Can Breast Cancer Be Prevented?

Breast cancer sucks! It afflicts our mothers, grandmothers, sisters, wives, daughters, aunts, girlfriends, and even men. Pink ribbons everywhere speak to its far-reaching effects. We walk for breast cancer, make donations, and highlight it every chance we get. Everyone knows someone who has been diagnosed with it. Breast cancer devastates lives and families. For survivors, it hangs over their heads like a 'Sword of Damocles,' ever fearful of a relapse.

So what are we doing about it? The National Institutes of Health spent almost $2.4 billion on breast cancer research in fiscal years 2008 to 2010. The question is do we have the right strategy to stop its growth? Are we making the right research moves? The answer is unfortunately mostly no.  Maybe now, that will finally change.

On October 8, 2008, Congress passed the Breast Cancer and Environmental Research Act . The Act required the Secretary of Health and Human Services (HHS) to "establish an Interagency Breast Cancer and Environmental Research Coordinating Committee (IBCERCC) of federal and nonfederal members to examine the current state of breast cancer and the environment, research and make recommendations for eliminating any knowledge gaps in this area."

A new report just published after nearly four and a half years of meetings and information gathering, highlights the committee's conclusions that breast cancer research needs to focus more aggressively and coherently on environmental factors that may contribute to its development. Chemicals, radiation, drugs and consumer products are foremost among the environmental factors addressed in the report, but so are less obvious factors related to lifestyle and socioeconomic concerns.

But the most important recommendation of the committee is evident in the title of its report, "Prioritizing Prevention." Why? Because according to the report, "despite decades of productive breast cancer research, the number of women diagnosed with breast cancer continues to rise.  In 2012, 227,00 women and 2,200 men will be diagnosed with breast cancer and 40,000 women will die from it."

While untold money has been spent on early detection of breast cancer and on research for treatments, scientists and doctors have barely dented the epidemic of cases.  Along comes a federal commissioned group tasked with stepping back and figuring out where we should spend our resources and what does it decide? Spend the most money on prevention, it urges.

The facts are clear. Most women who get breast cancer have no family history. The interaction of genetic and environmental factors are known to play a role because as the report states, "breast cancer rates can vary with changing environmental circumstances." Like most cancer and disease prevention efforts, the committee recognized that efforts to prevent cancer have lacked sufficient resources and that moving forward, our limited resources should be mostly reapplied towards prevention versus detection and/or treatment/cure.

The report's first recommendation states that not enough has been done "to identify and mitigate the environmental causes of the disease." It asks that we prioritize prevention. It states that we should modify "social and lifestyle factors implicated in breast cancer." Early this past week, I wrote a blog before this report came out asking "Isn't It Time We Got Serious About Prevention?"  I don't know how many more federal dollars will be spent trying to figure out where we should spend our valued research dollars, but one thing should be certain-avoiding cancer should be our number one priority.

In addition to protecting its citizens from known environmental carcinogens found in foods, household chemicals, and pollutants, the government needs to pay doctors to take the lead in helping patients modify lifestyle factors, such as obesity, to prevent cancer. Even among cancer survivors, recurrence rates are much higher among obese women. A recent study showed that breast cancer survivors who lose weight reduce the rate of the return of the disease.

It is sometimes lonely for me to keep crying out about the importance of choosing the right foods and staying physically active, managing stress effectively, socializing, finding meaning and purpose, and getting adequate sleep, but it's reassuring that others are now reaching the same conclusions about the importance of lifestyle factors. A recent study showed that flaxseed, for example, may prevent breast cancer. Did anyone even hear about the study? (Here's the study: Consumption of flaxseed, a rich source of lignans, is associated with reduced breast cancer risk. http://www.ncbi.nlm.nih.gov/pubmed/23354422) based on this one study, should women run out and consume lots of flaxseed? I don't know the answer. In general flaxseed is a healthy foodstuff, but does it really prevent breast cancer? We need more studies to know for sure and so the question is why aren't there more studies looking at the role of diet in breast cancer prevention?

A review of the last two hundred plus studies published about breast cancer prevention revealed that only a handful of studies focused on actual prevention. (By the way, one interesting study showed a correlation between sun exposure and reduced rates of several cancers. The more sun, the less cancer. The researchers felt more was involved than the fact that it's known that the more sun you get, the more Vitamin D you produce.  I have always been a fan of daily sun exposure and encourage my patients to get at least a half hour of sun exposure everyday without fail. I do caution them, however,  to cover their faces with wide brim hats.  Here's the study:
Is prevention of cancer by sun exposure more than just the effect of vitamin D? A systematic review of epidemiological studies. http://www.ncbi.nlm.nih.gov/pubmed/23237739)

A recent study looked at the role different fats play in breast cancer development and showed that only the Omega-3 fats seem to be protective. (Here's the study: Dietary intake of specific fatty acids and breast cancer risk among postmenopausal women in the VITAL cohort. http://www.ncbi.nlm.nih.gov/pubmed/23137008).  Another study focused on the role that the combination of polyphenols (found in berries, etc.) and alcohol play in breast cancer development. (Here's the study: Dual association between polyphenol intake and breast cancer risk according to alcohol consumption level: a prospective cohort study. http://www.ncbi.nlm.nih.gov/pubmed/23132534) As the federal committee just concluded, we need a lot more of these types of studies focused on prevention and environmental factors such as diet.

You get the drift. There are scattered studies that fail to nail down any real conclusions, which leaves everyone to their own devices to figure it out or do nothing. If you are one of the people trying to figure it out, here's what I can tell you at this point. Prevention efforts seem to pay off and lifestyle intervention is the key. "Prevention is the key to reducing the emotional, physical, and financial burden of breast cancer," wrote the committee. "By urgently pursuing research, research translation, and communication on the role of the environment in breast cancer, we have the potential to prevent a substantial number of new cases of this disease in the 21st century."

My preventive medicine practice can show you how today; I want to help you, but you need to want to be helped. Make the right choices now and enjoy the fruits (no pun intended) of wise decision-making. With one out of three women developing some form of cancer and one out of two men doing the same, again I ask, isn't it time you got serious about preventing cancer? Stop waiting for the terrible news and take charge of your health today. There's no better time!

Remember, prevention is preferable to cure.

Calcium and Heart Disease: What's The Story?

I don't know many doctors who would tell you that taking calcium supplement pills may be a bad thing.  Alas, I was one of them, but I think that's about to change big-time.

As far back as I can remember, women were told to take calcium supplements to prevent osteoporosis. It was practically a staple of childhood that we all needed to drink milk with calcium to develop strong bones. Apparently as we grow older this need increases, and ignoring the debate if dairy is even healthy, most doctors must believe that dairy is no longer a sufficient source of calcium because they recommend that women take 1,000 to 1,200 mg of extra calcium daily as supplements to keep their bones strong.

If you had asked me two years ago, I would have raised no objections to such advice.  Then a funny thing happened. (Not the "ha, ha" kind of funny, but the "that's odd" type.) I started noticing over the past couple of years a few studies that suggested that calcium supplements may actually do more harm than good. A study in New Zealand showed that even 500 mg a day of calcium increased the risk of heart attack by 30%.

Looking around, I kept expecting to hear something from other parts of the medical community warning about calcium and chastening doctors to weigh the risks and benefits before making further recommendations. But there was nothing. Nevertheless, I began to speak about it in my lectures sharing my new knowledge about the potential role of calcium supplements in the calcification of arteries and heart disease.  My audiences were stunned; I would literally hear gasps. How could a doctor be openly challenging the long held assumption that all post-menopausal women should take calcium supplements to prevent osteoporosis and not hear a peep of concern from their own doctors.  Obviously, I must be wrong.

The truth be told, sometimes I wonder if I misread or misunderstand the information I come across. For example, when the Institute of Medicine lowered the threshold for a Vitamin D deficiency from 30 ng/ml to 20 ng/ml, again I waited for the reactions from the medical community.  Again, zip.  So confused by the lack of reaction, I went back and reread it. There it was again clear as day. The threshold had definitively been lowered and like the line from poem, "not a creature was stirring, not even a mouse." There was nothing but dead silence.

Well I hope that's about to change. During the past week or so a flurry of studies has emerged which has put the issue on the national radar. The first study cautioned men about the role of calcium supplements in forming kidney stones and the second study warned about its role in heart disease. This week a new study about women came out that should have everyone talking.

Checking if calcium supplements raise the risk of dying from heart disease, Dr. Karl Michaelsson, a clinical professor in the department of orthopedic surgical sciences at Uppsala University in Sweden, analyzed data collected on more than 61,000 women enrolled in a study on mammograms. The study, published in the British Medical Journal, showed that over 19 years of follow-up, nearly 12,000 women died with the highest rates of death identified among women whose calcium intake was higher than 1,400 milligrams a day. Women who took less than 600 milligrams of calcium a day also were noted to have an increased risk of death.  (That makes sense since calcium is an essential mineral, which means you can't live without it.)

The Swedish study showed that death was ONLY increased among women whose calcium came partly or wholly from calcium supplements.  (Of course, a supplement industry representative weighed in immediately that the study was flawed because it was not specifically meant to address calcium supplements and heart disease. Who cares? Even though it was not a cause and effect study, didn't look at Vitamin D, and its initial research purpose was not to evaluate what calcium does to the heart, the study offers a pretty compelling argument that calcium supplements may be very dangerous.)

But don't take my word for it. Quoting from Medline, "Many older adults increase dietary intake of calcium or take calcium supplements to prevent bone loss and there had been speculation that increased calcium intake with or without vitamin D could improve cardiovascular health," said Dr. Gregg Fonarow, an American Heart Association spokesman who wasn't involved in the study.

However, a number of recent studies have suggested that higher dietary intake or calcium supplementation may not only not improve cardiovascular health -- they may be associated with increased risk for cardiovascular events and mortality, said Fonarow, a professor of cardiology at University of California, Los Angeles."

For over a year, I have been asking my audiences if their doctors adjust their calcium recommendation based on how much calcium they get from their diet. The answer has always been no. The key finding in the new study was that if women exceeded 1,400 mg of calcium a day based on a combination of food and supplements or supplements alone, the death risk doubled. No such risk was seen with food alone.

So the bottom line is everyone needs calcium and it is best and safest to get it from foods like broccoli, almonds, tofu, sardines, kale and other leafy vegetables, and almond milk. As I am not a fan of dairy, I don't recommend dairy products but Greek yogurt, etc. are also good sources of calcium. Avoid antacids with calcium, they are just as bad as calcium supplements.

It will be curious to see if doctors now change their calcium recommendations and actually take the time to adjust for diet. I give patients handouts with the concentration of calcium in healthy foods so they can make their own adjustments. As I like to say, to paraphrase Sy Syms the retailer, "an educated patient is my favorite type."

By the way, if you are interested in strong bones and a healthy body, there is no substitute for weight-bearing exercises.

Isn't It Time We Got Serious About Prevention?

The United States Preventive Services Task Force (USPSTF) recently posted a draft research plan for public comment under the banner: behavioral counseling to promote a healthy diet and physical activity for cardiovascular disease (CVD) prevention in persons with known risk factors for CVD.  The USPSTF describes itself as “an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists).”

The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screenings, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements."

Having previously founded, built, and sold HealthDrive, the largest medical and dental practice in the U.S. providing care to elderly residents of nursing homes and assisted living facilities, I witnessed during my tenure what happens to older Americans who succumb to chronic diseases and require constant nursing care. Spurred on by the introduction of Medicare’s Annual Wellness Visit, I came out of a short retirement almost three years ago to answer the same basic question, does counseling work to prevent disease, now also posed by the USPSTF. The Annual Wellness Visit, now only covered by Medicare, is a service in which a physician is paid to identify health risk factors as opposed to performing a routine exam or treating an existing condition.  It is an opportunity to try to prevent disease as opposed to treat it.

As a doctor who practices primary prevention on a daily basis, having last year counseled hundreds of patients to eat better and get more physical activity, I can share that success is a function of spending considerable time with patients to help them identify their motivations to live a longer and healthier life. I have found this process to be different for each patient and very time-consuming, often extending beyond an hour and sometimes more than two hours; my longest session took over four hours. Helping patients identify and articulate their motivations takes time and effort because motivation is often not the simple “I want to live.”  

True motivations range from wanting to meet their great grandchildren to seeing what gets invented next (mine).  Often they are uniquely personal.  Case in point was a patient who after considerable discussion ultimately shared that his prime motivation to live healthier was to outlive his wife so he could spend more time with the other woman he also loved.

Once I identify a patient's prime motivation, it is then critical to choose the right intervention(s).  For example, a patient who has lived a sedentary life for many years will often find it difficult to suddenly initiate physical activity on his or her own.  Extensive muscle atrophy from lack of use may require the services of a physical therapist or personal trainer (which few can afford) to start moving again. Eating healthy takes work as well. For both those who knowingly eat unhealthily or are simply confused what comprises healthy food choices because of widespread food marketing and misinformation, it is helpful for them to sit with a registered dietitian to learn how to develop healthy meal plans. 

This can sometimes be a complicated undertaking because of underlying medical conditions. For example, a patient taking Coumadin, a blood anticoagulant, cannot simply add more green vegetables to the diet as such vegetables can reverse the effect of the drug.  A plan is needed to reintroduce green vegetables while adjusting drug dosages.  A patient with fecal incontinence, a condition where bowel movements are not well controlled, must be very careful with how much fiber is added to the diet, as one of my patients recently learned as he barely made it to the toilet in time.  It requires much reassurance to overcome the fears of patients with diverticulosis, an abnormality of the colon that results in growth of out-pockets of tissue that can become clogged,  that they can in fact consume nuts and seeds after years of being told otherwise. But with patience and perseverance, I have seen the amazing happen.

One of the largest draws to my practice is our obesity counseling program.  As part of the Affordable Care Act’s new preventive measures, in 2012, The Centers for Medicare and Medicaid Services (CMS) introduced a new service called Intensive Behavioral Therapy for Obesity (IBTO). This service was introduced in accordance with the USPSTF’s conclusion that there was value in offering such a service for treating the growing obesity epidemic now estimated to affect thirty-six percent of the population, with seniors no exception.  Each obesity counseling session may last up to fifteen minutes. This limited time allotted for by Medicare has proven to be insufficient to fully address all weekly concerns as patients try to adapt new foods into their diets and change their overall lifestyle.  The hastened time often adds to patient frustration, particularly for those who need much hand holding.

But losing weight often involves more than food.

For most patents there are psychosocial reasons why they eat too much or fail to engage in significant physical activity. On the food side, there are sugar addictions or what many call “a sweet tooth,” poorly managed stress leading to inadequate sleep which stimulates increased appetite and food consumption, eating to punish one's self or gaining weight as a buffer from a difficult world, etc. Many seniors for example, suffer from depression, and food offers comfort. Excess food leads to added weight, which leads to pain which leads to decreased physical activity, which leads to little to no sun exposure, which in totality exacerbates their depression.  To change the way people with relevant psychosocial issues eat and live, a psychologist is often needed.  (Psychiatrists are often too quick to prescribe medications that don’t address lifestyle issues.) At a time when an increasing number of Americans, particularly seniors, are  suffering from emotional and mental health issues, not only are psychologists not getting their due, in 2013, Medicare further decreased their reimbursement.

The costs of entitlement programs such as Medicare and Medicaid clearly consume a large portion of our tax dollars but that is no excuse for being penny wise and dollar foolish.  For example, according to CMS provided data, in 2012, the first year of availability of IBTO services, there were only a total fifty thousand total sessions (patients are entitled to 16-22 sessions per year) provided in the entire United States.  It’s not surprising. IBTO has not been well received by the medical community because it is impractical and not cost-effective for most busy medical practices to expend their resources to schedule patients for sessions of not more than fifteen minutes to receive reimbursement which is one-third of similar reimbursement for a fifteen minute Evaluation & Management code (E&M).  For less than thirty dollars a session (national average according to CMS: twenty five dollars), a primary care medical practice must verify eligibility, schedule a patient, remind them of the appointment, greet them and process their arrival, gather biometric data such as height, weight, blood pressure, temperature, calculate body mass index, discuss progress and counsel the patient, and bill for the service.   

The realities of running a medical practice today with associated overhead costs and regulatory demands, makes it impractical for most primary care medical practices (only primary care practices can offer the service per CMS guidelines) to provide a behavioral counseling related service for which it will probably lose money.

The Centers for Disease Control has weighed in that the evidence for the power of prevention is now indisputable.  Accordingly, behavioral counseling can and will have a meaningful impact on patient's lives, as I have demonstrated with my patients. However, other doctors will not embrace preventing chronic diseases such as CVD until adequate reimbursement is available. For doctors to invest in the knowledge needed to be effective counselors for their patients will take time and for them, time is money.  Today, few physicians have meaningful knowledge of the nutritional sciences. Many physicians still graduate medical school without a single course dedicated to nutrition.  Most states don’t even mandate it in the curriculum. Therefore it is probably fair to say that if we want physicians to be motivated to educate themselves regarding their patients’ nutritional needs, we will have to incentivize them.

The bottom line is that behavioral counseling can be highly effective in altering the trajectory of patients’ chronic disease development and advancement when a practice either has the resources to address the myriad factors that affect behavior or can make appropriate referrals for critical assistance. 

Having previously built a national health care practice which I sold to a private equity firm, I find myself in the unique position of being able to experiment with my own money to prove my points.  Unfortunately, to date, even though my medical practice is the largest provider of IBTO in Florida, such services have been provided at a financial loss because of inadequate reimbursement.  This is obviously not a perpetually sustainable model for us or for anyone else for that matter. While it is not within the scope of the USPSTF's mandate to set reimbursement rates, I urge it to consider the importance of not only identifying the value of the behavioral counseling service it now is attempting to determine, but also to make clear to its constituencies that allocating enough time and resources for medical practices to fully embrace such services that can decrease the burdens of chronic disease, both for individuals and society, is of utmost importance.

About twenty-five hundred years ago, Hippocrates, the widely acclaimed father of medicine, was noted to have said that “prevention is preferable to cure.”  I know that message has never fully resonated with our sick-care oriented system, but I hope most people would agree that the time has come to shift resources from not only  treating diseases but to also preventing them. The USPSTF has wisely reached the same conclusion in the past and I trust it will do so again. I hope in this time of much needed fiscal constraint, CMS will recognize as Ben Franklin once said that “an ounce of prevention is worth a pound of cure” and fund prevention efforts accordingly by setting reimbursement rates at levels likely to encourage more doctors to act.

If You Jump Up and Down After Reading Today's Blog, You May Actually Remember It When You Get Older!

It won't come as news to anyone that exercise helps you stay fit and being fit is good for your health. It also probably won't come as a surprise that being fit is good for your mood. But what about memory? Will exercise preserve memory? Does being fit earlier in life affect what happens many years later? Will being fit prevent Alzheimer's and other forms of dementia?

Until now, scientists have had strong suspicions that lifestyle plays a meaningful role in preserving healthy brain function, but they didn't know for sure. A new study just came along that moves the needle along in validating the key role that exercise plays in prevention.

Published in the February 5, 2013 issue of the Annals of Internal Medicine, the study titled "The Association Between Midlife Cardiorespiratory Fitness Levels and Later Life Dementia" was a cohort study that does not prove cause and effect but deserves close attention. The study performed at The Cooper Institute in Dallas Texas involved 19, 458 middle aged people who had a treadmill exercise test as part of health care preventive visit. Based on the amount of time that a person was able to run on the treadmill, researchers grouped them into two categories of most fit and least fit. They then followed these people for many years, beyond the time they reached 65 years, to see who developed dementia.

What did they find? You guessed it. The people in the most fit group were far less likely to develop dementia. Although the study did not look at diet, which is obviously an important contributing factor to health, and was limited to mostly healthy white people, it does offer possible evidence of an association between fitness and memory preservation.  Again, the study did not prove cause and effect but it does provide yet another reason to stay fit by being physically active.


While only 1 out of 8 Americans develop dementia by the age of 65, that number rises to 3 out of 7 by age 85. Although that represents less than half of those over the age of 85, no one, but the most cynical, would disagree that it would be better to avoid dementia than experience it.  It's no fun to lose your memory. Just ask anyone who suffers from a form of dementia or watched a loved one die from it. The good news is that science suggests that if you get to age 90 without developing dementia, the probability of development appears to decrease due to possible suppression of the gene responsible for it.

So if you are sitting down when you read this, it may be a good idea to get off your seat and jump up and down.  If you keep doing that long enough and as often as possible, you may remember this blog for many years to come. That would be nice, right?

Nu? So what are you waiting for? Get up and get moving! Now, before you forget how important it is to your future memory...

Beware of Doctors Bearing (Medifast) Meals!

When MDPrevent first opened in Delray Beach, Florida, I visited with many of the physicians whose practices surround us. One of those physicians was a cardiologist who expressed concerns about his expectation that we would emphasize supplements as his view of the world was that a preventive medical practice would push supplements. Of course given my disdain for such products, he had nothing to fear. Nevertheless, I was impressed at the time that he was concerned about his patients being subjected to a doctor trying to push unnecessary products on them.

So imagine my surprise when after having never heard from him again, I suddenly received a call two weeks ago.  He had heard about MDPrevent's success with running an intensive lifestyle intervention program for weight management and wanted to discuss a new undertaking in which he was getting involved.

He proceeded to explain how he had heard about the weight loss program created by Medifast and how he had found a way to not only help his patients lose weight, but also make more money for himself.  Over the course of two phone discussions, he explained how Medifast would sell his patients a '5 and 1 meal plan' that involved the patient buying five small daily meals from Medifast and preparing one on their own. Medifast would charge the patient $2 for each meal and  $10 in total for the five meals, which would be consumed every two to three hours. (Really, $2 a meal? What kind of quality food can you buy for $2??? None that I have ever seen.)

In return for peddling the product, the doctor would receive a fee of anywhere from 2 to 20% of the sales money that Medifast received from the doctor's efforts.  The doctor's efforts involved not only initiating the sale of Medifast's products, but also serving as a health coach to the patient and answering any questions about weight loss that may arise. The higher percentages would be paid for enlisting more doctors to sell products to their patients as well.

In this multi-level marketing like scheme, the more doctors a doctor signed to sell products to patients, the more money the doctor on top made, with each doctor in the pyramid at a lower level earning slightly less. If you are the only doctor selling, you only get 2%. He said that this plan had resulted in some doctors earning as much as an additional $80,000 a month in income.  I guess he thought it was impressive to throw out the potential of earning roughly an extra million dollars a year, which I suspect very few doctors if even more than one have ever achieved.

Nevertheless, I asked him a few basic questions.

My first question was is the food healthy?

His response was that studies showed that it helped people lose weight.  He couldn't answer the question if the food was fundamentally healthy or is the same processed food used by many similar programs. (Wondering myself, I launched an investigation into the ingredients used in their products.  I wish I could tell you that I was pleasantly surprised, but it would not be true. Their products were similar to many other commercially produced products that include artificial flavors, sugar, dyes, and other chemicals. I could never in good conscience recommend such products to my patients as a daily meal replacement plan. Shame on any doctor who would.)

The doctor also forwarded Medifast's propaganda package that included several studies.  Suffice it to say that in fact, many of the studies provided to support the effectiveness of the program were unpublished studies, studies published in unimpressive journals, or studies that proved little.)

My second question was how could he afford to be an unlimited health coach to a patient for $73 a year?  (I calculated that if the patient buys the $10 food for an entire year, that would generate $3650 in revenue for Medifast. The doctor's cut at 2% would be $73.)

His response was that he would hand off the coaching responsibilities to his nurses or assistants. He didn't have a good answer as to what qualified them to be health coaches under any circumstances, let alone for weight loss purposes.  Coaching is generally a skill that must be developed and it would be potentially harmful to give unlearned counsel to a patient expecting professional advice.

Finally, I asked since Medicare now pays 100% for Intensive Behavioral Therapy for Obesity, how can he charge his Medicare patients privately for weight loss coaching?

His answer was that there was no conflict as the programs could work together. Since I know he has never referred a patient to MDPrevent's program, the only known integrated primary care practice offering Intensive Behavioral Therapy for Obesity services here in South Florida and the provider of one-third of all such services in Florida in 2012, I believe he has no intention of doing so.

It is a very sad commentary that a doctor who initially impressed with his apparent ethical standards has decided to sell out to a scheme to embellish his income.  Between the doctor who recently tried to convince me of the merits of selling NuSkin's dietary supplement products to this one doing the same with Medifast's program, I can only fear for the future of the medical profession.  Doctor's are getting desperate to maintain their incomes and that forebodes poorly for patients' best interests. There is a rising tide of these get rich quick schemes that are detracting our doctors (I say "our" because I am also a health care consumer) from the basics of good patient care.

So if a doctor comes bearing processed food meals, I suggest you run as far away as possible. Actually, running may be the best part of the deal.

Think Like A Doctor, Act Like A Patient

An Op-ED article appeared in today's NY Times, The Boy With a Thorn in His Joints, about a mother that found relief for her child's malady by incorporating alternative therapy.

In response, I posted the following comments.

As a physician that practices integrative healthcare, but defines integrative differently, I combine the services of a MD, registered dietitian, health psychologist and physical therapist into one practice that addresses the four main constituents of healthy living.

1. Identify and address any underlying medical condition(s).
2. Optimize nutritional status.
3. Identify and develop a strategy to tackle encumbering emotional and psychological issues.
4. Ensure that a person can engage in low to moderate intensive physical activity as part of daily living.

Everything we do is based on the scientific method of trial and error. If it works great; if not, next. Each patient is treated as an individual. No one size fits all.

First, let's look at some numbers to start. The reported statistic for Celiac disease is that it affects about 1% of the population, with 4 out of 5 cases going undetected. A gGT test is very good at making the diagnosis. Somewhere between another 1 to 10% or so may suffer from gluten insensitivity. A food allergy test can help diagnose that as well.

Second, I often tell my patients to "think like a doctor and act like a patient." Thinking like a doctor means considering all possible diagnoses and all possible treatments, using those considered most effective for the diagnosis most likely. If that doesn't work, you must consider alternatives.

Acting like a patient means following the therapy prescribed by a doctor you trust. Acting independently unnecessarily raises risks and creates confusion as to what did and did not work.

If traditional medicine fails, it is more than prudent to consider alternatives. But don't be fooled into thinking that alternatives that have medicinal properties don't carry the same risks as do all medicines. Don't use an alternative until you have researched its viability and discussed it with your physician. You also need to confirm that you are taking the right dose, understand the side effects and contraindications, are aware of the effects on other medications, and have a product that is properly manufactured and labeled. Otherwise, you may end up doing more harm than good.

There's a reason why botanicals and other non-regulated supplements are called "complementary and alternative" therapies because they are usually not the best first-line treatment. It pays to keep that in mind when you are looking for a solution to a new health problem. As for eating properly, which mostly includes whole foods, that always make sense regardless of your health state.

Dr. Oz, Dr. Block and Donuts. Can You Trust Them?

To paraphrase an old English saying, "You can trust a man by the company he keeps." If we accept this notion, then it must also be fair to say a man can be judged trustworthy by considering those in whom they implicitly trust.

On his show last week, Dr. Oz said he "implicitly" trusts Rovenia Brock, a nutritionist with a PhD from Howard University. He made these comments in response to Dr. Brock's statement that it was okay to consume a sweet for breakfast in order to lose weight. She claimed she based her statement on studies that supported her.  In fact, she offered a donut as an example of a sweet that could be consumed and Dr. Oz said he trusted her judgment. (Let's not forget this is the same Dr. Oz who says people should eat regular ice cream. See my previous blog on the topic.)

Before we tackle the question of which study or studies, if any, support this statement, let's analyze the substance of donuts for a moment.  Donuts come in different shapes, sizes, and flavors. There are glazed donuts, cream filled donuts, sugar-coated donuts, etc. Donuts are often fried.  Most donuts have somewhere between 200 and 400 calories with fat often comprising half of the calories. Dr. Brock made no distinction between the type of donut she was recommending and Dr. Oz asked for no clarification. He simply stated he trusted her.

Now let's look at the science.  In the journal Steroids, a paper was published based on research done in Israel that included 193 obese (BMI 32.2±1.0kg/m(2)), sedentary non diabetic adult men and women (47±7years) who were randomized to a low carbohydrate breakfast (LCb) or an isocaloric diet with high carbohydrate and protein breakfast (HCPb). (To read about the study, cut and paste this url: http://www.ncbi.nlm.nih.gov/pubmed/22178258 Meal timing and composition influence ghrelin levels, appetite scores and weight loss maintenance in overweight and obese adults.)

During the study, both groups of subjects consumed the same amount of total daily calories, except one group consumed more calories during breakfast than during other meals. These calories came from both proteins and carbohydrates.  This loading of mixed calories to breakfast resulted in subsequent greater weight loss than those who balanced out calories during the day.

Carbohydrates come in several forms. There are simple and complex carbohydrates and there is soluble and insoluble fiber. A whole grain cereal can be high in both carbohydrates and fiber.  Fiber can be expected to increase a sense of fullness. In fact, a previous study showed that consuming cereal for breakfast results in greater net weight loss. (To read about the study, cut and paste this url: http://www.ncbi.nlm.nih.gov/pubmed/16339127  Dietary intake of whole and refined grain breakfast cereals and weight gain in men.)

So the question is how did Dr. Brock and Dr. Oz make the leap from the Israeli study (which is the only study available to show such results) to declaring on national television that it is okay to consume a donut for breakfast if you want to lose weight.

By the way, at no time did he or she add that doing so required less calorie consumption later in the day. Rather, they implied that doing so would result in less calorie consumption during the day, a fact not supported by the study that required specific adherence to a strict calorie count. The study did show that a larger breakfast with protein and carbohydrates increased satiety for the rest of the day. Wow, imagine that. Eating a big breakfast may make you less hungry later in the day. Where's the news in that? Nevertheless, the study never said you should use fatty donuts as a source of your carbohydrates, so don't.

Furthermore, the researchers did not study what results would be obtained if the breakfast only included protein without carbohydrate. A recent study done in England and published in the European Journal of Nutrition showed that, in fact, consuming protein for breakfast offered more satiety than carbohydrates (in the form of a croissant and orange juice), with ingesting the protein alone resulting in lower subsequent calorie consumption during lunch and dinner. (To read about the study, cut and paste this url: http://www.ncbi.nlm.nih.gov/pubmed/22948783 Variation in the effects of three different breakfast meals on subjective satiety and subsequent intake of energy at lunch and evening meal.)

So why did Dr. Brock and Dr. Oz use donuts as an example.  In my opinion, it's TV ratings, pure and simply.  If they had said you should eat more whole grain cereal as a source of carbohydrate, no one would notice. But say you can eat a donut for breakfast to lose weight and that becomes newsworthy and sensationalistic; people take note.

One can only wonder how many Dr. Oz disciples hastened to follow the show's advice and will now add a donut to their breakfast routine. Poor, misguided souls.

So to answer the question posed in the title, should you trust Dr. Oz and Dr. Brock, I say no. You cannot trust their advice on donuts, and once you can't trust one thing they say, you make the decision regarding what you can trust.

If you want to include carbohydrates in your breakfast meal and want to satisfy your sweet tooth, then include a naturally sweetened, healthy, non-preservative muesli and leave the donuts to mortals foolish enough to take advice from doctors who have sold out to celebrity and TV ratings.