Thursday, December 29, 2011

Make A New Year’s Commitment to Your Health

New Year’s resolutions are commonly made and broken within weeks. We all know the story: ‘I will do this…’, ‘I will stop doing that…’, ‘I need to learn how to…’ Unfortunately, most of us make a resolution, expect immediate results, and are discouraged when we don’t see the results we want.

As far as I know, no one keeps stats on New Year’s resolutions (thankfully), but one that I hear commonly is a resolution to lose weight. A lot of people overdo it during the last two (or three) weeks of December and so head into January with a little bit of extra weight. Others have struggled with their weight for some time, but take the New Year as a chance to commit to losing the weight once and for all.

Weight loss, however, is no easy feat for most people, especially when the excitement and enthusiasm of New Year’s has you setting the bar high. A healthy rate of weight loss is generally rated to be 1-2 pounds per week, a rate that is hardly awe-inspiring – if you’re looking to lose 20 pounds, and after a few weeks of challenging diet and exercise changes, you’ve only lost 3 or 4 pounds, it can be easy to get discouraged.

Find someone with whom you can form a therapeutic alliance. Weight loss is a challenge, but there are strategies that are proven to work. However, though these strategies are effective in taking weight off and keeping it off, they require consistent, ongoing work – there are no quick fixes where weight loss is concerned. As a result, it’s important to have someone you can work with, whether that’s a health professional, a personal trainer, a friend, or a family member. I think I harp on this just about every week, and I’ll continue to do so – when working with chronic health concerns or long-term health projects, don’t go it alone. In times of difficulty or discouragement, it helps to have someone to lean on.

Exercise is key, even if the weight doesn’t seem to be coming off. A recently published study showed that in the long run, staying active reduces mortality from all causes, regardless of weight change. These reductions were not small potatoes, either – staying fit reduced all-cause mortality by 30%, and an even larger drop was seen in those who improved their fitness. I don’t think this study shouldn’t diminish the health benefits of attaining a healthy weight, but should serve as encouragement to those who exercise without seeing the immediate benefits. Here’s a great video to give you some more encouragement, and here’s a little entry I wrote about what ‘counts’ as exercise. A lot of people, especially around the New Year, rush into vigorous exercise regimens they can’t keep up, but I recommend starting closer to home – go for a walk, get in the garden, take a bike ride. The key to exercise is to be regular about it, not to be vigorous.

To sum it all up, here’s my invitation to you – make a New Year’s resolution to your health. Losing weight has tremendous benefits, but equally important is to get active. Weight loss improves your cardiovascular health (a big issue among us Americans), and exercise is good for just about everything under the sun. And as always, work with others in achieving your goals – when I was in school, one of the mottos they taught us when preparing us for 4 years of school was this, ‘If you want to walk fast, walk alone. If you want to walk far, walk together.’ Nowhere is this truer than with weight loss – if you want to achieve your goals, find someone who will support you in doing so.

I wish you all health and happiness in 2012.

Monday, December 26, 2011

Do You Know Your Vitamin D Level?

There's a campaign in Scotland at the moment to have more foods fortified with vitamin D, on the premise that it would reduce incidence of multiple sclerosis (MS), a neurodegenerative condition that can have crippling effects. Though the drive to fortify foods is unique to Scotland, the issue of low vitamin D levels is common throughout the Northern Hemisphere.

Seattle, where I went to naturopathic school, has a climate fairly similar to Scotland, with similarly low levels of sunlight throughout much of the year, and with similarly high incidence of MS. In my time there, I don't know if I saw one patient with a healthy blood level of vitamin D who wasn't actively supplementing it. In fact, researchers believe that most Americans aren't able to make adequate vitamin D throughout much of the year, due to weather, indoor lifestyles, and seasonal changes in the angle of the sun's rays to the earth below.

The good news is - vitamin D is inexpensive and effective at raising blood levels. It's an easy test with an easy fix, and the health benefits are significant. So the question is, do you know your vitamin D levels?

Thursday, December 22, 2011

Managing Stress During The Holidays

Last year, I posted a little tidbit about managing stress during the holidays, recommending to you, my dear readers, that you treat yourselves gently in stressful times. Holiday events with friends and family can be joyous occasions, but for many of us, they can also be laden with stress. The advice to ‘treat yourself gently’ is an aphorism for healthy living I learned from a psychologist who was one of my teachers. The basic meaning is to give yourself space for self care in times of stress, when others are making demands of you and your time. Treat yourself gently – don’t be hard on yourself, give yourself time and space, and above all, pay attention to what you need to feel well.

This year, I return to the topic, with some more recommendations based on what I’ve learned from working with my patients. A large proportion of my patients are stressed out for a variety of reasons. In working with chronic stress, I’ve learned two important lessons from my patients.

1. Stress is not stress is not stress. We all respond to stress in our own unique ways. Some of us become sad, others angry, others fatigued, and others eat when stressed. The variability of own unique responses to stress makes it hard to make general recommendations about stress. There are a whole host of supplements out there that purport to treat stress, including herbs, vitamins, and even minerals, but because stress is so individual, it takes a trained professional to recommend one treatment over another. I’ve found a number of herbs and supplements that help people find relief from stress, but it takes an office visit to determine what’s helpful. For example, l-theanine would help someone who become nervous with stress, but would aggravate someone who responded to stress by becoming fatigued. Similarly, rhodiola might help someone who became fatigued with stress, but worsen symptoms for someone who was irritable or nervous.

Before I move on to the second point, let me interject here to say that supplements don't fully answer the problem of stress. Supplements and medications help people cope with stress, but it’s the changes to their diet and lifestyle that will help keep them healthy in the long run. After all, supplements don’t get rid of stress, they only help us deal with it better. Which brings me to my next point…

2. When treating stress, you can either reduce the external stress or improve your response to the stress. We all know what causes us stress – our jobs, our family, our partner, our parents, schoolwork, the economy, Christmas shopping, our budget, the government… the list goes on and on. Some of these things we have power over and can change, thus reducing our stress. Other things, we have less power over, and so it falls to us to improve our response to the stresses we face. Used properly, herbs and supplements can help us achieve an improved response to stress, but as I said earlier, these are a means to an end, not an end unto themselves. They may relieve symptoms, but in the long run, cannot achieve the resilient mental attitude that comes from exercise, yoga, meditation, tai chi, or other lifestyle practices.

In managing stress, herbs and supplementation require individualized attention, but the lifestyle factors that can help improve our response to stress are applicable to nearly everyone. These sorts of things include regular exercise (and I’m not talking about triathalons), adequate sleep, a healthy diet, meditation, yoga or tai chi. These practices feed our core so that we are able to deal with stresses from a place of strength, not weakness. Encountering stress from a place of strength allows us to deal with it without allowing it to affect us.

A healthy response to stress also takes some mental work – to deal with stress effectively, I find that a person often has to cultivate a resilient mental attitude. We often hear about a positive mental attitude, and while positive thinking is by all means excellent, I find that people who are very stressed are more helped by adopting a resilient mental attitude – one that allows them to deal with the stress, not let it touch them too strongly and then bounce back. There are a wide variety of books for people to read on the topic of dealing with stress, and people have been writing books on the topic of stress management for millennia, though these books did not always deal explicitly with ‘stress management’. The Tao Te Ching and Bhagavad Gita, for example, deal with the topic of how to act wisely and live happily. Within the context that I am writing, I might say that they teach us how to act effectively to deal with stress, and without letting stresses affect us to strongly. Even The Bible (parts of the Old Testament and especially the New Testament) deals with the eternal conflict of how to deal with the stresses we encounter in life. A spiritual practice of whatever tradition speaks to you can be helpful in developing the resilient mental attitude that serves us in time of stress.

I hope this blog finds you some peace during the holiday stresses. As I said last year, be gentle with yourself. Give yourself the space and time you need, despite the demands that others make on you. Additionally, the lifestyle recommendations I made this year can help keep you healthy and stress-free, not only through the holiday season, but throughout the year. And as always, working with a professional, be it an MD, ND, counselor, psychotherapist, acupuncturist, or psychiatrist can be an important step. Building a therapeutic alliance with another person helps to build core strength and resilience.

Sunday, December 18, 2011

A Solstice Gift

Many of you may be familiar with Gluten-Free Girl and The Chef, a blog devoted to gluten-free cooking, and especially gluten-free baking. Recently, I was searching for a recipe to adapt to making piparkukas, a traditional Latvian Christmas cookie which features a formidable mixture of nine spices that makes even curry look simplistic. The key to piparkukas is that they must be really light and crispy, like a ginger snap, but even more so. As a kid, I would spend hours in the kitchen, baking piparkukas and listening to Christmas music with my mom. Needless to say, the bar was set high as I attempted to recreate them.

Considerable searching yielded this (totally fantastic) recipe. I was amazed to find a gluten-free cookie recipe that was so simple, and yet yielded such fantastic results. The taste and consistency are spot-on - you would never know that these were gluten-free unless someone told you. The recipe calls for the dough to be set in the freezer overnight, so I'm posting this a few days before the Solstice, so that you can have them ready to go on the big day.

Cookies play an integral role in the holiday season, and I ache for all of the kids who can't take part in this essential childhood experience. Not having cookies is like not playing baseball, not losing teeth, or not going to summer camp - it's just part of the package. Hopefully this recipe gives some kids some holiday delight.

And the piparkukas spices... Normally, these things are closely-guarded family secrets, but in the age of the Internet, there are no such things as family secrets. Rather than having you go out trying some of those other recipes, here's mine:

1/2 tsp white pepper
2 tsp cardamom
2 tsp cinnamon
1 tsp cloves
2 tsp coriander
2 tsp ginger
1 tsp allspice
1/2 tsp nutmeg
1/2 tsp mace

The final step to making these authentic piparkukas is to glaze them with egg white and press an almond sliver into the center of each cookie before baking.

Priecigus Ziemassvetkus!

Thursday, December 15, 2011

The Three Most Important Non-Science Classes A Physician Will Ever Take

Recently, I was chatting with a cardiologist of about 30 years experience. He’d lived in Israel for several years, and went to all four years of college there. He considered pursuing his MD at an Israeli medical school, but through circumstance, he ended up back in the US. In the course of our discussion, he mentioned that Israel follows a European model for medical education, one which features a truncated pre-med program consisting solely of science classes, rather than a four-year college education which balances the sciences and humanities. We agreed that while the sciences comprise the core of a pre-med education, the education shouldn’t start and end there. This week I’m devoting my column to three non-science courses that every physician should take.

Contrary to the opinion of some, a physician is not merely a scientist. A physician is a scientist who communicates that information to his or her patients, relates it to the life they live, and tries to help them put it in context. While this a role well-known to pediatricians, primary care docs, naturopathic doctors, and other healthcare providers who work in a primary care environment, this is equally important for surgeons and other specialists. The ability to communicate to a patient about their health is especially important when that patient’s health is in acute distress.

Last year, the New York Times ran an article about a program run by Mount Sinai School of Medical, the Humanities and Medicine Program, which accepts a small number of students every year who have not taken some of the traditional pre-requisite classes (physics and organic chemistry) nor taken the dreaded MCAT exam. Instead, students are encouraged to major in a humanities subject of their choice, and so long as they maintain a high GPA, they matriculate along with all of the other students. While I myself believe in the value of physics and organic chemistry, I like the fact that this program encourages study in the humanities. A well-rounded education creates a well-rounded doctor, and with that, here’s my list of the three humanities classes that every physician should take.

A Literature Class – The poet in me sometimes likes to say that a physician must deeply feel and understand the human condition. While this is perhaps more poetry than practice, it is absolutely true that a doctor has to understand the character of the patient who comes to see him/her. It’s important to be able to anticipate the emotional or mental needs of our patients, so that we can communicate in ways that are appropriate to our patients’ needs. Good literature, especially but not exclusively good modern literature, explores human needs, motivations and behaviors in a profound way that educates us about the people around us. In our culture, we rarely give each other true insight into our inner lives, but books thrive on this. A well-read doctor reads and learns, and then understands his patients better, being able to both relate compassionately and cater individually.

A History, Anthropology or Sociology Class – In the same way that a patient doesn’t start and end at an injured body part, a patient extends beyond the individual person who presents in the exam room. A patient’s health is determined by a whole host of factors in the world around them, including their work, their home environment, their ethnicity, their economic status, and their culture – in short, their place in the world around them. These factors play important roles in an individual’s health by influencing factors such as their diet and ability to access healthcare, and yet they are rarely discussed in biology, chemistry or other pre-med science classes. A well-rounded education, in which the student learns about the individual’s place in the broader world helps that future physician to understand what factors may be influencing a patient’s health, and to make recommendations that fit within that patient’s real-life experience.

A Foreign Language – As I said earlier, a physician is not merely a scientist, but a communicator. Learning a foreign language has important philosophical and practical value for a physician. On the one hand, a doctor should have a broad mind and flexible way of thinking, two attributes that come with studying a foreign language and the culture that created it. On the other hand, in a multicultural society such as the United States, it is increasingly important that a physician be able to speak a second language in order to serve his or her community. Certain languages thrive in certain parts of the United States (such as French, German, Chinese, Vietnamese, and others), but Spanish in particular is now becoming a clinically important language, with at least 10% of American families primarily speaking Spanish at home. Speaking a patient’s native language allows for better communication, not only by allowing the patient to better describe their situation, but also by giving them the confidence and comfort of knowing that they are being understood.

Being a physician is not merely being a scientist. Being a physician is being a translator, an intermediary between the concepts of science and the human experience. In order to fulfill that role successfully, a physician has to have a strong grasp of the world beyond the sciences, and so these courses must be a part of his or her education. A physician needs to understand his or her patients’ inner life and character, the social forces that affect them, and needs to be able to communicate to them in a language they understand. As I said earlier, a well-rounded education creates a well-rounded physician, and a better servant of his or her community.

Tuesday, December 13, 2011

Watch This Video And Then Go For A Walk

For the most part, this blog is a once-a-week affair written by yours truly. However, this week, in addition to my usual, weekly blog entry, I'm including a presentation made by someone else. This video is a great presentation of a simple message, and one that is echoed in this post I wrote about living longer, and this post about exercise. My colleague Dr Liz Kaltman, ND brought it to my attention. Take the next ten minutes out of your day to watch this video by Dr Mike Evans, MD and then go out for a walk.

Friday, December 9, 2011

Lowering Your Cholesterol Using Supplements Part 2

Welcome to Part 2 of this blog entry. As I said last time, the point of this blog is never to take the place of professional medical advice – if anything, it’s to encourage you to seek out a medical professional to work with. High cholesterol, like high blood pressure, is a chronic complaint that needs professional monitoring. And of course, like any long-term project, don’t try to do it all yourself – a professional healthcare provider can help you chart a course and guide you along the way, redirecting you where it’s necessary and praising your success when you get it right.

Another reason to work with a provider (like a naturopathic physician) that sort of came up yesterday, but will come up even more so today, is this: garlic is not garlic is not garlic. What do I mean by this? I mean that quality and potency of supplements can vary considerably, not to mention that preparation methods of various supplements dictate their effects. As a result, it's important to work with a practitioner who has done his or her homework regarding supplements.

OK, and now on to the meat of the article. (Here’s that cholesterol labs cheat sheet in case you need it)

Garlic – Why not start with garlic, having mentioned it so recently? Garlic has long been promoted as a cholesterol-lowering treatment, but the jury is still out on whether or not it’s effective. Some studies have shown significant cholesterol-lowering effect from certain garlic preparations, (1, 2, 3, 4) and at least one has shown that a preparation of garlic slows coronary artery disease. Other studies and meta-analyses (analyses which collect data from multiple separate studies) have shown no effect on cholesterol (1, 2, 3). As I said earlier, the jury is still out on garlic. One of the confounding issues in this discussion is the fact that there are a wide variety of garlic preparations being used in these studies, some of which appear to work, others of which appear not to do so – thus when taken all together, the data is inconclusive. Garlic still deserves an important place on your table as a ‘functional food’, but don’t rely on it exclusively to lower your cholesterol.

Niacin – Niacin has been used to lower cholesterol since at least the 1950’s, both by mainstream doctors as well as integrative ones. Its true claim to fame is that it has been shown to raise HDL significantly, an effect that statin drugs are not capable of producing. Niacin comes in a variety of forms – in the form of nicotinic acid, its ability to improve blood levels of total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides is formidable to say the least. A therapeutic dose of niacin can reduce LDL by as much as 22%, total cholesterol by as much as 16%, triglycerides by as much as 44%, all while boosting HDL by as much as 35%. But as with many good things in the world, there is a down side, namely the ‘niacin flush’. Doses of niacin high enough to have therapeutic effect inevitably cause flushing of the skin, accompanied by intense itching. On the plus side, many people are able to adapt to the sensation, or are able to time their doses such that they don’t interfere with daily living.

Niacin has lately received a lot of attention from the conventional medical community for a few reasons. One is the development of a prescription form of niacin (Niaspan) with a fairly low incidence of flushing side effects. Second is an increased interest from cardiologists in being able to increase HDL cholesterol because of HDL’s protective effect. Prescription niacin has been shown to reduce LDL cholesterol both alone and in concert with statin medications, though only niacin has the added benefit of raising HDL. At the beginning of the article, I recommended working with a healthcare provider when addressing cholesterol. This is especially important with niacin – it’s effective, but don’t try this at home folks. Make sure you have a doctor on board. And of course, the recently-developed prescription niacin (Niaspan) is only available by prescription.

Red Yeast Rice – Last but not least, red yeast rice. I’m often asked what red yeast rice is made from – red yeast rice is rice that has been fermented with the Monascus purpureus fungus for use in traditional Chinese foods and medicine. More recently, however, it was discovered that this fermented rice contained naturally occurring statins, a class of medication used to lower both total cholesterol and LDL cholesterol. Since this discovery, red yeast rice has gained popularity as a treatment for lowering cholesterol levels, but it’s not been without controversy. Because red yeast rice contains a compound, monacolin K, which is identical to lovastatin, there was an effort by the FDA in the late 1990s to ban red yeast rice in the United States. Most companies voluntarily withdrew the product from store shelves.

Since then, however, red yeast rice has begun reappearing on the market as a dietary supplement. In some cases, red yeast rice is now being embraced by conventional medical doctors, who are now recommending it to a newly defined class of ‘statin-intolerant’ patients, patients with high cholesterol who were started on statin medications, but were unable to follow a full course of medications because they suffered side effects. Recent studies have shown that certain red yeast rice preparations have significant cholesterol-lowering effects, in some cases comparable to statin medications, and are more easily tolerated by patients, even those who were previously unable to tolerate the side effects of statin medications (1, 2). Additionally, data has recently shown that red yeast rice extracts prevent serious cardiovascular events comparably to statins. The quality of commercial preparations of red yeast rice remains mixed, so it’s important to work with a professional who has done his or her homework in finding a high quality product. The take home message is that certain red yeast rice products are as effective as statins in lowering cholesterol and preventing disease, though this shouldn’t be a surprise, as red yeast rice contains naturally-occuring statins.

I hope you’ve enjoyed my review of supplements and cholesterol. As I said at the beginning of the article, lowering your cholesterol isn’t something that you should do alone – work with a practitioner. However, being equipped with information is important to getting the best outcome. As I said in last week’s entry, sometimes medication is the best route to take, but never is it the one and only answer. Through diet and exercise, as well as the use of some supplements, many people can limit their need for or dose of medications.

Thursday, December 8, 2011

Lowering Your Cholesterol Using Supplements, Part 1

After last week’s blog entry about lowering cholesterol through diet and exercise, a fellow naturopathic physician, Dr. Melanie Trowbridge, emailed me asking about the supplement side of lowering cholesterol. I mentioned it last week, but it really warrants a longer discussion. So long, in fact, that I’m going to have to split it up into two entries to cover everything!

There are a number of supplements out there that claim to lower cholesterol, and it can be hard for consumers and practitioners to assess what does and doesn’t work. I’ve searched the medical literature to try to generate an accurate picture of what’s effective, and what to expect from these supplements.

At the risk of sounding like a lawyer, I’m going to state here that by no means is this meant to constitute medical advice or otherwise take the place of a consult with a healthcare provider. Unlike, say, seasonal allergies, you can’t tell if your cholesterol is improving unless you have it tested by a healthcare provider – this is part of the importance of working with someone. Additionally, high cholesterol is a chronic condition that requires long-term work. Don’t go it alone. Get some assistance along the way, someone who can assess your current situation, help you set goals, figure out a plan to reach those goals, and help you weather the inevitable challenges. I'd be remiss if I didn't mention the AANP's Find a Naturopathic Doctor Service here.

One last thing before we dive in – here’s an entry I wrote on understanding cholesterol/lipid lab tests, just in case you need a refresher as we go.

Plant sterols (including beta-sitosterol) – I’m including this first because plant sterols are actually recommended by the ATP III as a way to lower cholesterol. So what are they? Plant sterols are molecules found in fruits and vegetables that resemble cholesterol, but are not used by the human body in the same way as cholesterol, and don’t appear to have the same harmful effects. They act by competing with cholesterol for absorption in the small intestine, thus reducing the amount of dietary cholesterol absorbed into the blood. They have been documented to reduce cholesterol, LDL cholesterol and triglycerides, in a manner that appears to be dose-dependent; moderate doses produce a 10-14% reduction in LDL cholesterol, whereas higher doses can generate larger reductions in LDL cholesterol. In addition to lowering cholesterol in therapeutic doses, amounts of sterols that occur naturally in food appear to have a protective effect, helping to keep cholesterol in a healthy range. Plant sterols generally appear to be safe, though at least one study I read suggests potential side effects, which have yet to be fully described and documented – all that much more reason to work with a professional.

Green tea – Regular readers of this blog will know how much I love tea – it’s healthy, it’s delicious, and it’s endlessly varied. So what about cholesterol and green tea? A few studies I found demonstrated that either green tea or a green tea extract lead to a mild decrease in total cholesterol and LDL cholesterol (1, 2, 3), though at least one other found no benefit. The decrease is mild, less than 10% change in total cholesterol or LDL cholesterol. For some, this might be enough to bring their cholesterol into a healthy range, though for many, this change is too little to control cholesterol adequately. What sets green tea apart from the other supplements I’m discussing today is that it has been demonstrated to reduce LDL oxidation (1, 2). Here’s why this is important: While doctors generally test total LDL to assess a patient’s cardiovascular risk factors, it’s becoming more and more clear that it’s oxidized (damaged) LDL that accumulates in artery walls, forming plaques and obstructing blood flow – this is part of the reason that smoking is so bad for you. Thus, while green tea’s ability to lower cholesterol is only moderate, it has the ability to prevent that cholesterol from becoming a potently harmful form of cholesterol.

Fish oil – Omega-3 fatty acids, like those found in fish oil, have received a lot of attention recently for their cardiovascular benefits. So what does the data say? Well, my research into the topic is by no means exhaustive, but clear trends started to emerge fairly quickly. According to the studies and reviews available, fish oils either have no effect on cholesterol levels, or slightly raise them – across the board, including total cholesterol, LDL cholesterol and HDL cholesterol (1, 2, 3). So how do we reconcile this? Isn’t fish oil supposed to be good for your heart?

The answer is yes, fish oil is good for your heart, and without going into a full discussion of fatty acid metabolism and transport, I should point out that there is good news buried in this elevation of cholesterol. Firstly, HDL cholesterol is ‘good cholesterol’, and the fact that it fish oil increases it is good news. Secondly, though fish oils apparently raise blood levels of LDL cholesterol, it has been observed in some studies that the size and shape of LDL is modified towards less disease-causing forms, (1, 2) though this was not universally observed (1, 2). Additionally, there is reason to believe that the slight increase in LDL levels is linked to a significant decrease in VLDL levels (1, 2). Like with green tea, the emphasis is not on the change in the LDL levels, but rather on the health of those LDL molecules – green tea makes the LDL less oxidized/damaged, and fish oil makes the LDL larger, more buoyant, and less likely to cause damage to arteries.

In assessing fish oil, we should also remember that cardiovascular disease isn’t all about cholesterol. Several studies have demonstrated that fish oil has a significant protective effect when it comes to cardiovascular disease itself, including angina, stroke, heart attacks and other disease. A large Italian study in the 1990s showed that fish oil given to heart attack survivors significantly reduced their chance of having another heart attack, having a stroke, or dying from other causes. A similarly large Japanese study found that patients with high cholesterol taking EPA (an omega-3 fatty acid found in fish oil) in addition to statin medications had a significant reduction in non-fatal heart problems compared to patients on statins alone, though LDL levels did not significantly differ between the groups.

The take-home message is this: fish oil may not lower cholesterol, but it is clearly good for your heart. Fish oil is one of the few supplements I recommend to nearly all of my patients. But for those of you out there who have taken it and not seen a lowering of cholesterol levels, this may go some of the way to explanation. Even so, it’s still good for you!

Phew! I think that’s enough for the day. Tune in again next time for Part 2, which will feature discussion of garlic, niacin and red yeast rice.

Thursday, December 1, 2011

Lowering Your Cholesterol Through Diet and Lifestyle

It’s no secret that one of my main passions in life is preventing disease through natural management of cholesterol and blood pressure. Nerdy I may be, but I’ve written in the past about how to interpret your cholesterol labs and how to lower your blood pressure through diet and exercise, and will continue to do so in the future. The evidence is clear that eating a healthy diet and pursuing a healthy lifestyle works not only to prevent but also treat high blood pressure and high cholesterol, so it’s probably about time that I devoted a weekly blog to the cholesterol side of the story. (If at any point you need a refresher, here’s an explanation of LDL, HDL, Cholesterol and all the rest.)

The ATP III was published by the NIH in 2004 to be a guide for clinicians to diagnose, evaluate and treat high cholesterol in adults. Like the JNC 7, which I blogged about a few months ago, the proposed guidelines include recommendations for treatment using diet, lifestyle, and pharmaceuticals. While the ATP III focuses heavily on pharmaceuticals, it makes strong recommendations for lifestyle changes, or as it refers to them, TLC (Therapeutic Lifestyle Changes). Unsurprisingly, these lifestyle recommendations look remarkably similar to the ones suggested to lower blood pressure.

Eat less saturated fat. There’s a longstanding rumor out there that cholesterol in foods causes high blood levels of cholesterol, a rumor that lays a lot of blame on eggs in particular. The truth of the matter is that saturated fat plays a much more important role in causing high cholesterol, as it stimulates the body to raise blood levels of cholesterol, especially LDL (“bad cholesterol”). As a result, it’s much more important to avoid saturated fat than cholesterol in your diet.

To help decrease your cholesterol levels and prevent future disease, the ATP III recommends that fewer than 7% of your calories for the day come from saturated fat. As a practicing physician, I know that this number means very little to most people, and even I can’t tell you what percentage of my daily calories come from saturated fat, so here are clearer instructions. Most if not all saturated fat comes from animal sources, like milk and meat, so to limit your saturated fat, limit your intake of animal-source foods, and choose low fat options, like fish, lean poultry or game. Also note that individual people vary in their individual dietary needs, so discussing your diet with a doctor or other healthcare professional can help you to assess your current situation, set goals for the future, and work out a plan for getting there.

Get more fiber in your diet. When I was in naturopathic school, we had to learn the details of the many ways that dietary fiber reduces cholesterol, an activity that many of my colleagues worked into mnemonics, songs, and other memory aids. I don’t have any songs to share with you, but I can tell you the most important part of the story – dietary fiber helps the body rid itself of excess cholesterol.

Without going into all of the gory details, here’s how it works: The body releases cholesterol into the digestive system every day as part of the digestive process. When there is fiber present in the digestive tract, it picks up that cholesterol and carries it out of the body as part of normal elimination. If there is not adequate fiber in the digestive tract, however, it is reabsorbed into the blood stream and continues to circulate, thus keeping cholesterol levels high. Here too, we have some numbers from the ATP III, which recommends 10-25 grams of fiber a day. While this can be a little easier to figure out, I always find that making recommendations about the food you eat is more helpful than number crunching. Fiber primarily comes from fruit, vegetables, legumes and grains, so boosting these will boost your fiber intake. While all of these plant-based foods are good sources of fiber, I especially recommend beans, lentils, and other legumes, as their fiber content far outpaces that of even high-fiber veggies like cabbage and broccoli.

Get regular exercise. Regular exercise helps with a number of things, including weight loss, stress management, blood pressure and cancer prevention, so it’s no shock that it helps with cholesterol too. Importantly, regular exercise not only lowers LDL (“bad cholesterol”), it raises HDL (“good cholesterol”). While the exact mechanism by which this occurs is not fully understood, it is currently believed that at least part of the action is by encouraging the LDL cholesterol to be taken out of circulation by the liver, and put into the digestive tract for elimination. The ability to raise HDL is very important, as there are no drugs currently available that raise HDL, and HDL exerts a strongly protective action on the cardiovascular system. For further reading on what ‘counts’ as exercise, and how much to get, read this blog which I wrote a few months ago. The most important thing about exercise is to get out there and start moving – many Americans lead very sedentary lives, and it’s important to note that even some exercise is better than none.

Watch your weight. If you follow the above recommendations, it should help you lose weight. That said, weight loss is a challenge to most people who attempt it. Because the benefits of maintaining a healthy weight are so great (including lowering blood cholesterol levels), it’s important to commit to weight loss, and for most people, that means getting some assistance from a healthcare professional, personal trainer, or other provider. Weight loss, even when it proceeds steadily, rarely happens quickly, and so it’s important to build a therapeutic alliance in order to help you stay committed and persevere through the inevitable challenges.

Let me close by saying that, naturopathic physician or not, I believe that medications are sometimes necessary to help reduce the risk of future disease. However, medications are never the only answer. Some people are able to bring their cholesterol into a healthy range through diet and exercise alone, some through diet and supplements, some through a combination of diet, exercise and medications. In my practice, I find that many people are able to limit the number and dose of medications they require through diet and exercise. Not only is this a more sustainable and effective treatment, but being able to take control of one’s health also empowers people in a way that medications cannot, and will never be able to.

Thursday, November 24, 2011

Giving Thanks For Another Year

The modern American holiday season is a mix of stresses, joys, rituals, and extensive advertising. With so much going on, it’s hard for many of us to remember why we’re celebrating in the first place. With that in mind, I’m writing this week’s blog entry as a paean to autumn, because for me, the holidays are a great time to reconnect with the Earth. The leaves change, the winds blow colder, and all around us, things are changing. While throughout the summer we grow lazy and comfortable, the autumn reminds us of how we are inextricably linked to the planet’s changes.

I gained my strong appreciation for this natural shift in the seasons while I was living in Cambridge, Massachusetts and was a member of the Lindentree Farm CSA. Summer was always a time of excess, a time when I’d wonder every week about what exactly I was going to do with yet another 10 pounds of summer squash and zucchini. Eventually, we’d make our way towards the peak of the season, getting tomatoes, corn, peppers, potatoes, and the rest of the foods we associate with harvest. But at the end of the season, things changed – we’d see kale, cabbage, root veggies and pumpkins, foods that remind us less of irresponsible gluttony and more of careful storage.

I remember clearly spending one November day out in the fields at Lindentree, scrabbling amongst the dirt for a few leaves of spinach. While July and August had featured tomato vines, pea vines, corn stalks, and large heads of lettuce, all forming an undulating sea of green that rippled in the warm breeze, November found the fields empty. Everything had been chopped down and hauled off for composting, or had been tilled under. The warm, gentle breeze was gone, replaced by a chilly wind that skimmed across the bare earth, finding little resistance. The time for lazing in the sun was gone – it was time to head indoors and rest for the winter. It was a beautiful thing, this change that had occurred, and in celebrating the holidays, this is always foremost in my mind of things for which to be thankful.

This soup was concocted from a mix of everything that Lindentree Farm provided in late September and early October, so some of the food isn’t perfectly seasonal, but hopefully you froze some of it when it was coming in such mass quantities a few weeks ago.

1 winter squash (such as butternut, acorn, pumpkin or kabocha), providing about 2-3 cups pulp
2 tbsp butter
1 medium onion, chopped
1 bell pepper, chopped
1 medium carrot, sliced
¼ tsp cinnamon
½ tsp thyme
¼ tsp nutmeg
2 bay leaves
2 large tomatoes, chopped, providing about 2-3 cups
2 apples, cored and chopped
¼ cup half & half or cream
Salt and pepper

Peel and chop the squash, then boil it in just enough water to cover for about 15-20 minutes, until soft. Don’t get rid of the boiling water – you’ll need it later.
Sautee the onion, pepper and carrots in the butter over medium heat until the onions are soft, stirring to prevent carmelizing.
When the onions are soft, add the spices and sautee for another 2 minutes.
Add the tomatoes, apples, squash, and about 1 ½ cups of the reserved water, and bring to a boil. Cover and let simmer for about 30-40 minutes, until everything is tender and soft.
Puree in batches in a blender or food processor. When everything has been pureed, reheat lightly, adding ¼ cup half & half or enough to achieve your desired creaminess. Season with salt and pepper to taste.

Thursday, November 17, 2011

A Naturopathic Physician By Any Other Name

In the course of writing this blog (and especially last week), I find that I sometimes use the terms naturopathnaturopathic doctor, and naturopathic physician somewhat interchangeably. Though this isn’t exactly wrong, there are differences between these terms, in some cases subtle ones, in other cases legal ones. Additionally, it may be confusing for consumers to tell the difference between these terms. Therefore, I’m devoting this week’s blog entry to a brief discussion of these terms, to help all of the consumers out there who are trying to get the healthcare solutions they want.

Naturopath – Without a doubt the oldest term of the three, naturopath is also the broadest in its meaning. The term arose in the late 19th century to describe a growing movement of health practitioners who utilized natural methods, including diet, lifestyle, exercise, and herbs. Most graduates from a four-year, accredited program in naturopathic medicine would identify themselves as naturopaths when asked. However, in states without naturopathic medicine licensure laws, a broad range of other practitioners can also call themselves naturopaths, many of whom have received their ‘degrees’ through mail-order correspondence courses. Naturopath and naturopathy do not imply physician-level training, and so they are the broadest terms for practitioners of natural health, including but not exclusive to licensed naturopathic doctors. These terms have fallen out of favor in recent years because they are non-specific. I sometimes think of these terms as being comparable to the label ‘natural’ on food products – there’s not a lot of regulation over the term, and you really need to read the label before buying, so likewise, you need to assess the credentials of anyone calling themselves a ‘naturopath’. Here’s a list of accredited programs that you can use when checking up on a practitioner’s credentials.

Naturopathic doctor – Starting in the late 1970s, the practice of naturopathy became significantly more medicalized. Four-year post-graduate programs combining didactic and clinical education had existed for a long time (notably at the National College of Naturopathic Medicine), but with the founding of the John Bastyr College of Naturopathic Medicine (now Bastyr University) in 1978, they became standard. These programs were now attracting college-educated young people who had strong scientific backgrounds, many of whom had considered pursuing MDs, but who were seeking to promote health through less invasive, non-toxic, more natural methods. The colleges began conducting research, with Bastyr being the first naturopathic college to receive funding from the NIH in 1984. Similarly, licensure laws began to expand, and licensed naturopathic doctors began to have access to pharmaceuticals in addition to the natural therapies that were and are the mainstay of naturopathic medicine. This major shift in education and practice called for updated terminology. Naturopathic doctor and naturopathic medicine were favored over the older terms. As I said earlier, though graduates of accredited programs would accept the term naturopath, most are more accustomed to referring to themselves as naturopathic doctors. The older term came into usage over a century ago, whereas the more modern term gained prominence in the closing decades of the 20th century and was reflective of seismic changes in the education and practice of naturopathic medicine.

Naturopathic physician – Reflective of the most recent wave of change in the naturopathic profession, naturopathic physician is becoming an increasingly preferred term. The term dates back to at least 1985, when the American Association of Naturopathic Physicians was founded, though the term was in usage before that. Taking the term naturopathic doctor a step further, naturopathic physician represents the trend within the naturopathic profession to move into the role of primary care providers. In states like Washington, that have a long history of licensing naturopathic physicians, with a broad scope of practice (including a range of pharmaceuticals and even minor surgery), and with insurance coverage, naturopathic physicians are increasingly playing the role not of ‘alternative’ providers, but of primary care providers. In this role, naturopathic physicians are family doctors who do yearly physicals, order screening labs to check up on things like cholesterol, and make sure you’re up to date on mammograms, for example. Not every person with an ND practices this way, but an increasing number are, and they are filling an important role in American healthcare. Though it is always important to check up on potential providers in states that do not license naturopathic doctors or physicians, the term naturopathic physician is rarely used by practitioners who have not graduated from one of the seven accredited programs.

As I hope you can see, these terms have their own unique meanings. Sometimes, the English major in me uses them interchangeably, just to prevent the writing from being monotonous, but the naturopathic physician in me grates against it every time.

One of the great advantages of licensure laws is that it takes the guesswork out of finding healthcare – if you live in one of the 16 US states or 5 Canadian provinces that license naturopathic doctors, you can rest assured that a person calling themselves a naturopath, naturopathic doctor or naturopathic physician went to an accredited program, and that you are in capable hands. If you aren’t so fortunate, always check the credentials of someone using these terms – someone who went to an accredited program will be more than happy to tell you about it, and most in fact hold licenses in another state, which they would be proud to show you. Licensure efforts are ongoing in many unlicensed states, so if you are truly motivated, find out how you can get involved with your local naturopathic organization!

Thursday, November 10, 2011

Are Naturopathic Physicians Opposed To Conventional Treatment?

There’s a very common misconception about naturopathic physicians, that they are ‘opposed’ to conventional treatments. This belief leads some to believe that naturopaths are ‘against’ vaccination, ‘against’ surgery, ‘against’ pharmaceuticals, etc. Unfortunately, this way of thinking can get in the way of optimal health care.

The reason this belief is so prevalent is hard to determine. It may be due to a small but vocal minority of naturopaths who claim to ‘oppose’ conventional treatments. On the other hand, it may be due to a similar vocal minority of MDs who make exactly the same claim, in an effort to discredit naturopathic doctors. It may be because naturopathic physicians, as a small profession, are lumped in with other movements or groups that indeed are opposed to conventional treatments. It may be simply due to the fact that some people find it easier to define naturopathic medicine by what it isn’t, than by what it is; thus it’s easier to call it anti-vaccination, anti-pharmaceutical, anti-surgery, rather than holistic, natural, and life-affirming. One way or another, this misconception is present and needs some mention.

I always like to quote a mentor of mine who passed along the following tidbit, ‘There’s no room for dogma in medicine.’ A born healer in the tradition of village wise women who treated the sick using herbs, she once said this to me while prescribing Paxil to a patient for whom that had been the most effective treatment. When practicing in a patient-centered ethic, your opinions and beliefs always come second to the needs of your patient. Sometimes this means working with a patient for an hour on improving their diet and exercise regimen (or introducing one where there hadn’t been one before), other times this means prescribing life-saving antibiotics.

I think any naturopathic doctor worth his or her salt would say that they support intelligent medicine, rather than strictly supporting one or another discipline of medicine. This means discerning use of lab testing, imaging, diet, supplements, medicines, and other therapies. It’s rare that you meet a naturopath who is ‘against’ conventional treatment, but it’s fairly common that you meet a naturopath who feels patients are frequently given treatments that are too forceful or invasive before milder, gentler options are fully explored (and sometimes even mentioned). On the other hand, most NDs have had experiences where a stronger treatment was the best option for a given patient, even given the ND’s preference for a gentler medicine.

I myself worked once with a patient who came in having had an acute flare of chest pain for which she had gone to the ER. This patient had a long history of anxiety, and specifically mild chest pain during anxiety attacks. She walked into my office with a number of complaints, including a feeling that despite a long list of tests and prescriptions, she didn’t know what was wrong with her. When she had gone to the ER, she was first evaluated to make sure she wasn’t having a heart attack. She wasn’t, which was good news. If anything, she was in excellent health. The hospital kept her overnight to do further evaluation. At each step along the way, everything was normal. Not merely normal, but actually excellent. In fact, all of her symptoms could have been explained by her history of anxiety, a fact she kept mentioning while at the hospital. In the end, she walked out with two prescriptions (neither of them for anxiety), a large stack of lab and imaging reports, and a feeling that she was dreadfully ill when in fact she wasn’t. In my time with her, we worked on her anxiety, as I was satisfied that she wasn’t suffering from cardiovascular disease. We worked on her diet, I had her doing regular exercise, a few other lifestyle changes, and I prescribed her a homeopathic remedy which helped relieve her anxiety symptoms. She was a patient best helped by mild treatments, but who had had too much testing, too much treatment, but not enough attention.

Now let me relate the tale of another patient. This patient came in with a vague feeling of being unwell, some vague symptoms of joint aches and fatigue, and a general sense of malaise. ‘Angst’, though far from a medical diagnosis, is a fairly common complaint in Seattle, where I received my education (it may or may not be due to the vitamin D deficiency which is fairly rampant in Seattle). I saw this patient while I was still in school, so I had the benefit of being able to read old chart reports, during which I noted a few references to a longstanding, non-healing skin ulceration. As any doc will tell you, this was a pretty big red flag, and so I made sure to check it out during the appointment. Fortunately for the patient, I was being supervised by a doc who specialized in dermatology, who identified the lesion as a dead ringer for squamous cell carcinoma, and immediately started writing a referral to a dermatologist. “But wait,” said the patient, “I came to you because I thought you didn’t believe in that stuff. I don’t want to go see a dermatologist, and even if I do go, I don’t want their treatment. I want to discuss the spiritual factors that caused this to develop. I want to work with you.” This was a patient who wanted less treatment but needed more. Far from being opposed to conventional treatment, I now had to make the case for a biopsy and whatever further treatment might be necessary. We eventually prevailed on her to take our referral to a dermatologist. The spiritual aspects of cancer are important, and an area in which naturopaths have an important role to play, but equally as important are proper diagnostics and potentially life-saving treatment. I told my patient that I too wanted to discuss her spiritual life, but that she needed conventional help as well, so that we could continue to have that discussion.

I hope this helps to capture the relationship of the naturopathic physician to conventional medicine. It’s far from simple, and certainly can’t be summed up as being ‘opposed’ to conventional treatment. Naturopathic physicians straddle the line in a lot of ways, between the old and the new, the gentle and the strong. In all cases, it’s the uniquely individual needs of the patient, seen in a totality, that determine what treatment is appropriate. As I now say too, ‘There’s no room for dogma in medicine.’

Friday, November 4, 2011

Questions About Sports Medicine

The New York Times has been running a series of articles on the topic of sports medicine, written by Pulitzer Prize-winning journalist Gina Kolata. One catalogued the author’s own attempt to recover from an injury, another discussed issues of evidence-based medicine arising around sports medicine, and the most recent discussed the specialty’s alleged overuse of MRI technology. The articles, while fairly open-minded in their investigation, are also sharply critical of sports medicine.

Here’s a brief (very brief) summary for those who are too busy to read the articles: Sports medicine is rife with treatments that are expensive, high force (meaning they involve more forceful interventions such as surgery, as opposed to more moderate interventions like therapeutic exercise), and which may or may not be effective. Patients often experience a long line of treatments but may not gain any relief. Additionally, doctors rely too heavily on expensive imaging procedures without taking adequate case histories, resulting in overtreatment. As I said, these are the criticisms levied by the author.

So what does a naturopathic physician think about all of this?

I’d like to address two main points that these articles have brought to light. The first is one of ethics. A confluence of various economic factors act on all doctors, ranging from med school debt to mortgages to the need to give one’s own children the advantages we’d want them to have. In all professions, there are practitioners who act less scrupulously for economic reasons. This is not owned by any one profession, though it manifests differently in different professions. Some docs order expensive testing, others perform elaborate procedures, still others recommend costly supplement regimens. All professions suffer from economic issues, and sports medicine is no exception. By no means should sports medicine be demonized, and indeed the articles above are full of quotes from sports medicine specialists seeking better work from their colleagues.

I can’t speak to the experiences of my MD colleagues, but at ND school, the ethical practice of medicine was a topic of serious debate. As a naturopathic physician, I place an emphasis on low-cost treatments, such as diet and lifestyle, treatments that require work, but cost little. Not only do these treatments have weighty scientific backing, but they also provide lasting results at minimal cost to the patient. Additionally, I focus on taking a good history, which only costs as much as the visit, and provides the most important clues to diagnosis.

The second point I’d like to address is one of sloppy medicine. Again, this is not owned by any one profession, but is a shared problem, though it may have different permutations in different professions. In my time at med school, the docs I worked with all drilled home the important point that all patients deserve your best effort. Rushing through an intake, jumping to testing before you hear what the patient has to say, employing a gimmicky or faddish treatment, or worse, giving every patient the same treatment, is just bad work. There’s any number of reasons why this can arise, and sports med docs are hardly the only offenders, but patients deserve better.

Here’s the take-home message: Sports medicine has its own unique problems, but isn’t at any more fault than other professions out there. When looking for a doctor to work with, be they a sports medicine doc, a chiropractor, gastroenterologist, or whatever, do some investigating first – look around online and see what their colleagues and patients say. Your work doesn’t stop there – when in the visit, make sure you feel the doctor listens to your story, and ask for a few potential treatment options. The doctor-patient relationship is a two-way street and it requires work on both ends to achieve the best outcome. 

Friday, October 28, 2011

Saluting my fellow doctors, and exhorting them as well

A few months ago, I wrote about the plight of doctors and nurses throughout the Middle East, who were being prevented from treating protesters who had been injured while demonstrating against unjust governments. In Bahrain, 13 doctors and nurses were convicted by a military court of crimes against the government for working to save the lives of civilians wounded by security forces – under massive international pressure, that conviction has been overturned, and they are being given a new trial in civilian court. I’ll state again, as I did then, that the duties of doctors, nurses and other health professionals are beyond question. The obligation to alleviate suffering and save lives is one that dates back far beyond the writing of the Hippocratic Oath, and one that transcends national and political boundaries. The red cross and red crescent are inviolable symbols respected the world over, and the sanctity of health professionals’ duties is recognized even in wartime.

I bring this up now because I have been moved with greatest respect to salute the men and women working to save the life and health of Scott Olsen, the Iraq war veteran who was critically injured after being hit in the head by a projectile fired by the Oakland Police Department as they attempted to clear protesters from Frank Ogawa Plaza in downtown Oakland. It is shocking that a young man who served two tours in Iraq should have been wounded so severely in his own country by the police force employed to protect and serve American citizens. This is especially shocking because many Army and Navy veterans in the Occupy Wall Street movement have pushed so strongly for a cooperative approach to dealing with law enforcement agencies, one that emphasizes common desires and nonviolence. Most shocking, however, is video evidence that shows a flash-bang grenade being thrown at civilians going to Scott Olsen’s aid as he lay bleeding on the ground.

So again I want to say thank you to the team of medical professionals working to save Scott Olsen. Most recent reports indicate that he is in fair condition and that he has probably suffered a brain injury affecting the portions of his brain responsible for speech. Why this young man suffered this cruel fate is beyond reason. A man working in peace for the betterment of his country deserves better.

Health professionals occupy a central role in promoting social justice. Around the same time I wrote about physicians in the Middle East, I wrote also about how the quest for social justice was a quest for health. Likewise, physicians must advocate for justice to better the health of the people they are sworn to serve. Just as we alleviate suffering from bacteria, viruses and other ailments, so too must we work to alleviate suffering from poverty, unemployment, injustice, and other social ills. These too affect the health of our patients, not only through the long arc of biochemistry I suggested earlier, but also by limiting our patients from attaining their true potential, from realizing their greatest abilities, and from contributing to the world around us. Justice is what health looks like on the grander scale of society.

Friday, October 21, 2011

A Simple Message about Smoking

Some weeks I write a lot, some weeks I write a little. This week, the message is short and to the point – I have two articles in the works, but I’ve sidelined them for some brief reflection on clinical experience.

This past week, I started shadowing a cardiologist, in an effort to learn more about cardiovascular pathology in order to better serve my patients. So far it’s been an excellent experience. We’ve talked a lot about prevention with diet and lifestyle, when to prescribe pharmaceutical drugs, how to interpret imaging, and how to assess prognosis. Few naturopathic physicians get the opportunity to spend time looking at carotid doppler scans, echocardiograms, and perfusion studies, and so I feel very blessed to have this opportunity.

The main message I’ve taken home from my experience thus far has been this: Don’t Smoke.

Often, health and lifestyle recommendations can seem a bit vague. It’s easy to know smoking is ‘bad’, but aside from a lingering odor, that negative effect can seem distant. A relative may develop emphysema or lung cancer, but even that can fade with memory. The effects of smoking aren’t always immediately obvious, which is part of the reason that it is an insidious killer. While emphysema or cancer seem to come suddenly, the groundwork is laid daily for years.

One place smoking acts is in the arteries. In the cardiovascular system, it contributes to strokes, heart attacks, and a variety of other conditions. The primary method it does this is through atherosclerosis – the hardening of the arteries due to the build up of plaques. To prevent this from sounding like stratospheric talk, let me bring this home by saying that carotid doppler scans allowed me to visualize these plaques in living, asymptomatic patients in a way that I hadn’t been able to before. These plaques become larger and go to either obstruct and prevent blood flow to the brain, or break loose and lodge in smaller arteries downstream, also preventing blood from flowing to the brain. Even for a doctor it can seem remote – we talk about blood pressure, we talk about cholesterol, but to actually see the arteries narrowing brought things home. Imagine it this way: a man shows up at your doorway and casually saying that there seems to be a ticking time bomb in your garage, but that he’s not sure when it will explode, if it will explode, or if it will even cause much damage when it happens – not too worrisome is it? Now instead imagine that he says there is definitely a bomb, shows it to you, tells you how long till it goes off, and says that it’ll blow up your whole house unless you do something about it – sounds more pressing, doesn’t it?

Smoking helps these plaques to build steadily, day by day, for years. It also damages DNA in cells throughout the body, causing cancer to develop, and damages the cells of the lungs, causing emphysema. A few weeks ago, I blogged about a study showing that smoking was the most important causative factor of premature death. Today I’m blogging about it again. Don’t Smoke.

Friday, October 14, 2011

A primer on the varieties of tea

Regular readers of this blog will know that sometimes I choose to write on topics of healthy living, not just medicine or healthcare, and so it’s in continuing in that tradition that I’ve chosen to write yet again on one of my favorite topics: tea.

A few months ago, I wrote a blog entry on the health benefits of green tea, and recently a friend wrote to me asking to blog further on the topic, focusing instead on the varieties of tea out there. As I’m a regular tea drinker and an avid explorer of the world of tea, I was more than happy to oblige. So here they are, the most common types of tea:

Green tea – The variety of tea best known the West for its health benefits, green tea is made from tea leaves that undergo little to no oxidation during processing. Because it isn’t allowed to oxidize, green tea is generally higher in antioxidants and theanine than other varieties (if any of these words are unfamiliar, check out my older post). China, the original home of tea, produces some excellent green teas, including Dragon Well, Gunpowder, Jade Tip and others. Japan as well produces excellent green teas, and in some ways green tea is the dominant tea of Japan, with varieties and processing having been explored more extensively than they were in China. Well-known Japanese varieties include Sencha, Bancha, Kukicha, Genmaicha, Hojicha, and Matcha. The green teas of Japan are varied, and include some that have light, delicate flavors that are highly dependant on proper brewing, and others which are heartier and more full-bodied. As with wine, the flavors of varietals are complex and hard to cast in simple terms. As a tremendous fan of green tea and its health benefits, I recommend exploring the varieties and finding yourself a trusty reliable that you can drink daily – there are thousands of types of there, so I assure you that you’ll find a perfect fit.

White tea – The difference between white tea and green tea is one of timing. Both are processed soon after picking so that oxidation is minimal, but white tea is picked very early in the season, typically early spring. It is picked so early, in fact, that most white teas are comprised largely of tea buds, the freshly-sprouted tea leaves that have not fully unfurled yet. Like green tea, white tea is also high in antioxidants and theanine, and provides significant health benefits. White teas are also grown almost exclusively in China, and even more specifically in the Fujian province, which is famous for the Silver Needle and White Peony varieties. White tea has a flavor profile similar to green tea, though generally is sweeter. Silver Needle is known for having a sweet but subtle flavor, while White Peony is sweet but stronger, having a nutty, woody flavor. White tea, especially White Peony is a great everyday drinking tea that pairs well with meals.

Oolong tea – Where to start with oolong tea? Oolong tea is not very well-known in the West, although it’s actually consumed quite frequently – if you ask for hot tea at a Chinese restaurant, you’ll most frequently been given a type of oolong. Though I’m sure I’ll hear people raise objections, oolong is more or less the dominant tea type in China and Taiwan. That said, oolong’s diversity makes it almost impossible to classify. Oolong teas are oxidized (‘fermented’) for a period of time longer than green tea but shorter than black tea – this allows for a great variation in preparation type and flavor. Some oolong teas, like the high mountain oolong Alishan and Pouchong teas of Taiwan, are very floral (lilac is a common descriptor) and produce yellow/green teas. Others, like the well-known Ti Kuan Yin (‘Iron Goddess of Mercy’) or Wuyi varieties have a much roastier, nuttier, deeper flavor, and produce a darker cup of tea. And then there are some that defy the simple light-heavy dichotomy, and produce cups that are virtually indistinguishable from a mix of honey and nectar – some Dan cong varieties are well known for their ability to do this. Because of this tremendous variation, each variety of oolong should be approached individually – they are all unique and are truly the connoisseur’s tea.

Black tea – Known in China as ‘red’ tea, black tea is the most common tea type in the West. Despite how ubiquitous it is here in the West, I am continually surprised to find how delicious a cup of high quality black tea is when compared to the average cup of Lipton. Black tea is defined by the amount of oxidation/fermentation that the tea is put through as part of the processing (more than either green tea or oolong) – as a result of this fermentation, the antioxidant content is lower than green tea, and the caffeine content by weight is higher. Here as well, China produces excellent varieties, though India also produces high quality black teas, as black tea is traditionally the most common type of tea in India. A number of varietals are grown in China, but the best known are Keemun, which has a semi-sweet, pine-like flavor, and Yunnan, known for a malty, slightly spicy flavor. India produces varietals in Assam, which tend to be robustly-flavored, as well as Darjeeling, which are more delicate in flavor. Black tea also has a long tradition of flavoring, with well known types such as spiced Masala Chai, bergamot-scented Earl Grey, and smoked Lapsang Souchong. When exploring the world of tea varietals, don’t forget to check out black tea – it may not seem as exotic or interesting as oolong or white tea, but there are some true gems in this category.

Pu-erh tea – Last but not least, Pu-erh. Without a doubt the least-known variety of tea in the West, Pu-erh is probably best described as undergoing a fermentation and aging process after their initial processing. Pu-erh is grown exclusively in China, and mainly in Yunnan province. There are some ‘green’ Pu-erh varieties out there, but the majority are more similar to black tea, producing a cup of tea that is very dark, looking almost like coffee, and having an earthy, molasses-like, smooth but intense flavor. In order to be stored, pu-erh is frequently pressed into blocks of a variety of shapes – most commonly, these are bowls, but pu-erh can be pressed into discs, bricks, melons or mushrooms, and many of the blocks will have text pressed into to identify their origin. To the Western palate, these are wholly unique, almost completely unlike all other types of tea, and need to be tried to be appreciated. Be bold and give them a shot.

So that’s all for today. In the future, I’ll probably write further about the differences within each category, differences dictated by growing region, preparation, etc., but for now, this ought to help you on your way to becoming a true tea connoisseur. As always, health isn’t just about how many healthy things you do, it’s about how you do them, and enjoying them as you do it. Drinking tea is phenomenally healthy from a biochemical point of view, but also an art that enriches the lives of millions the world over.

Friday, October 7, 2011

More On High Blood Pressure

Cardiovascular disease is one of my favorite topics, in no small part because of the important role that diet and lifestyle play in preventing and managing it. Admittedly, not all cardiovascular disease is caused by diet and lifestyle, but the vast majority, especially in contemporary America, can be traced to these two factors.

Today, I’m writing about high blood pressure (called hypertension by us medical professionals), because I regularly see patients looking for help bringing down their blood pressure, and have noted some misconceptions. And as always, I believe in putting knowledge into the hands of patients, especially high quality, peer-reviewed knowledge. There’s a lot of info out there on the Internet anyway, not always of reliable quality, so it’s important to me to make good quality material available as well.

Here’s an important caveat before we launch into the discussion: Maintaining your health isn’t easy and you shouldn’t go it alone. It’s important to have the knowledge you need to take proactive steps towards health, but it’s also important to recognize the benefit of working with a trained professional who can help you set and reach goals, monitor your progress, make modifications when needed, and otherwise help guide you.

So here’s the misconception: A low-salt diet is the most important dietary change you can make to help reduce your blood pressure. There is some truth behind this, and indeed a low salt diet can help to lower your blood pressure. However, according to the JNC 7, the most recent report on hypertension published by the National Institutes of Health, that effect is modest at best. A reduced salt diet will indeed help reduce your blood pressure, and excessive salt consumption isn’t particularly healthy, but the JNC 7 is clear – the expected effect is a drop of only 8 points, possibly as few as 2 points, and for most people with high blood pressure, that isn’t enough to take care of things.

Regular, moderate aerobic exercise can also be expected to help lower blood pressure. Here too the effects were moderate but noteworthy, bringing blood pressure down about 5-10 points. While this effect is moderate, regular exercise has a lot of additional benefits, so I am unreserved about my advice regarding exercise. We’ll return to exercise in a moment.

Despite mild to moderate effects from these two recommendations, the JNC 7 is very clear that there are diet and lifestyle changes that are effective and can produce stronger therapeutic effects. While salt restriction alone results in only mild decreases in blood pressure, the DASH diet, a more comprehensive dietary plan, can produce drops in blood pressure of up to 14 points. The DASH diet does include recommendations for salt restriction, but also includes broader dietary recommendations that help to boost its blood pressure lowering effects. A broader, more complete description of the DASH diet is available from the NIH, but the basic premise is this: low amounts of saturated fats, low amounts of refined carbohydrates (sugars), plenty of vegetables, fruits and whole grains. In my experience, most patients with hypertension need to cut their blood pressure by 15-20 points, so this diet plan is going to be an important addition to anyone’s treatment plan.

Back to exercise. Exercise alone, in an otherwise healthy person, would have mild to moderate effects on someone’s blood pressure. However, exercise as a means to an end can have more significant effects. The JNC 7 report clearly and unequivocably states that the most significant reduction in blood pressure comes from maintenance of healthy weight, going so far as to say that reductions of up to 20 points can be achieved from every 10 kg (22 pounds) lost. Healthy weight is defined as having a BMI between 18.5 and 24.9 – calculating BMI involves some tricky math, so here’s a neat calculator to use. For folks with hypertension, it’s an intervention like this that will help bring numbers down the most, and with a drop large enough to help restore normal blood pressure, and to be worth the effort.

Let me repeat the caveat again: Work with a doctor when lowering your blood pressure. Not only can a doctor help setting goals and monitoring progress, but as you can see, reducing blood pressure through diet and lifestyle changes is effective but can be challenging – weight loss in particular is frequently no easy feat. A doc can help determine the best methods to pursue, and help you implement plans. While naturopathic physicians are more than happy to spend the time with you to work out these plans, don’t rule out MDs either – after all, these recommendations were developed by a group of high-ranking MDs. And as always, these are prescriptions for healthy living, not just high blood pressure.

Friday, September 30, 2011

Too much care?

The US healthcare system is in a state of crisis. At this point, we’re starting to sound like broken records. Increases in healthcare premiums have been outpacing increases in wages for several years now. A National Academy of Sciences slideshow I saw gave projected prices for staple foods had their prices increased at the same rate as healthcare costs – picture paying $134 for a dozen oranges. What is absolutely certain is that this is not going to be an easy fix, and that cutting costs is going to involve trimming in many sectors.

Interest in reducing healthcare costs resulted in a recent survey of primary care physicians, which found that many primary care docs are over-treating their patients because of current factors in health care. At first read, most people would probably react negatively to these findings, for after all, most Americans feel that they’re receiving substandard healthcare and paying increasingly more for it. In my experience, patients feel their visits are too short, and that their doctors just order labs and write prescriptions without spending the time to listen or answer questions. I often joke that I could base my entire practice as a naturopathic physician around explaining to people how to read the labs their other doctors have ordered.

It turns out that patients and doctors agree on this topic. The results of this survey, published in the prestigious Archives of Internal Medicine, indicate that physicians feel they aren’t given enough time with patients, aren’t able to follow up with patients by phone or email as much as they would like, and have to order lab tests and imaging studies more aggressively than they would like. Most primary care physicians surveyed would prefer to treat more conservatively and spend more time with their patients than they do currently.

There are two main messages I think are important to take from the survey. The first is that both doctors and patients agree on what they want from the doctor patient relationship. Patients want to be heard, and doctors want to listen. This sets us a goal for assessing the quality of healthcare delivered.

The second message is this: the doctors surveyed were very clear about the factors they felt interfered with their ability to deliver quality healthcare. One such concern was fear of malpractice litigation, which was causing doctors to over-prescribe and over-diagnose for fear that they would be sued. Also high on the list were concerns over insurance reimbursement. It’s a sad truth that insurance doesn’t reimburse for quality time spent with patients, but rather for referrals to specialists, procedures, prescriptions, and for seeing lots of patients for shorter periods of time. The article concludes that the quality of healthcare could be improved by reforming malpractice liability and modifying financial incentives to reward quality time spent with patients.

Of important note is the fact that the article’s lead author works for the Veteran’s Administration, an organization that currently provides its physicians greater protection from malpractice suit and doesn’t offer the same financial incentives, but which has traditionally performed very high when it comes to patient satisfaction and quality of care.

Go back now to the slideshow I mentioned earlier – the section titled ‘How Much is Waste?’ highlights some ways that healthcare dollars could be saved. Here we see that $210 billion dollars were spent on ‘Unnecessary Services’, due in part to defensive medicine – overly aggressive treatment done to avoid lawsuit or other repurcussions. Similarly, $55 billion dollars were misspent on ‘Missed Prevention Opportunities’, probably because doctors don’t have the time to spend with their patients discussing prevention. I bring this up to point out that the same factors that get in the way of delivering quality care are also driving up healthcare costs.

Doctors and patients want the same thing. They want quality healthcare and they want a system that works. This survey showed that doctors want to give patients the time and care that they deserve, rather than just rushing them out to see a specialist, and it turns out that it would save the country money as well. A few years ago, we missed a real opportunity to make fundamental change in the country’s healthcare system – it looks like the topic is coming around again soon. Let’s see if we can do a better job this time.

Friday, September 23, 2011

How much exercise should I get?

For years, I got very little exercise. I broke my kneecap when I was thirteen, had it immobilized for months, never got rehabbed afterwards, and was pretty much resigned to no sports for years afterward.

When I finally decided to start biking again (a low impact form of exercise I figured would be easier on my knees), I found that I had to work through significant tendonitis pain brought on by suddenly using a joint that had been inactive for years and which was damaged to begin with. Ultimately, perseverance saw me through this, and I’m back on track and training for a half marathon – not bad for someone who dropped out of his high school cross country team.

Anyway, I only provide this story to illustrate a point. Not every seemingly sporty young person you see out jogging on the weekend is a born athlete. Everyone has to start somewhere, and some of us have a slightly higher hill to climb before we can get there. So take those as words of inspiration as we discuss exercise.

At this point, everyone knows that exercise is good for you. It helps prevent a number of chronic diseases, including high cholesterol, some cancers, high blood pressure, osteoporosis, diabetes, and depression, to name a few. A few weeks ago, I blogged about a study showing that regular exercise is one behavior that can help you live longer, too. But how much should you get and what counts as exercise?

The current consensus is that every adult should get 150 minutes a week of moderate aerobic activity and strength training twice a week, or 75 minutes a week of vigorous aerobic activity and strength training. These guidelines have been by numerous high-profile organizations, including the CDC, the US Department of Health and Human Services, and the American Heart Association.

OK, so what is ‘moderate aerobic activity’? According to the folks writing the guidelines, this category includes brisk walking, water aerobics, light biking, ballroom dancing, or general gardening. 150 minutes a week breaks down into 30 minutes five days a week, and many of the websites also suggest that this can be done in 10-minute chunks. Doesn’t sound so bad, right? An afternoon of gardening and a walk around a local pond has you well on your way. Biking to work also counts. If you walk your dog daily, you may be pretty much covered. And heck, if you go out ballroom dancing, well then you win style points in addition to getting exercise.

What about ‘strength training’? Here things are a bit vaguer, as no time or weight guidelines are given, but examples include push-ups, sit-ups, and weight training, which some people find imposing, as well as everyday-life activities, such as lifting heavy loads and doing heavy gardening.

‘Vigorous aerobic activity’ covers most of what we think of as ‘exercise’, including jogging, running, swimming laps, playing tennis or other sports, vigorous biking, or hiking. When discussing this level of activity, most NDs say, ‘Some activity which causes you to break a sweat.’ For those who want more information, the CDC’s website provides excellent resources about the benefits of higher amounts of exercise as well as how to measure the intensity of your physical activity.

The general theme with these activities is to make using your body part of your routine. It doesn’t need to be elaborate, regimented, grueling or strenuous, but it’s important that you do it regularly. You don’t have to be a trained athlete to prevent chronic disease, but you can’t be sedentary. Our bodies are built to move, so get out there and do what generations on generations of your ancestors did – move around and have some fun!