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Is Alzheimer’s a Form of Diabetes? | March 2017
Last month I got a little personal. This month I am taking you to the very cutting edge of scientific thought. There seems to be a real connection between diabetes and dementia. Someone coined the term that Diabetes Type 3. Until recently I had never heard this term. The contention is that Alzheimer’s Disease is really a brain form of diabetes. This is not really new info in the scientific community but it sure didn’t make it to the front line caregivers. The real culprit, as I understand it, is once again INSULIN. Simplistically Type 1 diabetics have no insulin and need to take shots of insulin to control their blood sugar. Insulin is a growth hormone that pushes the sugar in your bloodstream into the individual cells where they can be used. Type 2 diabetics don’t respond as well or strongly to the high sugar in your blood so it takes more insulin than normal to get the sugars into cells. This is called insulin resistance. Type 3 diabetes appears to be abnormal insulin effects in the brain resulting in histochemical and pathological changes identical to those found in Alzheimer’s brains. This is big big news which appears to be based on pretty good scientific underpinnings. The idea that Alzheimer’s is a form of diabetes has been around since 2005. Roughly one third of Americans have diabetes. Diabetes and dementia are both epidemic in this country and increasing over time. It has been known for some time that diabetic patients are 2-4 times as likely to become demented as those who are not diabetic. Besides telling the bodies cells to take in sugar, Insulin also tells fat cells to grow. If you are Insulin resistant, which the vast majority of Type 2 diabetics are , you have higher amounts of insulin in your bloodstream to keep your sugars under control. This same higher insulin level makes losing weight very difficult because insulin puts your body in growth mode not weight loss mode. You need insulin to live but you want to get away with as little as possible.
Suzanne de la Monte a neuropathologist at Brown University did rat research that showed when she blocked insulin to the rats brains they acted demented and their brains showed “all the signs of Alzheimer’s”.
Shall we get more technical? In the Journal of Diabetes Science and Technology published November 2008 experts reviewed the evidence regarding this possible connection and found “extensive disturbances in brain insulin and insulin like growth factor (IGF) signaling mechanisms represent early and progressive abnormalities and could account for the majority of molecular, biochemical, and histopathological lesions found in Alzheimer’s Disease. “ Furthermore , when they experimentally induced brain diabetes these rats brains shared many features with Alzheimer’s and when they treated these rats with currently used insulin sensitizers the changes were reversible. Now we are not rats and many times what’s true in rats and mice does not translate to humans but it’s a pretty strong chain of evidence nonetheless.
Shall we talk numbers? According to an article in the NY Times…Diabetes and Dementia have nearly tripled in the US in the last 40 years. Both Diabetes and Dementia are separately listed among the top ten causes of death in America today. Currently 2 % of Americans have dementia…that’s over 5 million people and dementia costs our healthcare system 200 billion dollars. Add the cost of Dementia care and the cost of Diabetic care and you are talking some real money and a real impact on the health care system.
For further reading check out the well known Dr. David Perlmutter’s book Grain Brain.
The most important finding in all this is that Alzheimer’s is no longer just a “condition that befalls us by chance.” You might be able to dramatically decrease your risk of dementia with your diet and exercise program. No fancy medications, no special treatments. The same diet that can improve your brain is the very same diet that improves your heart, your waistline, and your liver….so now what’s stopping you ! Next month we finally take on the supplement industry with hard science and new technology. Stay tuned…until next month…get well and stay well. Jtb
JANUARY 2017 TABLEHOPPING ARTICLE – RESOLVE TO STOP RESOLVING
Rather than belabor the whole New Year’s Resolution thing I wanted to start out the new year with a top 5 stories list. You know I don’t think people should wait for a certain date before they begin the process of changing themselves. The day to start changing is today. I have a friend who says … ”I will start my diet on XX date.” He then uses this as an excuse to overeat until that date … ”Well, soon I will be on a drastic diet … overeating now can’t make a difference.” Then, of course, the date comes around and he has another excuse as to why he is putting it off. My friend is very well intentioned and I think he really means it but this pattern has occurred so often you would think an intelligent person would recognize this but that just goes to show that it is hard to really know yourself. Change your life and habits or don’t but the day to do that is today … not tomorrow or Jan 1st.
My top 5 medical stories are probably not the 5 your own doctor would list. I would urge you to bring up any of these articles to ask your doctor if they are in fact true but I think you’re just going to upset your doctor because it’s extra work for them or challenges their long held beliefs.
Story #1 is the United States Preventive Task Force statement regarding treating cholesterol and primary prevention. They state “There is insufficient evidence to recommend for or against statin use for people older than age 75.” I know many many people older than 75 that are taking a statin drug just because their numbers are high. I have seen multiple patients in their 90s never having had a heart attack or stroke that are given a statin drug which is designed to prevent premature death but I don’t think there is anything premature about death In your 90s. This recommendation from this independent panel is likely to go ignored because it doesn’t agree with current practices for most doctors. One of the scariest things to me is that when we have new evidence —unless it agrees with our current thinking— we have a tendency to ignore it.
Story #2 is the recent article in the New England Journal of Medicine that suggested that most supplemental oxygen is a waste. Essentially if you can walk around with your oxygen bottle you probably don’t need it! Medicare, who makes most of the rules, has long stipulated that oxygen therapy is appropriate for people if their oxygen saturation when tested in the office is less than 89%. If oxygen is low you should prescribe oxygen and the patient should benefit and live longer and require less hospitalizations and feel better. It certainly made sense but unfortunately this most recent study shows that for the vast majority of people getting submental oxygen there is no difference of hospitalizations, life expectancy or patient’s satisfaction. Again, what we have been doing for many people for many years seems to be not appropriate or not cost-effective or simply not impactful to the patient’s health. Despite this report which was well done and published in a major journal I believe most doctors again will not change their practice. Don’t get me wrong … people with very severe lung disease who require oxygen should not have it yanked away from them but many people who had episodes of low oxygen saturation when they’re walking or moving around do not benefit from supplemental oxygen based on this most recent and thorough report.
Story #3 is more speculative and claims that there is a link between Alzheimer’s and insulin resistance. There has long been evidence that diabetes increases your risk of dementia and it may actually double your risk although the numbers are debatable. Newer understanding suggests It’s not the sugar itself but the insulin resistance that may cause these proteins to build up in the brain. For every patient out there with known diabetes there is at least one other with insulin resistance so it’s understandable how dementia could be a major problem in the years to come. Of course I liked this finding because it confirms the validity of my suggestion of skipping breakfast to help you lose weight and lower your insulin level. Google intermittent fasting.
Story #4 is about hot peppers. Hot peppers can apparently kill you. I am a big fan of a moderate use of spices, onion, ginger, and garlic. I think they’re all healthy for you and when I was younger I used to hit the hot peppers a bit more than I do now and even now I can get a good sweat going from eating a hot pepper. There is however a danger from hot peppers and that is if you have a pepper that so irritating that it causes you to vomit violently. This can cause a spontaneous esophageal rupture which is also called Boerhaave’s syndrome. There was an article recently about a patient who was in hot pepper eating competition and vomited so vigorously that he ruptured his esophagus and this is usually 100% fatal unless treated surgically. I’m told he recovered fully but he did spend over 3 weeks in the hospital and I’d hate to see his hospital bill! Although this is a cautionary tale I think most of us are safe and I continue to recommend peppers, onion, horseradish, etc. because I think these vegetables and preparations are very healthy for you.
Story #5 is that we finally have proof of the benefits of breathing. Not your day to day breathing although it’s obviously beneficial to keep breathing. I’m talking about conscious breathing likely doing yoga … being aware of your breath and focusing on your breath. There was an article in the December 6th Journal of Neuroscience that mentioned that scientists at Northwestern Medical Center have discovered the rhythm of breathing creates a “activity in the brain that enhances emotional judgments and memory recall. Northwestern Medicine scientists have discovered for the first time that the rhythm of breathing creates electrical activity in the human brain that enhances emotional judgments and memory recall. “When you breathe in, we discovered you are stimulating neurons in the olfactory cortex, amygdala and hippocampus, all across the limbic system.” You know I love yoga and recommend yoga to almost everyone … I really don’t need any more studies to make me a believer. Anyone who has practiced deep breathing exercises knows how powerful these techniques can be but it’s nice to see scientific evidence of their benefits.
Listen, it’s the beginning of the year. You don’t have to make a resolution but you can make a plan so that this time next year you are healthier and in better shape than you are now. Maybe it’s the time to finally quit drinking soda. Maybe skipping breakfast will find you 5-10 pounds lighter next year. What separates the dreamers from the successful people is making a plan and following up on the plan. Start today! Until next month … get well … stay well.
Holiday Health | December 2016
As I write this in mid November sitting by the fireplace by the pool it’s such a nice almost summer like day that it’s hard to imagine that Thanksgiving is around the corner and then it’s time for Xmas plans. There is as yet no holding back the hands of time so might as well get ready for it. Not too ready … I still shudder at all the Xmas decorations even before Thanksgiving but that’s just the traditionalist in me.
There’s a lot of health issues around the holidays and we might as well deal with the most common and get our Xmas cards on the table … so to speak.
This can be a rough time of year both physically and mentally. Physically because this is when you go a little cra-cra with the diet … The typical adult puts on 1-3 pounds of weight each year and this is the time of year when that happens. You did fine the rest of the year but now look at you!?! Are you really cutting into that cakey thing made of nutella and dried prunes? You can’t possible reel it in after that first piece of pumpkin pie? You can at least go for a walk before or after dinner … it won’t give you any real weight loss but at least when you are walking you are probably not eating. I know there are those proud few of you that can eat and exercise at the same time but you are not reading any articles about health or medicine so I can safely exclude you from the conversation. I love how people act like the holidays sneak up on them every year … I had no idea we would be sitting down to a full turkey dinner with all the trimmings? Who knew there would be treats on the table for the holidays? Who could have guessed?
You could actually plan for these occasions … intentionally bringing a healthy choice to the communal dinner, you could get some extra walks in and or trim down your usual portions for the week or two before the get together to keep the weight gain down. I am not saying you should not enjoy the holiday … life is way too short and I have no objection to the eat dessert first crowd. I am saying throw some cranberry on that plate … even the kind that still has the ring imprints from the can it came from. (That’s my personal favorite). Take a couple spoonfuls of that green bean casserole … it’s good and it’s good for you. Well, as I write this I realize when you read this you will already have debauched yourself at Thanksgiving but you can still get yourself together for the rest of the year end festivities.
This is also a tough time of year physically because people “turtle up” for the winter. They have no problem being outdoors and active during the three months of the summer but wintertime comes and they go into exercise hibernation waiting out the long cold months for the sun and warm weather to return. That’s too much down time for a person of your age. You have to keep moving it in the winter. You don’t have to go to the gym but you should move around more than you are. Don’t kid yourself … if going down the stairs with the laundry is really exercise for you … you are not the fittest amongst us. Of course I’m a big fan of walking but I understand the dangers of the slippery sidewalk, etc but you can always walk at the Mall. It’s absolutely nothing like being outside in the elements but it is safer!
Turning to the psychological side of the holidays this can be a stressful time. A lot of people let the whole family gathering and or gift giving get them anxious and depressed. Also people who have lost a loved one during the year are experiencing their first holiday without them and I just don’t know how to lessen that pain except to urge them to find comfort in the company of others. Of course I would be remiss if I didn’t recommend the great local charity Hope for Bereaved because this is completely their bailiwick.
Now on the issue of gift giving … Last year I gave someone who I thought I knew a gift of Bacon of the Month … and I mean this was high end, thick cut, special rubs and salts specialty bacon not a package from the Gas and Go … in return I got a disco ball from Spencer’s gifts with the promise that if I gave more bacon further disturbing gifts would follow. Needless to say all subsequent bacon was diverted … to my house … I still don’t know what to make of this incident because I thought a love of bacon was shared by all guys my age. My point being you can torture yourself trying to think of gifts and be oh so wrong so why not try something new? Is it too trite to suggest you give the gift of time together? Instead of that sweater you know they will exchange … why not movie tickets to a show you can all go to together. Why not a dinner gift certificate that includes you? Tickets to a baseball game are dirt cheap so you can’t throw down the $$$ excuse. Speaking of getting together as a gift, which it surely is, this is the perfect time of year for that because there are Christmas shows aplenty. To bring just two to your attention why not check out The Desantis Xmas show at the Palace Theatre Sunday Dec 11th … This is a great venue for great Xmas music provided by local talents both new and legendary fronted by Maria Desantis. For something a little different check out the Solstice at the Cathedral Celebration on December 8th, 9th and twice on the 10th. This series of concerts features other local powerhouse performers like Joe Whiting, Donna Coulton, Loren Barringer, Matt Vacanti to name just a few. There is something for everyone at both of these events. There are memories to be made. Isn’t that the best gift of all?
Until next month … get well and stay well.
Asprin …To Take or Not To Take | November 2016
Today I take on aspirin. Why not? I have already talked about the overuse of statin drugs, the crazy dietary recommendations including salt restriction, the beneficial role of fat in your diet, and supplements so why not take on aspirin. Seems like everyone in America is taking an aspirin or knows someone taking aspirin. It’s almost expected on people’s records that if they are adults you just mark multivitamin and aspirin as presupposed medicines. I think most doctors just assume adults are taking a multivitamin and an aspirin … on general principle. But what’s the science behind it? I was going to write that there is no evidence that aspirin is beneficial for most people. That would be wrong. There is evidence that aspirin is beneficial … but there is also evidence that most people don’t need it and actual can be hardened by it. You shouldn’t just drink the aspirin-aide … you should decide for yourself and should base it on the evidence.
If you ask your doctor if you should take an aspirin he or she will probably say … ”sure why not?” This is the conventional wisdom. The current thought is to take a low dose aspirin product because you get all the benefit with the least risk. Sounds great. Sounds prudent. But what does the evidence say? What are the guidelines? That’s what I will focus on here. If you mention to your provider that Dr. Barry questioned the universal use of recommending aspirin they will respond … ”Dr. Barry is off his meds !” So instead clip out this article and bring it with you and ask them to refute the expert testimony herein!
Let’s start with the recommendations from one of the most prestigious organizations: the United States Preventive Services Task Force. “The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.”
Furthermore “The current evidence is insufficient to assess the balance of benefits and harms of initiating aspirin use for the primary prevention of CVD and CRC in adults younger than 50 year or older than 70 years.“ So yes I am saying that one of most prominent organizations say that aspirin only has really good evidence in people between 50 and 60! There are bleeding risks associated with aspirin. I am not worried about the increased risk of GI bleeding with the drug … I figure that is offset by the possible benefit of decreasing colon cancer. The bleeding risk I worry about is in the brain. If you take aspirin and have a fall with head injury aspirin can increase the amount of bleeding around the brain. If you have a bleeding type of stroke, which thankfully accounts for only a small percentage of strokes, having been on aspirin increases the bleeding in the stroke area. This is not good. I can transfuse blood but I can’t transfuse brain. At least not yet.
OK so this is just one panel … what do the other experts say … surely the American Heart Association and the American Diabetes Association weigh in on the use of aspirin. In the September 2015 edition of the American College of Cardiology commenting on the American Heart Association and the American Diabetes Association joint statement which state that “low-dose aspirin (75-162 mg/d) is reasonable for those at 10-year CVD risk of at least 10% without increased risk of bleeding (ACC/AHA Class IIa, LOE B, ADA LOE C) and in those with diabetes at intermediate risk defined as 5-10% 10-year CVD risk (ACC/AHA Class IIb, LOE C, ADA LOE Expert Opinion).”
A careful reading of the above will show that only in the sub population of people that have a 10 year risk of heart event of 10% does aspirin show any proven benefit. Translation = most people don’t need aspirin! Even the American Heart Association website specifically states “You should not start aspirin therapy on your own.” How often have you and your doctor calculated your particular 10 year heart and stroke risk score? After all, heart disease is the number one killer of adults in America … isn’t it worth 5 minutes of your time and your doctors time to calculate your risk or at least have a conversation about your risk factors? The calculators are available on the web and if you have access to your labs you can do your own calculation. These calculators have their detractors but they at least set the stage for the important conversation about your heart health and therefore your overall health. Don’t be a passive observer of your health care experience … bring questions … expect at least conversation and education if not definitive answers about your health. Your doctor can only guide you … only you can improve your health and that’s a great thing. You don’t need a good insurance company. Its nice to have but it doesn’t ensure your health. You don’t need a gym membership. Its nice to have but it doesnt mean you can’t take care of your exercise business anywhere. You are the one who has to put down the cigarette and say “I’m done.” You are the one that has to look at your dinner plate and say “My new lifestyle starts today.” Does that empower you or scare you. Just because its up to you doesnt mean that you cant get help in lots of different ways to improve your health. Build your team. Work your team. Hopefully your medical provider is part of that team.
Until next month … get well and stay well.
And They’re Off! | October 10, 2016
Maybe it’s just me but I think you should practice what you preach. Can you really take advice on weight loss from a doctor who could lose 50? Has the professional that is recommending a colonoscopy had one themselves? pv-1Hey, I know I’m no stud muffin but I make an effort to keep my weight in check and work out regularly and aggressively. The aches and pains you take Tylenol or Aleve for are my regular companions and a reminder of the workout. I feel guilty if I don’t have an ache or pain because it means I haven’t pushed myself in a while. Although I have my regular exercise routines I think it’s also important to mix it up a little and one nice way is to do some event. There are 101 charity events with some run / walk seemingly and probably literally every weekend. You get out of the house, you test yourself a little whether you run or walk, you have new experiences, meet people you know and make new acquaintances. What’s not to like? Plus it’s usually for a good cause and not usually expensive. Winner Winner chicken dinner.
Earlier this year I did a charity run for Hope for Bereaved … you know I love that organization. I hadn’t run again until an event came up last weekend to which I made a donation and promised to do the run … I don’t run much anymore but these folks do my compounding when I want to use topical meds and I think they are nice people and it was in support of 9/11 with Todd’s Fund. Etc …
So there I was cruising down a country road en route to a 5k run at Vernak Farms Store somewhere nears Skaneateles … I don’t know how long the run is or what the course is like but it’s a beautiful day and by using the Chi-Running technique I can usually power through most races. Not winning any awards but plugging away … never stopping … getting ‘er done. No matter how long or short the race I will look near death at the end. I see a sign on the side of the road —presumably a country church— as the sign says … “Whenever 2 or 3 may gather in my name there I am.” Mathew 18:20.
Now what goes through my mind first is that this is a nice affirmation that even a little group has the attention of God. Then, on pondering a little further it occurs to me that this implies that you need at least 2 people to get things going. So does that mean if I were to pray alone at night, which many people do, that I don’t have God’s ear? It doesn’t say “Whenever one person” no … it says “Whenever 2 or 3.” Seems like a minimum to me but I know that can’t be right. Now I have this conundrum in my head while I am getting my race game face on. You’ve seen my regular face … race face is no prettier. I am trying to think of some Biblical passages that might provide more insight at the same time I am double knotting my sneakers before the race. I got my mind right before the race by listening to some Bob Marley … the question of the utility of singular prayer put away for now.
The whole event was nice … They have a yearly wellness fair and expo with an impressive layout of vendors and informational booths. The race was tougher than your usual 5K. It starts out uphill … short flat section then what seemed like a mile and a half slow steady up hill. It was an out and back course so there is a turnaround but I didn’t know that because the pain of going uphill for so long would have been mitigated by my knowing I have a long downhill on the last part of the race … At the top of the long slow … for me … uphill part there was a steep downhill with the turn around at the bottom … So you know you are going to have to go back up the steep uphill once you turn around but beyond that is the blessed long gentle downhill part … I can shamble like a corpse from the Walking Dead indefinitely on the downhill and I am not alone. Everyone who beat me looked much younger than me so I wasn’t disturbed by my performance.
I hope you see more and more health professionals at these events. It’s good to show people we are doing the things we recommend. It might be one more way to make a difference.
Until next month … get well … stay well.
Salt Of The Earth | September 9, 2016
Having written about cholesterol and saturated fats I now turn the Eye of Sauron towards another perennial topic which is sodium restriction. Excessive salt intake can raise your blood pressure and increase your risk for heart attack and stroke. So if salt (sodium chloride) is bad for you it should be restricted.
Lower salt intake should result in less heart disease and stroke. Unfortunately this just isn’t the case. As you will read below, cutting down on your salt intake too much can be dangerous. You shouldn’t sprinkle salt on your food even before you taste it. Even today the American Heart Association states that dietary sodium should be restricted to less than 1,500 mg a day. This guideline is exceeded by 95% of Americans! Even if you accept this premise the experts say this will only reduce your blood pressure by a few points. Going from 180/100 to 176/96 just isn’t enough to change any clinical outcomes. Don’t get me wrong: Hypertension is a killer. -It’s the main cause of stroke and a leading cause of heart disease and should be treated. Exactly how low to go is still under debate (See the recent Sprint trial). Lowering blood pressure is important. Dramatically restricting salt is just not the way to achieve meaningful results and restricting salt too much can actually have adverse effects as well. I am going to quote from several articles instead of paraphrasing as I usually do because I can’t improve on what’s on the page. Melinda Wenner Moyer wrote in the New York Times reporting on a 2006 American Journal of Medicine study: they “compared the reported daily sodium intakes of 78 million Americans to their risk of dying from heart disease over the course of 14 years. It found that the MORE sodium people ate, the less likely they were to die from heart disease.“
Don’t like that study? Too old to be relevant? How about a July 2011 meta-analysis of seven studies involving over six thousand people — published in the American Journal of Hypertension — this study “found no strong evidence that cutting salt intake reduces the risk for heart attacks, strokes or death in people with normal or high blood pressure. In Many European researchers publishing in the Journal of the American Medical Association reported that the less sodium that study subjects excreted in their urine — an excellent measure of prior consumption — the greater their risk was of dying from heart disease. These findings call into question the common wisdom that excess salt is bad for you, but the evidence linking salt to heart disease has always been tenuous.” Still not convinced? Want something more recent? The American Journal of Medicine November 2013 had this to say: “The American Heart Association recently strongly recommended a dietary sodium intake of <1500 mg/d for all Americans to achieve “Ideal Cardiovascular Health” by 2020. However, low sodium diets have not been shown to reduce cardiovascular events in normotensive individuals or in individuals with pre-hypertension or hypertension. Moreover, there is evidence that a low sodium diet may lead to a worse cardiovascular prognosis in patients with cardiometabolic risk and established cardiovascular disease. Low sodium diets may adversely affect insulin resistance, serum lipids, and neurohormonal pathways, leading to increases in the incidence of new cardiometabolic disease, the severity of existing cardiometabolic disease, and greater cardiovascular and all-cause mortality. Although a high sodium intake also may be deleterious, there is good reason to believe that sodium intake is regulated within such a tight physiologic range that there is little risk to leaving sodium intake to inherent biology as opposed to likely futile attempts at conscious control.”
You have to wonder how the Heart Association can make such a drastic recommendation when it comes to sodium restriction in the face of these findings? I don’t get it but I don’t get the dietary fat recommendations either.
Until there is real science behind the guidelines I think you are best off following a moderate path. Don’t be afraid of salt but don’t go crazy either. Most importantly check your blood pressure periodically and if it is elevated get it down with diet, exercise and medications as needed. Don’t make the pills your first choice! Talk with your doctor about potassium chloride instead of sodium chloride because there IS evidence that a higher potassium diet may actually lower blood pressure! And you don’t have to take potassium pills; you can find plenty of potassium in mushrooms, bananas, green veggies etc. That’s right, healthy eating can lower your blood pressure! Why not give it a try … Utica Greens are still in season.
P.S. Remember … what happens at the Fair stays at the Fair!
Medical Mythbusters | August 8, 2016
Sometimes that’s how I feel. I am by no means a lone voice crying out in the woods in talking about the exaggerated benefits of statin therapy, the limited data to support dietary sodium restriction, the modest and controversial benefits of aspirin therapy for primary prevention but it sure seems like it.
I write today about birth and death. The birth of dietary guidelines and the death of common sense. I know you think the government is careful and thorough in all things…I mean look at how well Obamacare is doing, our war against terrorism, our carefully balanced budgets etc. Well, the dietary guidelines were crafted years ago…perhaps the government was somehow better, more honest then. Sorry to disappoint but read on.
I will write more about the cholesterol con in further posts but today I focus on dietary guidelines. In 1977 the United States Select Committee on Nutrition and Human Needs convened a consensus panel… (one of the participants quipped that if there was real consensus they wouldn’t need a panel) That panel concluded… despite the lack of any real evidence that dietary fat caused heart disease and obesity. Interestingly enough for you history buffs the chair of the committee was Senator George McGovern. The panel’s guidelines became the Dietary Goals for the United States and the instructions were to eat more carbohydrates and less fat. Specifically the guidelines said you should consume 55-60% of your calories from carbohydrates! As the great Dr. Jason Fung points out in his book “the Obesity Code” the American Heart Association’s guidelines in 1995 “Americans should eat six or more servings of breads, cereals, pasta and starchy vegetables and to choose fruit juices and carbonated beverages as your liquids of choice.” Six servings of bread? Carbonated beverages as the liquids of choice? This seems laughable ! How can this be a real recommendation? The results of these recommendations? Heart disease did not decrease significantly as was predicted but obesity has increased to “epidemic” proportions. Current recommendations are still based on misguided interpretations of research done years ago. There is almost no scientific basis for the current guidelines. For a an absolutely superb video on this subject… check out Dr. Peter Attia on youtube or his website “the eatingacademy.com”. His common sense, easy to follow review of massive amounts of historic and current data…the same data some of the guidelines use to make their recommendations and so much of the conflicting data that has been ignored will completely convince you of the errors of our current thinking.
Just from a common sense standpoint… who could believe that such completely natural things like eggs and butter could be deadly and you should instead use this alien yellow substance in a slightly different yellow colored plastic container. We were told the fat in milk is bad for us… not a shred of evidence to support that and instead we became a nation of soda drinkers or just as bad… juice drinkers… if, as is typical, the juice contains high fructose corn syrup. We all learned to cut off the fat from our steak while at the same time consuming more nitrate containing bologna and hot dogs. We were told that breakfast was the most important meal of the day which is worse than nonsense since the typical american breakfast consists of some cereal product. News alert… there is no healthy cereal period. It’s all processed carbohydrates. It’s the worse thing you could put in your mouth in the morning. The worse thing. I recoiled in horror the other day when I learned that a relative of mine was so proud of the fact that they had the same thing for breakfast every day… Cheerios. First, wouldn’t a little variety be nice? Who really wants to eat the very same thing every morning ? Well I could understand if the results were impressive but let’s just say the Cheerios have left an impression on my relative. A BIG impression.
So yes I am saying that eggs and butter and steak and milk are very healthy foods. The idea that you should substitute one fat for another is flawed. The one exception is trans fats… completely manufactured fats for the most part. You avoid trans fat and processed sugars when you avoid processed foods. Anything out of a box is processed. Many current dietary guidelines say to limit saturated fats and substitute fats like linoleic acid will cut down the risk of stroke and heart attack.
Now it gets interesting because recently data from the Minnesota Coronary Experiment which looked at just this question has been reexamined. As published in Cardiology Today July 2016 (hows that for current data!). The data are very damning for the guidelines. This was a double blind study involving almost 10,000 people They wanted to see if substituting linoleic acid for typical fats would cut down on cholesterol levels and heart attacks and death. Those are some easy to understand endpoints. Dr Zaomora and colleagues found that the change in diet did indeed lower cholesterol but it had no mortality benefit whatsoever. The change in diet did not decrease deaths. In fact the researchers found that as the cholesterol level lowered the risk of death actually increased! At autopsy the group on the linoleic acid died were found to have twice as many heart attacks as the regular diet group… twice the number of heart attacks!
Now I don’t trust metaanalysis data (where multiple trials are lumped together to try to find significant findings) as much as I trust the double blind trials like the one above but the same investigators included the above trial and 5 other trials and found there was no association between serum cholesterol and BMI. They found no association between cholesterol lowering interventions and heart disease mortality or all cause mortality. This is pretty damning stuff! This analysis is saying that cholesterol lowering drugs have not shown any benefit in terms of how long you will live!! This is not the only trial that has shown this. A recent paper looked at trials in high risk patients… the elderly, people with diabetes, people with kidney disease, and people who have had bypass surgery and the vast majority of these trials showed no benefit in terms of all cause mortality. Even in high risk patients… taking a statin will lower your cholesterol nicely but just doesn’t have an impact in terms of how long you will live. We will talk about relative risk and absolute risk and the number needed to treat in subsequent articles but even the most “convincing” data from a recent trial showed that a thousand people have to take the pill for years and only one person might actually live longer…that’s not very convincing or encouraging to me.
Unfortunately when you show data that disputes the current “Cholesterol is bad…if your cholesterol is high you must take a pill” dogma usually the establishment just rejects it. For example when Dr Willett …chair of nutrition at Harvard… was confronted with the evidence that changing the fats in your diet was either unhelpful or actually harmful..evidence from a large trial done using what we think are the best research methods available… his response was “this report adds no useful new information and is irrelevant to current dietary recommendations…” How do you argue with a person who won’t even acknowledge the basic data?
Well you and I have had 40 years or so of dietary brainwashing and it’s going to take more than one column to help you come into the light. For some great summer reading on this from much better and more knowledgeable doctors than myself look to Dr. Malcolm Kendrick , Dr. Peter Attia and Dr. Jason Fung.
Lest you think me a lone nut job… well I may be a nut job but I am not alone in my distrust of much of what we have been told…let me end with a quote from someone more prominent and public than myself…”It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgement of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of the The New England Journal of Medicine” Dr. Marcia Angell. Until next time…yours in gentle scepticism.
Original Published in Table Hopping Night Life Magazine, August 2016.
Forget the Obits Skip to the Memoriams | July 7, 2016
Sure I used to scan the obits every day when we had a newspaper that was delivered daily. I guess that dates me…I remember when we got the newspaper delivered twice a day, a time when we only had 3 channels on TV, when you had to go to the library if you wanted to research something. If my arms were a little shorter I would be reminiscent of a T Rex.
So, in this modern age you can get the obits on your smartphone but there seems to me to be something unseemly about the ability to “swipe right” to leave the obit almost like you do with a dating site. It’s just not the same on line.
If you do peruse the obituaries..a practice I know is common… one of the things you notice is that there seems to be times of year with more deaths than others. Especially around the holidays. I guess that speaks for itself but I still don’t understand it. Are some people holding on to having one more Easter with the family? I understand holding on for a grandson’s graduation or a niece’s wedding but when someone you love passes away on a major holiday it sets up immediate conflict in the cortex cerebral. You want to celebrate or at least observe the holiday for its sake and you want to give the departed their due as well…celebrate / mourn…celebrate / mourn…this is what I mean about the conflict. What I am saying here is that all other things being equal you should try to avoid keeling over on any major holiday or at any major family gathering. I’m not saying go quietly ….quite the opposite let’s go out celebrating but lets not share the memory of your passing with Passover. I think you, of all people deserve your own day. So yes I am saying that you should avoid dying during the Holidays. All of them. Still leaves plenty of other days. Obviously , most people don’t have any choice about when they die but a surprising number of people do. You know who you are.
When you read the obits in print form you can often see some people have lengthy columns and others have just a few lines. Does a longer column mean a more important life? How many inches will your column be? T.S. Elliot wrote in his poem, The Love Song of J Alfred Prufrock that we have measured out our lives in coffee spoons.Do we measure out our deaths in inches of newspaper column? The obits reflect what a person accomplished in their life…what they did and when. What they don’t reflect are the emotions surrounding their life…for that you have to read past the obits to the memoriams. These are the remembrances posted by those who remain and remember the loved one usually at the anniversary of their birth or death. These can be positively gut wrenching. A good gut wrenching can be a positive and therapeutic thing. To experience strong emotion without having some direct involvement is the stuff of Greek Tragedies. Reading these memoriams can really help you remember what’s important in life. It seems disrespectful to use any actual quotes from the memoriams but suffice it to say these are heart and gut wrenching postings. And that’s precisely why I read them. I don’t read the obituaries and say to myself…I would like a long column about my accomplishments and achievements. I can be dispassionate about the deaths of strangers. I read the memoriams and say to myself I hope my life impacts others as deeply as these people have done! You can’t possibly read these postings…some of which use standard phrasing and many are very personalized…and not stop and think and feel. I find it a very powerful exercise. Thats right…I read the memoriams to help me stay mindful about the life I am living now .
Steven Covey the author of the bestseller “The seven habits of highly effective people” wrote that one habit of success was to begin with the end in mind. It’s difficult to accomplish anything if you don’t know what you want to achieve in the end. He recommended extending this idea not to a project but to your life as a whole. He recommends that one day a year you go to the cemetery and just sit and ponder. You will be in the grave eventually…what do you want to accomplish between now and then. Who do you want to have an impact on. What will you be remembered for and by whom? Instead of just going through the motions…stop and think about your life and where it’s heading…be mindful of your words and actions.
As a physician I write about this because I think an awareness of our mortality is a healthy thing and the memoriams are a daily poignant reminder of how our lives can impact others. I dare you to read a few memoriams and not feel something. Until next month…get well stay well.
Original Published in Table Hopping Night Life Magazine, July 2016.
Chronic Care Management (CCM) You Want It & You Want It Now! | June 6, 2016
I have written separately about the way that Medicare and other insurance companies are going to change the way they reimburse doctors. The government wants to move away from paying a doctor or physician extender a fee for each visit and moving towards paying for measures of performance. These include the percentage of patients that have had a mammogram, the doctors immunization rate, their hospital readmission rate..their management of heart failure etc…These seem like good ideas but ,as always, the devil is in the details. One of the ways that Medicare intends to reimburse doctors is based on the management of the patients chronic medical conditions and this part is called the CCM program. Although I am no fan of a lot of things about Medicare I am a big fan of this program and once you hear about it you will be as well.
Listen, I don’t have to try to sell you anything here. This is not my program. I have a program..SignatureMD …this has nothing to do with that. This is a first ever available extra level of coordination of your care, This is a program crafted by Medicare which finally acknowledges the tremendous amount of work it takes to really coordinate care properly for patients with multiple chronic illnesses. This is not for the young , or the healthy…They don’t need their care co¬ordinated. When you start seeing more than 2 doctors regularly you qualify. When you have multiple caregivers changing medications or ordering tests you qualify. When you have two or more significant health issues on an ongoing basis you qualify. You get the idea.
Chronic Care Management means your primary caregiver is taking extra steps to have someone check up on you regularly and actively so that we know you are not missing medications, appointments etc,. You have a dedicated person overseeing all your visits. This involves making sure all the providers and whatever family members the patient has designated have all the same information. This involves more transparent but HIPPA etc compliant access to the patient’s medical history. This involves following up on all the appointments and reviewing independently all the records. This is a person reaching out to the patient on an ongoing basis to minimize the screw ups that could have serious consequences. Do I have to go there? Last month’s British Medical Journal suggested that medical mistakes could be the third leading cause of death in America. Really?! This program could significantly impact that likelihood and its covered by insurance. !!
If this is now available and you are eligible why wouldn’t you give this a try? For the doctor this is extra work and there is an extra charge. . Most, if not all, of the cost is covered by Medicare, Medicare Advantage and Blue Cross / Blue Shield. This is an available, covered, upgrade to your medical care that could save your life or your mother’s life… if you are a child living out of town or across town worried about your momma! Accurate information , easily accessed, can make an immense difference in your care and in your ultimate health care spending and that’s why Medicare and some of the big insurance companies are so interested in it. They see the financial advantage and that’s their job… I see the advantage to your health and health care!
Your primary care physician is supposed to be the conductor of the orchestra . He’s the one that refers patients to other doctors and then follows up with the other appointments and tests that were ordered etc. This sounds simple and appropriate but in the real world this is very fragmented. Some patients know the medicine changes that their last specialist made and many don’t. Some patients remember all their appointments and some patients don’t. If You have multiple medical problems or see multiple specialists… good luck at keeping the communication open and up to date. This is extremely difficult in practice. One patient could have a cardiologist, a kidney doctor, an eye doctor, a vascular surgeon, etc. and each of them is trying to keep in communication with the others and is a very fragmented system. Currently the electronic medical records do not communicate well with each other. This will not be fixed anytime in the near future. It infuriates me when patients tell me… ”the doctor didn’t have the report”… perhaps you have had a similar experience?
Once a doctor recommends that the patient see a specialist he may have no way of knowing what day the visit was, what the findings were etc. until the doctor sends his report. Some offices are quick with their reports and some are not so quick. What if I don’t get a report. How can I review a report I didn’t get? What if the patient misses the appointment or a test or labs? What if another health care provider changes the patient’s medications? Sometimes important details are lost in a 3¬10 ¬page consultation note and it is a nightmare trying to keep the medical record true and correct let alone attend to the myriad details of the outside consultations, tests and appointments. This is very difficult and important work and finally the importance of this work has been recognized and codified.
So Medicare has offered physicians a monthly extra monthly incentive to really step up and stay on top of patient’s care. To actually “coordinate the care”. This means hiring someone in particular who will monitor the appointments, the results, coordinate communication between the medical offices etc. on an ongoing basis. I can either hire one person to manage between 200¬/250 patients or I can outsource it to professionals. Luckily, here in America, companies have risen to the occasion to offer this service to physicians and their patients. The internet, the fax machine and the phone enables the co¬ordinator to work from anywhere. Anywhere for me at least means anywhere in America. The person co¬ordinating your care will be calling you from somewhere in the USA. I understand the reasons to outsource to China but this is way too important to handle offshore.
This is a new program. These are new opportunities to improve patient care. This is actually the most proactive thing for patients I have ever seen Medicare do. EVER . I think this can really make a difference by decreasing errors and increasing communication. In terms of medical dollars this is dirt cheap and can have a big impact. It’s encouraged and covered by many insurance companies and each patient can sign up or drop out anytime for any reason. I always find that type of arrangement very reassuring. No special contracts. This is an opportunity for patients to get better co¬ordination of their care by a incentivized caregiver. This sounds like a win¬win to me.
Again, this is not some crazy program I have cooked up. This is a program that has been encouraged by the government and is part of current and future Medicare programming.
Usually the other major insurance companies follow suit. For people with complicated medical situations or any combination of serious chronic medical conditions this level of oversight can make a real difference in your health. Best of all is that this is not some limited time offer, this is not something available only to the first 100 callers… this is something your primary care practice can be doing. This, as I have said, is a new program and many practices just don’t know how to approach this program but it’s something that every office can do in one form or another. This program, like the cognition test Cognivue, passes my test. For me the test.. ”Is it in the best interest of the patient?” This could be a great thing for patients if it works out. It may turn out to be too good to be true but you must know by now that I am an Optimist. Check out this new program and how it can make a difference in your life or the life of someone you love! This is the shizzle my nizzle!
Original Published in Table Hopping Night Life Magazine, June 2016.
Chasing Longevity | May 5, 2016
Some pundits opine that with advances in medicine the average life span can be extended to 120 . After all ,wasn’t the average lifespan just 30 or 40 years of age something back in the 1800’s?….we are so far advanced from that time period it should be easy to extend life from 80 to 110 or 120?
Well, It turns out that the real life expectancy has not changed much in 2000 years. After all Socrates died at the age of 70…and it wasn’t from natural causes at that. It turns out that the claim that average life expectancy was 35-40 was very much skewed by infant mortality and that the usual span of life hasn’t really changed over time. Sure, we have made strides with public sanitation and infection control but that just means that the average person is living longer not that we have extended maximum life expectancy over time.
Sure there is evidence from manipulating the environment in nematodes , yeast, mice, etc you can increase longevity in these lower species but really..?? Really? Are you serious about comparing human beings to worms and yeast?? I would trust more the research from the primate world….that at least might have some real relevance to our species. Nature magazine published in 2012 a study of 25 years of primate research that involved caloric restriction as a means of living longer. Caloric restriction is one of THE leading concepts in life extension. Eat less and live longer has been shown to extend life in much lower life forms. The Nature article showed no benefit to caloric restriction in extending life duration.
Before we go organ by organ in our search for long life let’s quickly dispense with all the cloning and gene splicing come on’s. We are just as likely to unleash some alpha helix armageddon as we are to cure any real disease or extend life and neither is likely in the lifespan of anyone reading this article despite all the recent headlines so let’s move on to what’s currently plausible.
Alright ….let’s take this one organ at a time…..We can keep your heart going or use a replacement or artificial pump..we have this technology already. We can keep your lung function going indefinitely with the respirator. We already have the tech to replace your kidney function. We can’t replace your liver function yet but we will have artificial pancreas soon and we can control your gastric system very well. Sure your joints will suffer over time but we can design exoskeletons to support us in our dotage. We can replace your blood and most of your joints and there will be artificial skin aplenty. BUT the one thing we can’t seem to make any headway in life extension is mentation. The body functions we can maintain perhaps indefinitely but the brain seems to wear out at a certain point regardless of what we do.
Before I unload the truth as I know it on you let me share the thoughts of some of the leading experts in longevity. Thomas Perls is the Director of the New England Centenarian Study at the New England Medical Center. He believes that Iron is a cellular toxin and that we can extend life by decreasing our iron load. He therefore donates blood every 8 weeks to keep his iron level on the low side. Lower iron levels might be one reason women typically seem to live longer than men.
Perhaps you prefer the advice of Dr. Mark Mattson ,Chief , Laboratory of Neurosciences, National Institute of Aging,National Institute of Health…He advocates intermittent fasting and keeping daily calories to below 2000 calories a day.
Personally I rather like the advice of Felipe Sierra, Molecular Biologist, Director of Aging Biology, National Institute on Aging…”I laught a lot” …Reflecting his scepticism about the current state of life prolongation.
So the experts have weighed in but I would like to add my three cents as to why living longer is not really such a great thing for individuals or for society.
Penny One
Think what this would do to the divorce rate?….People have a hard time in this day and age to stay married for 10-20 years….If you get married at age 20 and are likely to live to120 what is the likelihood that you will still be with the same person? Living longer doesn’t necessarily mean living longer happily together.
Penny Two
Who is paying? You know most people don’t plan for retirement already…if they live twice as long someone is going to have to pay to take care of them …how can this be sustained? Where will these resources come from? The social security lockbox is already busted open…who can afford for you to live longer and almost certainly need more care as you get over the 100 year mark.
Penny Three
What’s the point of sustaining the body when the mind has faded. What do we do if the limiting factor is your mental function. Even those geriatric patients that have been able to avoid dementia at an earlier age eventually have more trouble with memory and cognition. There are a very few people living into their 90’s and beyond with remarkably preserved mental function. Most people hit the memory wall at or before the age of 85 plus or minus 5 years and it’s all downhill from there. Is there a point to living until 120 years of age if the last 10 years are in diapers?
On a more philosophical note I would suggest that most people have a much more limited existence after a certain age….Depending on the person this could be at age 50 or age 75 but sooner or later most people start to really “ turtle up”. They do less and less…don’t go out as much, don’t interact with family as much, don’t travel as much,, do less and less in their social groups, the church, etc ..in short….don’t live as much.. Is it too offensive to say they are slowly shutting down and I think their quality of life dwindles incrementally ?. My sister Marijo, tells me that I am too judgemental….If they are happy to go from bedroom to couch to kitchen with slippers and doing the tea and toast thing and slowly slip away who am I to judge? I just don’t think that’s the best way to spend your golden years. I’m just saying that most people don’t do more, try more, press onward as they reach the last chapters of their life and I am afraid that living to 120 is only going to prolong the most difficult chapters not the most desirable chapters.
I close by exhorting you to carpe diem! Living long is, I am sure, a desirable thing but Living well I think might be a better goal. Until next month….get well …stay well!
Original Published in Table Hopping Night Life Magazine, May 2016