More on the future of healthcare: a tale of quantity and quality

American healthcare is changing at the moment, and is doing so rapidly. As I’ve highlighted in the past, the way that we pay for healthcare is changing at the moment, and will continue to change until a more sustainable model is found. The rise of integrative medicine is an irreversible trend, and I predict that in the future, primary care physicians will move away from pharmaceuticals, embracing instead diet and lifestyle, simple home remedies, and many will incorporate supplements too. Additionally, and without trying to play the role of soothsayer, I predict that in the future, we will see a greater effort to integrate the occasionally opposed principles of quality and quantity.

The development of scientific method, from the 17^th century through the 20^th, has brought many things to the field of medicine. Modern diagnostics, labwork, imaging, and pharmaceuticals are only the tip of the iceberg. Diseases have been essentially eradicated, debilitating illnesses cured, and lives saved. This blog entry is by no means meant to diminish the work of the generations of doctors and researchers who have taken us so far. Even so, we are now starting to see some of the limitations of our current use of scientific method.

These limitations are dictated by an essential feature of the scientific method – the need for quantification. Science runs on experiments and reproducibility, the ability to observe measurable changes, and be able to communicate them to colleagues. To do that, everything needs to be quantified, from milligrams of a drug, to cholesterol levels, to changes in waist circumference. Ironically, even quality of life has been quantified so that the effect of pharmaceuticals can be measured.

Unfortunately, quantity of health doesn’t always equate to quality of health, and in some cases, quality of health is sacrificed in favor of quantifiable measures. Pharmaceuticals and surgeries can regulate your cholesterol, blood sugar, weight, and blood pressure, but that combination doesn’t make a healthy person – it makes a person who is statistically less likely to suffer a cardiovascular event. By no means am I saying that this is somehow bad – as a doctor, I work every day with patients to reduce the likelihood that they’ll suffer a heart attack or stroke. What I am saying, however, is that health is a complex mix of quality and quantity that needs a better system of assessment.

Quality is traditionally trickier to work with. For one, it requires more time to assess. Also, training physicians who are able to assess and determine quality is far more complicated than training physicians who can assess quantity – the one involves an ability to understand and interpret the human condition, the other the ability to read a lab report. True primary care physicians should have the ability to assess health in its fullest scope, and should be trained to do so.

Next week, I’ll discuss the growing Death with Dignity movement in greater detail, but suffice it to say that this is a case study for the debate on quality vs quantity. The life of a terminally ill patient can be prolonged far beyond what nature alone would allow, but often at the price of quality of life. The Death with Dignity movement attempts to reconcile those two opposing principles for the terminally ill. While this branch of the debate on quality vs quantity is sometimes dramatic, many more Americans quietly wrestle with quality and quantity in their everyday lives. Such people include those Americans who struggle with chronic diseases, some of whom feel the cures are often worse than the disease.

As healthcare changes in the future, let’s commit ourselves to a future where both quality and quantity are both taken into account. This is the core principle of patient-based medicine. One of my guiding principles in patient care comes from my teacher and mentor, Dr. Maryanne Ivons, who paraphrased Dr. Samuel Hahnemann in saying, “It’s not about you. It’s all about the patient. It’s about what they want, and getting them healthy.”

The healthiest recipe I know

When it comes to food, I’m a traditionalist. I tend to go for more tried and true foods when I cook, foods that our ancestors enjoyed and passed down. Thus, while I enjoy colcannon, a British standard that can include kale, cabbage, or any number of other cruciferous veggies, I tend to avoid odd combinations of quinoa, kale and tofu. Our ancestors cooked based on taste, and since then, we’ve learned that these foods were healthy – in modern times, people sometimes go the other direction, from healthy to tasty, which produces some strange culinary results. Here’s a great recipe that’s delicious, and is probably the single healthiest recipe I know.

This recipe comes from Claudia Roden’s excellent cookbook, The New Book of Middle Eastern Cooking, which is chock-full of excellent recipes that are healthy nearly across the board. Muhammara comes to us from the cooking tradition of Syria and Turkey, and combines four foods which science has since proven to be ‘superfoods’, foods with extremely high nutritional value. Multiple recipes for muhammara exist, ranging from spicy red pepper dips, to this, a tangy pomegranate/walnut dip.

One of the great superfoods, walnuts are rich in omega-3 fatty acids, specifically ALA (alpha-linolenic acid), which is one of the healthiest, but hardest to find compounds in nature. The search for vegetarian-source omega-3 fatty acids has driven people to some sources not traditionally viewed as food. As I’ve discussed in blog post upon blog post, omega-3 fats are extremely healthy, decreasing inflammation and promoting cardiovascular health. The humble walnut is an understated, but uniquely healthy food.

Tomatoes are near ubiquitous in American food, but are often eaten as colorless, warehouse-ripened fruits, with no more nutrition content than iceberg lettuce. Vine-ripened tomatoes, especially in the form of tomato paste, are rich in a variety of carotenoids, specifically the much-lauded lycopene. Lycopene is a potent antioxidant that has shown some benefit for a variety of conditions, including several types of cancer (including prostate cancer) and cardiovascular conditions.

Olive oil, a staple of the Mediterranean diet, is featured here as well. Olive oil’s main role in a healthy diet is as a healthy alternative to butter, due to its healthier fat profile. Olive oil is rich in unsaturated fats, as opposed to butter’s inflammation-producing saturated fats. Additionally, there is some evidence that the antioxidants in olive oil may provide some of it’s beneficial effects on cardiovascular health.

Finally, we come to that all-important, antioxidant-rich powerhouse, pomegranate. Pomegranate is full of vitamin C, a well-known antioxidant, but also a number of other antioxidants, like ellagic acid, anthocyanidins, and catechins. A food revered across the world since ancient times, pomegranate is mentioned in the Bible, the Qu’ran, and the Homeric Hymns.

Put these all together, and you’ve got a potent blend of antioxidants and anti-inflammatory unsaturated fats. This really is a massively healthy recipe, although I know I’ll get some flack from the gluten-intolerant – just leave the bread out!

Ok, here’s the recipe:

1 ¼ cups of chopped walnuts

1 ½ - 2 tablespoons of tomato paste (see note below)

Bread crumbs from one slice of bread, crust removed, lightly toasted

½ cup of olive oil

2 tablespoons pomegranate concentrate (also called syrup or molasses)

1 tsp red pepper flakes, or a pinch of cayenne

1 teaspoon cumin

Salt to taste

Combine the ingredients in a food processor and blend to a coarse grind.

This is very enjoyable on its own with pita, or as a condiment for traditional foods like kefta, fish, or other meats.

There are a number of pomegranate concentrates out there, with varying flavors –as a result, the recipe can vary in taste significantly, from tangy and sweet to mild and tomato-y. You may have to go to ethnic markets to find pomegranate concentrate, depending on where you live. Additionally, pomegranate concentrates made by health supplement companies are often very different than those made by ethnic food companies - just so you're aware of it!

Hope you enjoy this delectable dish, which has become a favorite of mine.

Note: Thanks to my friend Darren for pointing out to use tomato paste packaged in glass, rather than cans, unless the cans are specifically labelled that they aren't lined with BPA (bisphenol A). BPA is about as nasty as a compound can get, and the acids in tomato products leech it from the can lining into the food itself. Maybe I should post about this in the future. . .

Allergy season starts again

Last year, a friend of mine wrote to me looking for advice about his seasonal allergies. As soon as spring started to take hold in Massachusetts, he’d be sneezing and stuffed up, and would remain so for months. For years, he’d been taking Claritin and Zyrtec but wanted to cut back on them, going instead for a more natural approach. I made some recommendations, and he was able to cut his usage back to about 25% of what it had been previously! He emailed me last week to let me know about his continued success, and is looking to see how much more he can do this year… Maybe even go off the meds altogether. We’ll see how it goes, but it got me to thinking that I probably ought to write about natural approaches to allergies.

The first line of defense when it comes to allergies for most naturopathic doctors are vitamin C. Simple and unassuming, sometimes overlooked, vitamin C packs a punch against seasonal allergies. The exact mechanism is as yet unknown, although it appears as though it helps to block histamine release, as well as improving the breakdown of histamine once it is released. Dosing with vitamin C is variable, but 1-2 grams per day is an average dose. During acute flares, some patients take higher dosages, but this should only be pursued while under the supervision of a doctor, as there can be some side effects – loose stool and abdominal cramping being the primary one.

Quercetin comes next on the list, and for similar reasons – it’s a mast cell stabilizer that prevents those cells from releasing of histamine. Dosage is lower than the vitamin C dosage, and quercetin doesn’t generally come with any abdominal symptoms. Try going for around 500-1000 mg per day. In my experience, this does not have as strong an immediate effect as vitamin C, but can bring great results if used for long-term maintenance and prevention of seasonal allergies. Quercetin is often available in products along with vitamin C, making it easy to get these nutrients together. The friend I mentioned above used what is often called a ‘QBC’ product, meaning that it contains quercetin, bromelain and vitamin C. Bromelain is used in these products because it is an anti-inflammatory enzyme – when taken on an empty stomach, it enters the bloodstream and helps break down inflammation-producing molecules.

There is some question about the exact mechanism by which quercetin acts in allergies, as it is absorbed poorly in the gut, but nonetheless, it’s used clinically with great success. In vitro research has clearly shown that it acts directly on mast cells with great efficacy, leading a teacher of mine to suggest that its actual mode of action is calming the immune response in the gut, thus indirectly calming the systemic immune system.

It seems that people can’t get enough of probiotics lately, and allergies are no exception. Several studies have emerged recently that indicate that various preparations of probiotics help to relieve allergy symptoms. The exact mechanism is as yet unclear, but it has been suggested that the positive effect may come from actually influencing the immune system to shift the type of immune cells it produces – a shift from Th2 cells to Th1 cells, a shift associated with a less allergic immune response.

One issue in the use of probiotics that hasn’t been fully answered is the question of what strains to use. Clinical trials of probiotics always use specific strains of probiotics, because such is the nature of clinical trials – in order to meet the standards of clinical trials and facilitate reproducibility, researchers need to note exactly what species and strain was used to generate the results. Unfortunately, this doesn’t always translate to what is available to consumers! Here’s the good news, however – other research states that non-allergic people have higher levels of beneficial bacteria in their digestive tracts across the board, not just one or two strains. This means that probiotics of various types may offer benefit to those with allergies, so as long as you are buying from a reputable brand, you are in the clear.

Fish oils are sometimes used by clinicians for allergies, and although the research isn’t as strong, the reasoning is straightforward. As I’ve stated in previous columns, unsaturated fats, like those found in fish oil, are used by the body to produce anti-inflammatory compounds. This is in contrast to saturated fats, which are used to produce inflammatory versions of those same compounds. The logic says that by reducing saturated fats and increasing unsaturated fats, you shift the body towards a non-inflammatory state. Fish oils are a good idea for almost everyone anyway, and while the research isn’t specifically there for allergies, I recommend this as a general health measure.

And finally, for those of you who thought you could get away this allergy season by just taking vitamins, here’s the part where I say you should eat veggies and exercise. So there it is. Eat veggies and exercise. End of story.

Actually, it’s not the end of the story, but everything I’ve already said will be repeated here in this section. Less fatty meat and more fish will shift your body towards a less inflammatory state. Yogurt, sauerkraut, and other fermented foods contain live probiotics that can help promote healthy gut flora. Remember that veggies are chock full of vitamin C and bioflavinoids (like quercetin), which help to block the release of histamine, and the other antioxidants and minerals may help out as well.

I also want to make sure that I recommend drinking plenty of water and exercising. Part of the problem with allergic symptoms is water balance. Some folks have thick mucus that blocks their nasal passages, others have profuse flowing snot – either way, it’s a question of balance. By consuming water regularly and sweating it out, you help train your body to regulate the flow of water, not to mention helping to keep a steady flow of inflammatory compounds out of the body. There is, of course, no research showing this to be true, but I but I think it’s sound judgment. Let’s be honest, drinking water and exercising are helpful anyway, so get out there and get moving!

Long as this list might seem, it can actually be broken down into a fairly straightforward regimen. Eating vegetables and drinking plenty of water is the basis for any healthy regimen, as is moderating the amount of saturated fat you eat, and increasing unsaturated fat. Beyond that, make sure you get enough vitamin C and bioflavinoids (like quercetin) – in high doses like the ones listed above, they can really shut down the allergic cascade. Finally, probiotics seem to help just about everything, and the research is clearly there on allergies, so make sure you get those little guys in every day. Most importantly, all of these recommendations help prevent allergies in different ways, which means they won’t interact with one another, and will have an additive effect by shutting down your allergies in multiple locations.

And remember: the earlier the better – the more you can do to get your allergies under control now, before they start, the better. An ounce of prevention is worth a pound of cure.

A ringing endorsement of the Mediterranean Diet

Diets are a dime-a-dozen in America, and most will make elaborate claims for their effectiveness, ranging from losing a few pounds, to losing all of your body fat, growing an inch or two, and marrying the celebrity of your choice. Few deliver on these claims, and fewer still come with rules that are easy to follow. Many also focus on weight loss as their sole purpose, without regard to the effect of the diet on the rest of the body – the Atkins Diet is the classic example. In contrast to most diets, the Mediterranean diet is fairly simple to follow, has strong research behind it, and promotes healthy weight without sacrificing the rest of the body. I advocate eating in accordance with a Mediterranean diet even for those not seeking to lose weight, as I believe it to be one of the best diet plans currently known.

One of the things that makes it so easy is that it focuses on food, rather than numbers. What I mean is that when you sit down to eat, instead of counting calories, fat content, sugar content, or whatever, you decide based on the food itself. Thus, rather than pulling out a calculator and saying, ‘Ok, if I get the salad minus the dressing, and the pasta dish, but not the one with the cream sauce, and a non-fat latte, that will be the right amount of calories,’ you would instead say to yourself, ‘Ok, Salmon and Kale – salmon has omega-3s and protein, kale has fiber, vitamins and minerals. Good choice, I’m going to enjoy this.’ Focusing on what foods offer, rather than avoiding ‘bad stuff,’ is easier to do, and a healthier way to interact with food. Additionally, being in a positive state of mind while eating and being happy about the food you are eating, rather than fearful that it will make you fat or unhealthy, allows you to enter a parasympathetic state while you are eating, improving your digestion and helping you make the best of your meal’s nutrients.

Ok, the nuts and bolts... Here’s what you should eat the most of: olive oil or other unsaturated fats, fruits, vegetables, unprocessed grains, legumes and fish. Consume moderate amounts of eggs, dairy and wine, and low amounts of red meat. The resulting diet is high in fiber, high in unsaturated fat, high in antioxidants, low in sugar and low in saturated fat. The additional rule is that this should be accompanied by regular physical exercise – remember that before supermarkets, if you didn’t work, you didn’t eat!

The unwritten rule to the Mediterranean diet, which I feel is at least partially responsible for the diet’s beneficial properties, is to eat whole foods, and cook for yourself. These two rules go hand in hand as part of a diet plan. Based as it is on a traditional diet, the Mediterranean diet emphasizes food in its natural form, not in a processed, manufactured form. The health upshot of this is that by eating fewer processed foods you consume less saturated fat (and trans-fat) and less sugar, which are used to prolong the shelf-life of foods.

The research is very strongly in favor of the Mediterranean diet. The first data to support the efficacy of Mediterranean eating patterns came from the Seven Countries Study, which showed that deaths from heart disease in Southern European populations were lower than Northern Europeans and North Americans. Since then, many large studies have shown added benefits to a Mediterranean style of eating, including lower rates of depression, Type II diabetes (non-insulin dependent diabetes), obesity, hypertension, hypercholesterolemia,  and all-cause mortality. The message here is that the Mediterranean diet promotes a healthy weight, as well as dramatically improved cardiovascular health.

One of the reasons that I believe the Mediterranean diet to be especially beneficial and easy to follow is that it is modeled on how people actually eat, coming from traditional eating patterns in coastal Greece, Italy, Spain and Morocco. Many diets are based on scientific research into nutrition and biochemistry, and try to target one macronutrient as the cause of weight gain or ill health – low fat, low carb, etc. diets fall into this category. The Mediterranean diet is based on a diet that has proven healthy for millions of people for generations. As a result, it takes into account a healthy balance of macronutrients, combined with vitamins and minerals. Additionally, and importantly, the diet is an enjoyable one, for after all, people wouldn’t have been eating this way if it didn’t make them both healthy and happy. So get out there, get some exercise, then come home and cook up a healthy meal, and above all, have a blast doing it – your heart and waistline will thank you. 

Seeking new ways of paying for healthcare in the United States

Few if any people would argue that the healthcare insurance system in the United States works, at least unless they are making political arguments against President Obama’s health care bill. Even those folks, however, I’m sure would privately admit that the system is failing. Americans are paying more for their healthcare every year, yet health outcomes here are average at best. Additionally, with health insurance benefits being steadily cut, many Americans are finding themselves in the situation of having to pay for their healthcare, in addition to paying for their healthcare. Now is the time to begin experimenting with alternative ways to pay for healthcare, and I’ve recently noticed a couple of options that have really caught my imagination. And despite being a ‘crazy naturopath,’ I’m not going to suggest you go out bartering free-range organic quail eggs for your healthcare!

The first interesting trend I’ve noticed is the rise of fee-for-service practices. While NDs and acupuncturists have traditionally operated such practices, an increasing number of MDs and NPs are operating their businesses this way as well. This new wave of providers are offering not only primary care, but urgent care as well. In such an arrangement, you pay for services only when you need them, rather than paying a monthly premium whether or not you use the services. As a result, one of the groups that has gravitated towards these practices are the uninsured looking for lower-cost urgent care visits. Many fee-for-service clinics argue that by not contracting with insurance companies, they are able to offer lower prices to consumers, as much as 40% lower, in fact. For the uninsured, these clinics are often the best option in non-emergencies.

The other group that gravitates towards these types of clinics is the underinsured. This group is increasingly large, and includes everyone from people with high-deductible ‘catastrophic’ plans they have purchased themselves, to those with employer-based plans that also carry high deductibles and offer few services. Fee-for-service clinics often have shorter wait times, and patients find that they are able to get appointments sooner than they would with the doc designated by their insurance plan. Additionally, most of these clinics offer paperwork that can be submitted to insurance companies so that their fees can be applied to deductibles or be reimbursed. The combination of a high-deductible ‘catastrophic’ plan to guard against emergencies, combined with visits to fee-for-service clinics for urgent care and primary care is becoming an increasingly viable option, as it decreases the amount of money spent on unused services, and allows for better patient care and better access to doctors.

The second movement, still in it’s infancy, that’s caught my eye is being pioneered by Qliance in Seattle. This clinic operates as a modified ‘concierge’ practice, in that members pay a monthly fee that guarantees them access to a primary care doctor, covers visit fees and covers the most common lab work. Patients are still responsible for some incidental fees, such as medications and more advanced lab testing, but even so, Qliance offers very affordable services. The practice recommends that patients purchase high-deductible ‘catastrophic’ health insurance plans in addition to their subscription to the clinic, and most patients thus end up in a situation where they pay separately for emergency care (through insurance companies) and primary care (through Qliance). While in most circumstances, purchasing items a la carte increases costs markedly, this arrangement keeps costs low for consumers, and most importantly, provides excellent customer service. Qliance deserves plaudits for taking the ‘concierge’ model and using it to create affordable healthcare at a larger clinic.

Finally, I read recently about a start-up company named Castlight, who are taking it as their mission to ‘cast light’ on healthcare costs, with the goal of allowing patients to do comparison shopping when they purchase health insurance. If you are like me, you’ve tried to do comparison shopping for health insurance and have found it maddeningly impossible. It’s difficult to compare services, it’s difficult to compare what will and won’t be covered, and above all, it’s difficult to compare how much it will all cost you. Castlight seeks to enable consumers to comparison-shop, and understand how their actual health expenses will vary depending on what plan they choose.

While still in a pilot phase that’s being offered only at select employers, Castlight is planning on offering its services more broadly as they expand. This company has been lauded by the Wall Street Journal for applying free-market mechanisms to health care, and I believe that it will likely be a company you’ll hear more about in the future, and one that may inspire competitors offering similar services. I applaud Castlight for working to arm consumers with information; as I wrote in a previous column, I believe that it is important for health care consumers to be knowledgeable about health when they see their doctor, so why shouldn’t they also be informed about the economics of health as well?

The days when physicians were able to maintain something of an ivory tower about health are gone, and it’s time for us doctors to work in co-operative partnerships with our patients, not in benevolent dictatorships, as was done in the past. Patients want high quality care, and they want to be able to afford it. For decades, the American push for low prices has meant a similar trend to low quality, but these fledgling programs are showing that affordability and quality don’t have to be mutually exclusive. Ever skeptical, I can’t fully anticipate whether or not this will be able to expand into a viable option for millions of people, but even as we speak, a growing group of Americans are feeling great and not breaking the bank to do it.

In solidarity with doctors around the world

As I write this column, doctors in a number of countries in the Middle East are being attacked, arrested, and otherwise prevented from saving the lives of people injured while demonstrating for the right to have a say in their government. In some countries, far worse is being done.

As a naturopathic physician, I cannot stress enough that I find this unacceptable. Amidst the debate over the No Fly Zone in Libya, and calls for more strident action in other countries, not nearly enough is being done to ensure the protection of doctors, nor enough to guarantee access to medical care. This is something that we can all agree on – humanitarian aid to those in need. I urge you all to contact your representatives in government to make your opinion known. People across the Middle East don’t have governments that respond to the will or desires of the people. We that have that luxury should use it to help those in need.

To contact your US Congressperson

To contact your US Senator

To contact the White House 

Food Intolerance and ADHD

Some of you may have heard on NPR about a recently published study that demonstrated that dietary changes can reduce symptoms in about 2/3 of children diagnosed with ADHD, so that they may not need medication. I listened to it myself, as ADD/ADHD is a special interest of mine, and did a little more research to learn more about the proposed diet, and how to implement it. Some of you may also remember my earlier article about ADHD and diet; to be clear, they are proposing something altogether different.

The interview on NPR was a bit vague, and I was left wondering what type of diet they had found was effective. The diet that was found to be successful was a food sensitivity elimination diet, based on elimination of foods found to test high on an IgG blood test. Essentially, the researchers ran blood tests on 50 children diagnosed with ADHD, determined which foods they were having reactions to, and then had those children avoid the foods for five weeks (of course they also had a control group of 50 children who weren’t avoiding any foods). At the end of five weeks, 30 out of 50 children had reduced symptoms of ADHD. For the next four weeks, those children were fed the foods that they had been avoiding for the past five weeks. Of the 30 kids who had had reduced symptoms when they avoided the foods, 19 relapsed when they started eating them again.

This is confirmation of what has been clinically observed by some naturopathic doctors in the past, that reactions to foods are part of the cause behind ADHD for some kids. The exact mechanism is not yet known, but this study indicates that in some cases, ADHD isn’t a disease proper, but rather a symptom caused by an immune response to foods.

There are, however, some factors that prevent this from being implemented immediately. One is the fact that most physicians haven’t been properly trained how to interpret these tests, or implement the necessary dietary changes, a limitation recognized by the authors of the article. Some solace may be taken in the fact that many naturopathic doctors are well-versed in how to deal with food allergies, both in testing for them as well as counseling patients on avoidance. Beyond this, however, is the question of food sensitivity testing technology. As I stated in a previous blog entry, food sensitivity testing is unfortunately not yet at the standard of other testing procedures (such as cholesterol, blood sugar, electrolytes, etc.). Additionally, the study itself doesn’t discuss the testing methods in the detail necessary to implement their methods. I am keenly interested in learning what testing method was used in this study, as it appears to be one that correlates well to clinical outcomes. As I learn more, I’ll keep readers of this blog updated on what I learn.

As always, this information should be considered as just a piece of the puzzle. ADHD is not as simple as a food allergy, it’s not as simple as a behavior problem, it’s often multiple things. Proper treatment of ADHD can include food avoidance, behavioral therapy, coaching, supplements, homeopathy, biofeedback, and even medication. There is unfortunately no magic bullet, but at the same time, the fact that so many of the interventions are lifestyle-based should encourage us, because these things are within our control. There is a lot that we as parents and practitioners can do about ADHD before having to use medications, and I encourage you to explore those options.

*For those seeking the article itself, you can find it here.