimistic Studies that ingesting microorganisms could have substantial health benefits for humans. Microorganisms are invisible to the naked eye and exist virtually everywhere. Scientists continued to investigate the concept, and the term “probiotics”—meaning “for life”—eventually came into use.

Picturing the human body as a “host” for bacteria and other microorganisms is helpful in understanding probiotics. The body, especially the lower gastrointestinal tract (the gut), contains a complex and diverse community of bacteria. (In the body of a healthy adult, cells of microorganisms are estimated to outnumber human cells by a factor of ten to one.) Although we tend to think of bacteria as harmful “germs,” many bacteria actually help the body function properly. Most probiotics are bacteria similar to the beneficial bacteria found naturally in the human gut.

Various mechanisms may account for the effects of probiotics on human health. Possible mechanisms include altering the intestinal “microecology” (e.g., reducing harmful organisms in the intestine), producing antimicrobial compounds (substances that destroy or suppress the growth of microorganisms), and stimulating the body’s immune response.

Probiotics commonly used in the United States include Lactobacillus and Bifidobacterium. There are many specific types of bacteria within each of these two broad groups, and health benefits associated with one type may not hold true for others."

Okay, so now you have a good broad understanding of what they are, the question remains should you actively consume them?  I have studied this subject extensively, and yet I claim no definitive expertise on it because there is so much ongoing study. However, here is what I can tell you.

As far as I have come to understand after review of multiple sources, probiotics do no harm. Of course, that statement only holds true within reasonable limits. If outlandish quantities were consumed (trillions), I'm not sure what would happen.  For example, even drinking too much water can be harmful as it would overwhelm the kidneys and flood the gastrointestinal system.

So if it probiotics aren't harmful, does that make them helpful?  For general use, the jury is still out, but the overwhelming consensus and numerous previous studies suggest that they provide no real benefit for a person with a healthy gut.  Changing the bacteria composition of one's gut is not easy under normal circumstances, and in fact, most commercially available probiotic products neither contain sufficient colonies (need at least 1 billion) nor the wide range of different types of good bacteria to make any difference.

(As a side note, carnivores (meat eaters) typically have different bacteria colonies than herbivores (plant eaters). The significance of this fact is not well understood at this time. Also, immediate family members often have the same bacterial colonies and if a family member wants to be restored to their historical composition after a bout of serious infection or illness, it can be accomplished by fecal implant through a nasogastric tube or sometimes through a fecal enema.)

So when are probiotics helpful? They are helpful when you are taking a course of antibiotics, which by definition kills all bacteria, good and bad. The probiotics help to replenish the healthy bacteria even as the unhealthy perish. Probiotics are also believed, based on several studies, to be helpful with diarrhea, dysentery, and allergic gastritis.  In fact, with diarrhea related illness, they are said to reduce symptoms and duration of disease by as much as 50%.

(On a personal note, I can attest to their apparent efficacy after recently being afflicted with such a viral illness. Taking probiotics gave me some relief, even if it was only through peace of mind that I was doing something to help myself. Imodium and electrolyte replacement with pedialyte helped as well.)

Some studies report benefits from taking probiotics with Irritable Bowel Syndrome (IBS) and inflammatory bowel diseases such as Crohn's Disease (Terminal Ileitis) and Ulcerative Colitis. They are also reported to be useful for atopic eczema (a skin condition most commonly seen in infants) and with Helicobacter Pylori or H Pylori as it is often referred, infections, now known as the main cause of gastric ulcers.

The good news is that studies are continuing and we expect to have more definitive answers in the not too distant futures.

In the interim, I suggest you save your money and only use probiotics when either something has already gone wrong that may be amenable to correction with probiotics, or in the case of you are taking antibiotics where they may prove protective.

Notwithstanding, make sure that you only use products that contain at least 1 billion colonies and have at least a few different strains.   VSL3, Bio-K, and Lactobacillus GG seem to be three reputable products. (No, I have no financial or other relationship whatsoever with any of these manufacturers.)

The best advice I can give you is be careful what you put in your mouth, don't eat anything if you are not sure it is fresh, and wash your hands well before eating. Also, learn how to manage your stress. These protective measures may spare you ever needing a probiotic. Stay healthy, my friends!

Update for September 2013

A very recent study shed light on the effectiveness/ineffectiveness of probiotics. This recent well designed study failed to show any benefits for probiotics in preventing Antibiotic Associated Diarrhea (AAD). This is significant because many doctors, myself included, often recommend adding probiotics when taking antibiotics for the specific reason to prevent AAD and Clostridia Dificile superinfection. This new study throws that recommendation into disrepute and knocks off yet another reason to take probiotics.

Sunday, April 22, 2012

Can You Grow Your Brain?

Does exercise lead to a better brain? According to an article in today's New York Times Magazine, it can.  In a recent blog, I discussed a number of studies that show that exercise can elevate mood and can have the same medicinal effect as antidepressants in treating mild to moderate depression. So you don't need to be a Rhodes Scholar to appreciate the therapeutic benefits of exercise.  However, we apparently do need a scholar by the name of Justin Rhodes to tell us why. Dr. Rhodes, a psychology professor at the University of Illinois conducted an interesting set of experiments with mice that showed that among four sets of mice, those who engaged in the most exercise saw an increase of new neurons or brain cells, even more than those who received the most mental stimulation.

The credit for this effect is partially given to something called B.D.N.F. When I first saw this acronym, I immediately thought that it stood for Brains Do Need Fun. Alas, it actually stands for the more mundane Brain Derived Neurotrophic Factor, which in layman's terms means it makes brains grow. I still like mine better because fun does make everything better, but it's still good to hear that we can potentially grow our brains. Scientists, however, believe that the growth from exercise in mice is not solely from  B.D.N.F, because they think that the process must include other complex biochemical processes and genetic cascades.

I am a huge believer in the benefits of exercise not only for mental health, but for heart health as well. Every study I've ever read supports that conclusion. However, I have my usual set of problems with these mice studies. First, it was done in mice, which means it is not necessarily extrapolatable to humans. In fact, scientists are unable to study similar affects in humans, although studies do show an increase in B.D.N.F levels after exercise.

Second,and more importantly, if exercise increases brain size and density, wouldn't professional  athletes have bigger, healthier, and more durable brains than the rest of us? I've yet to read or hear of a study that showed that athletes are smarter, develop less Alzheimer's, and in general have healthier brains than the rest of the population. Have you? Perhaps there is a threshold regarding the effects of exercise? Perhaps, when you start from zero and steadily increase, you experience heart and brain benefits up to a point, and then further increases lead to deterioration? That theory would be consistent with a couple of studies I've read that showed that professional athletes all develop some form of heart damage from their high levels of exertion.

Now please don't us this blog as an excuse to avoid exercise. It's not. The average person is no more likely to reach that turning point when exercise becomes potentially harmful than they are to grow their muscles "too big" in a gym. Professional athletes generally waive caution in pursuit of excellence, and most people will never get close to that level of endurance (nor should they).

Physical activity is the hallmark of health and longevity. All studied centenarian communities are predicated on constant physical activity. If that's not possible for you due to the nature of your work or other circumstances, then schedule, if possible, robust exercise for ideally 30 minutes a day. If you miss a day, ignore it and do better the next day  Even ten minutes of brisk activity a day was shown in one study to decrease heart attack risk by 50%. (Not a perfect study, but as you may have learned by now they never are, are they?) Minimally, get out of your chair every 55 minutes ans either take a walk, go up and down stairs, or do some jumping jacks.

Nevertheless, how do you know if your exercise is adequate for good heart and brain health? My rule includes singing. For endurance related aerobic exercise, try to get to the point where singing becomes difficult. Not where your singing becomes difficult for others, which may always be the case, but for you. By the way, if these words compel, you to start exercising or increase your level of exercise, please consult with your personal physician before doing so.

Ultimately, I can't tell you if the brain is figuratively or literally like a muscle that grows stronger with exercise, but I'm pretty sure that like a muscle, if you don't use it, you will lose it. 

Friday, April 20, 2012

Want Milk?

Contrary to popular opinion, I am not a fan of dairy products. Perhaps it is because of my own lactose intolerance or because of the several books and studies I have read.

One book with the heady title, The China Study: The Most Comprehensive Study of Nutrition Ever Conducted and the Startling Implications for Diet, Weight Loss and Long-Term Health, written by  T. Colin Campbell, a PhD long-time nutrition researcher, particularly gave me pause for thought. In his highly controversial book, Dr. Campbell puts forth the argument, supported by some data, that dairy products and their derivatives are a major culprit in the development of diabetes, heart disease, and cancer. I'm not sure I accept all the books arguments or conclusions, but I'm also not ready to dismiss them out of hand.

Therefore, when it comes to milk products and their protein derivatives like casein, I have been urging caution. Therefore, imagine my surprise when today I read a banner on a medical website that declares Low Fat Dairy Skims Off Stroke Risk. First, the study done in Sweden, one of world's five highest countries that consume dairy products, was an observational study. In other words, after the fact, they looked at what happened. Second, all the study showed was a reduced risk of stroke from eating low-fat versus full fat dairy. It should not be a surprise that consuming less saturated fat will cause less strokes. The study did not compare dairy to non-dairy eaters.

So after careful review of two descriptions of the study (no access to actual study), I surmise that the results are basically meaningless (nothing new) and no conclusions can be drawn without further study. That's also the stated conclusion of the study's authors.

So for the moment, I continue to recommend against dairy products. But,if you have to eat them, then choose the low fat variety such as yogurts, Greek yogurts, low-fat organic (whatever you do, don't drink conventional milk, which is full of hormones), low fat organic cream cheese, etc.

Wednesday, April 18, 2012

Money and obesity. Is there a link?

It's a staple of popular belief, even cited by First Lady Michelle Obama, that poor neighborhoods are food deserts, generally void of healthy fare. As a result, it is believed that  socioeconomically challenged people are nutritionally disadvantaged because they cannot access nutritionally-sound food, which results in increased solicitation of fast food restaurants and a higher incidence of obesity. Well it turns out, based on two new studies, that such neighborhoods may, in fact, be food swamps, concentrated with a high density of grocery stores and supermarkets in addition to the fast food establishments.

To quote the NY Times, "Such neighborhoods not only have more fast food restaurants and convenience stores than more affluent ones, but more grocery stores, supermarkets and full-service restaurants, too. And there is no relationship between the type of food being sold in a neighborhood and obesity among its children and adolescents."

Okay, so I guess you may say we can cross that cause off the obesity list.  I say hold your horses.

First, even though stores like groceries and supermarkets may be present, the studies revealed nothing about pricing. Over the course of my lifetime, I have read and witnessed numerous cases of predatory pricing in poorer neighborhoods. There have been a number of publicly reported mortgage scams involving companies charging higher rates and costs to poorer people. I know of clothing stores located in poor neighborhoods that charge a premium for their wares because they know that convenience is more important for their customers who can't easily get to malls and mainstream stores to shop comparatively. So just because the stores are in the neighborhoods doesn't mean they sell affordable healthy food.

Second, it takes more time, effort, and decision-making to prepare healthy food versus buying fast food.  In his book, Willpower, Roy Baumeister lays out a cogent argument that willpower is a function of decision-making--the more decisions you make the less willpower you have. He bases this on studies that show that decisions require neurotransmitters which rely on blood sugar. As decisions are made, sugar is depleted, and fatigue takes hold unless sugar is replenished. (This is not an excuse nor should it be construed as a reason to consume white sugar products; rather, it merely indicates that eating throughout the day complex carbohydrates found in fruits and vegetables allows for better decision-making.)

Baumeister gives the example of the car buying experience. Devious or clever car dealers, you make the call, exhaust your decision-making ability early with your choosing the free stuff such as interior and exterior colors and then wait until the end of the process to entice you with the expensive add-ons. (Next time you buy a car, eat well before you go and start with the add-ones.) Another example he gives in that in the Israeli penal system, paroles are less likely to be granted before lunch and at the end of the day, and more likely at the start of the day and after lunch. The reason he gives is that when their decision-making has been taking place for a while, the parole board members become more wary of making bad decisions and err on the side of caution by denying parole. The study he cites states that it made no difference whether it was an Arab or Jew that were up for parole; instead, the time of day was a major deciding factor. (By the way, the Israeli's addressed this finding by providing fruit snacks to the parole board members throughout the day.)

It's been said that the only people who think more about money than rich people are poor people who think of nothing else. Applying Baumeiter's thesis to poor people, by the time they need to make dinner plans, they are mentally depleted from the numerous decisions they needed to make all day, which are far in excess of the more affluent. So let's cut poor people some slack for making poor dietary decisions at the end of the day.

Now don't get me wrong. I'm not condoning this sad state of affairs nor dismissing it as incurable. The facts remain that poor people experience more obesity than wealthier people, although there are plenty of overweight and even obese "rich" people and plenty of fit and well-nourished "poor" people. Nevertheless, society has a serious problem wanting a definitive solution.

The solutions to the obesity epidemic are not easy regardless of what some pundits argue. It will take the concerted effort of public and private crusaders to teach people the true value of good food choices,  provide consistent access to affordable "healthy" foods, and the support and guidance of the the health care industry to effect real change. The pace to date has been slow but the topic has gotten much attention of late and let's hope it stays on everyone's radar and a solution is found.

In the interim, here's a new recipe my daughter shared with me. Kale, a type of cabbage-like, green leafy vegetable, has the highest nutrient density of virtually any vegetable and should be part of a healthy diet.

Cut off and put the the leaves of Kale into a bowl
Tenderize the leaves with lemon juice.
Add a touch of olive oil and a dash of salt.
Cut mango slices into the salad and add pumpkin or pine nuts.
You may also add a tsp of honey if needed.

This salad blows me away and I suspect you will love it as well. Hearty appetite!

Monday, April 16, 2012

My responses to NY Times Opinion piece.

An "Opinion" piece ran in Monday's NY Times in which six individuals weighed in on what it will take to address the poor eating habits of Americans.

The link to the NY Times piece is at end of this blog.

In the comments section, I posted the following three responses.

Part 1: After reading the views about improving healthy eating, one subject was untouched--the role of physicians, nutritionists, and registered dietitians (RDs) in correcting American's poor eating habits. Most Americans continue to trust their physicians and the advice they receive. A recent study demonstrated that patients are likely to heed nutritional advice when given. Nutritionists/RDs have the most relevant training of anyone to address patients' dietary habits. Yet, most health insurances do not reimburse for such services. Medicare primarily only pays for nutritional therapy for diabetics and end stage kidney disease. Due to no reimbursement for nutritional services, physicians do not employ nutritionists/RDs in their practices. This may be the most shortsighted aspect of our healthcare system. In 2011, Medicare added an Annual Wellness Visit. This visit requires completion of a health risk assessment, and appropriate referral as needed. Often, that need centers on nutritional services. During a July 2011 conference call regarding the Annual Wellness Visit with Centers for Medicare and Medicaid Services (CMS), I asked how is that referral to be successfully made given there is no reimbursement available to cover it. The response was that I had asked a good question that needed to be addressed. During a similar conference call last month, the issue was unaddressed and there is still no solution.

Part 2. Patients developing chronic diseases, i.e. diabetes and heart disease, generally have poor access to a nutritionist or RD. Absent insurance coverage, they must pay out of pocket. As few seek such services, dietitians need to charge more to cover costs. Yet, when diabetes, heart disease or other diet-related diseases, e.g. dementia, cancer, strokes etc., emerge, then the floodgates open and we pay. From 1989 to 2010, I led an organization that provided medical care to over 5 million seniors and saw what happens to many Americans who live an unhealthy lifestyle, get sick, and are institutionalized. Lifestyle intervention could have made a difference because as the CDC states, "the evidence for the power of prevention is now indisputable." In response, I opened in October 2011, MDPrevent, a primary care/preventive medicine/education center committed to helping patients stay and get healthy. We group doctors, nurse practitioners, health psychologists, nutritionists/RDs, fitness instructors, and health educators to facilitate affordable nutritional seminars, weight loss, mindfulness and cooking classes, diabetes education, life-transformation classes, fitness and yoga classes. So while others debate how to get people to eat healthier, we are busy doing it. If insurance companies started covering lifestyle modification programs and nutritional services, we could all start focusing on prevention instead of treatment.

Part 3. Despite this apparently righteous debate about improving diets in America, I fear that this discussion will be put to a more nefarious use--support for dietary supplementation. The marketers of such products, despite the absence of supporting evidence for their value (and most recently evidence of heir harmfulness), often argue that Americans eat poorly and need to supplement to maintain good health. Most Americans despite their obesigenic and otherwise unhealthy diets, get sufficient vitamins and minerals from the numerous fortified foods they consume. Yes, there is a huge problem with the nature of food most people eat, but the answer is not increased supplementation.

Link to NY Times article:

Sunday, April 15, 2012

I Just Don't Know

Today's blog has two parts and thought-trains.

Part 1

I typically don't read Glamour Magazine. However knowing my penchant for all things related to vitamins, my youngest daughter was delighted to share an article she came across in the magazine. The gist of the article were the responses from three experts to a question regarding the appropriateness of taking multivitamins after recent studies have suggested they may be harmful.

The first response came from a PhD who works at the Fred Hutchinson Cancer Research Center whose response was basically no, they are not needed. The second response came from a MD and professor of prevention at a Harvard teaching hospital who basically said no except in specific cases like folate during pregnancy shown to avoid birth defects. The third response came from Dr. Michael Roizen, the Chief Wellness Officer of the Cleveland Clinic who basically said yes because people don't eat good diets.

I was infuriated that he answered as he did. I met the man a little over a year ago when I visited the Cleveland Clinic in Ohio. The purposes of the trip was to explore partnership with him and the Clinic regarding my new prevention initiative. (For full disclosure, there were a number of subsequent conversations and correspondences after the trip as I vigorously pursued the opportunity. Eventually, however, I walked away because I found their terms of partnership to be highly lopsided.)

Notwithstanding, during the trip, I had an opportunity to speak to Dr. Roizen in privacy. During that time, which was relatively early in my auditing the field of prevention, I asked Dr. Roizen which dietary supplements he believed stood out among all others and that he would personally recommend for daily consumption. His list included baby aspirin, fish oil, probiotics, Vitamin D, and turmeric.

On the surface, it's not a bad list. Under the right set of circumstances, the first four have clear benefits. However, he did not know my medical history and therefore it was probably imprudent to him to make such specific recommendations, but then again I asked and he was happy to oblige. (Read more about this in part 2 of this blog.) 

For example, aspirin can prevent platelet aggregation (thereby decreasing blood clots) and some studies show some benefit in preventing colon cancer, but aspirin can also increase gastric bleeding and can lead to the development of macular degeneration. Given my history of gastric ulcer, aspirin is a tough choice.

One of my recent blogs dealt with fish oil at length, so just to summarize, its not the panacea everyone has made it out to be and given the option, eating fish like Wild Alaskan Salmon beats it hands-down.

Another one of my blogs dealt with probiotics and an extensive body of research supports my assertion that probiotics have no benefit if you have a generally healthy gut. They can be beneficial when taking antibiotics and when dealing with inflammation of the bowels, but they are not useful routinely.

Many people are apparently (I say apparently because no one knows for sure) Vitamin D deficient because of lack of sun exposure. However, treating anything on presumption, I believe is a mistake. First of all, many foods are fortified with Vitamin D so even though one does not get much sun exposure one is not necessarily deficient. Second, it is easy enough to check for a Vitamin D deficiency and by doing so the result will indicate if you there is a need to supplement and also how much should be taken.

So viewed in their entirety, the first four suggestions from Dr. Roizen were not outlandish as they generally do not cause harm (except for aspirin.) and may be beneficial at times. Tumeric, however, is another story.

Dr. Roizen told me that tumeric prevents Alzheimer's and is good for brain health. Based on Dr. Roizen's suggestion that day (and my hearing him repeat the same advice a few days later on the Retirement  Living TV channel), I naively purchased tumeric and began to add it regularly to my food.

Unfortunately, the highly staining substance turned my teeth bright yellow.  After this disconcerting turn of events, I began intensively researching tumeric and discovered two disturbing facts. First, tumeric has little validated science to support its use for the indications Dr. Roizen asserted. Second, I discovered that in the absence of a black pepper called piperine, tumeric is very poorly absorbed by normal ingestion and so adding it to my food was an effort in futility, except if turning my teeth yellow was my endgame. (By the way, I had to go to a dentist to get rid of the stain.)

Despite these five recommendations, I should have been even more wary of Dr. Roizen's advice when he also practically whispered to me, as to share a well-kept secret, that a certain statin drug had also been shown to decrease the development of Alzheimer's. The whispering should have been the giveaway. All statins are now widely accepted to have no efficacy for such purposes, but I suppose he was depending on some source of information to make his claim.

So now you know why it was disturbing for me to read about Dr. Roizen confidently disseminating advice about multivitamins.

Part 2

After reading Dr. Roizen's comments, I became curious about his background and read his bio available online. I find his credentials to be excellent.  I started thinking why a person like him would spew out what I believe is basically worthless, if not harmful advice, with such certainty. I also started thinking about Dr. Oz, a close friend of Dr. Roizen, (they've authored a number of books together and Dr. Roizen is an adviser to the Dr. Oz Show). Like Roizen, Oz's credentials are also top-notch.

Why, I asked myself, are such erudite men propagating such apparently bad advice about dietary supplements?  Why were they either ignoring or reaching different conclusions that I do from the numerous studies now widely available that show the dangers of dietary supplementation?

So let's assume for a moment that I am reaching the more valid conclusions. If so, what causes them to support the industry? Your first instinct may be to say money, but I dismiss money as the main motivator because I suspect they have already accumulated enough to live quite comfortably and I don't believe that for such distinguished and successful clinicians, it is the end to end all.

So what's the answer? I thought back to a recent episode of The Dr. Oz Show. The guest was a cryptographer (hand-writing expert). As part of the show, the expert analyzed a writing sample from Dr. Oz. His conclusion based on how Dr. Oz forms a wide-open at the bottom scripted 's.' was that this demonstrates that Dr. Oz is very susceptible to the opinion of others. Basically, he concluded that Dr. Oz's popularity stems from his genuine desire to please others. I think most people would agree that this is a pretty good trait to possess.

Let me preface my next comments by stating I have basically no training in psychotherapy. All that follows is conjecture. If you are interested, allow me to speculate why I think this trait of wanting to please others can be problematic especially for physicians in the limelight.

Most physicians are highly intelligent and possess a great deal of accumulated knowledge. Patients know this and expect doctors to be able to routinely answer their questions. However, the body of clinical knowledge, which continues to grow daily, is already far beyond anyone's grasp and that is why there are many specialties and sub-specialties in medicine.

For doctors in the limelight, however, they work hard to create a persona of all-knowing. They want to be viewed as saviors of sorts, able to help both small and wide audiences alike. They never want to disappoint by saying I don't know or I'm not sure.

This realization has caused me to think about my own approach. Until a few weeks ago, I grew more confident in my assertions and more provocative in my conclusions. Then a funny thing happened which I wrote about in another blog. During one of my lectures, an audience member challenged my statements virtually one by one. This forced me to recalibrate and make sure that everything I was saying was defensible. I think my conclusions were generally accurate, but generally was no longer good enough.  I realized after that talk that I was falling into the same trap that I think many before me have fallen into.  I realized that because almost nothing in regards to science can be said with absolute certainty, that it is not fair for someone who can get up and comfortably speak to an audience to assert otherwise.  A speaker should not be expected to always please his or her audience out of expediency if it is the truth that the audience needs and wants.

I believe that many of the doctors like Hyman, Oz, Roizen, etc, say what they say not because it will make them even more money; rather, because it will make their audiences like them more as they offer simple solutions to complicated problems. Some problems require the audience to work hard to accomplish effective solutions and promising quick fixes may be dangerous and inappropriate.

I promise to keep Mark Twain's words close to heart whenever I speak and write. Twain said "it's not what you know that gets you into trouble, it's what you know for sure that does."  Accordingly, as I continue to learn more about dietary supplements, I will work hard to report the facts (if they can be called as much), not my biases. I promise to answer "I just don't know" when that is the most appropriate answer. I think my patients and audiences deserve no less. What do you think?

Thursday, April 12, 2012

It's A Matter of Time

One of the most jarring memories of my life took place during my surgical residency. It's been almost 30 years ago and it still haunts me.

A young woman was admitted to the hospital because she had a brain tumor. The good news was that the brain tumor was benign. The bad news was it was growing so fast that if it was not operated on shortly, it was going to compress the woman's brain and cause her demise. The problem was that the woman was refusing surgery.  Under the circumstances, I was sure that time would be invested in overcoming any of her objections and persuading her to move ahead with the life-saving operation. Her life was at stake and surgery could easily save it. As an intern, I had no say or control over the situation, but was I sure the senior residents and attending physician would address the issue.

I was wrong. No one seemed to have the time that appeared necessary to speak to this lady and convince her of the imperative nature of surgery and of the immediate threat to her life. She died. I have never been able to reconcile in my mind how that was allowed to happen. Yes, maybe despite best efforts, she would have ultimately refused anyway. But such efforts were never truly expended. I have always thought what happened was a crime and tragedy.

Yesterday, a dangerously overweight patient came to my office with her daughter. She had been referred by a home care agency and her first words to me were, "I am here under duress." She explained that her daughter, who lives out of town and was visiting, insisted she come in for a wellness visit. Suffice it to say that the lady resisted my charms and persuasive skills. She would have nothing of what I was offering. Nevertheless, I am a persistent fellow and I simply kept trying. I outlined the benefits of her losing weight and the dangers of staying so overweight. I even played the "do you want to see your granddaughter get married and meet your great-grandchild" card. Every attempt was met with a "no...not necessary...not interested...not needed."

Then something amazing happened. At about the half-hour mark, she suddenly said yes, "I will come in for one session of weight loss counseling." The nurse practitioner with me quickly chimed in that it would take at least three sessions to get a feel for the program. The patient again responded in the affirmative that she would try the three sessions. I exuberantly shouted out. "Wow." I was so happy that the time I had spent trying to convince her had appeared to pay dividends. I am still excited. From my residency days, I have believed that given the time, patients can be convinced to do the right thing for themselves. It just a matter of time.

Time is a commodity in short supply in the medical profession today. The days of doctors playing golf in the afternoon are long gone. This past week I tried to have a conversation with my brother, a cardiologist, at 9 PM who could not speak to me because he was still seeing patients and then reached a close friend, a pediatric ear, nose, and throat doctor, who was still in his car on the way home from the office. Doctors are working harder than they ever worked before just trying to keep up.

This is a shame because the more time a doctor can spend with a patient, I believe the better the care. Doctors cannot work all day and all night and provide good care. I know that the appeal of concierge medicine is improved access and increased time with a doctor, but it is unfortunate that people have to pay thousands of dollars more out of pocket to get that type of attention.

Recently, I was asked to respond to a national home health magazine request on how patients should make sure that they have enough time with their doctors to get all their questions answered. Here was the query:

Looking for therapist, nurses and doctors to share tips on how patients can have useful conversations with their doctor to discuss their pain, symptoms, medication etc. for a health magazine targeting senior citizens and home bound patients.

Here's what I wrote:

"The ideal way to ensure that a meaningful conversation can take place is to schedule the time for it. When scheduling an appointment, the patient should ask the scheduler to ensure at least 45 minutes are made available for the appointment to address all concerns. That may require scheduling an appointment further out, but it sets expectations for both patient and doctor that this will not be a rushed appointment. At the start of the appointment, the patient should hand the nurse a list of issues that need to be discussed and keep a similar list. As the issues are addressed, I recommend checking them off. If a doctor is unwilling to give you such extra time, I recommend finding another doctor who will."

Amazing things happen when appropriate time is spent with patients. Insist that your doctors give you the time you need. To be fair, try to schedule for it so expectations on both sides are met.

Wednesday, April 11, 2012

Weight loss requires blah, blah, blah...

A recent medical review teaches us nothing new. Yet, there is something important to learn from it.

In this month's issue of the American Journal of Preventive Medicine, a review of data from the National Health and Nutrition Examination Survey (NHANES), reveals the best strategies for losing weight. The methods, listed below, were significantly associated with losing up to 10% of body weight or more, at least in the short term, according to Jacinda Nicklas, MD, MPH, of Beth Israel Deaconess Medical Center in Boston, and colleagues who published the review.

The methods were:

1. Eating less fat (5-10% reduction)
2. Eating less calories (5-10% reduction)
3. Exercising more (5-10% reduction)
4. Prescription weight loss medications (5-10% reduction)
5. Joining a weight loss program(5% reduction)

The review also identified that fad diets, liquid diets, diet food products, over the counter dietary supplements and herbs did not work.

There is nothing on these two lists that should surprise anyone.  Yet, there is a pattern to both lists that merits close attention.

The first list, other than the prescription medications, is a  list of things a person must do that requires effort and personal responsibility. It also requires sustained focus and attention. Eating less of something or doing more of something else requires a conscious effort. Even joining a program, requires a commitment of time and effort.

The second list identifies mostly short-term focus and basic abdication of responsibility. It's the low-road. You solely depend on some scheme perpetuated by someone such as adherence to a scientifically unproven fad diet, eating processed, often chemically heavy, diet products, or taking some unvalidated supplement that is purported to keep you healthy and help you lose weight, when in fact, at best it is ineffective, and at worst, is harmful to your health. HCG supplements recently proved that point. The facts say these diets and products are a sham and you probably know that based on past failures.

Yesterday, we welcomed over twenty new members to our LEAN (Lifestyle Education And Nutrition) Weight Loss Program. I made an effort to meet with each participant before the session began to deliver a message consistent with the findings above.

My message was that MDPrevent does not have a magic wand or pixie dust. I told each person that the key to his or her success would be sustained commitment. We offer no specific diet plans. Rather, we teach in detail what is good and bad for your health and your weight. We teach how to build your willpower by effort and planning. We teach how to engage in difficult conversation with would be saboteurs of your weight loss agenda. We provide valuable and useful information and teach how to put it into practice. The emphasis of our program is giving you the tools you need which you can put to work. Our program works for those who truly want to improve their health and shed unwanted and unhealthy weight.

When it comes to sustained and healthy weight-loss there simply are easy solutions. Even prescription medication cannot be taken indefinitely. It takes real effort to lose weight and even shortcuts like bariatric surgery fail if a new attitude is not adapted. The good news is that such effort pay-off. That was another conclusion of the study cited above. 10% weight loss can have a huge impact on your overall health.

Regardless if you think that being very overweight is a disease or a choice, you played a role in your weight gain and you must play a role to be successful in your weight loss. MDPrevent can give you the critical knowledge, the support, and the guidance you need to make changes. It's up to you to put it to good use.  I assure you that your meaningful efforts will be rewarded. The best part is that most insurances now cover our approach and as far as we know, no one else offers what we do. If you are tired of not succeeding, maybe it's time you came to us?

Tuesday, April 10, 2012

Et tu fish pills?

In his tragic play Julius Caesar, William Shakespeare created a powerful scene that has given many pause for thought. In the scene, Julius Caesar, the Emperor of Rome, is set upon by assassins (senators of Rome) that includes his friend Marcus Brutus. Although Caesar initially resists the attempt on his life, he relents when he discovers his close friend is among the conspirators. At that point, he utters the classic Latin phrase, "Et tu Brute, then fall Caesar." The loose translation is that Caesar is asking, "you too, Brutus?" This is widely understood to represent Caesar's acknowledgement that if his close friend is involved he knows that the nefarious deed against him must succeed. It is an utterance of sheer capitulation.

A reader of this blog knows that I am not a fan of supplementation. Notwithstanding, one dietary supplement that I have been kind to has been fish oil pills. It has been my understanding that these pills generally do good and in the absence of eating actual fish, are the next best thing.  It turns out I was too generous. I too now cry out in capitulation, "Et tu fish oil?"

Fish oils (omega 3s) are often recommended, even by many in the medical establishment, as a natural means to lower cholesterol and prevent cardiovascular disease. Given the prevalence of heart disease in our society, it's not surprising that pills containing it are among the most widely used dietary supplements. Many fish oil marketers make claims that fish oil is not only good for preventing disease, but also reversing it. In addition, many marketers of fish oil sell mega-doses with the implication that the more you take the better.

Two recent reports shed some meaningful light on these two assertions.

In a Nutritional Research Report developed by Tufts University (Boston, MA) and prepared for the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services, Tuft's researchers concluded that the maximal positive effect of eicosapentanoic acid (EPA) and docosahexanoic acid (DHA), the two fatty acids known as Omega-3s, appears to plateau at a mean daily intake of 0.20 grams or 200 milligrams. There is no evidence that the effect of EPA and DHA on mortality phenotypes differs across populations and settings. In plain-speak, this means these findings hold true for all populations and that above 200 mg per day there is no additional benefit (it does make you fatter, however) from taking extra fish oil.

The second study looked at the benefits of taking fish oil when heart disease already exists. The study published in the Archives of Internal Medicine throws the theory into doubt: based on an analysis of 14 controlled trials in which nearly 20,500 patients with a history of heart disease were randomly assigned to take omega-3 supplements or placebo. It turns out that those taking the fatty acid pills had about the same rates of heart disease, including dying from heart attacks, congestive heart failure and stroke as did those who took placebos.  The authors of the study were quick to caution that this applies to fish oil supplement pills, but may not apply to consuming fish oil by eating fish that naturally contain these fatty acids..

Slowly but surely, every known dietary supplement, as it is subjected to closer scrutiny falls by the wayside as a viable product. Yet, sales continue to grow. Like many of Shakespeare's plays, this should be construed as a tragedy because money is being wasted on false hopes and possible harm. 
If you don't like what you are hearing, please don't shoot the messenger. I am not ignoring the studies that show the benefits of such supplementation. They simply don't exist or are not being published in any reliable peer reviewed journal. I will faithfully report any that I come across. In the interim, I find the mounting evidence against dietary supplementation to be convincing and in the case of fish oil pills, this new data merits serious consideration.

The bottom line remains that you should get your vitamins and minerals from vegetables and fruits, and you should get your fish oil from fish, preferably Wild Alaskan Salmon. Otherwise, you may find out one day, as Caesar did, that the dietary supplement(s) you held dear was actually not your friend.