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.

I hope that, respecting tradition, you have dedicated yourselves to creating some better health habits in this New Year. I also hope that you are going about that in a joyful way, understanding that doing the right things will help you enjoy your life more. Also, pursuing good health habits should be fun, not tedious and just “good for you”. Sure, sometimes it takes a little while before you start noticing the benefits, so a little discipline is needed to establish your new habits. Other times, you feel better right away. Instantaneously or gradually, disease-reducing, longevity-promoting or not, do it because you will feel better. This newsletter is a map, guiding you along the most direct path towards a better life. Change is not just a matter of will-power. Going about it the right way makes it much easier, and markedly increases your chances of success.

I am in an exercise focus right now. Admittedly, some of that is because of the time I spent during the last month working at the Olympic Marathon Trials and attending a sports nutrition conference, but more importantly, a lot of new data is coming out that is very interesting and will be useful to you. In this blog I will soon post some thoughts about some physical training specifics. The purpose will be to make your exercise more efficient and more effective.

Making changes

The idea of making changes in the New Year is easy fodder for comedians. Everyone talks about it, but no one really accomplishes anything. That’s right and it’s also very wrong.

In the Northern Hemisphere, where most of us live, the New Year roughly marks the return of the sun. The days start to become longer and warming weather will follow. Greeting the New Year with hope and new ideas has been the tradition as far back as we can trace human cultural history. I think this tradition would have died out long ago if every attempt were met by failure. On the contrary, every day I see patients successfully change their lives for the better, not just at the New Year. You should be optimistic about making changes.

Change doesn’t happen simply by rolling out of bed on New Year’s Day, although that IS a necessary first step. To ensure success, you need to develop a plan.

Self-Assessment

The dark, cold months of the year are traditionally a time of reflection, a time of the inner life. Figuring out where you are is essential to creating a map to get you where you want to be.

I cannot overemphasize how important an honest and thorough self-assessment is when you are trying to make changes. Your self-assessment must be as objective as you can make it. An inaccurate assessment inevitably carries the seeds of failure. If you think you are in better shape than you really are, the training for that April marathon WILL injure you. You might think you aren’t eating well enough when your lack of exercise or poor stress-management is the bigger issue.

We usually perceive some problems clearly, but others we think are bigger than they really are, while still others are invisible to our own eyes. Trying to sort things out by yourself can be a lot like painting a self portrait without a mirror, or maybe having only a distorted, funhouse mirror to look at. This is the reason so many people find the help of a professional useful. A professional can identify problems and solutions you might not recognize or know about. A professional should have learned from the experience of many patients and can use that accumulated wisdom to guide you. Seeking the advice of family and friends can also be helpful at times.

Reflection is an inward, ideally a meditative, process. In keeping with that inwardness we should start from the inside, meditating on who we are and who we want to become. Following is a list of some areas to consider:

Essential health habits

Drink Enough Water

Exercise Almost Every Day

Eat Well

Take Your Supplements

Avoid The Things That Make You Sick

Get Enough Sleep

Be Involved in Your Community

Have A Healthy Sex Life

Remember That Attitude Is Important

Spirituality/Life purpose

Goal Setting

After you sort out where you are, you can create an image of where you want to be and construct a map to get you there. Deciding that you want to be younger is not going to work anymore than deciding you want to be taller or win the lottery. Make your goals achievable! That is the first step in goal setting.

In a more subtle way, deciding that you want to be stronger or thinner or calmer won’t work either. There is an art to creating goals that will help you achieve success.

Second Step - Goals Must Be Specific

If you set a goal but don’t have a path to follow towards the goal, or you don’t know when you are there, you won’t ever get there. For example, you decide that you want to lose weight. You then must sort out how you are going to do that and how you are going to measure it. Let’s say you determined that, for you, the keys to improved health are to increase your activity and change your diet by eating more vegetables and cutting out soda and alcohol.

You could begin by tracking your activity level for a week, either by timing yourself, or better still, wearing a pedometer. Then, as you set about implementing the changes, you have clear evidence and incentive by simply reading the numbers.

The same applies to your diet. You could decide that you will eat some vegetables at every meal, including two servings at lunch and dinner with a leafy green salad every night. You also determine to limit yourself to no more than one alcoholic drink and one soda a week. All you have to do is look at your plate and into your drinking glass to learn whether you are reaching your goals.

I have a couple of comments about weight loss as a goal. First, it is not a particularly health oriented goal, so I don’t like it much. As long as you are sort of close to “normal”, other factors (especially physical fitness) are much more important than the reading on the scale. There is some evidence that, as long as you are physically fit (i.e., good aerobic capacity and strength), obesity might not be a risk factor for death, disease or feeling poorly. The scale does not tell you what you are made of, your body composition. Most people who do a lot of strength training are overweight on the charts, but have low body fat. Increased levels of body fat are more risky than similar increases in body weight. Many people find that improving their diet and exercise pattern does not change their weight as much as it changes how they feel, their physical capacity and how their clothes fit. Muscle is denser than fat, so patients usually tell me their clothes are fitting looser even when their weight has not changed significantly.

Third Step - Early Success

To maintain and build on a change we need positive feedback. If you try to do too much, feel horrible while doing it and feel worse the next day, how likely are you to try it again?

Creating those specific, achievable goals helps you set in motion a positive feedback cycle. You met your goal. What you did made you feel better. You felt good because you met your goal. You then want to keep it going. It is vital to let yourself feel good about your accomplishment. CELEBRATE YOUR SUCCESSES!

Short-term vs Long-term Goals

Tied closely to the concept of early success is the distinction between short and long-term goals. If you are only going to be satisfied when you have gone all the way from couch potato to triathlete, you are going to be unhappy for a long time and probably never going to become a triathlete.

Short-term goals are the steps on your path. Long-term goals are the destinations to where the path leads you. If you think only about the beach, you are going to get lost on the path through the jungle.

Taking Action

Implementing your strategy requires determination, but it also demands gentleness. Living with a drill sergeant is not going to work, especially if YOU are the drill sergeant. For some patients I need to be a cheerleader, doing everything I can to convince them of the need for change and applauding their positive steps. For many others, particularly those who are less healthy than they used to be because of age, illness or they just let themselves go, I have to work hard to reign in their over-enthusiasm.

Particularly with exercise, it is very easy to do too much too fast. The consequence is often an injury, and the time then needed for recovery often sets the patient further back than she/he was to begin with. You will make the fastest progress by going slow. When increasing physical activity, I tell all but the youngest, strongest patients to increase EITHER intensity or duration by 10% a week.

The other side of it is that changing several problem areas in your life at the same time can be very good and a highly successful approach. Diet changes in particular are often most successful when they are dramatic. You feel better quickly and that experience helps you do more. As you feel the benefit, your commitment will be stronger and you will have more energy to do more to feel better still.

The greatest wisdom is in simply paying attention to how you feel and adjusting accordingly.

Failure

The road of excess leads to the palace of wisdom - William Blake

Failure is good. It is good because we have to make mistakes to learn. When I see a patient who has not implemented my recommendations I always want to know why. Actually I have to understand why they failed, in order to help them go further. Problem-solving is an inevitable part of doing anything new. If I recommend swimming for a patient with back trouble as the best exercise for her condition, but she can’t swim, what is the point? If a patient has not been using the breathing exercise I recommended because he did not understand it, I need to make it clearer.

The only real mistakes are those that we do not learn from. Mistakes teach us how to correct our course before we get way off track. If you haven’t made mistakes, you haven’t been trying.

The rate of Attention Deficit Hyperactivity Disorder (ADHD) is rapidly rising and estimated to be 12% nationwide by US Census Bureau data. According to community estimates, ADHD rates are as high as 20% in some areas. Nationwide the percentage of children receiving prescription medication for ADHD is approaching 5% (and well over that in some areas). As the number of children diagnosed with ADHD soars in the US, parents, educators, health care providers and scientists are asking, “why”?

The list of answers and possible explanations is quite long. With no blood test to diagnose ADHD, and many reasons why overworked teachers, stressed parents and hurried doctors would want easy fixes, stamping a child with the ADHD label and starting that child on medication is an appealingly quick shovel-it-under-the-carpet response. Anyone with the most superficial experience of the challenges posed by these children will be sympathetic.

One reasons for over-diagnosis is uncertainty about what really is normal. Kids who are creative and unusually smart, need challenges or they will often create them for those around them. Kids who learn well but need a lot of physical activity also draw negative attention. Sadly, a child who sits quietly underachieving is often neglected. We live in a culture where driving a two ton metal projectile hurtling down the road, inches away from dozens or even hundreds of other vehicles, is boring. So we crank it up by talking on the phone, messing with CDs, running videos in the car and TEXTING! Driving has become our most popular extreme sport. Our culture is ADHD. We create children in our own image.

Cultural elements have a huge impact. So does diet. As I’ve discussed before, many in the medical community have decades-long experience of the ADHD-reducing effects of a diet limited in additives, preservatives and sugar. Even the British government is on board with this idea, after they funded a study expecting to discredit the theory. Prenatal care is vital, as is getting enough of the right nutrients, physical activity, positive parenting and teaching. Besides avoiding food additives, more and more research is linking unwanted “environmental additives” (ie, toxins) to ADHD.

The latest is a newly released Harvard study of nearly 250 pregnant women. Researchers tested their urine for BPA, finding it in over 97% of the women, and compared those BPA levels to mothers’ reports of ADHD behaviors in their children at age 3. With each 10 fold rise in BPA levels, there was a significant rise in mothers’ reports of their daughters’ emotional instability, anxiety and depression. Although ADHD is much more common in boys, there was no correlation between BPA levels and the behaviors of boys in this sample.

For decades now, we have known that the poisons we dump into our world poison our brains, causing ADHD and other problems. In the early 1970’s Harvard researcher Herbert Needleman discovered a very close correlation between blood lead levels and IQ. Since then the list of bad actors grows year by year. Organophosphates, developed for chemical warfare and present now in herbicides, pesticides and other chemicals, cause severe neurologic damage, as originally intended. Studies by UC Berkeley on the young children of agricultural workers in California’s Central Valley, by Harvard on preteen and early teens and by Columbia have all found links between even barely detectable levels of organophosphates and ADHD. In 2008, 20-30% of US samples of foods such as celery, strawberries and blueberries found contamination with one or more organophosphates. Korean studies have discovered strong links between phthalates and ADHD in school-aged children. Government research shows that nearly every American man, woman and child now has detectable levels of phthalates in our bodies.

What to do? Follow the essential health habits. Drink enough water. Exercise. Eat a healthy diet. Take a moderate amount of vitamin and mineral supplementation. Develop and maintain a positive attitude and social interactions. Avoid the stuff that makes us sick. That covers a broad range. Avoid food additives, including preservatives and flavoring agents. Select foods least likely to expose you to unwanted chemicals (review the list below and favor organic and local). Make your water as clean as possible. Create a stable, calm and pleasant environment. Use music and physical activity to help your child move in the rhythm that suits him or her.

Most contaminated

Fruits - peaches, apples, nectarines, strawberries, cherries, imported grapes, pears

Vegetables - bell peppers, celery, kale, lettuce, carrots

Least contaminated

Fruit - pineapples, mangoes, kiwis, papayas, watermelons

Vegetables - onions, avocados, sweet corn, asparagus, sweet peas, cabbages, eggplants, broccoli, tomatoes, sweet potatoes

Water For Weight Loss

An interesting weight loss study found that people who drank 2 cups of water before each of their three daily meals lost five pounds more than the unwatered folk in the trial. This was a small study, with only 48 people, all of whom were between 55 and 75 years of age. All the subjects were on a diet restricting their calories. Over a 12 week period those in the water group averaged about 15.5 lb weight loss, while the other subjects lost 11 lbs.

Now, someone can slap a fancy label on bottles of water, rename it and roll out a scientifically-substantiated advertising campaign. Just kidding, aren’t I?

Doctors and Diet
I became interested in the health effects of diet long before I thought seriously about going to medical school. As my interest grew, I found a physician who became my mentor and encouraged my nutritional studies. He also inspired me by demonstrating the effects of nutritional interventions with his patients. (See his books DIET AND NUTRITION and RADICAL HEALING, both impressively still in print after decades).

In medical school a few of us created a student group that brought in outside experts on healing alternatives to broaden our education. Although I am proud of that effort and the fact that the group is still functioning over 30 years later, I am dismayed that it is still necessary. A new study makes it very clear just how necessary. Even considering uncontroversial, basic nutrition training, medical education is woefully anemic.

That student group (we called it the Humanistic Medicine Committee), sponsored one lunchtime lecture every week. During the time I was there we also organized two weekend seminars. One of those was on birthing alternatives. Because we felt it was so urgently important, the first of these seminars was on nutrition. Just over 80 out of 460 first and second year medical students attended. Pathetically, those students DOUBLED the number of hours of nutritional instruction they received during medical school. For the others, the extent of their nutritional training was a one hour lecture each day for two weeks in our first year biochemistry class. The lecturer’s lack of enthusiasm for healthy nutrition was revealed during one of those lectures when he sniveled about “the odor of the rancid fatty acids from those organic muffins you in the back row are eating”. Guess where I sat. I was forced to do my own studies. Bizarrely, my medical school was renowned for much of the most important research on human nutrition ever since Ancel Key’s landmark studies of the effects of starvation on World War II conscientious objectors.

In the mid 1980′s the National Academy of Sciences recommended that US medical students receive a minimum of 25 hours of nutritional instruction. A new study shows that only a small minority of medical schools require that of their students.

I fully accept that my interests and perspective were and are unusual. That was evident even as a college undergraduate. When I went for the mandatory career planning interview required by my university, the counsellor unsuccessfully attempted to convince me that, because of my interest in nutrition I should become a dietician instead of going to medical school. However, I am confident that my decision was correct. Instead I wonder if, reflecting their disinterest in nutrition, many doctors should have been routed towards some other career.

The best solution would be for medical education to teach more nutrition, but the most important goal might be to educate docs about how important nutrition really is. If the medical community truly recognized the importance of a healthy diet, this ridiculous educational vacuum would be filled quite quickly. Just think of how much better hospital food might also become.