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.