An Apple A Day

Pooh-poohing Mind-Body Interaction

I surprise patients some times when I tell them that I do not believe in what is often called “mind-body interaction”. My explanation, though, convinces them not to run away and look for a different doctor. The idea that thoughts affect the body and physical disease alters emotions is right, but also very wrong. This concept falsely splits us apart.

The truth is that the brain is in the body. Every time I look at my books, there it is. The same was always true in anatomy lab, as well as looking at MRIs and CT scans. Despite this incontestable fact, there are those who view habits of thought as entirely divorced from biochemistry and physical health.

The problem starts on the medical side.  A doctor tells a patient that the tests are normal. Therefore, there is no problem or the problem is 100% emotional. Go away and fix yourself. This ignores the limitations of our testing and allows us to abdicate our response to provide help.  We fall into this trap out of ignorance at times, deluding ourselves into believing that thoughts are not biochemical, produced by and creating our physiology.  We know better.  MRIs show that the physical structure of our brains change after going through psychological counseling.  Proteins, hormones, immune factors, and alterations in the levels of a broad range of the compounds normally found in our blood, can all have subtle and lethally dramatic impacts on our brains’ ability to function, including thoughts and feelings.

On the patient side, recognizing the importance of right thinking tends to lead to blaming the victims of suffering, including themselves, for getting sick. Thoughts and feelings are supposed to be all powerful from this view point.

My experience is entirely at odds with both of these limited perspectives.

Regardless of whatever spiritual radiance/vitality we manifest, our bodies always break down.  The Law of Entropy applies to everything in the material world. You can do a lot to make your life healthier and better, but not forever.  Responding to an influenza infection, your body will work as hard as it can to create massive quantities of immune factors to save its/your life. Those immune factors make you feel tired and alter your brain and thinking.

Honestly, I can not figure out how to separate mind and brain enough to determine which is changing the other.  In reality they are one, influencing and influenced by everything.  Managing stress, thereby improving the quality of your life, is an excellent idea if you have cancer, heart trouble, depression, any other disease, or even if you are well.  Meditating increases telomere length, and then probably how long you will live.  Being angry cuts off the blood supply to your heart and kills far too many people every day.

This is not New Age, airy fairy, trivial or simply about living a beautiful life.  It is quite predictably a matter of life and death.  The only part that is unpredictable is the due date.

Building on that perspective -

Sudden cardiac death risk and emotion
Considering the effects of emotion on physical health, death is about as meaningful an outcome as one might imagine.

Swedish investigators recently determined to do something about what we know (BRAVO!). They took 362 patients who had been discharged from the hospital after a heart attack or a procedure to increase blood flow to the heart, and randomly assigned them to usual care with or without twenty sessions (2 hours) of small group cognitive therapy focusing on stress management. Patients in the counseling group were over 40% less likely to have any cardiovascular event (like a heart attack) and 28% less likely to die for any reason. It is notable that these effects were seen despite an absence of differences in the traditionally recognized risk factors (cholesterol levels, cigarettes, etc) between the groups.

Scientifically, this extremely impressive result should be confirmed but as far as those of us living in the real world, it is absolutely certain that if you do not want to die from heart disease or at least live as long as possible, you MUST become a master at stress management.

Preventing Sudden Cardiac Death

Women are less prone to heart attacks than men, but just barely.  Unfortunately, the symptoms they suffer are often not as easily recognizable as caused by their hearts, and often they have fewer symptoms.    We have much less research on women and heart disease than we have on men.

Sudden Cardiac Death (SCD) is much more common in men than in women.  You probably know of someone “who just dropped dead” one day unexpectedly.  Usually this is a surprise, coming out of the blue in the sense that most victims of SCD have not been diagnosed with coronary heart disease.  However, it turns out that a lack of diagnosis does not mean absence of disease.  At autopsy, the hearts of SCD victims usually show evidence of previously unrecognized coronary heart disease, suggesting that some of them ignored or did not recognize symptoms caused by their heart trouble.  Others, especially women and diabetics, are prone to unusual symptoms and might not even have any pain.

What are the usual symptoms?  Crushing left sided chest pain “like an elephant sitting on my chest”.  The pain can extend to the left arm or jaw.  Physical activity, emotional upset and eating can worsen the pain.  The heart will often beat rapidly or irregularly.  Shortness of breath, sweating and dizziness are also common symptoms.  Of course, each of these can have other causes, but you should not assume that the cause is minor.

Prevention is always the best idea, and studies of SCD are giving us useful ideas.  Fortunately, the major risk factors for SCD are the same in women as in men.  Harvard investigators dug into data  collected from 1984 – 2010 in the Nurse’s Health Study to learn what factors might lead to SCD.  What they found is really exciting, because it confirms that we are not so powerless against SCD as we had thought.

They found that following a healthy lifestyle dramatically reduced the risk of SCD.  The factors they considered were avoiding smoking, keeping weight down, averaging more than 30 minutes of exercise daily, and eating a Mediterranean type diet (lots of veggies, nuts, beans, fruit, fish, whole grains and moderate alcohol).  Women who did one of these right cut their risk of SCD in half.  Add another and the risk was down 60%.  Following three of these four wise health practices lowered risk by two thirds and a clean sweep of all four lowered risk of SCD by a dramatic 92%.  Looking at the data the other way around, they found that fully 81% of the Sudden Cardiac Deaths were attributable to lifestyle factors.

The most frequent supplement question I’ve been hearing lately is about taking calcium. These questions have been inspired by a recent study of calcium supplementation, which received a great deal of attention. The authors of this study combined data from other studies and determined that calcium supplementation increased the risk of heart attack.

Most of us get way less calcium in our diets than is recommended. Calcium is vital to a broad range of biological processes (heart rhythm, immunity, cancer protection, etc) and not just bone formation, as some assume. Calcium is unlike most other dietary nutrients in that it is so vitally important that the body maintains a huge stockpile of the nutrient (our bones) and then routinely breaks into that store to maintain a precise level in the blood. The body works very hard to keep calcium blood levels in that very narrow range, and even slight deviations occur only with serious problems.

Long ago our ancestors consumed much more calcium than we do. Today calcium supplementation is both common and apparently necessary, as so few of us consume recommended levels in our diet.

There have been hundreds of clinical trials involving calcium and heart disease. They only used the data from 15 of those studies. Demonstrating their own lack of understanding and naivete, they repeated the erroneous conclusion that calcium does not build bones (You can dig back in my old newsletters to read my discussion of that very poor study which they cited, but in fact proved just the opposite). If the increased risk of heart attack was meaningful, one would expect the risk of death from heart attack to also increase. It did not. Because they are they same process, only in different parts of the body, the risk of stroke should also have increased, but it did not.

In a lamentable declaration of enthusiasm for medication and radiation, one of the study authors recommended that patients get bone scans and wrote “If their risk is high, they should consider using medications rather than calcium supplements”. Reflecting a similar promedication bias, an accompanying editorial written by English cardiologists recommended “Given the uncertain benefits of calcium supplements, any level of risk is unwarranted…. On the basis of the limited evidence available, patients with osteoporosis should generally not be treated with calcium supplements, either alone or combined with vitamin D, unless they are also receiving an effective treatment for osteoporosis.” They also recommended diuretic drugs, which theoretically might increase bone density, while claiming that supplements are ineffective, dangerous and a waste of time.

Ignoring calcium and D, this is like dumping synthetic fertilizer on your garden without giving the plants water and sunshine. Not terribly smart.

Magnesium and calcium both compete and complement each other metabolically. Too much of either relative to the other can create risks. Similarly, as calcium barely dissolves in water and most people drink too little water, ignoring fluid intake can lead to false conclusions. As you have probably anticipated, I will also criticize their overlooking the influence of vitamin D, which is essential to most aspects of calcium metabolism and perhaps the most glaring vitamin deficiency in the world.

One of the world’s foremost experts on calcium metabolism, Dr Robert Heaney, commented that the paper was highly suspect. His group had conducted many of the studies reanalyzed by the investigators in the current meta-analysis. Heaney also said that, using the same data, the New Zealand investigators reached the opposite conclusions than his group and chose not to include data from other studies conducted by Heaney’s group.

I am especially interested in Dr Heaney’s comments, for several reasons. He is a member of the panel that sets recommended calcium intake levels in the US. Several years ago he wrote an extremely interesting article on the very high calcium intake of our ancient ancestors and the broad health impacts of calcium. He was also one of the handful of speakers at the first national medical meeting focused on the growing body of information on vitamin D. I spoke to him at that meeting, specifically questioning whether recommended calcium levels were too high, as they ignored widespread vitamin D deficiency. He convinced me that that was unlikely.

I am also a bit uncomfortable about this new study for a couple of unusual reasons. First, the lead author has been an investigator in many of the negative studies of calcium supplementation. That is more notable, given that the majority of clinical studies have not reached negative conclusions. Secondly, the team of investigators reside in New Zealand and are funded by the New Zealand government. As milk is an important income source for the country, they often fund investigations which tout the health effects of milk. This includes milk as a calcium source compared to supplementation. However, neither of these is proof of bias.

My conclusions are:
1) As I have instructed so many of you in the office – diet is best (see list at-
http://www.carlstonmd.com/docs/calcium.htm)
2) The recommended calcium intakes are reasonable. If you eat a lot of meat, you might need a bit more, or a bit less if you don’t.
3) Looking at dietary logs of many thousands of patients over the last 30 years, I can confidently state that most of us need to supplement our dietary calcium intake.
4) The kind of calcium supplement is important (calcium citrate and calcium malate are the safest and best absorbed)
5) Other factors like water, magnesium and vitamin D are essential to proper absorption and utilization of calcium.