Thursday, August 30, 2012

Adolescent Cannabis Use and IQ

One thing I’m asked about quite regularly is my view and the naturopathic view on medicinal cannabis usage. Everyone seems to want to ask me about this, whether it be friends, colleagues, or patients – it seems that everyone wants to know whether I think it’s a good idea, what my experience with it has been, and whether or not I prescribe it.

I’m not sure whether it’s because I use a variety of other (legal) herbs in my practice, or because I’m an ‘alternative’ provider, but this is a question that some people can’t wait to pose to me.

The irony of all of this is that, in four years of naturopathic medical school, I don’t think that the use of medical cannabis was discussed once. If I recall, we discussed cannabis usage in our Addictions and Disorders class, we discussed it briefly in our Jurisprudence class, and I believe that we discussed it in Normal Maternity class one time as having a potentially damaging effect on the developing fetus. And that was pretty much it – we didn’t discuss it in Botanical Medicine class, we didn’t discuss it’s use for cancer patients in Oncology, we didn’t discuss it in the hours we spent discussing chronic pain in Orthopedics, Naturopathic Manipulation, and Sports Medicine classes. To be completely honest, if I were to go out and prescribe medical cannabis, I would be practicing pretty much in the dark, drawing on basically no instruction, very little research, and no clinical experience.

Few would argue that cannabis doesn’t have an effect on the human body, but important questions regarding clinical use have yet to be answered. These questions include: What is the proper dose of cannabis? What is the proper dosing schedule? How does one evaluate response to therapy? I feel confident in recommending 1000 mg of curcuminoids twice daily and re-evaluating at 4-6 weeks, but when I’m not aware of similar regimens for cannabis prescription. Prescribing cannabis in a manner that amounts to supervised self-medication is haphazard and prone to inconsistent results.

Not, of course, that I would prescribe medical cannabis. Though Washington, D.C., where I practice, does allow for the usage of medical cannabis, cannabis remains a scheduled drug that is without a doubt outside the prescriptive scope of naturopathic physicians. All of this continues to add to the irony.

What this all boils down to is the fact that I’m really not the guy to ask about medical cannabis. I haven’t been trained to use it, and even if I were, I wouldn’t be able to prescribe it. That said, I do take some interest in the topic, and so wanted to share an article that came across my desk recently.

A study published in the Proceedings of the National Academy of Sciences has found that chronic use of cannabis does in fact result in loss of IQ points. The study tracked approximately 1000 people from the area in and around Dunedin, New Zealand. The study has achieved a remarkable 96% retention rate since its inception in 1972, thus adding credibility to its results – not only were a large number of people included in this study, but they have been taking part in the study for approximately four decades. This is some of the first solid evidence that cannabis use does in fact impact cognition – we’ve suspected as much for several decades, but this study helps confirm it.

What was also extremely interesting is that the study found that those who started using cannabis before their 18th birthday were more susceptible to the damaging effects – those who started using cannabis in their teens suffered an average loss of 8 IQ points compared to their non-partaking counterparts. 8 IQ points may not seem like a lot for a test where people regularly score above 100, but can actually make a significant difference in percentile rankings – 8 points in either direction of 100 (the average score) can place you in either the 70th or 29th percentile.

So what’s the message of this study? It’s pretty plain: cannabis is not for kids. We live in a time when cannabis laws are becoming more relaxed, and are likely to continue to become more relaxed. Without making comments on that trend, I will say that this study indicates that, no matter the direction of legislation, future laws should maintain the same type of age restrictions that current laws for tobacco and alcohol do. The law restrictions for alcohol and tobacco were done a bit arbitrarily, but given that we now have some data to go on for in this case, I think we owe it to ourselves and our children to act on it.

Monday, August 27, 2012

Two (Similar) Graphics About Quitting Smoking

Last week, while on vacation, I posted about a recent court ruling by the Australian government, which would require tobacco to be sold in generic packages with graphic pictures on the box, a ruling which would effectively cripple the tobacco industry's ability to market their products. To say that I am impressed with this move is an understatement.

I was happy to find out, then, that the Australian government continues to impress in its efforts to fight smoking. I recently found these two images, which are nearly identical, that summarize the benefits of smoking cessation, even going to far as to give a timeline of benefits. Quitting smoking is among the hardest things that a person can do, in part because the goal often seems so far away, and it comes with little reinforcement along the way. Fighting each craving is often its own individual battle, and with no rewards along the way, it can become a seemingly endless effort. Of course we all know that quitting smoking reduces one's likelihood of developing lung cancer, or having a stroke or heart attack, but these goals are way off in the future. I love this chart, because it gives goal posts along the way, starting at 8 hours, and proceeding through the days, weeks, and months that follow, each with an additional health benefit. 

Thursday, August 23, 2012

An Article About Smoking

It's Thursday, and even though I'm no longer at the AANP conference in Seattle, I'm still on vacation. I hope you're all getting some time to enjoy the summer weather with your friends and family.

That said, I'm sending a quick missive to you readers that I feel is of great importance. Last week, Australia took a great step forward in the battle against lung cancer, emphysema, stroke, hypertension and heart disease, when the nation's highest court upheld the constitutionality of a law that would cripple the tobacco industry. The law will force tobacco companies to completely de-brand cigarette packaging, requiring that cigarettes be sold in generic, olive-green packages listing only the brand and product name, accompanied by graphic pictures of the disease associated with smoking. I haven't seen this receive much press here in the US, so I thought I'd share it with you all.

Given that our country that considers itself a world leader, I think it's shameful that many other countries have taken the lead in targeting big tobacco companies. Australia, and even our (sometimes mocked) neighbors Canada have taken much stronger stances against these disease-mongers, and it's time we followed suit. Having shown our ability to lead the world in the political and financial arenas, it's time we similarly got moving in the health arena - we've made some steps forward recently, but in most, we're still playing catch up.

Monday, August 20, 2012

A Graphic On Cooking Oil

Today’s blog entry focuses on fat, and I’ve found this interesting graphic to share with you folks to serve as a talking point. I don’t totally agree with the following recommendations, but I think it’s helpful to learn from them. The broad brush strokes of these images are correct, including using saturated fats for high heat uses, and reserving unsaturated oils for dressings, salads, and other circumstances in which they would not be exposed to heat. The reason for this is that unsaturated fatty acids are damaged by heat, becoming oxidized in the process – oxidized compounds breed more oxidized compounds, and unless you’re eating an antioxidant-rich diet, this fire can be hard to put out.

Similarly, the graphic recommends avoiding highly-processed, refined oils, including margarine, hydrogenated oils, canola oil, and others. Many of these oils are heavily oxidized in the refining process, with the concommitent problems that that causes. Others contain trans fats, which, thankfully, many of us know to avoid.

However, this graphic is not altogether perfect, so let me offer my own opinions on a few topics. One thing I’d like to note is that the author doesn’t emphasize enough that saturated fats should be avoided. Coconut, butter and ghee may be preferable to margarine or hydrogenated oils, and are less-easily damaged under high heat conditions, but modern American diets still overwhelmingly favor saturated fat, and nearly all of us could do with some reduction in the amount of saturated fat we take in.

Secondly, there’s a small note saying that PUFAs (polyunsaturated fatty acids) should be avoided in the diet, which I don’t agree with. The author is right in that ALA, the main omega-3 fat in flaxseed oil, may have some negative effects (and I do want to emphasize the word may), but this fact is far overshadowed by the massive benefit offered by the polyunsaturated fatty acids EPA and DHA, which are found in fish oil, and are remarkably beneficial to health. You wouldn’t want to put fish oil on your salad, but at the same time, I think it’s important to underline the health-promoting qualities of PUFAs.

I hope you enjoy this chart, and I’ve come back from the AANP conference buzzing with ideas for the blog! Stay tuned!

Monday, August 13, 2012

An Infographic About Beer

I don't drink much beer anymore, but that doesn't mean I don't still have a lot of affection for it. Beer, in its pre-industrial, natural form, is high in B vitamins, high in minerals, and was an important source of calories for those who spent their days toiling in fields. Of course, things have changed significantly since then, and modern, mass-produced beers have little nutritional value, not to mention the fact that beer can pack the weight on for us sedentary Americans. Craft beer has returned flavor to beer, but these high-alcohol beers are a far cry from the 'liquid bread' beers of old.

I came across this lovely infographic on beer recently and felt I should share it. Some of the health statements made about beer are embellished to say the least, but hey, it's August, and most of us are on vacation anyway. I myself am off to the AANP's annual convention in Seattle, Washington, and while I won't be posting this coming Thursday, I'll be bringing some great info to you folks next week!

Beer Infographic

Thursday, August 9, 2012

How Common Is Celiac Disease?

Following a gluten-free diet is suddenly mainstream – there’s even a Prius ad that mentions ‘gluten-free alternatives’. Unfortunately, determining how common celiac disease – a severe immune intolerance to wheat gluten – is has proven a difficult task.

Part of the problem is that celiac disease has proven notoriously hard to diagnose in a simple, affordable manner. A disease like hypertension is easy enough to diagnose, and anyone with a blood pressure cuff can do it, but celiac is a complex interplay of symptoms, blood tests and tissue damage. We’ve all learned that an intestinal tissue biopsy is the gold standard for diagnosing celiac disease, but obtaining a biopsy is invasive and expensive, to say the least. There are a variety of blood tests that can be run, but combining them to achieve perfect sensitivity and specificity hasn’t been fully agreed upon, and genetic testing, while theoretically perfect, can also be prohibitively expensive. The combination of imperfect testing and high costs means that very frequently, celiac and gluten-sensitive enteropathy (a fancy word that includes a spectrum of gluten-sensitive intestinal syndromes) are diagnosed clinically, based on symptoms and clinical picture.

While lab testing still leaves a little bit to be desired, one thing that is clear is that celiac disease itself is far more common than we thought it was even a few years ago.

A recently published article in the American Journal of Gastroenterology found that celiac disease (as measured by a combination of the more established blood tests) had a prevalence of 0.71% among Americans a whole, but was higher among non-Hispanic white Americans, at 1.01%. This is in stark contrast to previous data on celiac disease, which in the distant past put its prevalence at around 0.02% of the population, but also more recent data, which put prevalence at around 0.33-0.70% of the population.

Sometimes, when diseases become ‘more common’, it’s because testing methods improve and awareness increases – the disease itself doesn’t become more common, but our ability to detect it and patients' likelihood of asking their doctor about it means that the amount of cases increases. This, however, does not appear to be the case with celiac disease – yes, our methods of detection are improving, and awareness of the disease is also increasing, but the disease itself seems to be increasing in prevalence. A population study that analyzed blood samples drawn from adults between 1948 and 1954, and compared them to blood samples of matched subjects drawn in the mid-2000s found that contemporary adults were 4.5 times more likely to have celiac disease than their counterparts 50 years ago. Why the disease is apparently more common is unclear, but what is clear is that the disease is rapidly on the rise.

What is also clear, especially based on this last study, is that we need to continue to improve diagnostic methods around celiac disease, so that we can screen for the disease, and institute treatment for patients. Among the findings of this study was an indication that all-cause mortality for persons with undiagnosed (and therefore untreated) celiac disease was 4 times higher than people without celiac disease – even though the percent of the population with celiac disease is much smaller than the percent of the population with, for example, high blood pressure or high cholesterol, this greatly increased risk of mortality is enough to make us pay attention to this population. There was no further discussion of the increased mortality, but because celiac disease results in chronic immune activation, inflammation, and poor nutrient assimilation, there are any number of potential causes for increased mortality.

Of course, this doesn’t really address the growing population of people who follow gluten-free diets, but who haven’t been formally diagnosed with celiac disease – the study mentioned previously, in addition to finding that celiac disease was more common than expected, also found that more people follow gluten-free diets than have been formally diagnosed with celiac disease. While we are improving our ability to diagnose celiac disease itself, there will probably remain a set of people who have some degree of gluten sensitivity – this is a grey area, and one which lab testing is unlikely to clarify any time soon. These folks are the ones whose IBS or eczema improve with a gluten-free diet, but who don’t test positive for celiac disease. It’s still advisable to be under the care of a health care provider if you fall into this category, as with any long-term treatment – a naturopathic physician can help assess whether or not it would help to follow such a diet, help determine your progress, and above all help you implement it. While resources do exist for celiac patients, it’s an overwhelming world of information, and almost everyone needs some help in sorting it out – a naturopathic physician can help guide you through the process, pointing out pitfalls, and helping you overcome obstacles.

While celiac disease is indeed on the rise, it is in some ways surprising that gluten-free diets have become popular, because of how restrictive they can be. Unlike vegetarianism, it’s not a diet that I would advise anyone to undertake unless they were working with a healthcare professional, for the reasons listed above. Even so, a gluten-free diet can be extremely helpful for a variety of immune-related conditions – sometimes celiac disease itself is at fault, but in other cases, it’s a gluten-sensitive spectrum syndrome. As always, I urge you to work with a healthcare professional, as they can best determine the cause and solution to your health issues, and provide needed guidance and support in finding resolution.

Monday, August 6, 2012

Your New Favorite Fish Sauce

I'm a late convert to eating fish. I grew up in a household that embraced seafood of all types, even anchovy pizza, but I was never able to get a taste for fish myself. However, as a naturopathic physician intent on eating a healthy diet, I've made a strong effort to start eating fish. Part of this effort has meant learning about the omega-3 content of fish, as well as mercury content of fish. However, it's also lead to a lot of experimentation with fish recipes, a process that I'd like to continue to bring to you blog readers.

Here's the latest, greatest fish recipe, featuring your favorite sauce you've never heard of: Chermoula.

Chermoula is a spicy, garlicky sauce from Morocco that is traditionally served on fish of all sorts - grilled, baked, fried, etc. It is a strong flavor to be sure, and it can overpower just about all other flavors, so use it wisely. I've become a great fan of it, but it's not well known here in the US, which is a shame.

Now without further ado, here it is:

2/3 cup of chopped cilantro
4 cloves garlic
1 tsp cumin
1 tsp paprika
1/4 - 1/2 tsp ground chili pepper
6 tbsp olive oil
Juice of 1 lemon or 3 tbsp wine vinegar

Combine them all in a food processor.

The sauce can be used as a marinade for grilled fish, or added afterwards. The easiest way to use the sauce for us grill-less apartment-dwellers is to pan-cook whole fish fillets in sauce - marinate the fish for 30 minutes, and then cook the filets on medium heat for 3-4 minutes a side.

Note: This recipe has been slightly adapted from Claudia Roden's excellent cook book, The New Book of Middle Eastern Food.

Thursday, August 2, 2012

What’s The Deal With Fasting?

I get regular questions about fasting, from people trying to lose weight, cleanse their bodies, or just learn more about ‘alternative’ practices. It’s sometimes a tough question, as fasting is a practice associated with both life-changing healing experiences as well as horror stories, and so there are some strong opinions out there. Additionally, fasting has a long association with religious practices – monks, shamans and lay people the world over have fasted for spiritual reasons since recorded history began. Finally, it’s Ramadan, the Muslim month of fasting, so this week, I’ve opted to give my thoughts on fasting.

Let me start by saying that there is not a lot of research on fasting in humans – the little I have been able to turn up focuses on the performance of athletes observing Ramadan, and a few lab studies on how fasting affects gene expression. There is evidence that caloric restriction does increase lifespan among a wide variety of animals, but there are questions as to whether this would apply to humans as well. The most interesting research I came across was a group of studies that indicate that fasting induces production of a group of proteins called sirtuins, which have been characterized as ‘anti-aging’ proteins, and have the effect of increasing alertness and energy efficiency. From an evolutionary perspective, it appears that these proteins were induced during periods of famine, increasing our ancestors’ likelihood of finding food and surviving to pass their genes on. They have recently become major targets for commercial ‘anti-aging’ products.

So in the absence of a large body of research, here are some basic ideas on fasting, based on clinical experience and sound judgment.

First of all, let me say that I am not in favor of drastic fasting, like multi-day water fasts, multi-day juice fasts, or the perennially popular Master Cleanse. I don’t see benefit in depriving oneself of all calories for substantial periods of time, and I especially don’t see benefit in consuming sugary drinks at the expense of nutrients. It’s my belief that juices and the Master Cleanse, because they lack the mollifying effect of fiber and protein, subject your body to the stress of a blood sugar roller coaster, without much benefit. One of the benefits of fasting is giving the body a bit of a ‘metabolic break’, and drinking juice causes unhealthy spikes and valleys in blood sugar levels.

That said, I do believe that fasting can be healthy. Here are some essential components of healthy fasting: avoidance of unhealthy foods, mild caloric restriction to induce sirtuin proteins, reduced activity levels so as not to stress the body, short duration to prevent negative outcomes, and easily digestible foods consumed to break the fast.

Before I cite specific fasting practices, let me say that I think our bodies are more complex than we understand, and that practices that have a long cultural history are worthy of our attention. Our scientific minds have limited understanding, and can sometimes lead us astray – low-carb dieting is a good example – and I believe that long-standing cultural practices have survived because they work. This is why I recommend the Mediterranean diet over low fat diets.

I find two main healthy examples of intermittent fasting, or periods of lean eating, in our cultural history. The traditions of both Lent and Ramadan are associated with forms of fasting, which I believe may have more beneficial health effects than our modern aggressive forms.

Fasting during Lent has taken many forms in the past, including daytime fasting with evening breakfasts and abstinence from animal products. Certainly, the abstinence from animal products for substantial periods of time has beneficial health effects, as it provides a respite from significant sources of saturated fat and cholesterol in the diet. In our modern time, Lent has been associated with abstinence from meat on Fridays, a theme that I believe can be converted into a plan for weekly fasting – caloric restriction once a week for a set period of time satisfies the criteria I mentioned previously for a healthy fast, and I think that we may do well to embrace this form of fasting.

Daytime fasting, followed by breaking of fasts with balanced, easily digestible meals is also worthy of our attention. I’d posit that this method of fasting is effective at inducing sirtuin proteins while also providing adequate nutrition. While this method of fasting is practiced daily for long periods of time in Ramadan, and was practiced for long periods of time in older Lenten traditions, I don’t think that it needs to be practiced for long periods to be effective. Fasting once a week on occasion may be similarly effective. Most important, I think is that the meal that breaks the fast be easily digestible and provide a balance of protein, fat, and carbohydrates, along with a range of vitamins and minerals.

Several years ago, I learned of the Moroccan practice of eating harira to break the Ramadan fast, and was really inspired. Harira is a soup consisting of lentils, chickpeas, tomatoes, onions, rice, olive oil, a small amount of meat or broth, and a rich array of herbs and spices. This meal provides a good balance of protein, carbohydrates and unsaturated fat, and is rendered extremely easily digestible by a combination of long-cooking and the use of spices that aid digestion and assimilation, such as ginger, pepper and coriander. When it comes to easily digestible foods after a period of fasting, I think harira may have it nailed.

And finally, one important oversight that I see people make consistently is that they don’t give themselves a break while fasting, and just keep at their normal activities. Sometimes this is difficult to avoid, but I think it’s important to give our bodies a break while we are depriving them of calories – maintaining a high level of activities on a low amount of calories stresses the body physiologically, which I think is less than healthy.

My final message today is a restatement of the important components of a fast: avoid unhealthy food, mildly restrict calories, take it easy, keep it short, and eat gently to break the fast. Above all, keep it sane – crashing your system is the opposite of what a fast should achieve.