Want The Truth?

In a scene in the play and movie of the same title, A Few Good Men, written by Aaron Sorkin, there is the following scene involving the interrogation on the witness stand of a Colonel Jessep, played by Jack Nicholson in the movie, by a Lieutenant Kaffee, played by Tom Cruise in the same movie.

It goes like this:

Witness Jessep: You want answers?
Lawyer Kaffee: I think I'm entitled to them.
Witness Jessep: You want answers?
Lawyer Kaffee: I want the truth!
Witness Jessep: You can't handle the truth!

That line is considered one of the most notable movie lines of all times.  However, for me, it poses a much larger question. Do people always want the truth?

We know that in social situations, the truth may be best avoided. For example, if your friend just got a awful haircut or your spouse gained some weight, when asked, should you always be honest? Some may argue that one should always tell the truth, but I think we can mostly agree that a white lie such as expressing approval of someone's new clothing (that they are currently wearing and which you wouldn't be caught dead in) may be the right thing to do on the spot. Later on, may be a different story.

Nevertheless, when people come to a doctor they should always expect and always receive the most honest answer the doctor can provide. Quite frankly, it really doesn't matter if they can handle the truth, they are legally obligated to it and should expect no less. And by truth, I mean all the facts.

That's the way I feel about the preponderance of information disseminated by mass media to the unwary public. The media may believe that it is more important to create an emotional response than to give you the actual facts. A reporter who interviewed Dr. Oz conveyed to me that this was his belief. He thinks he should nudge people in the right direction rather than give them the facts. You may agree, but I am vehemently opposed.

Why? Since opening MDPrevent in 2010, I have encountered hundreds of patients who were not explained all of their previous blood results. Every time I see an old blood laboratory result, I query patients if the doctor who ordered the test ever discussed all the listed abnormalities. Unfortunately, most of the time the answer is no.

The most commonly ignored laboratory findings appear to be pre-diabetes and early signs of anemia.  The doctors are so busy turning off the red light (the reason the patient came to see them for in the first place) that they are essentially ignoring the yellow lights at risk of turning red.  When I ask other doctors why this is the case, I get the expected answer. There simply isn't enough time to address problems that haven't yet happened.

To that I say phooey!  Medicare and other insurances pays doctors more for the more time they spend with you. The doctor's first obligation is to the patient in front of him or her. If they need more time than scheduled, they should schedule another appointment. But there is no excuse not to review all your findings and discuss ways to avert greater problems.  An ounce of prevention may be worth a lot more than a pound of cure--it may be worth your overall health and life.

If you have had blood work in the past two years and there were any abnormalities (numbers out of range) noted on the results, I urge you to ask your doctor to explain what the results mean and if they indicate a potential longer-term problem. Such discussions are necessary. Trust a doctor when I tell you it is best to be aware of everything (not to obsess or get neurotic) even if action is unnecessary and imprudent.

From my perspective, an educated consumer is the best patient. You may sometimes have trouble handling the truth, but you are entitled to it, the truth and nothing but the whole truth, from your doctor.

Pressure Rising...

Although the rising obesity epidemic has become a hot topic, it should not be the only widespread concern. There is another health phenomenon that does not get enough attention. It is the incidence of high blood pressure, or hypertension (HTN). The most common reference to high blood pressure usually comes in the form of warnings to curtail your salt intake.

While salt levels in your blood stream are one mechanism that affects your blood pressure, it is not alone.

Here's a quick primer on high blood pressure and its common causes.

It all starts with your heart and your arterial blood vessels. HTN is affected by how your heart is pumping, how much it is pumping, and what it is pumping against. So if your arteries, which are the blood vessels your heart pushes blood through to get it to your organs, are narrowed because of arteriosclerosis or spasm, your pressure goes up. If your blood volume is increased because of water retention, your pressure also goes up.

Blood pressure is also affected by neurological systems called the autonomic system, which is controlled by the brain.  Although it's role is not perfectly understood regarding its contribution to HTN, it is known that the system can raise and lower your blood pressure by sending signals to blood vessels to narrow or dilate. This system is also called the "fight or flight" system because it controls your body's reaction to external factors.

Your kidneys are believed to play a major role in HTN. First, kidneys regulate fluid balances in your body by controlling how much fluid and salt is excreted to maintain a good circulating fluid volume. If you ingest more salt, the kidneys are suppose to excrete more salt to keep the balance.

The kidneys also release a hormone and enzyme called renin, which perhaps plays a very significant role in fluid maintenance and blood vessel control as part of the renin-angiotensin-aldosterone axis. This axis is the body's system that ultimately controls one of the kidney's main functions--to excrete excess sodium and potassium. The amount of two elements in your body affects how much water the body retains. This axis also controls the flexibility of blood vessels walls and has the ability to narrow the blood vessel when beneficial to the body. Obviously, if the system malfunctions and blood vessels narrow inappropriately, this can cause HTN.

HTN is deadly to your body because of the extra strain it puts on your always pumping heart to work harder. This can lead to the growth of heart-muscle, which is not a good thing. As the heart works harder, it can grow larger and actually become flabby and dysfunctional. Untreated, this often leads to heart failure and eventual death.

So when a doctor confronts HTN, the first instinct, if not rule, is to lower it with medication(s) to prevent any damage. There are many types of medications to treat HTN, including diuretics which simply cause the kidneys to excrete more fluid, calcium channel blockers,beta-blockers, vaso-dilators etc.  Unfortunately, many doctors do not effectively address many of the root causes of the rising blood pressure such as stress, eating the wrong foods and avoiding the right ones, weight gain, etc. This brings to mind one of my favorite childhood anecdotes.

My father drove an old car and one day a red light went on in the dashboard. We drove to a gas station and my father asked if they could address the problem. They said sure, we can "disconnect the red light."  It seems that when it comes to high blood pressure, doctors often disconnect the red light with medication rather than address why the red light went on in the first place.

This morning, I received an email from a website called REALAGE.com.  The website is now owned by sharecare.com, which is partially owned by Dr. Oz (yes, him again).  Clicking on the link and probing around the website, I found an article titled Reduce High Blood Pressure with Yogurt. The article claims that yogurt and low fat dairy can reduce high blood pressure. To quote the article, "In a recent study, a diet that was rich in low-fat dairy seemed to help curb the risk of high blood pressure by as much as 31 percent."

Wow, that sounds pretty good, but it couldn't be more misleading. I previously blogged about that study (Want Milk?, Friday April 20, 2012, http://mdprevent.blogspot.com/2012/04/want-milk.html). It showed that compared to eating dairy with a higher fat content, there was a decrease in blood pressure by eating low-fat dairy. The study did not look at how low fat dairy compared to no-fat dairy and no dairy altogether. Telling you something is the lesser of two evils without telling you what it is compared against I believe is misleading.

I guess by now, you may not be surprised that health information provided by anything connected to Dr. Oz may be misleading.  If you want to lower your blood pressure, learn what foods to eat and which to avoid, and most importantly get the right type of exercise, a good night's rest, and manage your stress effectively. All of these affect blood pressure. Either way, always consult a doctor if you have high blood pressure, rather than a website or TV show that may be misleading. Accurate information allows you to make informed choices. Isn't that what you want?

MDPrevent

Don't Take Two Aspirins...

We all grew up with the old adage of "take two aspirins and call the doctor in the morning." This saying referred to the advice doctors often gave patients who bothered them by phone late in the day with what the doctor perceived to be a triviality that could wait until the next day or forever, for that matter. Today, when you try to call you doctor later in the day, you often get a voice message that states, if this is an emergency, please call 911 or go to the nearest emergency room. So was it good advice?

Clearly, aspirin is an effective enough fever reducer, pain reliever and anti-inflammatory medicine for mild ailments. However, it's hardly used for such purposes anymore because of superior medications such as acetaminophen (Tylenol) and ibuprofen (Motrin, Advil, etc.) and other non-steroidal anti-inflammatories (NSAIDS).  Aspirin began to decline in usage for pain and fever not only because of the more potent alternatives, but also because an increasing number of people were having allergic reactions to it and it was discovered that children (and some adults) were at risk of developing Reye's Syndrome.

Reye's Syndrome is a deadly disease that strikes quickly and can affect people of all ages without warning. It affects the entire body, but the brain and liver are the most harmed. Although the exact cause and cure are unknown, there appears to be a link between it and aspirin and other salicylate containing medications, and it seems to affect people who have had a chicken pox infection at some point. As the use of aspirin declined, the incidence of Reye's Syndrome has also markedly declined to very rare occurrences. It should stay that way.

More recently, aspirin has regained center stage due to its anti-platelet, anti-clotting abilities. It has also been linked to possible benefit in reducing the risk of colon cancer.  Unfortunately, it also is responsible for most bleeding episodes in the U.S. and is reported to be among the top four reasons for emergency room visits. The bleeding risks are increased by concomitant use of other NSAIDS, and unfortunately, enteric-coated aspirin, does NOT appear to decrease the bleeding risk.  Aspirin can also cause gastric ulcers, and I can confirm that from personal experience.

Therefore, the recommendation to consume a baby aspirin (81mg) to prevent blood clots must therefore be balanced against the risk for bleeding, ulcer formation, and the long-shot Reye's Syndrome. A thorough discussion with your doctor can determine if it is the right choice for you based on your risk factors for blood clots. Taking it on your own would not be advised.

That's what most doctors agree is the prudent course, but then again Dr.Oz is no longer like most doctors. An article appearing in this week's People magazine quotes him as saying that everyone should take two baby aspirins every day. Without knowing your risk factors and apparently throwing caution to the wind, he appears to ignore the risk factors for bleeding and ulcers and continues to make this foolhardy recommendation. Sometimes he recommends a fluid with it, but I have heard him say on his show to take aspirin without mentioning the need for fluids. Fluids are said to decrease the corrosive nature of aspirin on the lining of your stomach. I wish he would add at least a whisk of caution to his recommendation, if not stop it altogether.

By the way, you may ask, why do I keep writing about Dr. Oz?  As I've said before, it's because he's everywhere I turn (everyone turns) and quoted widely. His words are taken seriously by many people and I fear for the consequences.

A reporter for a Canadian major newspaper, whom I wrote about previously and spoke to the other day, told me that when she was among other reporters interviewing Dr. Oz when he visited Canada, she was the only reporter who did not get a hug because she asked him tough questions he apparently didn't appreciate.  Her conclusions after interviewing him is that he rationalizes promising miracle cures and magic pills (which he knows don't exist) and pushing products that are potentially harmful by telling himself that people need false hope and emotion to drive change.

I say people need good information to make good choices in consultation with their doctors. On that point, Dr. Oz and I seem to be diametrically opposed and that is why I keep trying to educate the public. 

MDPrevent

Dr. Oz and Dr. Hyman Make Quite A Pair of Showmen!

The other night, I happen to catch Dr. Mark Hyman on a local PBS affiliate. Having heard Dr. Hyman speak at the American College of Preventive Medicine conference in February 2012 in Orlando to a group of doctors, I was keen to hear what he had to say to a layperson TV audience.

It started out innocently enough. He spoke about the dangers of diabetes and obesity, the need to eat well, get plenty of exercise, etc.  Then the garbage started. He started touting the need for special blood tests like the NMR LipoProfile test for cholesterol particle size, the need for a special blood test to identify insulin resistance, and the need for everyone to take dietary supplements. My recollection of his speech at the convention to doctors was that he made no mention of the need for these tests or for dietary supplements (other than to me when I questioned him about his own usage).

I'm not surprised that he didn't do so in front of a sophisticated audience; but, I was flabbergasted why he was now singing another tune to a raptly attentive and susceptible TV audience. I didn't have to wait long for my answer. As the show ended, there was a reference to organizations that had helped fund the show.  Among the sponsors were NMR LipoProfile, the company that sells the cholesterol test, and Metagenics, a company that sells supplements.

I was so disappointed that Mark Hyman had essentially sold out his audience. People don't need more blood tests than the conventional tests to tell them that they have a cholesterol or blood sugar problem. Does it really matter if you have a 33% versus a 38% relative risk of developing diabetes or heart disease? Either way, you should make lifestyle changes to avoid them.

These tests are by and large, in my opinion, just plain ridiculous and unnecessary and they only serve to line the pockets of the companies that sell the tests and the doctors who order them with reckless abandonment.  Patients don't need more tests from doctors; they need more time, guidance, and support from them. In my opinion, for whatever it's worth, Mark Hyman is another doctor gone astray by the lure of fame and money.

Of course, he's not the first, and he's not alone. He has his good friend Dr. Oz to keep him company.

Today, I was contacted by a Canadian reporter doing a story on Dr. Oz. She let me know that she had cited my blog in a previous story she wrote about Oz and directed me to the story.

I have often wondered if Dr. Oz actually believes it when he says that a supplement he promotes is as good as he claims or it is all showmanship. If the Dr. Oz quote from her article is accurate, it appears that he doesn't truly believe in his "miracle cures" and "magic pills." For example, in regards to raspberry ketones, he believes that it may have, at best, a marginal benefit.  He is actually quoted as saying that raspberry ketones have the value of a "nudge."  A "nudge" does not quite match the characterization of raspberry ketones as an amazing weight loss product as he claimed on his show.

The article goes on to reveal Dr. Oz's main excuse for pushing so many different products on an unsuspecting audience--which is to give people hope. After reading the article, I can only conclude that he makes such pronouncements at best to make himself seem like  a savior by giving people hope, albeit false hope at that, and at worse to make some money by promoting the sale of a product.  

Read his own words in describing himself. I couldn't make this up:

"There are three words to describe what I do. I’m a doctor. This comes from the Latin docere, teacher. I’m a physician, which comes from the Latin, physica, science. I’m a medicine man, which means healer. To help someone else, you have to have science, you have to be able to heal, and you have to be able to teach. They all work together. In Western medicine, we put a disproportionate (emphasis) on the science part."

Did he really say a "disproportionate (emphasis) on the science part." Really? What should we rely upon when it comes to your health? Opinions? Anecdotes? Marketing? 

Here's another Latin word that seems to be lacking in Dr. Oz's vernacular.  It's veritas, which means truth. Used in the motto of many leading universities including Harvard, Yale and Duke, it is the essence of education to seek and find truth.  If he were a true teacher, he would espouse the truth. It is a shame that Dr. Oz feels his audience doesn't deserve or can't handle the truth.  Instead, he gives them false hopes in the name of good TV and money-making.

May I speak for others when I say we all would like some veritas from Oz and Hyman if they wish to be considered true teachers?

Calcium Pills Raise Concerns -- Again!

If you've heard me say it once, you probably have heard me say it many times -- taking dietary supplements in the absence of known deficiency is a mistake. One of the more controversial supplements I've rallied against has been calcium. Most women are told by their doctors, particularly as they get older, to take calcium supplements, usually about 1,000 mg.

When I give lectures, I often ask of the audience whose doctor adjusted their calcium recommendation based on the calcium the individual consumes through his or her food. The answer is almost always that none of their doctors made any such adjustment. I've always considered this problematic because why supplement at all if you are getting sufficient calcium in your diet, and why not adjust when you are getting calcium from other sources.

My real concerns about calcium began to grow almost two years ago when studies began to emerge challenging the wisdom of taking this supplement.  Specifically, these studies linked calcium supplementation with increased heart attack risks. Some studies suggested the mechanism for this, calcium supplements, were contributing to calcification, or hardening, of the heart.

So a new study that just came out should be of no surprise to my patients.

The large European study showed that people taking calcium supplements had nearly double the risk of heart attack as individuals not taking any dietary supplements. Among 23,980 participants in the European Prospective Investigation into Cancer and Nutrition (EPIC-Heidelberg) study, the hazard ratio for heart attack in those using calcium supplements, compared with nonusers of supplements, was increased according to Sabine Rohrmann, MD, of the University of Zurich in Switzerland, and colleagues.

"This study suggests that increasing dietary calcium intake from diet might not confer significant cardiovascular benefits, while calcium supplements, which might raise MI risk, should be taken with caution," the researchers concluded. In an accompanying editorial, two New Zealand physicians went further and suggested that use of calcium supplements should be actively discouraged.
 
This was an imperfect study as it was an observational study that relies on self-reporting. Nevertheless, once again, the red flag rises over taking calcium pills, or any dietary supplement for that matter. The evidence continues to mount that at best they confer no benefit, and at worst, they are harmful.

Eat a Mediterranean diet consisting of fruits, vegetables, beans, nuts, and some whole grains, add in some wild fish and save yourself some money from not buying unnecessary pills.

Hugging Patients

Is it appropriate for doctors to hug patients when they ask to be hugged? This is more than a theoretical question for me. A number of my patients ask for hugs.

Just yesterday, a patient told me that that I was the first doctor ever who actually took the time to listen carefully to everything that bothered her. She was 78. She had a lot to say and I listened patiently, only interrupting when I had something of value to add. After taking in the full scope of her situation, we developed a prevention plan focused on keeping her healthy and in good spirits for years to come. When we were done, she asked for a hug.

People want to know that someone cares. Some may look to a religious figure for such empathy, while many hope to get it from their doctors. Unfortunately, the time pressures put on so many doctors make it difficult to give patients the time and attention so many crave. I am privileged to be able to afford the luxury of time with my patients. For me, it is a pleasure to hear life stories, although some are heartbreaking, in order to learn as much as can be reasonably learned about the individual sitting in front of me. I get the full megillah and relish it.

It amazes me what colorful lives so many have lived and how sharing their anecdotes enhances both the speaker and the listener. I feel bad that most doctors can't enjoy this level of interaction and satisfaction. Medicine is a noble profession, but many regulatory and reimbursement changes have made its practice less enjoyable for many practitioners. That's too bad because they are really missing something special.

For my patients, if you want a hug, just let me know. They are free and I have plenty to give.

What Do You Put Your Faith In?

Many things are done on the basis of faith. Religion is one example, relationships are another.  However, proper practice of medicine should be based on evidence not blind faith.

Making the headlines yesterday was the United States Preventive Services Task Force recommendation that doctors discontinue routine testing for Prostate Specific Antigen (PSA) in healthy men. This recommendation was based on two studies, one which showed no difference between men tested versus not tested, and the second study which showed that among tested men, there were many false positives that led to further unnecessary testing e.g. biopsies, which led to complications e.g. infections.

Not surprising, many urologists and oncologists came out against this don't test recommendation. What's the answer? My view is that if you have symptoms, you should test, and if not, you should not test. I believe this is true in many medical situations not because I have an opinion but because the facts support that conclusion.

Yesterday, I exchanged a number of correspondences with a lady on LinkedIn regarding the need to test everyone for Vitamin D deficiencies.  She emphatically believes that it is necessary to test everyone because most people who don't take Vitamin D supplements are deficient; I don't agree.  My reason for not agreeing is because that's not what the science shows. As I wrote the other day about Vitamin D and The Endocrine Society, the facts are inconclusive as to the effects of mega-dosing with Vitamin D. This lady insisted that she needed twice the normal lower level of Vitamin D to be healthy. It's not surprising that so many people are confused by what they need because rumors and false information often circulate unabated without correction about supplements. You may remember my blog titled Supplementum, The New Religion. It was a parody of Americans' growing blind faith in supplementation in the absence of compelling evidence.

I can understand why many put their faith in things that aren't true. We sometimes just want to believe; sometimes we just need to believe.  Oftentimes belief is a good thing if it gives you solace or helps you navigate an often confusing world. That's all fine as long as such belief does not lead to dangerous situations and irreversible harm. While I believe that it is important to be vigilant, I don't believe that it is proper to test for no reason. In the Longevity Project book, the authors concluded that a little bit of neuroticism is good for your long term health, but chasing diagnoses in the absence of symptoms is full blown neuroticism and that's not healthy.

My biggest issue with supplement marketers is that they give people false hope by promoting science fiction as fact, when there are better solutions available that won't be pursued because of reliance on placebo-like products. If people had all the facts, the supplement market would be a fraction of its size and it knows it. That's why it fights the FDA with everything it has because the FDA wants the facts to be known.

Faith works, but when it comes to your health, I think you would be better off relying on evidenced based medicine. I know I do.

One Person At A Time

The release of the Institute of Medicine's report last week about obesity and the airing of HBO's The Weight of the Nation the past two nights have created quite a bit of hoopla. Both associated reports have highlighted the growing epidemic of obesity in our country and the pressing need for a solution.

This morning at 5 AM, I watched two hours of the HBO show and was delighted by its even-handedness. The facts were presented in a non-sensationalistic fashion and flowed nicely, so if you haven't seen the show yet, I encourage you to do so.

For me, there was an immediate take-away from the individual stories of struggle and success that were reported. The take-away was that everyone had a unique story and everyone needed help to lose weight. Yet, despite this underlying theme, other than a discussion with a bariatric surgeon, there were no specific recommendations to seek such help. Suggestions were given to exercise more, eliminate certain foods like fruit juices and soda from one's diet, etc.;  but, never once was it stated that one seek consultation with a nutritionist or health psychologist. Neither were there any suggestions to discuss your weight problem with your physician, nor your difficulty, for whatever reason, to get the exercise you need, with a fitness trainer.

Ultimately, the show commits the cardinal error of simply telling people the oft repeated advice to eat better, exercise more, become more mindful, etc. If it were that simple to lose weight and modify one's lifestyle, there would be no obesity epidemic and 68% of Americans would not be overweight.

True, our country as a whole has a collective weight problem that merits the closest attention. But the problem can only be solved one patient at a time. I'm sorry to beat this horse to death, but the type of help people need can often not be determined by the individual alone. As I've said before, patients who are their own doctors, or what I call Doctients, have a fool for a doctor.

That is why I believe, when it comes to a weight problem, that a 360 degree assessment, provided by a primary care practitioner, registered dietitian/nutritionist, health psychologist, and fitness trainer is the best approach. That is why before we opened MDPrevent, before we had even a single patient, we hired all these professionals to be on hand full-time so that every and any patient who would benefit from their assistance could immediately access it.

While the sum of the parts means that the weight of our nation is a pressing, perhaps even the defining problem of this generation, the solution can ultimately only be accomplished by interventions geared to helping one person at a time.

I hope someone is listening, but if not, I'll raise my voice even louder. This nation's weight problem will not go away on its own and neither will I.

Prevention May Be The Best Path

Did you hear the good news? Yesterday, researchers at Duke University using a new model, predicted that by 2030, only 42% of Americans will be obese. Today that number is 36%, but the apparent good news is that a previous model predicted it would be 51%.  At the same time, the researchers predict that severe obesity would rise to 11% instead of the previously predicted 9%. 

The reasons for the discrepancy were described as the researchers taking into account factors such as unemployment rates; prices for alcohol, gas, and fast food; prices of healthy versus unhealthy foods; access to the Internet; and the number of fast-food and full-service restaurants per 10,000 people.

So is this really good news? Should we break out the champagne or the tissues? I find it hard to imagine that nearly half of all Americans will be considered obese in less than twenty years. But what is even more difficult to absorb is that our government is not obsessing about this problem.

This year, the Centers for Medicare and Medicaid Services (CMS) took a big step forward and initiated coverage of Intensive Behavioral Therapy for Obesity. They define obesity as a body mass index (BMI) of 30, which is about a 5 foot 4 inch woman weighing about 170 pounds or a 5 foot 9 man weighing about 200 pounds.  The problem is that if your BMI is 29.9, you are out of luck. At that number, you are entitled to no therapy whatsoever.

I can appreciate that there needs to be a threshold at some level, but I believe it should be several BMI points lower. Why wait until someone is already obese to intervene? Studies show that many things change including our gut bacteria, metabolism, and hormonal balances as we gain weight. Basically, it gets harder to lose weight the more you gain AND it gets harder to keep it off after we gain it and try to lose it again.

The other problem with CMS's obesity initiative is that the reimbursement is approximately $27 for 15 minutes up to 16 times spread across 6 months (6 more spread across the next 6 months if you lose 6.6 pounds after the first 6 months). That extrapolates to about $108 per hour, far below what the average primary care physician, which is the only type of physician that can offer the service, earns before overhead, staff, malpractice insurance, billing costs, etc.

Multiple google searches have failed to identify a single doctor or practice in the U.S. offering this service. I can find no practice marketing it. I also asked dozens of primary care providers and they have said they do not as well.

Is it the low reimbursement? Maybe. Is it the lack of knowledge necessary to provide intensive behavioral therapy? Maybe? Is it the reluctance of doctors to tackle their patients' obesity?  I can only say maybe again because I don't really know any of these answers as to why other doctors choose as they do. But I do know we have a problem and it's not just doctor engagement.

I think the real problem is the patients.  Tackling obesity with just primary care practitioner led therapy, instead of pills and surgery, requires real commitment on the part of patients. Obese patients know they have a health problem and that their long term health prospects are at play. Most also know that obesity is not particularly attractive. Yet, whether you believe it is a disease or a choice, these same people find it difficult to tackle their issue. Few prefer to be so overweight and need help to break out of their weight captivity.

So what do we do about this problem? Some may say financial incentives. I don't think that is a long term solution and I have previously explained why. While short-term incentives may work, weight is often easily regained unless fundamental changes to lifestyle are made and such changes can most of the time only be brought about by a concerted effort.

So how do we do that? I propose an integrated and interdisciplinary approach. In other words, I think it will take a team effort of motivated, committed, and trained practitioners to support, guide and educate patients to bring about real change. About 4 months ago, MDPrevent proposed such a model to CMS. MDPrevent asked for funds, to which I and others would contribute additional funds, to tackle not only the rising epidemic of obesity, but also heart disease, diabetes, dementia, and cancer.

MDPrevent's program, which we titled, Intensive and Integrated Behavioral Therapy for Lifestyle Modification would combine the talents of a primary care provider, a registered dietitian, a health psychologist, a fitness instructor, and a health educator to work with patients on both an individual and group (group success can be contagious) basis and help them tap into their own motivation to make change.

We anticipated that it would take a full year to bring about meaningful success and expected to be able to do so at a cost of slightly above $600 per patient. For this meager amount, we believe that we can change the course of someone's health and life trajectory.

Can anyone argue that it isn't worth the effort given the obesity and other chronic disease projectories? There is no profit for MDPrevent in the amounts requested because we believe that we must first prove the success of such a program before profits can even be considered.

The goal of the program is to identify and tackle pre-obesity, pre-diabetes, pre-stroke, pre-heart attack, and pre-cancer situations and implement a series of lifestyle changes to prevent, delay or even mitigate the development of these life threatening conditions.

The decision from CMS regarding funding this initiative was originally due March 30. We are in overtime. I am told it will come shortly. This program could be a game-changer for the country at large. Wish us luck!

Look In The Mirror. Part 2. Better To Buy A Bike!

Yesterday, I wrote about the dangers of using the services of a mobile testing company. As fate would have it, after writing my piece, I received a solicitation from one such company.

The solicitation included a marketing flyer, which on one side was titled, "6 Reasons for Regular Screening." Let's analyze their reasoning.

1. Your health changes over time.

Based on this logic, we should be doing all sorts of testing all the time because we never know when our health changes.  Applying this principle, this should include blood tests, ekgs, x-rays, CT scans, MRIs, PET scans, ultrasounds, cardiac-stress tests, spinal-taps, endoscopies, etc. If you agree with their thought process, why exclude more elaborate tests that are better detectors of problems. The answer is because most of the tests they do are unnecessary, because the tests are not free, because you can't obsess about your health by constant testing (a little neuroticsm is ok), and most importantly, because you are likely to get many false positives that will lead to further stress and unnecessary testing.

2. Your physician usually cannot order these screenings unless symptoms are present.

That's an easy one. Good physicians don't go on wild goose chases looking for problems. When they hear hoof-beats, they think of horses, not zebras, and they use the proper tools to diagnose the problem(s) the patient shares with them.

That said, certain medical tests are covered and recommended in the absence of symptoms because the evidence for thier prospective use has been carefully evaluated by the United States Preventive Sevices Task Force (USPSTF) and determined to be of good use. However, these tests are generally covered by insurance and can be ordered by your doctor.

3. Your previous results may have revealed important risk factors.

This is a doozey. It reminds me of my experience with the pre-diabetes. Do they think (or hope) you ignored the previous abnormal results, did not bother to consult a medical professional, and should now return for another test only to keep repeating the process of excluding a medical consultation?  Apparently so. Testing in the absence of follow-up is dangerous. Do not be a doctient, a person who thinks he is both a patient and a doctor and can self diagnose and treat.

4. Screenings can help prevent stroke.

Screenings do not help prevent stroke. They may detect your increased risk for stroke after which you can consult a doctor for preventive measures. The issue here is that in the absence of sign and symptoms of stroke related disease, such as heart disease, diabetes, obesity, high blood pressure, high cholesterol, atrial fibrillation, etc., the probability of having a stroke is extremely low. If you have these medical issues, you are at higher risk for a stroke and you don't need a test to confirm the risk. You should take action immediately to decrease your risk by changing your lifestyle and seeing your physician for medical intervention.

5. Screenings can detect serious risk factors in just minutes.

If you have nothing better to do with your life, then by all means go for these unnecessary tests in the absence of sign and symptoms because maybe, just maybe they may find some abnormality that requires action you should have already taken anyway. But don't worry, they will confuse you fast.

6. You may suffer from Peripheral Arterial Disease (PAD).

That's a true statement. You may suffer from hardening of the arteries and about a thousand other diseases. Again, PAD itself is associated with heart disease, diabetes, obesity, high blood pressure, and high cholesterol. If you eat what you want and barely exercise, there is a high probability you will develop PAD at some point in life. You don't need this test, and in the absence of signs and symptoms, that is why it is not covered by insurance.

Many insurances today, including Medicare, offer a full range of preventive benefits, including screening tests, that have, based on the scientific evidence, been to be found worthwhile. Don't succumb to fancy marketing and be sucked into getting unnecessary testing.

If you have any concerns about your health, speak to your medical provider as soon as possible.

One final note, a study just published in the American Journal of Cardiology, focused on men who had at least one parent who'd had a heart attack before the age of 55. The study found that despite this apparent gentic predisposition to heart disease, those men with a healthier lifestyle were less likely to develop heart failure over two decades.

"Healthy habits included not smoking, exercising regularly, keeping a normal weight and drinking alcohol in moderation."

Many screening companies use your family history to scare you into unnecessary testing. The bottom-line remains that testing doesn't prevent disease--you do by the lifestyle you live. Save your money on testing and buy a bicycle or some other piece of exercise equipment. It will do you more good.

Longevity and Weight: What's the connection?

For the past year, I have been meeting with, treating, and lecturing to over a thousand seniors. Although this is not a scientific conclusion, I notice that people in their late 80s and above are never markedly overweight and those who are markedly overweight often look older than they are. This is consistent with a study of Jews of Eastern European descent that are believed to have a longevity gene that confers the potential to live into their 90s and above. The study showed that despite sometimes living unhealthy lifestyles, none of those living into their 90s were overweight.

A study reported today further supports this conclusion.

First, let's review what is the Body Mass Index (BMI).  BMI is a measurement of weight classification calculated by factoring in your weight and height. It is an imperfect measurement because it doesn't differentiate between high body fat and muscle content. BMI has been used by the World Health Organization as the standard for recording obesity statistics since the early 1980s. (The formula is pasted at the end of the blog.) Here in the U.S., it is also the most commonly used measurement to determine underweight, normal weight, overweight, and obesity.

Generally a BMI below 18.5 is considered underweight, 18.5-25 is considered normal, above 25 to 30 is overweight, 30 to 35 moderately obese, 35 to 40 severely obese, and above 40 very severely or morbidly obese.  (It is used differently for children but I won't discuss that here. Write me for more information.)

In a new study,  Nicholas J. Timpson, PhD, of the University of Bristol, in England, and colleagues found that for every .8 (point eight)  increase in BMI, ischemic heart disease risk rose 52%.

 "These data add evidence to support a causal link between increased BMI and ischemic heart disease risk, though the mechanism may ultimately be through intermediate factors like hypertension, dyslipidemia, and type 2 diabetes," the group wrote in the May issue of PLoS Medicine."

Furthermore, they explained that "Observational studies, both prospective and retrospective, consistently link higher BMI to heart risks across different populations, but haven't convincingly demonstrated causality because of the possibility of confounding, reverse causation, and bias."


Everyone knows that being overweight is often associated with developing chronic diseases like heart disease, diabetes, stroke, cancer and dementia. However, this study is a big deal because it shows a direct correlation between weight and heart disease risks.

So it turns out that what I have been noting empirically, is in fact, scientifically grounded. The heavier you are over a BMI of 25 the more likely you are to die prematurely from ischemic heart disease, and I suspect, from other diseases as well.

At a health fair on Monday, I greeted passersbys with "How would you like to add more healthy years to your life?"  I thought this question will receive a resounding yes every time asked and it would allow me to engage the person in a meaningful conversation regarding the benefits of taking advantage of Medicare's smorgasbord of wellness and preventive services. I was wrong.

At least a quarter of the people said they were not interested. Perhaps it was my delivery or they were wary of what I was offering as too good to be true.  I really don't know the reason, but it amazed me anyway that anyone could answer that question negatively. I shouldn't be surprised.  Since the introduction of new wellness and preventive benefits in January 2011, less than 94% of eligible seniors nationwide have taken advantage of over $1,000 worth of these life-enhancing benefits. These services were implemented by Medicare to help seniors avoid chronic disease, prevent heart attacks, lose weight, and allow for early disease detection. Yet, few doctors are providing the service and few seniors are receiving them. What gives? Do they not know of the benefits or are they simply not interested?

I can't profess to know exactly what goes through seniors minds (even though in my past work experience I led an organization that cared for 5 million seniors), as I am a generation younger, but it still breaks my heart that they are not all willing to do whatever they can to live longer, healthier lives.

I can only imagine the fears they have of doing so-fears of developing dementia, fears of running out of money, fears of being institutionalized, or being left alone with the passage of friends and family. These can be legitimate fears as they can and do happen, but early planning can make a difference and I know plenty of seniors who continue to enjoy life into their 90s and beyond. I recently presented to three centenarians, the oldest 103. They all peppered me with questions.

Many seniors don't realize that the longer they live, the more good years they have enjoyed. A researcher at Albert Einstein College of Medicine also concluded that the longer you live, the less you spend on medical care. That may not make sense at first pass, but when you think about it, it begins to resonate. Living longer typically means you have less sick days and that means less visits to doctors, etc. Medical costs are a huge drain as we age and avoiding such expenses preserves our capital.

The bottom line is whether you do it for yourself, for some member of your family, or for any reason that motivates you, take care of your health (and weight) so that you can enjoy a long, healthy life.

BMI formula:

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:

http://www.nytimes.com/roomfordebate/2012/04/15/do-we-need-more-advice-about-eating-well

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?

Are You A Doctient?

A couple of days ago, I was at a health fair speaking to prospective patients about MDPrevent. During the course of the day, a young senior woman walked by and I tried to discuss our program. Whatever I said to her was responded to by sarcastic facial expressions. She claimed that she was well versed in wellness and supplement usage and rattled off an alphabet list of different supplements she was using including boron, calcium, magnesium, etc.  As she walked away, I thought to myself that there is truly a new kind of patient today which I will now forever call a Doctient, the word created by blending the words doctor and patient.

When I was in medical school in the early 1980s, we were taught that patients absolutely must own their health care and be active participants in approving any treatment. We even were shown a video in which a patient slugs a nurse trying to add a drug into her intravenous line after asking th nurse not to do so and were dutifully informed that the patient was right to do so because the drug was the wrong medication and would have harmed her.  Accordingly, I have always believed in patients taking an active role in their care.

Yet, in the past 15 years, with the meteoric rise of internet usage, and the immediate access it provides to almost unlimited medical information, good and bad, patients have become more empowered than ever about their health care.  In general, I think that's a good thing. Still, I am afraid because I find much of the medical information available on the internet to be superficial, confusing, incomplete, alarming, and most importantly, often inappropriate for the specific patient. I read that a study showed that Wikipedia was accurate 98% of the time in relation to health information. That's great, but how do you know when you are reading the other 2%? 

If patients use their internet and book found knowledge in conjunction with a medical consultation, I think the truth can be determined and the best course of action achieved. But when patients solely rely on information they gather on their own from various sources, they are playing with fire. Fire in this case may be life-threatening.

An article on Yahoo the other day attacked artificial sweeteners in soft drinks as potentially harmful while lauding regular soft drinks as healthier. Really? Soft drinks made of mostly added sugars, chemicals, and artificial colors are superior to diet drinks? That's news to me. Neither is good, but there's no defensible position to argue that soft drinks are healthy, relative to anything edible. We all know we can't believe everything we read, but it's really hard sometimes to ignore the written word when it includes known facts mixed in with conjecture, hyperbole, and misinformation.

So if you are a Doctient, that's great, because understanding you health is important. But don't be a Doctient in a vacuum. It's often been said that a doctor who treats herself has a fool for a patient.  Here's my new adage. A patient who treats himself has a fool for a doctor. Be knowledgeable about your health but don't get overly confidant. As I quoted Mark Twain in a previous blog, "It ain't what you know that gets you into trouble. It's what you know for sure that does."