Thursday, May 31, 2012

A New York State of Mind - Ban Soda!

The big health related headline today is that New York City is banning the sale of cups larger than 16 oz. of sweetened sodas. NYC's plan to enact a far-reaching ban on the sale of large sodas and other sugary drinks at restaurants, movie theaters and street carts, in the most ambitious effort yet by NY Mayor Michael Bloomberg to combat rising obesity.
The New York Times

"The proposed ban would affect virtually the entire menu of popular sugary drinks found in delis, fast-food franchises and even sports arenas, from energy drinks to pre-sweetened iced teas. The sale of any cup or bottle of sweetened drink larger than 16 fluid ounces — about the size of a medium coffee, and smaller than a common soda bottle — would be prohibited under the first-in-the-nation plan, which could take effect as soon as next March. 

The measure would not apply to diet sodas, fruit juices, dairy-based drinks like milkshakes, or alcoholic beverages; it would not extend to beverages sold in grocery or convenience stores."

Is this a good thing? I am reluctant to criticize any measure or effort to combat obesity, but I am on the fence here. If this is merely the next salvo in the battle to incrementally decrease the consumption of unhealthy food by bringing attention to it and making its consumption more labor intensive, I vote thumbs up.  I applaud Mayor Bloomberg's desire to do something that is readily available to him without getting legislative consent.

My issue is that while sweetened sodas and drinks are an easy path to consumption of unhealthy calories, they may drive higher consumption of unhealthy fruit juices and smoothies (concentrated with fructose), which can also be counted as contributing to the excessive weight epidemic. I would prefer to see warning labels prominently displayed that identify foods that contain an unhealthy amount of simple carbohydrates of a processed nature with a viable alternative available. You can't sustain bans without making sure that a viable alternative is immediately accessible. 

I also prefer education and coaching over food bans (except in the case of the silent killer -- trans-fats.)  We need to educate the populace more explicitly regarding the harms perpetuated by all these sugar-heavy beverages. 

What's the big deal with high sugar consumption? In each of the past few days, I've diagnosed a patient with pre-diabetes. Everyone knows about the dangers of diabetes, but there is not enough discussion about pre-diabetes and that is a huge problem. Yesterday's blog covered the increased benefits of exercising while still pre-diabetic versus diabetic. With nearly 80 million pre-diabetics already in the U.S. and that number steadily climbing, we need to do a lot more than just force people to get refills (still allowed) of sweetened drinks.

Given the nature of this public health crisis, the government should declare war and wage battle as it would against any real enemy of this country. The threats to our nation based on the rising levels of obesity, diabetes, pre-diabetes, depression, dementia,etc. are as threatening to our safety and security as any faced by Homeland Security.  Isn't it time we treated it as such? 

Wednesday, May 30, 2012

The Three Questions Dr. Oz Needs To Answer

Last week, Dr. Oz did an entire show dedicated to his favorite supplements. As always, research of his recommendations raised alarms for me. For example, he recommended Forskolin again, which I previously wrote about is not scientifically validated for human consumption.

After watching the episode, I thought to myself that I would really appreciate it if Dr. Oz could answer three questions.

The first question relates to his motivation regarding his supplement recommendations. I would like him to tell his audience what relationship, financial or otherwise, direct or indirect, he has with the product or company he is recommending? I think we can all agree that if he has a direct or indirect financial incentive to recommend a product, it could skew his judgment, and at a minimum, he should be transparent and let the audience know that he has a conflict of interest.

The second question revolves around the scientific basis for his making such recommendations. I often hear him refer to research that was conducted by him or others, but I have never heard him reveal any facts or sources that one can rely upon. Therefore, my question to him is what source and quality of science does he rely upon to make such recommendations to an unidentified audience to take pills regardless of his knowledge of the various medical histories, and other medications and/or pills the audience may already be taking? Many of the products he recommends are pure rubbish. However, to some, they are potentially poisonous and fraught with other dangers.

Finally, as anyone who has watched a number of his shows has heard, he often refers to these supplements as miracle cures and magic pills. My question is if he really believes that these pills are so powerful to be of such major therapeutic benefit to be deemed miracle cures and magic pills, why aren't they regulated by the Food and Drug Administration (FDA) as a pharmaceutical? While the FDA has its flaws, I think most Americans agree that anything that has powerful medicinal effects should be under close scrutiny.

Here's a question for my readers. Why does anyone still believe a word this man says when clearly a number of products he has recommended have been shown through reliable research to have serious associated harms? As the old adage goes, fool me once shame on you; fool me twice, shame on me.

Beyond Ecstatic!

I read something this morning that validates the value of prevention in a profound manner and reinforced my convictions and sense of mission. It started with some bad news, but it got much better.

The bad news was that a recent pilot study,  led by Sabyasachi Sen, MD, from Baystate Medical Center in Springfield, Mass., and colleagues, showed that prediabetics have similar micro-vascular dysfunction as diabetics. Prediabetes is generally defined as fasting blood sugar between 100 and 125. Vascular dysfunction refers to the changes to the flexibility of arteries that contributes toward stroke, heart disease, and death. The less flexible your arteries, due to factors such as hardening of the arteries, the greater the vascular dysfunction.  It's long been known that diabetics have vascular problems, but this study showed that so do prediabetics. This is bad news because it is estimated that  nearly 80 million Americans are already prediabetic and that number is expected to steadily grow as the obesity rate grows.

The good news was that unlike with diabetics, aerobic exercise can have a profound effect. It's not to say that exercise doesn't help diabetics; rather, exercise has a dramatic impact on prediabetics. The researchers found that "exercise improves vessel function almost back to normal status, which is not the case with diabetes. It's been shown that exercise only improves the vascular reactivity of diabetics by half of what was achieved during the study."

The implications of the study is that there is a therapeutic window (an ideal period to treat) for prediabetics to return their vascular function to normal with a non-pharmacologic (no drugs) intervention. Aerobic exercise can "reduce the cardiovascular risk in a patient population that is at risk of developing diabetes."

The patients involved in the study did not have high blood pressure and were fairly active but not undergoing any type of formal exercise program. The exercise consisted of 150 minutes per week at 70% of the maximum heart rate, which is considered moderate exercise by American Diabetes Association criteria. This leads me to believe that those who are hypertensive and live sedentary lives will garner even greater benefit from increasing their exercise.

The implication of this study is further support of the Ben Franklin adage, "an ounce of prevention is worth a pound of cure."  Don't wait until you are diagnosed with diabetes. Don't wait until you add the next few pounds and become further overweight and obese. Don't wait until you find out you have heart disease or suffer a heart attack or stroke. Get more exercise today when your efforts will yield far greater results. You only have one life to live and one body to live it in. Get up now and start exercising! You must do it and you can.

Friday, May 25, 2012

Calcium Pills Raise Concerns -- Again!

If you've heard me say it once, you probably have heard me say it many times -- taking dietary supplements in the absence of known deficiency is a mistake. One of the more controversial supplements I've rallied against has been calcium. Most women are told by their doctors, particularly as they get older, to take calcium supplements, usually about 1,000 mg.

When I give lectures, I often ask of the audience whose doctor adjusted their calcium recommendation based on the calcium the individual consumes through his or her food. The answer is almost always that none of their doctors made any such adjustment. I've always considered this problematic because why supplement at all if you are getting sufficient calcium in your diet, and why not adjust when you are getting calcium from other sources.

My real concerns about calcium began to grow almost two years ago when studies began to emerge challenging the wisdom of taking this supplement.  Specifically, these studies linked calcium supplementation with increased heart attack risks. Some studies suggested the mechanism for this, calcium supplements, were contributing to calcification, or hardening, of the heart.

So a new study that just came out should be of no surprise to my patients.

The large European study showed that people taking calcium supplements had nearly double the risk of heart attack as individuals not taking any dietary supplements. Among 23,980 participants in the European Prospective Investigation into Cancer and Nutrition (EPIC-Heidelberg) study, the hazard ratio for heart attack in those using calcium supplements, compared with nonusers of supplements, was increased according to Sabine Rohrmann, MD, of the University of Zurich in Switzerland, and colleagues.

"This study suggests that increasing dietary calcium intake from diet might not confer significant cardiovascular benefits, while calcium supplements, which might raise MI risk, should be taken with caution," the researchers concluded. In an accompanying editorial, two New Zealand physicians went further and suggested that use of calcium supplements should be actively discouraged.
This was an imperfect study as it was an observational study that relies on self-reporting. Nevertheless, once again, the red flag rises over taking calcium pills, or any dietary supplement for that matter. The evidence continues to mount that at best they confer no benefit, and at worst, they are harmful.

Eat a Mediterranean diet consisting of fruits, vegetables, beans, nuts, and some whole grains, add in some wild fish and save yourself some money from not buying unnecessary pills.

Thursday, May 24, 2012

Hugging Patients

Is it appropriate for doctors to hug patients when they ask to be hugged? This is more than a theoretical question for me. A number of my patients ask for hugs.

Just yesterday, a patient told me that that I was the first doctor ever who actually took the time to listen carefully to everything that bothered her. She was 78. She had a lot to say and I listened patiently, only interrupting when I had something of value to add. After taking in the full scope of her situation, we developed a prevention plan focused on keeping her healthy and in good spirits for years to come. When we were done, she asked for a hug.

People want to know that someone cares. Some may look to a religious figure for such empathy, while many hope to get it from their doctors. Unfortunately, the time pressures put on so many doctors make it difficult to give patients the time and attention so many crave. I am privileged to be able to afford the luxury of time with my patients. For me, it is a pleasure to hear life stories, although some are heartbreaking, in order to learn as much as can be reasonably learned about the individual sitting in front of me. I get the full megillah and relish it.

It amazes me what colorful lives so many have lived and how sharing their anecdotes enhances both the speaker and the listener. I feel bad that most doctors can't enjoy this level of interaction and satisfaction. Medicine is a noble profession, but many regulatory and reimbursement changes have made its practice less enjoyable for many practitioners. That's too bad because they are really missing something special.

For my patients, if you want a hug, just let me know. They are free and I have plenty to give.

Wednesday, May 23, 2012

Who Knew???

In 1987, during my first year at Harvard Business School, my class was asked to consider a case study of whether or not there was a market for gourmet coffee shops in the United States. The significance of the question rested on the fact that due to Americans' increasing focus on health, coffee consumption had consistently dropped for the previous twenty years. Coffee had primarily been replaced by fruit drinks. We debated the case at length and overwhelmingly, students took the position that coffee was unhealthy, that its consumption would continue to drop, and therefore there was no market for such a product. Well the product turned out to be Starbucks and the rest is history.

This anecdote is relevant for several reasons.  It points out that what most people think doesn't necessarily pan out to be true. Second, the alternative that Americans pursued in place of coffee turns out to be less healthy than coffee. A well constructed, largest study of its type, conducted by Neal Freedman, PhD of the National Institute of Cancer and the National Institute of Health, revealed that  men who drank 2 to 3 cups of coffee daily had a 10% decrease in their risk for death during the 13 years of the study compared with men who drank no coffee. Women who drank 2 to 3 cups of coffee daily had a 13% decrease in their risk for death.

On the other hand, fruits juices proved to be generally unhealthy because many of their nutrients and fiber are removed during the juicing process.  Instead of a beverage full of vitamins, minerals and other healthy nutrients, you mostly get one with highly concentrated fructose, an unhealthy sugar in such large quantities. So it turns out that the health choices of Americans were simply wrong at that time.

This stroll down memory lane offers more than a nostalgic moment. It is a cautionary tale about the dangers of following the masses when what may seem to make sense simply does not. Today, I believe the situation is repeating itself with dietary supplements (and continuing with fruit juices). The idea that supplements are an insurance policy is just wrong. The science simply doesn't support this conclusion. Supplements have a role to play when used judiciously. However, it is estimated that nearly 80% of the population takes one form of supplement or another, with over 40% consuming multi-vitamins.  It is time for the facts to be widely disseminated regarding the dangers of random supplementation. In 1990, the FDA was given the power to do so. By 1994, Congress bowing to pressure from the supplement industry, took it away. We need to give it back to the FDA before real harm is done.

Tuesday, May 22, 2012

What Do You Put Your Faith In?

Many things are done on the basis of faith. Religion is one example, relationships are another.  However, proper practice of medicine should be based on evidence not blind faith.

Making the headlines yesterday was the United States Preventive Services Task Force recommendation that doctors discontinue routine testing for Prostate Specific Antigen (PSA) in healthy men. This recommendation was based on two studies, one which showed no difference between men tested versus not tested, and the second study which showed that among tested men, there were many false positives that led to further unnecessary testing e.g. biopsies, which led to complications e.g. infections.

Not surprising, many urologists and oncologists came out against this don't test recommendation. What's the answer? My view is that if you have symptoms, you should test, and if not, you should not test. I believe this is true in many medical situations not because I have an opinion but because the facts support that conclusion.

Yesterday, I exchanged a number of correspondences with a lady on LinkedIn regarding the need to test everyone for Vitamin D deficiencies.  She emphatically believes that it is necessary to test everyone because most people who don't take Vitamin D supplements are deficient; I don't agree.  My reason for not agreeing is because that's not what the science shows. As I wrote the other day about Vitamin D and The Endocrine Society, the facts are inconclusive as to the effects of mega-dosing with Vitamin D. This lady insisted that she needed twice the normal lower level of Vitamin D to be healthy. It's not surprising that so many people are confused by what they need because rumors and false information often circulate unabated without correction about supplements. You may remember my blog titled Supplementum, The New Religion. It was a parody of Americans' growing blind faith in supplementation in the absence of compelling evidence.

I can understand why many put their faith in things that aren't true. We sometimes just want to believe; sometimes we just need to believe.  Oftentimes belief is a good thing if it gives you solace or helps you navigate an often confusing world. That's all fine as long as such belief does not lead to dangerous situations and irreversible harm. While I believe that it is important to be vigilant, I don't believe that it is proper to test for no reason. In the Longevity Project book, the authors concluded that a little bit of neuroticism is good for your long term health, but chasing diagnoses in the absence of symptoms is full blown neuroticism and that's not healthy.

My biggest issue with supplement marketers is that they give people false hope by promoting science fiction as fact, when there are better solutions available that won't be pursued because of reliance on placebo-like products. If people had all the facts, the supplement market would be a fraction of its size and it knows it. That's why it fights the FDA with everything it has because the FDA wants the facts to be known.

Faith works, but when it comes to your health, I think you would be better off relying on evidenced based medicine. I know I do.

Friday, May 18, 2012

Vitamin D Benefits Still Inconclusive

On Tuesday March 20, 2012 I wrote a blog (link above) about Vitamin D. Vitamin D, like other vitamins, is an essential part of human functioning. Over the past couple of years its value has been so overblown that many supplement marketers have advocated mega-dosing with it. Many of my first-time patients present with multiple forms of Vitamin D which they have added over the years, which they don't seem to need.

In 2010, the Institute of Medicine explicitly warned against mega-dosing with Vitamin D, but the message apparently never got out to the general public probably because the marketers are very successful in out-shouting reliable medical sources most of the time.

So here's my attempt to get the latest news out. The Endocrine Society, the world's oldest, largest, and most active organization devoted to research on hormones and the clinical practice of endocrinology, put together a task force to look at Vitamin D and basically concluded that "large randomized trials are needed to determine whether vitamin D can prevent or treat cancer, diabetes, cardiovascular disease, and other non-skeletal disorders."

The task force examined more than 300 studies of vitamin D's role in tissues other than bone and published their report as an official "scientific statement" in the June issue of Endocrine Reviews.

The task force's most important conclusion was that although many of the studies offered tantalizing hints that the substance helps maintain health in a variety of ways, there remains "little hard proof."

So there you have it. You don't need to supplement with Vitamin D in the absence of a known deficiency, but if you insist, take into consideration the amounts of Vitamin D you get from sunlight (15-20 minutes a day typically reported to produce the recommended daily allowance), wild salmon (2-3 times recommended amounts), Almond milk, regular milk and other dairy products, etc. and adjust accordingly to avoid mega-dosing.

Please share this with your friends so that everyone has the facts and aren't ruled by the fiction.

An educated patient is my favorite type.

Thursday, May 17, 2012

One Person At A Time

The release of the Institute of Medicine's report last week about obesity and the airing of HBO's The Weight of the Nation the past two nights have created quite a bit of hoopla. Both associated reports have highlighted the growing epidemic of obesity in our country and the pressing need for a solution.

This morning at 5 AM, I watched two hours of the HBO show and was delighted by its even-handedness. The facts were presented in a non-sensationalistic fashion and flowed nicely, so if you haven't seen the show yet, I encourage you to do so.

For me, there was an immediate take-away from the individual stories of struggle and success that were reported. The take-away was that everyone had a unique story and everyone needed help to lose weight. Yet, despite this underlying theme, other than a discussion with a bariatric surgeon, there were no specific recommendations to seek such help. Suggestions were given to exercise more, eliminate certain foods like fruit juices and soda from one's diet, etc.;  but, never once was it stated that one seek consultation with a nutritionist or health psychologist. Neither were there any suggestions to discuss your weight problem with your physician, nor your difficulty, for whatever reason, to get the exercise you need, with a fitness trainer.

Ultimately, the show commits the cardinal error of simply telling people the oft repeated advice to eat better, exercise more, become more mindful, etc. If it were that simple to lose weight and modify one's lifestyle, there would be no obesity epidemic and 68% of Americans would not be overweight.

True, our country as a whole has a collective weight problem that merits the closest attention. But the problem can only be solved one patient at a time. I'm sorry to beat this horse to death, but the type of help people need can often not be determined by the individual alone. As I've said before, patients who are their own doctors, or what I call Doctients, have a fool for a doctor.

That is why I believe, when it comes to a weight problem, that a 360 degree assessment, provided by a primary care practitioner, registered dietitian/nutritionist, health psychologist, and fitness trainer is the best approach. That is why before we opened MDPrevent, before we had even a single patient, we hired all these professionals to be on hand full-time so that every and any patient who would benefit from their assistance could immediately access it.

While the sum of the parts means that the weight of our nation is a pressing, perhaps even the defining problem of this generation, the solution can ultimately only be accomplished by interventions geared to helping one person at a time.

I hope someone is listening, but if not, I'll raise my voice even louder. This nation's weight problem will not go away on its own and neither will I.

Tuesday, May 15, 2012

Myth: Dr. Oz Can Be Trusted To Consistently Provide Reliable Information

It's been a while since I commented on the Dr. Oz show, but yesterday proved too much to bear.

On yesterday's Dr. Oz Show, the theme was how to lose weight and look good in a bathing suit. One of the schemes Dr. Oz put forth was to consume grapefruit juice mixed with apple cider vinegar three times a day before each meal because "it burns fat."

According to the Weight Control Information Network, operated by the National Institute of Diabetes and Digestive and Kidney Diseases, one of the National Institutes of Health,  it's simply not true. To quote:

"Myth: Certain foods, like grapefruit, celery, or cabbage soup, can burn fat and make you lose weight.

Fact: No foods can burn fat. Some foods with caffeine may speed up your metabolism (the way your body uses energy, or calories) for a short time, but they do not cause weight loss."

I know it's a free country and we can all say what we want, but give us a break. Why do we permit a licensed medical doctor to propagate nonsense to the masses that is wholly misleading and potentially dangerous? Why is there no outcry from the medical community regarding the endless stream of nonsense that pours out of this show, presented as science? People trust him because they don't know better, but a little investigation and research will show that many of the products he recommends have no reliable science to support them.

You may ask why do I even bother watching this science-fiction show presented as science? The reason is because Dr. Oz has emerged as one of the most respected public voices of health and wellness. His show is watched by many and he is ubiquitous; he is quoted across many media platforms from magazines to websites. He influences many with his words. People trust him and believe that the information he is providing is reliable and actionable. Accordingly, they buy the products he recommends because he is a trusted doctor. That's why I need to know what he is saying so I can counter the misinformation for my patients.

For example, on episodes that have aired over the past week or so, he recommended suma extract and astralagus for stress, griffonia simplicifolia as an appetite suppressant, and then 5-hydrotrptophan (5htp), which is also essentially griffonia simplicifolia, to be added to two baby aspirins every night for pain.

Ignoring the fact that none of these products have been clinically proven to be effective for the reasons he recommends and some haven't been proven to be effective for any valid medical use, it is irresponsible for him to recommend 2 aspirins every night as aspirin increases risk for bleeding and can cause ulcers. First, it should not bet taken without fluids at night because it can be corrosive to an empty stomach (he did not recommend any fluids), second, its long-term use should be carefully evaluated before taking due to its anticoagulant effects, and third and most importantly, if you are having pain every night before going to bed, that pain should be evaluated by a medical professional instead of self-prescribing pain medications.

I know that eventually people will come to their senses and recognize him as purely a showman and not a doctor that can be relied on for good medical product information.  In the interim, I'll keep banging my drum whenever he gets really out of line like he did the past week.

For more about Dr. Charlap or MDPrevent, please visit


Monday, May 14, 2012

Doctors Need Help Tackling Their Patient's Weight Problems

An article appearing today at  titled, Doctors And Insurers Are Key To Fighting Obesity, discusses the role that doctors must play in fighting the obesity epidemic.
Here is a quote from the article in reference to why doctors are not dong more.

"Many harried physicians are unprepared to advise people about how to change their behaviors, unconvinced they have time to do so, and therefore look skeptically at screening," said Dr. Robert Kushner, clinical director of the Comprehensive Center on Obesity at Northwestern University.

If doctors are overweight themselves, they’re less likely to recognize the issue in their patients, research shows. What’s more, doctors aren’t trained in medical school to handle weight issues. They also often aren’t convinced obesity treatments work, and many believe there aren’t good community programs to which they can refer patients.

 “The question is, how many programs are out there for primary care doctors to refer to in the community, and answer is – not many,” said Dr. Ned Calonge, a Colorado physician who is the immediate past chairman of the U.S. Preventive Services Task Force."

The writer reports these facts as if they are a revelation. They are not. In fact, they are at the very core of precisely why I founded MDPrevent.

People need a resource to turn to for weight help and by and large, doctors aren't a good one. But even doctors in the know can't do it alone. They need the help of others like nutritionists/registered dietitians. Yet, most nutritionists/registered dietitians are either hospital-based or working in solo practice. Very few are employed in physicians practice even though close integration with a doctor would ensure clear lines of communication. Even fewer nutritionists/registered dietitians work along-side a health psychologist and a fitness instructor. The combination of a primary care practitioner, nutritionist/registered dietitian, health psychologist and fitness instructor are at the epicenter of the solution to the problems that cause obesity. People need help with this disease and this type of dream team can offer such focused, integrated help.

The good news is that at MDPrevent it is not a dream because we have brought together these four quintessential provider types. We have also implored the government to fund our efforts to grow this model so instead of keep talking, writing, blogging about the problem, we can actually do something about it.

I hope the government is listening because the problem will not go away on its own and MDPrevent has a viable, cost-effective solution.

Sunday, May 13, 2012

Another Reason To Go Wild Over Wild Salmon

Too many doctors have bought into the hyperbole regarding vitamins and other dietary supplements, often recommending them without all the facts. Some even go so far as to sell them without regard to consequences. Don't even get me started again about Dr. Oz.

For example, there has been such a preponderance of media coverage about Vitamin D deficiencies that you would think that everyone has a Vitamin D deficiency. It's simply not true. We often search without success.

Nevertheless, by now, unless you have been living in a cave, you've most likely heard the Vitamin D Story. If not, it goes like this. We need Vitamin D and we can get from 15 minutes a day of sun exposure. However, because some people don't get much some exposure for good parts of the year based on their geographic location, or because of they are afraid of sun exposure due to skin cancer, or because as people age they produce less Vitamin D from sun exposure, we need to supplement with Vitamin D.

Although products like Almond milk and regular milk are fortified with Vitamin D, as are a number of other processed foods like cereals, many still recommend supplementation in case we are not getting enough.  I do not recommend supplementation in the absence of known deficiency and because there is a viable alternative.

There is a great source of Vitamin D that also offers other potent nutrients and that is Wild Salmon. I sing the praise of Wild Salmon so much you'd think I owned a fish company. Well, I don't. But I am a huge fan because of the medicinal benefits of Wild Salmon. First, the wild variety has 4 times the Vitamin D than the farm raised variety. A 3.5 ounce Wild Salmon steak also has over 200% of the recommended daily allowance of Vitamin D.  In addition, Wild Salmon also has the omega-3s (EPA and DPH) which have cholesterol lowering, anti-inflammatory, and apparent pro-brain health effects. Finally, Wild Salmon is a great source of protein for your diet.

Cod liver oil is another great source of Vitamin D, but it has its own set of issues so I recommend Wild Salmon any day over it. In fact, consuming Wild Salmon 3 to 4 times a week would be wise.

So isn't it time you got rid of your Vitamin D pills and consumed a natural source of it?

Friday, May 11, 2012

Surprise! You're Dead!

A number of my blogs evolve around weight and for good reason. A new study shows that carrying too much weight in the belly -- having an apple shape -- may increase the risk of sudden cardiac death.

Researchers at the University of Minnesota and the VA Medical Center in Minneapolis showed in a cohort study (an observational study that includes an analysis of risk factors and follows a group of people who do not have the disease, and uses correlations to determine the absolute risk of subjects achieving a particular outcome) that the risk of sudden cardiac death increased along with waist-to-hip ratio (WHR).

Here are two graphics to illustrate how one measure WHR.

Measurement of waist hip ratio: In a lean person (above, left), the waist can be measured at its narrowest point, while for a person with convex waist (above, right), it may be measured at about one inch above the navel. The hip is measured at its widest portion of the buttocks at left, and at the great trochanters (part of your femur that protrudes) at right.

According to Dr. Selcuk Adabag, the lead researcher, the WHR, when it comes to the risk for sudden death, was the greatest determinant, ranking even higher than body mass index and waist circumference.

The general rule of thumb for WHR is lower numbers are better.

A WHR of 0.7 for women and 0.9 for men has been shown to correlate strongly with general health and fertility. Women within the 0.7 range have optimal levels of estrogen and are less susceptible to major diseases such as diabetes, cardiovascular disorders and ovarian cancers. Men with WHRs around 0.9, similarly, have been shown to be more healthy and fertile with less prostate and testicular cancer.

The study showed that for individuals in the top quintile of waist-to-hip ratio (0.97 and higher for women and 1.01 and higher for men), the risk of sudden cardiac death was a relative 40% greater  compared with those in the lowest quintile (less than 0.82 for women and less than 0.92 for men).

The lead researcher speculates that the reason for this correlation may have to do with the inflammatory markers produced by abdominal fat. Those markers result in fibrosis in the heart muscle, which could ultimately lead to arrhythmias and sudden cardiac death. Abdominal fat is composed of the more harmful white fat cells.

So if you didn't have enough reasons, motivation, incentives until now to lose weight and get into shape, maybe avoiding sudden death may help?

Here's a WHR calculator so you can calculate your own WHR:

Thursday, May 10, 2012

What Are We Waiting For?

I've participated in many discussions about why people would prefer to treat medical problems as opposed to preventing them. Opinions have ranged from that people are often in denial that something bad will happen to them to they think that genetics plays such a big role that it doesn't really matter what they do within reason. Others believe in the strength of our medical system so that if something bad does happen, the system will fix it. The most common opinion is that is just tough to change bad habits developed over many years and they will hope for the best.

Unfortunately, they are wrong on many counts. Everyone knows someone who died prematurely and so we know bad things can happen to anyone. Genetics plays a relatively small role, less than 30% in our health. The health care system is strong on science, but weak on miracles. Letting your health deteriorate and relying strictly on health care providers is a risky bet. Habits may be hard to break, but they are not impossible to change. Support, guidance, and good knowledge can help.

I think the real problem why we don't focus on prevention is because there is a perverse incentive for the health care system to allow you to get sick so it can treat you. And by health system I mean pharmaceutical companies, health insurance companies (they charge premiums based on a cost plus basis), and of course health care providers, which include hospitals, doctors, and suppliers, who are generally only paid for treating a problem, not preventing it.

A number of year ago, I read an article about how the pharmaceutical industry hardly ever works on developing preventive medicines because it doesn't think there is a market for it.  Some may think that Statins, the cholesterol lowering drugs, are of a preventive nature, but they would be wrong. Statins are only prescribed (and at that, at an excessive rate) only when you already have elevated cholesterol. I don't blame the pharmaceuticals. Why create something for which there is little demand?

So we know the problem, what should we do about it?

My answer is education. education, education. Let's expose our citizenry to a series of self-administered quizzes about their health. Let's open their eyes to the consequences of their behaviors likely to lead to the development of chronic diseases. Let's require schools to school our children to a level where they can demonstrate a fundamental knowledge of what eating properly looks like, the importance of physical activity, and how to best manage stress.

Let's require that every insured patient submit to an annual wellness visit within 90 days of their insurance renewal to stay insured. Let's require during that visit a specific review of medical and family history and dietary, physical activity, sleep, and stress patterns. Let's also do a thorough review of medications and dietary supplements to make sure that they are being used sensibly.  In its totality, this visit will force, yes force, people to take stock of their health before something goes wrong. I believe that while all may not respond well to such a requirement, enough will benefit for it to make a huge difference.

As a society that insures every person over the age of 65, we can no longer afford to hope for the best when it comes to the future of our health care system. We need to get serious about propagating wellness and lifestyle modification and it all starts with education.

This week, Centers for Medicare and Medicaid Services (CMS) announced the first round of grants for its Health Care Innovations Challenge Program. There are certainly a number of meritorious applications among them that will improve our health care system. But sorely lacking among the first group was any real focus on education and primary prevention. Does our government appreciate that an ounce of prevention is really worth a pound of cure? One can only hope that in the next round, to be announced in early June, this absence will be remedied.

We will all be better served if we stop, or even slow down, the progression of avoidable chronic diseases among our populace.  For that, we need our government to help fund such efforts.

Wednesday, May 9, 2012

Better Than The Alternative

It's often been said that laughter is the best medicine. Humor can also be a great way to communicate bad news in a less offensive manner. I love this cartoon because it really summarizes the reality of the situation for people who live sedentary lifestyles or hardly exercise.

Study after study now shows the dramatic impact that moderate physical activity has on your health. It reduces heart attacks and strokes, improves cognitive function and memory, alleviates depression, prevents and reduces the consequences of diabetes, etc.  The flip side is that lack of exercise increases your risk for osteoporosis and dementia. Bad things happen to people who don't move!

So folks, what are you waiting for? If you don't like gyms, find a hobby that requires physical exertion. Take steps, park far away from your destination, mow the lawn, wash the car, wash it again, whatever you do just keep moving. Get up, get out, and live the one life you have to the fullest.

 You may find this cartoon amusing, but don't let it be you. 
You are only fooling yourself by pretending to exercise.
A word to the wise should be sufficient.