Saturday, December 29, 2007

Weekly Wellness

Alzheimer’s Nursing Homes and Psychotropcis: There has been some press regarding off label use of anti psychotic medications in the elderly, especially older persons with Alzheimer’s disease. AD is a progressive, debilitating, brain illness. Basically the brain degenerates. Tissue actually dies and on a SPEC or PET scan one can see black spaces where brain matter should be. For whatever reason, some patients with dementia have significant behavioral problems. [Well, it actually makes sense in the same way that people who have brain trauma and lose brain matter often act out]. Sometimes in the AD cases, the behavior is related to an acute illness, like a delirium. Many times persons not familiar with geriatrics mistake these acute symptoms for a progression of the Alzheimer’s or even a chronic Alzheimer’s feature. There are actually so many things that can be happening which do lead Assisted Living Facilities or Nursing Homes to bring these residents to the ER. I say all this because I was one of the people on a multidisciplinary psychiatry in patient team who sought to stabilize these people. Our role was to manage their symptoms and return them to long term care. It was often a fight to return them to the SAME facility. It is absolutely not as simple as some consumer groups would have us think. I whole heartedly agree that zyprexa, risperdal, haldol, abilify and the like should NOT be used. I argue that acute illness be ruled out first, upon examination, i.e. bowel and bladder disturbance, renal disease, and blood sugar extremes. Just because an 80 year old has a diagnosis of dementia does not mean they don’t have a urinary tract infection. I fully support efforts to change the environment in the facilities as well. Add staff to redirect wandering, excitable, confused and scared persons. Yes, more staff. Another problem is that hospitals and facilities are scared to death of falls and thus a medicated person who won’t get up is a lot better on so many levels than a frail walking un medicated one. But I digress. That kind of hands on, low resident to staff ratio seldom occurs, in doesn’t occur in Medicare Medicaid facilities. In the hospital, physicians are pressured to get the patient out as soon as possible and the long term care facilities won’t take an aggressive restless person back so the only solution is overmedication. Family members often agree to the meds because they have no other choice for “placement” as they call it. Thus now you know, it is NOT that simple. What is simple is this. Dementia is NOT a normal part of aging.

Fish – Fish OIL: Ironically, the health benefits associated with the Omega 3s in fish include heart and brain health. The question is yet unanswered as to if the fish oil capsules are as protective as the fish itself. A recent study still leaves room for doubt. It is very important again that one read beyond the headline. The study involved a small group, two groups, of women. Less than 30 people total and that is too small to allow for any type of population generalization. Any way. One group took capsules while the other got the same mg of Omega 3s in actual fish. Afterwards both groups had the same blood level concentration of Omega 3s. That does not answer the question, “ Is the effect the same?” A long term study would be needed for that and frankly; you don’t have time to wait for that. Eat your fish. They contain additional elements, protein, minerals, and yeah, well ok, a little mercury, cadmium…….. Oops.

SWEET! Oh I like this study from a place called Kaleida Health in Buffalo NY. Actually more than one study and the results are also more suggestive than causal. Oxidative stress and inflammation occur often in our bodies. Bad things like smoking cause it. But good things like exercise also cause it as do necessary things like eating. There appears to be an inflammation process to all cellular activity and free radical release. The accumulation of free radicals is quite harmful and inflammation in the blood (c reactive protein, homocystiene) can be a marker of heart disease. We also have a built in clean up effect, the antioxidant process which can be enhanced when we eat foods like blue berries and fruits and vegetables. Obese persons generally have more inflammation and high fat foods themselves increase oxidative stress, acutely. A healthy, active person of normal weight may still have an oxidative response when they eat, but it abates quickly. The researchers found that normal vs. obese subjects who ate the same high fat high calorie (1800) meal [meal? That is what I eat in a DAY] had the same spike but it lasted much longer in the obese group. That will increase their already higher risk of heart disease, and heart attack. However, there was also a study in which the same 1800 calories was in high fruit and high fiber and there was NO SPIKE. I don’t recall if that included both normal and overweight persons.

Radiation: It has been said that X-rays should not be used with reckless abandon as radiation exposure can change cells and damage DNA which is one way cancer can initiate. Now there is a concern about warning people who have been given radiopharmaceuticals. This would be chemotherapy as well as perhaps dyes used in bone scans. Apparently it leaves the patient a little radioactive themselves. Enough so that days and months later the person will set off an alarm at the airport. Doctors are being asked to warn persons of this possibility. Geez.

Saturday, December 22, 2007

Weekly Wellness

Eating Out: Most of us realize that fast food is not typically low calorie and is sometimes ridiculously high in fat. The same can be said of fine dining establishments as recently highlighted by R. Sokolov in the WSJ. Chef’s generally cook with out consideration of the obesity epidemic and expect instead, that the diner will limit the amount they eat. Ah not so. We eat with the same reckless abandon with which they cook. That is ok – sometimes. It is also okay to request your food be prepared a little lighter. In the end, you live with the body you feed. You age and die with it too.

Dieing Too Soon: Speaking of lifestyle. A website related to tobacco use and cessation named has a statement that is very much representative of why I write this newsletter and have the passion I have about your being sagacious and salubrious. No author is listed for the statement, which is thus: “Dieing in old age is inevitable, but dieing before old age is not.”

Cancer and Lifestyle: The American Cancer Society released some global cancer numbers this week which they projected by using WHO resources. Differences in type, incidence, and survivability are seen between developing and developed countries with some overlap. Researchers are seeing changes in developing countries. There is less death and disability from infectious disease and there is less child mortality. That is the good change, the bad is that there is more of death and disability related to cancer. The cancers are associated with a rise or continuance of tobacco use (I make that distinction because in many developed countries smoking bans as well as prevention and cessation services are in place which have reduced tobacco use) as well as “fattier diets, “ says ACS epidemiologist Ahmedin Jemal.

1 in 3: One in three children and adolescents are overweight and obese. That is a rather staggering number. Two studies regarding the effect of this phenomenon were part of a Medscape CME activity I completed this week. Most importantly, these children will have risk factors for coronary heart disease, CHD, such as HTN and high cholesterol before they reach adulthood and will have CHD in their 30s and 40s. That, as my coworker likes to say, “Is Crazy.” It was also noted by the scientists that the drugs available to treat some of the conditions are first, intended for adults and secondly, untested for long term effects. I.E. we must get ahead of this with prevention.

Drugs: Everyday it seems there is something in the press about a prescription drug. Drugs changing formulas, drugs used off label, drugs losing patents, drugs causing unacceptable side effects, drugs not being approved, drugs having block buster sales… People rely on so many pills and drug companies depend on that. Especially interesting to me this week was information on a vaccine that will compete with Merck and Sanofi-Aventis’ Gardasil. The drug (vaccine) is from GSK and called Cervarix (geez these names). It is in use in some 45 countries but our FDA has requested additional information on it. The drug is supposed to protect people from the 2 HPV strains (there are 14+) that cause most of the cervical cancer cases. Gardasil does offer protection against four strains, two of which are often related to genital warts. I want to emphasize or reiterate something I have said before, the vaccines may protect against the virus, they do not necessarily stop the spread of the warts and they do not prevent cervical cancer directly. These vaccines do NOT obviate condoms and pap smears. Pap smears prevent cervical cancer.

Wishing you wellness and joy!

Saturday, December 15, 2007

Weekly Wellness

Byetta: In a commercial for this drug which I believe is intended to treat diabetes, the announcer notes that the pill effects appetite and thus one may eat less and lose weight. Well, yes. Usually we do lose weight if we eat less, that is how weight loss works, through an energy imbalance. You can achieve weight loss and maybe even make an impact on your blood sugar (recommended for pre diabetics), by eating less and moving more without the side effects of nausea and vomiting that accompany Byetta.

$350, 000 Test: If you paid that kind of money for genetic testing and were then told that you should eat better and increase your physical activity to reduce the chance of contracting whichever disease your genetic profile pointed to, would you listen? In other words, if one needs to pay an exorbitant amount of money to accept the message that I happily provide for free, if that is what it takes, by all means, spend the money. It might save you some health care expenses down the road.

Living Longer: Research continues to confirm the health benefits of eating a Mediterranean diet. This study from NIH and AARP used people ages 50 -71 who live in America and had them eat a diet more lean than most of us choose. The diet was higher in fish, fruits, vegetables and monounsaturated fats like nuts and olive oil. This style of eating, hey I like that, “style of eating”, not dieting, is low in red meat and dairy foods. People in the study were less likely to die of any cause in the 5 year follow up period. I did not read the study itself so I am not sure how long the people ate that way before the five year follow up. The group was however, compared to one similar in all ways but the foods ingested.

No OTC for Mevacor: The FDA panel put together to explore whether or not Merck’s cholesterol lowering drug should be available OTC voted against it this week. Two strikes. The FDA can still approve the sale, but it is unlikely. The reasons the panel offered for its decision are not necessarily ones I’d mentioned and are interesting. The concerns which arise from focus group type research of 1500 people, is that too many people who do not need this medicine would take it. There was also concern that some who take higher dose prescription statin, or cholesterol lowering drugs, would switch to this OTC which is of a lower dose. (Hey remember my thoughts a few weeks ago, is this stuff even effective at a lower dose?). Anyway. It was noted too that the prescription statins would be cheaper for people with prescription drug benefits than this OTC med. While doing this research, the panel found that 30% of that pool of 1500 people actually had very high risk factors for disease risk and complication, i.e. they may have already had a heart attack or stroke, and were not being seen by a physician. Now Merck might argue that those people would take the drug and benefit, but those are the very ones that need the prescription strength drug. Further, there is no way to tell if you have high cholesterol beyond having a lab test. Most OTC meds are for ailments which are symptomatic. In other words, we don’t generally use wart remover if we don’t have warts!

Would you Like Mevacor with that? However, if one were to sell Mevacor without a prescription, perhaps Hardee’s would be a good place to start. I.e a “Philly Cheese Steak Thick Burger.” Are these people insane? The sandwich alone, without fries or a drink, has 930 calories and 63 grams of fat of which 24 are saturated. Far from being Mediterranean, eh. So I ask, “And would you like a cholesterol lowering drug with your order today? How about something to prevent that colon cancer you’re working on there buddy?”

Fructose: One of our country’s (USA) obesity experts was interviewed on Australian radio this past week, Dr. Robert Lustig. I was able to listen to the interview on my IPOD (whilst running :)) and though I cannot give you the same detailed explanation of this obesity explosion that Dr. Lustig offers, I can recap some very interesting, research based points. He refers to insulin, leptin and fructose in his lecture. It has been some years since we (in this newsletter) explored the appetite regulators grehlin and leptin, but you may recall that grehlin, from the stomach stimulates appetite and leptin, from fat cells turns it off. These hormones are often studied in the big quest for an obesity pill. That is NOT what Dr. Lustig is doing. He explains that our insulin resistance has led to leptin resistance and because we do not get the message that we are full we continue to eat and we pretty much feel listless and do not expend energy either. That was very simplistic and Dr. Lustig might fall off his chair if he read it. He said that the job of insulin is to get sugar out of the blood stream and to store it as energy. It is stored in fat cells. Because we have somehow overloaded our delicate metabolic and endocrine systems with the foods that we eat (processed) we release more and more insulin to get the energy into the cells. That is insulin resistance. When we need more to do the same job that less used to do. Diabetics can become completely immune to insulin. Okay, once the energy is stored in the fat cells, leptin is released. It goes in the blood stream and is taken to the brain which is told that we are full. More insulin, More Leptin and thus, leptin resistance occurs as well. Dr. Lustig said that we don’t “see the leptin.” Cycle goes on and on. He notes that the problem could in large part be do to fructose which has been added to our foods. Fructose is also in HFCS and sucrose. He talks about foods that are low fat that are anything but because they contain this fructose. Fructose is fruit sugar without the fruit, i.e. without the fiber. That is very important. Fructose is metabolized in the liver and has adverse effects on the liver, such as alcohol does and does increase fats in the blood as well. It also impairs an insulin receptor in the liver. In the end, fructose also causes insulin resistance and then leptin resistance and obesity. This is due to day after day of fructose intake. Fructose is in so many of our foods it could be called the nicotine of the food industry. It triggers eating behavior because our appetite suppressant mechanism is no longer working. Dr. Lustig was asked a question about the glycemic index which he did not discount but qualified with the glycemic load (so you may want to read about that on your own). In this part of his discussion, low carb diets were compared with low fat diets and he told the story about low fat diets not being low at all because the sugars were increasing blood fats, and increasing eating behavior. He also spoke about the way Japanese people ate white rice but did not get fat. He stated that the carb part is ameliorated by the high vegetable intake that Japanese people consume. I.e. they add fiber to their simple carb intake, further, until recently, there was NO fructose in the foods available in Japan. Now older persons in Japan eat the way they always have and young people eat more western meals and are themselves becoming obese. Take home message: Fiber yes, fructose no. I.e. eat the fruit don’t drink the juice, eat the whole grains and leave the Twinkies. Now you may be wondering if eating a Twinkie with an apple would be helpful and truthfully I do not know.

Wishing you Wellness

Saturday, December 8, 2007

Weekly Wellness

Children: That I’ve been able to sit on this all week is a shock even to me. In fact, as it occurred, I had to call a friend to vent as I was so flabbergasted. Later in the week when an article regarding 2 studies reported in JAMA on children’s expected disease outcomes was published, I was anything but surprised. Children, people, hell, animals, don’t generally gain weight without a significant energy imbalance. Something causes weight gain and as the studies suggest, that weight gain can causes disease and that disease can significantly decrease one’s life expectancy. (In rare situations weight is related to genetics and disease processes more than EIEO). How do children end up so heavy? Here is a real life example. A family came to the pool; mom, grandma and two young boys. One boy may have been two and the other four. The four year old was a chubby fellow. None the less, I was excited by the idea of kids coming to swim and be active. Both boys got right in. They were not speaking English so I don’t have audio with this case history. Anyways. Mother calls repeatedly to the chubby kid who has begun splashing around in the pool. He goes to her finally and she gives him hard CANDY to eat. Oh yeah, it is a choking hazard but geez he was playing not asking for sweets! So a ½ hour later I leave the pool and by all I hold dear, I kid you not, the children were sitting in the pool on the steps eating fast food burgers. I SAW the bag. And that is why there is such a thing as an obesity program at Children’s Hospital of Boston and why it is far from the only children’s hospital that treats obesity.

Lies: More stunning behavior. A pharmaceutical company was highlighted in a little WSJ article this past week. The company, Sirtris, is developing a drug that might mimic a protein in our bodies called sirtuin enzyme one. People who eat low calorie diets seem to make more of this protein (enzyme) and Sirt1 seems to be protective of disease. Another compound that seems to activate the release of sirtuin is resveratrol, which is found in small, ineffective, quantities in red wine. This company and some others are working to create a chemical or pill out of resveratrol or one that acts like resveratrol but has none that will reduce disease by generating more sirtuin in the body. Still with me? They are trying to make a pill that does what the body will do on its own if one eats a low (probably reasonably low) caloric diet. That bothers me for all the reasons you already know, but it isn’t the lie. Here is the lie: In the WSJ, K. Winstein writes that the company Sirtris is doing this to make a drug to prevent diseases of aging such as: diabetes, Alzheimer’s and cancer. The FDA won’t call aging a disease so I guess the company can’t sell a drug that “treats” aging. Hear me now: diabetes, Alzheimer’s and cancer have all been repeatedly found to be most often caused by these things: overweight, too few fruits and vegetables, too little physical activity, too much inactivity, as well as genetics and environmental toxins. The above diseases are not caused by getting older! Damn it.

Heart Attack: There are more heart attacks and more fatalities related to them this time of year. The holiday months. In the past I have reiterated this at Thanksgiving. This year I did not. I read a long time ago that eating large meals, a lot at one time, could increase the risk of heart attacks. It is one of those things that I never forgot. This week a reminder comes from several cardiologists, including a past president from the American Heart Association. I trust you will believe them. Heart attacks are more common for several reasons. They are more fatal at this time because people are more reluctant to seek assistance when experiencing the symptoms of a heart attack during a holiday family time. There may be less medical staff on hand as well. You can certainly make a commitment to seek help if you experience the symptoms of a heart attack. Here are some other things that you have control over. Taking your meds if you are prescribed them, continue your exercise program and watch the fat, calorie and salt content of each meal. Seriously. I am not saying to diet at Christmas, hell, diets don’t work ever, but surely not at this time of year. From L. Neergaard of the AP, I quote, “a heavy meal stresses the heart AS it is digested, salt causes immediate fluid retention which means the heart has to pump harder, same with excess alcohol”. High fat meals may actually affect the lining of arteries and many Americans have clogged arteries which already have poor blood flow. Eat wisely, now and always. You can always eat that great meal in two sittings!

Fosomax: A class action lawsuit is pending as some users of this bone drug have had jaw bone degeneration. Isn’t that odd. A pill that is supposed to prevent further bone loss causing jaw bone to die. I think about the people who have osteonecrosis of their jaw with some sympathy and angst. I was on fosomax a year or so until I told my doc, the same one who gave me Vioxx, (and I really liked that doc better than any I’ve ever had), that I didn’t want to take something indefinitely which may or may not prevent a fracture if I happened to fall down sometime in the future. Especially because, I told him, we don’t know what the long term side effects may be. He said ok. I am so NOT the girl drug companies market to with their TV commercials, i.e. I ask my doctor if I can NOT take a pill.

CTs: Computed Tomography. Hmm, well, it’s a scan that docs use that can help them diagnosis internal problems and it exposes the patient to radiation. This is often an unnecessary risk and I know we talked about it last year. The practice of ordering CTs too quickly continues unabated. Researches supports that these scans could increase the lifetime risk of cancer by 2%, remember that several other things we do or are exposed to also increase that risk. If you think 2% is ok you probably haven’t been diagnosed with cancer. Still, this second study confirming the risk ends with encouragement for doctors or other health care providers to try alternative diagnostics when possible.

Wishing you wellness.

Saturday, December 1, 2007

Weekly Wellness

Beta Carotene and Memory: I thought that this study was cancelled years ago when it was found that smokers who took the supplement were more likely to be diagnosed with lung cancer. That being said, the results of a near 20 year study are reported in November’s issue of the Archives of Internal Medicine. I haven’t read the article but saw a little story about it in the local herald-tribune here in Florida. What I liked was the journalist’s synopsis which included who was in the study and thus who the results would relate to, where the actual study can be found and the admonition that you not change anything in your life based solely on this study. In her report it is noted that some men took beta carotene supplements every day for 18 years, while others took them every other day or for less years and some took placebo. One test for memory at the end of the study showed a little improvement in the every day, long term group. I am not at all convinced then that taking a supplement for 18 years is helpful.

Alzheimer’s and Mild Cognitive Impairment: Ironically, this week there were other stories about memory as well. One is a report that the three main Alzheimer’s drugs, when used not to treat behaviors associated with the illness, but to prevent mild memory impairment from becoming a progressive dementia, were not effective. They of course have side effects, the drugs, and thus should be used only out of necessity. Further, research continues to build that memory and intellect can be preserved (in fact, improved) in the same way that stamina and balance can be preserved. By doing things now to keep the blood flowing to the brain, i.e. exercise and by always striving to learn knew things.

More Exercisers? A confusing bit of survey results this week. More Americans appear to be exercising but obesity rates are not declining. Some ideas on that disconnect? One, people say they are exercising when asked because they know they should be. Two, people describe vigorous and moderate activity differently. And three, (this one is making its way through the expert pipeline), people are eating too many calories still and maybe even more when they exercise. Here is another thought on the calorie front, sports drinks and bars. Really, walking around the block does not make one an athlete. It’s GOOD to walk around the block, and then, have some water.

Smoking Vs. Obesity: Interesting that the smoking rates are now down to 17 % give or take for age group and state, while the obesity rate is double that at about 34%, nationally. Cigarettes are highly toxic as I have mentioned. Cigarette smoking contributes to if not directly causes, lung and other cancers, heart disease and death and respiratory illness and subsequent death. Cigarettes should be banned. Current smokers can receive the quit smoking counseling and NRT products available by way of tobacco settlement money. New money and New efforts should be spent on the obesity epidemic. No ONE needs to smoke a cigarette to live. Everyone needs to learn how to eat in order to live longer, well.

Wishing you wellness.