An Apple A Day

A recent article in the NY Times caught my eye. I couldn’t have agreed more, and also less. Titled “Let’s (Not) Get Physicals”, it was a reflection on the problems with conventional routine physical exams. http://www.nytimes.com/2012/06/03/sunday-review/lets-not-get-physicals.html?pagewanted=all

The time-honored tradition has been for a thoughtful patient to see her/his doctor for an annual exam. The article discussed several of the screening tests that have been the foundation of the annual exam routine. Many of these have been shown to be ineffective. Ineffective screening tests are worse than just a waste of time and money, as they lead to other needless tests and procedures. The procedures, the next steps looking to identify or treat the “disease” that is not there or does not need to be treated, usually create their own problems. The end result is that the patient has been harmed by this well-intentioned effort. Bear in mind that dumping procedural screenings is nothing new. Annual chest Xrays, anyone? We used to do that not so terribly long ago.

That was the agreeing part. My disagreement is based on the definition of what is done. From my experience it is certain that an appropriately directed annual health assessment is wise. That is true, even excluding the simple technology of a couple of blood tests. I see people every day who are so vitamin deficient that it shows up in simple blood tests from a conventional lab. But forgetting that, dumping all the post 19th century technology, there is ample, easily accessed and useful evidence of what needs to be changed to better a person’s health.

Taking to patients about how they feel, what they eat, their exercise patterns, how they are managing the stress of their lives, etc., tells me a lot. With that information, I can help them improve the quality of their day to day lives and avoid developing the most common diseases in our society (e.g., heart disease and diabetes). The risks of talking to a patient, looking over a three day diet record, reviewing his/her use of supplements/medications and conducting a simple physical exam are close to nothing.

Another shadow, looming over this discussion, is that doctors know that patients don’t change their habits. You can never get them (you) to change their diet or exercise. They won’t work to learn how to manage stress better. Docs know that. As you know very well, docs are wrong.

A child can learn to read and write without any help. but it will take a long, long time and incredible determination. When a doctor tells a patient that they should get more exercise, eat better, stop smoking or whatever, without providing the specific steps to achieve those formidable goals, almost no one is successful. The patient feels like a failure and the doctor’s negative expectations are confirmed.

What my colleagues do not know and what perpetuates this vicious cycle of hopelessness is HOW to help patients make changes. Medical school lasts four years. After that we have to get at least one year more of training, with most of us taking three or more. In all of that, there is little emphasis on the benefits of changing lifestyle and none on how to help patients make changes. When I earned a national level soccer coaching license I received some of my most valuable medical education. That was how I learned the nuts and bolts of helping people make changes. That has made a huge difference for me, and more importantly, for my patients.

If my colleagues were taught more about healthy lifestyle, low-tech examination and how to actually help patients make changes, annual exams would be powerfully positive health and life-enhancing experiences.

Who is that in the photo? It is Joseph Bell, MD. He was the inspiration for Sherlock Holmes. One of Conan Doyle’s medical school professor’s, Bell was renowned for his remarkable insight into his patients, based purely on his skills of observation and thoughtful deduction. He might be an even better model for physicians today than in his own time.

The Foods You Choose Can Help You Lose, Or Not

Many people think that Americans are obsessed with celebrity, politics or some sport. Yes, we are, but our chief obsession is not on that list. Americans are truly obsessed with weight, especially losing it.

One reason exercise is so important for those losing weight and improving their body composition is that our body’s response, after losing weight by cutting dietary calories, is to slow down its metabolism. Faced with starvation, your body slows everything down. In that state, which some studies show persists for years, you will burn fewer calories than another person who weighs less than you, but never starved themselves. Exercise helps keep that from happening by forcing the body to keep running at a higher metabolic rate.

The really, really bad consequence of the metabolic slowdown is that many people who lose weight not only regain every pound they dropped, but they also end up with a higher percentage of body fat than they started out with. They bounce back up to the same weight, but now they are fatter at that weight. That outcome is cruelly disappointing.

A small but very interesting study shows that what you eat, specifically the balance of fat, protein and type of carbohydrates, might change the rules in this losing game. Researchers helped a group of overweight men and women lose 10-15% of their body weight, and then rigorously tested their individual responses to three different diets. One diet was the traditional low fat/high carb diet with 60% of calories from carbohydrates and 20% each from fat and protein sources. At the other end of the spectrum was a diet with 10% carbohydrates, 60% fat and 30% protein. The third diet had a middle range of carbohydrates (40%), with 40% of the calories coming from fat and 20% from protein. The carbohydrates in this diet were specifically selected to control blood sugar (low glycemic index and moderate glycemic load). Consistent with other studies, those in the low fat/high carb group dramatically lowered their metabolic rate, burning 300 calories a day less than those in the Atkins-like low carb group. In other words, those in the low carb/high fat group burned more calories. That caloric difference is like running 3 miles every day, without getting up off the couch. Piled up over a year, those additional 300 calories a day become 30 lbs of fat. The “old wives tale” about potatoes making you fat proves the wisdom of listening to old wives.

The middle diet had a middle-of-the-road effect, but could be the best choice for the long term. During that phase of the diet people had the least hunger and reported feeling the best. There are reasons not to jump to the conclusion that the Atkins model is certainly the best way to eat. One reason is that during that phase of the diet the subjects’ blood samples showed the highest levels of inflammation. The most important shadow of uncertainty is cast by the problem of protein disparities in this and other trials. Dietary protein makes bodies run hotter, raising the metabolic rate and burning calories. The low carb diet in the study had 50% more protein than the other two diets, and so was then not perfectly comparable.

Regardless of the scientific understanding of how and why, success is the best outcome measure. Without any doubt, my clinical experience teaches me that patients find it easier to lose weight on a high protein diet. For most individuals the simplest approach to making this change is to replace carbohydrate-rich foods with protein-rich ones. Although exercise, sleep, taking a supplement to get the right amount of vitamins and other elements are also required, the dietary essentials are as follows:

1. Target a specific amount of protein intake by taking your weight in pounds and multiplying by 0.7 - 1.0. That number is how many grams of protein you should get in a day.
2. Do not be afraid of fats.
3. Remember that sugars and other foods that make your blood sugar rise quickly (potatoes, processed grains, candy) are going to make it tough to keep your weight down. Although whole grain products like whole wheat bread are less bad, they still have a high glycemic index that will fight against your efforts to lose weight.
4. Alcohol, while it has a very low glycemic index, creates blood sugar instability, leading people to eat more for up to 24 hours, fighting the hypoglycemia alcohol creates.

A study was just published with exclamatory headlines warning about vitamin D and calcium raising the risk of kidney stones. They studied the blood and urine of 163 healthy, postmenopausal women for a year. Investigators gave the women from 0-4,800 iu of vitamin D and raised their calcium to 1,200 - 1,400 mg/day. 1/3 of the women had high levels of urinary calcium and some had elevated blood levels.

That would seem scary, except it isn’t. First, no one actually had a kidney stone or other trouble. More important to me is a much bigger study, involving more than 10 times as many women over a 10-20 times longer time span, also showing no kidney stones and no otherwise unaccounted for calcium elevations on blood work. That bigger study is my clinical practice.

Maybe this is because I insist that my patients drink enough water. Dehydration is the major factor leading to kidney stones and calcium is notoriously insoluble.

It may also be another example of our ignorance about calcium metabolism. For decades, the standard medical advice for patients who had a common calcium-based kidney stone was to avoid calcium. Then someone actually did a study instead of just making it all up, and found that low calcium intake was associated with INCREASED risk of kidney stones.

Another contradictory example can be seen in the disease called hyperparathyroidism. More common than once thought, people with hyperparathyroidism have high calcium levels which can potentially become lethal. Many feared that giving these patients vitamin D would make things worse. Turns out that taking vitamin D does not raise calcium levels in patients with hyperparathyroidism. In fact, in many of these patients, taking vitamin D lowers calcium and helps the patient otherwise.

Bottom line - get as much calcium as you can from food, use calcium supplements to make up for what you can’t eat, take lots of vitamin D (targeting a blood level over 50) and DRINK enough WATER so that your urine just slightly tints the water in your toilet.

Newly released data, collected over nearly 40 years, indicate that runners live 5-6 years longer than other people. I like this but also have some doubts.

I began running as a 12 year old, and after a few more months of surgical recovery, hope to resume this life-long habit. I love it. My work as medical staff at marathons and as Medical Director of the Santa Rosa Marathon are the confluence of my interests. Just like this study shows, I am certain that running, and more broadly, being physically active, are crucially important to any person’s health and wellbeing.

Now for the doubts. Five to six years is a huge difference. The study has a number of flaws, unfairly visible with close to two generations of hindsight. Why “unfairly”? Well, any long-term study will have significant problems. There is too much we don’t know, including unknown and then unobserved variables. So, weakness are inevitable. Too much criticism is also unfair, because of course the reason to do research is to learn what we don’t know. We can’t expect researchers to know what no one knew when they began. So, my advice is to take these findings with a grain of salt. Running is great. However, exercise in any form is great and there are excellent reasons, theoretically, scientifically and understood by those with experience, why other forms of exercise are also essential and sometimes preferable.

As my father died of a heart attack at age 47, can I attribute my 10 additional years (SO FAR) to my running? Sure, but only in part. My diet has been excellent, way better than his was, for the last 40 years. That influence, other elements of my exercise regimen and many other factors for sure play their parts.

So, run if you want to run, but exercise, you must. While you are at it, adding in the other good stuff will help you live better, not just longer.

If you read about vitamin supplements you must be confused. Actually, it would be hard not to be. Vitamins are, by definition, essential to health. Studies of hundreds of millions of people confirm that truth. However, a rash of recent studies have linked taking vitamin supplements to higher rates of a variety of diseases, especially cancer. What’s up?

The fundamental problem is bad research. This bad research is the consequence of poor understanding, plus the difficulties inherent in designing and conduct nutritional studies that apply to the real world. The best examples of the faults in these nutritional studies are probably those dealing with folic acid and vitamin E.

Many studies show that dietary folic acid reduces the risk of many diseases, particularly cancer. The prevention of congenital spinal malformations is the main reason our food supply has been fortified with folic acid for decades. Surveys of the American population show that this approach works. That is the simple part. The confusing part is that some studies have shown an increased risk of cancer with folic acid supplementation, while others have shown that folic acid lowers the risk of the very same cancers.

As many of you have heard me explain following your own blood testing, nearly 20% of us have a genetic inability to convert folic acid to its metabolically active form. Those individuals among us need to take a special form of folate. If they take the common, most widely available kind of folic acid, not only does it not help, it seems to cause problems consistent with the unhappy research findings. After MERCK, which holds a patent on this form of folic acid, allowed others to use it, I had it added to my multiple vitamin. Very few multiple vitamins contain this form of folic acid, as it is more expensive. Two months ago I read an editorial in a major medical journal wherein a couple of prominent experts pointed out that negative studies on folic acid in diabetics had neglected to address this issue. Their opinion, with which I am in complete agreement, was that these studies were fundamentally flawed and almost certainly drawing incorrect conclusions as a consequence.

Vitamin E has also taken a lot of heat due, to a similar lack of understanding. Most of the vitamin E you can buy in supplements comes as alpha tocopherol. Unless you are a chemist, your brain won’t want to swallow that word or distinguish it from beta, gamma, delta or any other tocopherols. It is not even that simple, because even with all of those tocopherols, an additional class of compounds called tocotrienols are part of the Vitamin E family and seem to be important. Food contains all of these compounds, and it appears that alpha tocopherol might be the least important of all. As one vitamin E researcher wrote, “taking a mixture of vitamin E that resembles what is in our diet would be the most prudent supplement to take”. I would amend that statement to read, “taking a mixture of vitamin E that resembles what would be in an ideal diet and considers your individual needs, would be the most prudent supplement to take”.

A recent survey concluded that very few Americans were low on any vitamins or minerals. While that got significant media attention, the fact that hundreds of studies have shown the opposite, did not. Many of those studies actually measured body levels. That is especially important as estimates from dietary records are woefully misleading. Dietary records are infamously different from the truth of what people really do eat. On top of that, absorption varies tremendously from person to person and even time to time for the same person.

Thankfully, there is evidence that some who write about and study nutrition are thinking more clearly. The “experts” are becoming more expert. Also, those with a better understanding are getting at least some attention for their criticisms.

Positive evidence of the benefits of dietary supplementation continues to accumulate (of course). Recent studies have shown that the brains of people of all ages, from young children to elderly adults, function better beginning just days after starting to take a multiple vitamin. The same holds true of omega-3 supplements. In an example of the complexity of nutrient interaction, vitamin E lowers the rate of prostate cancer but only when taken along with selenium.

Bottom line-

Think critically - If something is vital, many of us need it.

Don’t forget the food - A vitamin pill cannot entirely replace good food.

Don’t go crazy - Take moderate amounts of nutrients as a safety net.

Go crazy if YOU need to - Some people, especially when ill, need much more.

Vitamins vary - Cheap forms of nutrients cost less, but they are usually a waste of money and can be harmful