Are You Showering Right? Part 2

While hydrotherapy is thousands of years old and was mentioned by Hippocrates, modern hydrotherapy came into being in Central Europe in the 19^th century. The two most famous proponents of the revival were Vincent Priessnitz and Sebastian Kneipp, the one a peasant who first cured himself, the other a priest who is considered the founder of naturopathic medicine. The spa towns of the Czech Republic and Germany remain the epicenter of hydrotherapy, and in the years since its revival, a very wide range of techniques have been developed and refined by practitioners. Naturopathic doctors learn about a number of techniques, including constitutional hydrotherapy, hyperthermy, contrast hydrotherapy, and others. One such technique, frequently recommended by naturopaths, is home-based contrast hydrotherapy done in the shower – this is a modern application of a method largely based on folk knowledge and clinical experience, but in recent years, there has been some research into the topic by some adventurous young docs.

For those who want to cut to the chase, here’s the treatment in its simplest form:

Step 1 – Take your shower as normal, using warm to hot water for approximately 5 minutes. (Some docs call this a pre-heating phase)

Step 2 – At the end of your shower, turn the temperature down, and finish with cooler water for about 30-60 seconds, making sure to expose your limbs, core (chest and back), head and face to the cool water.

To reap maximum benefit, this is meant to be a daily ritual.

One important point for those who are interested in trying it out is to accommodate to colder water slowly, over a period of days to weeks. Usually, this means starting with lukewarm water, getting used to that, then cooling the water a bit, getting used to that, and so on. In my practice, I’ve seen that patients find a more aggressive treatment to be hard to tolerate and harder to stick with – if you’re not used to it, freezing cold water first thing in the morning will leave you feeling cold all day, and that’s no help to anyone. If instead you follow a more moderate regimen and build towards colder water, you’ll reap the maximal benefit. In the process, don’t forget to be sensitive to how you feel from day to day – some days you’ll be able to tolerate colder water than others.

The modern theory behind this treatment goes like this – brief, controlled stresses improve your health by provoking a response from the body’s defense mechanisms. Major stresses (viruses, bacteria, etc.) provoke that same response, but in a way that comes at great cost. By stressing the body in a controlled fashion, we can experience a heightened effect from the body’s defense mechanisms, but with no significant side effects. This really shouldn’t surprise us, as it’s a similar process that causes plants to produce antioxidants. For plants, it’s the stress of being subjected to ultraviolet radiation and other environmental stressors that causes the formation of healthy antioxidant compounds, and in fact fruits and vegetables grown in more sheltered environments (like greenhouses) tend not to produce as high quantities of antioxidants.

So here’s what the research says about brief, controlled exposure to cold:

1. It can boost your antioxidant status, something that’s hard to do and even harder to prove. A German study showed that people who engage in winter swimming (an intense short-term exposure to cold) have higher antioxidant activity in their red blood cells. Here it was postulated that the improved antioxidant activity was due to repeated exposure to a controlled stress. To be clear: increased antioxidant activity in the blood is a true prize in the world of medicine. Few studies of antioxidants measure this as their outcome, so it’s good to know that something will do it. The reason this antioxidant activity is important is that it’s almost certain to prevent chronic disease of many types, including rheumatoid arthritis, cancer, and atherosclerosis, among others.

2. It modulates immune function. This has been studied in quite a large amount of detail at this point, and several studies have shown multiple immune enhancing effects from cold water stresses. (1, 2, 3) Those with scientific minds may want to know that the specific changes noted were a boost in Natural Killer (NK) cell function, CD8+ and CD4+ cells, as well as tumor necrosis factor (TNF-a). An additional study showed that the immune-stimulatory effects were boosted by exposure to either hot water or vigorous exercise before the cold stimulus. These immune modulating effects has prompted one researcher to postulate that cold water stimulus may have anti-tumor activity. This remains a hypothesis, but for those interested in learning more about the topic, the published paper is available in full text for free, and it contains a truly encyclopedic set of references.

Easy to do and effective, home-based contrast hydrotherapy is a recommendation I make to a lot of my patients with a variety of conditions. In addition to the benefits I’ve noted above, it also has effects on the cardiovascular system and on a number of hormones. Additionally, unlike many treatments, which are appropriate only for certain diseases or certain people, I believe this treatment to be mild enough and universally beneficial enough that nearly everyone can benefit from it. So that’s your cue – get out there and get your immune system working better!

Are You Showering Right? Part 1

“Am I what? Am I showering right?” you ask? The answer to this question is not as straightforward as it may seem. Soap, shampoo, and a scrub behind the ears are the obvious elements of this daily ritual, but there’s more to it than you may be aware of, and I’m devoting the next two entries to the humble shower.

Today’s entry is about the water itself, or rather, what’s in the water. Though we in the developed world can rest assured that we can drink from the tap without much risk of waterborne infection, we encounter a different sort of baddies in our water, namely toxic chemicals. Most of us have gotten used to using Britas or other water filters to filter our drinking water, but it may be a good idea to start filtering your shower water too. Let’s start with a quick round-up of what may appear in the water.

1. Biological contaminants – This category includes bacteria, viruses, fungi, etc. Fortunately, as I said, here in the developed world we don’t generally have to worry about these guys, but there are a few really stubborn critters that can slip through the defenses, albeit in very small amounts.

2. Metals – This category primarily includes lead, though there a few others in the list as well, including arsenic and chromium. Lead is a well-known concern in older homes because of the use of lead piping prior to 1986. However, even newer homes may have some amount of lead in the water – the government allows a lead content of up to 8% in new piping. This is important to be aware of, because the lead enters the water once the water enters the house – after it’s been filtered by the public works. Thus a second filtering is necessary.

3. Volatile Organic Compounds (VOCs) – VOCs make up a large and diverse group, but most VOCs are byproducts of manufacturing or industrial farming. Examples of well-known VOCs include MBTE and formaldehye. Their effects are similarly broad, but they can impair liver function, kidney function, the nervous system, the immune system, and some have carcinogenic effects. These are filtered by the public works, and the EPA has set acceptable levels for their presence in drinking water. At acceptable levels, the compounds have been judged not to cause disease, so that’s good, but I haven’t seen studies on the effect of encountering multiple VOCs simultaneously.

4. Trihalomethanes (THMs) – THMs can enter the drinking water through a number of routes, but one of the primary ones in the US is via water purification. In many states, chlorine is used as part of water purification processes, lending the water a slightly taste, and forming THMs. One of the best known, most common of these compounds is chloroform. Many THMs are considered carcinogenic. These also have approved acceptable levels, at which point they are believed not to contribute to disease, but again, multi-exposure is poorly studied.

(For more info about your tap water, go visit the EPA’s Ground and Drinking Water Homepage.)

Long story short, there are some nasty chemicals in the water you drink and shower with. The question, however, is whether or not they actually enter your body. These compounds differ markedly in their chemical activity, so some can be absorbed through the skin, whereas others cannot – inorganic lead (the type found in lead piping), for example, is essentially inabsorbable through the skin, whereas VOCs can be absorbed transdermally, albeit at a slow rate. However, one of the major issues in showering is that these chemicals become aerosolized, which then leads to them being inhaled. Inhalation is a rapid route of absorption for many compounds, for the same anatomy that makes the lungs especially good at taking in oxygen makes them similarly effective at taking in airborne chemicals. This is especially an issue for THMs, and chloroform has been the subject of much study.

Chloroform is a proven animal carcinogen and a suspected human carcinogen, which primarily targets the kidneys and liver. As I stated previously, showering is a major contributor to chloroform concentrations of indoor air, which has been attributed to lack of ventilation when showering, as well as the heat of the water. Hot water in particular seems to not only encourage formation of THMs in chlorinated water, but it also encourages aerosolization of those compounds. Regarding the real-life health effects of chloroform resulting from showering, the jury is still out, for Canadian studies showed that the risk of cancer due to chloroform in tap water is quite low, a Spanish study showed that chloroform levels comparable to what we encounter regularly are enough to cause bladder cancer.

As stated previously, each of these compounds is at an acceptable level in the water, but the sum total of encountering multiple pollutants has not to my knowledge been assessed. Sure, the levels of chloroform in the water may be sufficiently low enough that chloroform alone won’t cause you much damage, but consider the other THMs that may be in your water. Then add the VOCs, a massive category, some compounds of which may not yet be described. Then add the air pollution you encounter on a daily basis, which if you’re an American is pretty high. Add these all together and you’ve got a pretty heavy daily load. Take my advice – cut down at least part of that load. A good shower filter (an activated carbon filter) can reduce your exposure to water-borne toxic chemicals.

That’s all for now. Tune in next week when we talk about basic hydrotherapy for improved energy, better mood and increased sense of well-being.

A Czech Spa Town

Today, I redesigned my blog to have a cleaner, more accessible appearance. I hope you like it. One of the reasons I did so was to include more photos as part of the blog. If you look in the upper right hand corner, you'll see a pic of Lake Bled, former home to Arnold Rikli, a Swiss naturopath who had a sanatarium on the banks of the lake. Click through and you'll see some more photos of one of Europe's most scenic places.

In addition to the time I spent at Lake Bled, I also visited Márianské Lázně, a small spa town in the Czech Republic, built around a series of mineral-rich natural springs and nestled into a small valley. Once frequented by such celebrities as Frédéric Chopin, Johann Wolfgang Goethe, Thomas Edison and Richard Wagner, not to mention King Edward VIII, Czar Nicholas II, and Emperor Franz Joseph I, there are still many hotels there which offer restorative spa treatments.

It was a cloudy day when I visited this little town, but that almost added to the nurturing atmosphere. Hope you enjoy these pics as well:

There are a many, many spa towns throughout the Czech Republic, and you may be wondering why the Czechs are so active in taking care of their health. Well, here's why: 

Delicious? Hearty? Satisfying? Soul-replenishing? Yes, it's all of those, but let's just say... it sticks to the ribs. Thank god for exercise!

The Data Is In – Medicaid Works

A few years ago, Oregon sought to increase the number of its citizens on Medicare, but only had the funding to accommodate 10,000 new applicants, though 90,000 applied. Oregon was faced with the problem of having to distribute those 10,000 memberships at random. Realizing the opportunity present, social scientists seized on the situation, because it allowed them to conduct a thorough study of the effects of government-sponsored medical insurance. Prior to this, arguments had largely been made using epidemiologic data, with supporters arguing that countries with universal health care had better outcomes than those without. Oregon’s quandary gave the opportunity to study how health insurance affects the medical and economic lives of Americans, as compared to a similar group who don’t have insurance. The results were clear: Medicaid improves perception of health, improves use of preventive medicine, and improves the economic well-being of its users. And as a side note, Oregon has since found funding for the 80,000 initially denied access to Medicare.

I’ve written occasionally on the social and economic aspects of medicine, and I have to say that this is one of the most important studies to be published in some time. Never before has the effect of having health insurance been studied with the rigor that was possible here, and this study is likely to be cited by politicians for years to come, if not wholly shift the current discussion.

One of the basic findings of the study is that people with health insurance, even health insurance as flawed as Medicaid, are more likely to use healthcare services, including being 35% more likely to go to a doctor as compared to those without healthcare. Accessing doctors doesn’t mean that all of our problems are solved, but it greatly increases the likelihood that negative outcomes are prevented down the road. That said, the study didn’t indicate any difference in amount of ER visits, so it’s unclear as to whether the increased access to doctors had an effect on morbidity and mortality. The effect of Medicaid on the health outcomes of subscribers is currently being studied, and I’m anxiously awaiting results.

However, what is clear is that Medicaid subscribers were significantly more likely to access preventive health services, including mammograms and cholesterol checks. These factor are indeed likely to decrease morbidity and mortality. Similarly, people with insurance were overwhelmingly more likely to have an established doctor or clinic, adding greatly to continuity of care, an important factor in the quality of healthcare a patient receives. Additionally, patients with Medicaid were more likely to rate their health as being good or excellent, and significantly less likely to report deteriorating health.

Finally, the study shows that Medicaid provides significant financial benefit to its beneficiaries. People on Medicaid were significantly less likely to have unpaid medical bills sent to collection agencies, as well as being less likely to fail to pay other bills or borrow money because of medical expenses. This demonstrates that Medicaid works as a social program. While it is yet undetermined whether or not Medicaid improves health outcomes, it is clear that it is an effective economic safety net for those most in need – this alone vouches for its value.

This study and its yet-to-be-completed sequel are likely to shape public policy for years to come. It’s rare that we have the opportunity to study the effect of government programs with the same rigor as medical trials, but here the opportunity fell on the laps of a few lucky researchers. In a controlled study, Medicaid showed that it works to improve access to physicians, improves utilization of preventive medical services, and decreases economic hardship – if that’s not reason to keep it up and running, if not expand and improve it, I don’t know what is.

Happy 4th of July!

In honor of the nation's independence from Great Britain, I'm taking the day off - not to worry, though, as I have a great article coming up next week!

Let me just take today to thank all of you readers! I started writing this blog seven months ago, and it's been a great experience. I've learned a lot about what matters to readers, and how to communicate it best. Thanks for all of your feedback and here's hoping for a great future for this little blog!

How to interpret your cholesterol test: The Basics

Despite the fact that nearly every adult American has these tests done at some point, it never ceases to surprise me when I’m asked what the tests mean. I order this test fairly regularly, but additionally, I have patients ask me to explain what the tests mean when their MD has ordered them. It’s an unfortunate fact that doctors often don’t fully explain the tests they are ordering, what the results mean, and what to do about it. I’m going to avoid speaking to the question of what to do about it, except in general terms, in order to provide a brief explanation of what’s being tested and what it means.

Total Cholesterol

Cholesterol is a small molecule found almost everywhere in the body, and which serves a wide variety number of functions, most of them beneficial. However, the reason doctors test for it is because excessively high levels of cholesterol in the blood have been linked to increased risk for heart disease. The basic mechanism is this – overly high levels of cholesterol in the blood mean increased amounts of cholesterol being deposited in artery walls, causing the walls to become stiff and inflexible. This damage leads to other disease further on down the road.

As medicine has learned more, cholesterol isn’t tested alone, but is parsed out into HDL and LDL. One important thing to understand is that cholesterol includes molecules aside from HDL and LDL (such as IDL and VLDL), so when you add your HDL and LDL counts together, it may not add up to your total cholesterol. While an ideal cholesterol count is below 200 mg/dL, patients with counts between 200 and 230 don’t necessarily need medication, especially if modifiable factors are identified that could be contributing to high cholesterol – these include lack of exercise and poor diet.

HDL

First, ‘good cholesterol’. The reason HDL is referred to as ‘good cholesterol’ is because higher counts of HDL are actually protective against heart disease. HDL is a molecule that travels throughout the bloodstream taking cholesterol out of blood vessel walls, thus reducing damage. Ideal HDL counts are between 45 and 60 mg/dL, though higher levels (above 60) may confer additional protection. Among the things found to increase HDL in the blood are exercise and fish oil.

LDL

LDL has earned the term ‘bad cholesterol’, because LDL travels the blood depositing cholesterol into blood vessel walls, opposite to HDL. Ideal numbers most people are 100 to 129 mg/dL, though many people, especially those with a family history of heart disease, will need to aim for levels lower than 100. When a high LDL is seen in conjunction with a low HDL, this is often an indication that dietary and lifestyle factors are at fault. LDL can be lowered by exercise and dietary fiber.

Triglycerides

Triglycerides (TAGs) are more complicated than simple cholesterol, but provide a great piece of information. Though TAGs are tested along with fat molecules, they are actually made from sugars, and thus reflect dietary intake of carbohydrates, especially simple carbohydrates and sugar. While elevations in triglycerides don’t indicate diabetes, people with type II diabetes (adult onset diabetes) often have elevated triglycerides. Ideal levels of TAGs are below 150 mg/dL, and these tend to decrease fairly quickly in response to dietary changes.

Glucose

While not specifically part of cholesterol testing, these are often ordered at the same time, because diabetes is a major contributor to cardiovascular disease. Type II diabetes is very controllable with diet and lifestyle changes, and can actually be reversed in some cases. Ideal levels are below 100 mg/dL after an overnight fast. Many doctors are now also testing hemoglobin A1c (HbA1c) to assess for long-term exposure to high blood sugar levels, so you may start seeing that appearing on your lab tests in the future, if you haven’t already.

CRP or hsCRP

Many of you will have seen this on lab tests as well. These molecules are generally interpreted as indicators of inflammation in the body. There have been efforts to link them to heart disease, because they are elevated as a result of artery wall damage, but unfortunately they are not very specific, as they can become elevated due to a variety of factors including acute illnesses. While the search for a reliable marker for vessel wall damage is important, and it’s laudable that people are looking, this test isn’t as reliable as we’d like it to be.

Conclusion: Metabolic Syndrome

This disease has gone through a number of names, including Syndrome X and Metabolic Syndrome X. It’s important to be aware of Metabolic Syndrome because it’s a major health problem in the US, especially among men, and it’s largely a result of diet and lifestyle. While the tests discussed can be affected by a variety of diseases, when they add up to Metabolic Syndrome, diet and lifestyle changes can have a major impact. Metabolic Syndrome is defined as the presence of three of the following five criteria: abdominal obesity, high triglycerides, low HDL, high blood pressure, and high fasting blood glucose. The guideline numbers can be found here.

A basic prescription for Metabolic Syndrome is this: moderate fat consumption (with a focus on healthy fats), low sugar consumption, and an exercise regimen.  Because Metabolic Syndrome is induced by lifestyle, lifestyle is the way out, and it requires work – my advice is to find a qualified naturopathic doctor or primary care medical doctor to work with you on this, to help you set and reach goals. In the age of the internet, it’s increasingly possible for consumers to become educated about their healthcare, and I encourage you to do so. While it’s important to be knowledgeable about health, don’t forget that being healthy is hard work, and you’ll need help along the way – find a good doctor who you work well with. Form a therapeutic alliance and use that person as a trusted advisor. Not every disease is caused by diet or lifestyle, but many are, and it’s important to have someone in your corner working for you.

On the Importance of Pronunciation, or, The Benefits of a Classical Education

It has been pointed out that Modern American English is not Ancient Greek. It has also been pointed out that Classical Latin and Modern American English are distinct and separate languages. Thirdly, for all of the cultural poaching that the Romans did from the Greeks, Latin and Greek are nonetheless not one in the same. However, despite differences in alphabet, grammar and literary tradition, these three languages come crashing together in one area – medicine.

For most, a classical education merely provides the ability to guess the end to every movie ever made, as they are invariably based upon plots which have been recycled again and again since the days of Aristophanes. However, for the physician, a basic understanding of Greek and Latin provides many benefits, beginning of course with anatomy – foramen magnum or thyroid, anyone? Greek and Latin have historically provided the basis for naming in medicine, though as we’ve entered the era of genetics, and what once may have been given a tripartite, multisyllabic, heroically dense name is now referred to as BrCA1. Alas, how far we have fallen.

While the American educational system is well-equipped to make sure that most who make it all the way to medical school are able to differentiate between “there”, “their”, and “they’re”, it’s become deplorably commonplace that Latin and Ancient Greek are no longer required core classes, depriving millions of their Zeus-given right to a classical education, not to mention the joys of being forced to sing Gaudeamus igitur. Nowhere is this failing more evident than in pronunciation. As a first year medical student, my ears were put through agony by the attempts that my classmates would make at the new words we would encounter – for the most part, they did fairly well, but I’ve identified two specific instances in which the average medical student (naturopathic, anyway) could use a little advice.

1. The Latin pronunciation of the letter C

Latin is a man’s language. Most of what was written by the Romans describes thousands of people being killed, either in real life, as in the conquest of the Mediterranean, or in the mythological past, where we mere mortals were being killed left and right. As a result, there are few soft consonants in Latin. This is especially true of the letter c, which is almost always pronounced as a k and never as an s.

Sure, we may slip sometimes and say “extensor pollisis longus”, instead of the firmly masculine “extensor pollikis longus”, but when discussing the Seven Principles of Naturopathic Medicine, it’s important to get your pronunciation right. Remember, you’re a doctor, not a dostor, so don’t forget to emphasize the hard c when you talk about Docere to your patients. Similarly, Primum non nocere takes on a special ring when pronounced correctly, a ring that reverberates with the sound of harm not being done. These may seem like minor points in the greater scheme of things, but know that generations of Latin teachers will smile upon you for your good work.

Adding some complication to this is the fact that Medieval Latin, and by extension Church Latin, replaced many of the c sounds of Classical Latin with the softer ch. “Primum non nokere” gave way to “Primum non nochere”, and thus began the Dark Ages. Believe me, all it took was a few lazy students ignoring their teachers’ stern warnings about pronunciation, and soon half of Europe was dying from plague. It’s really that simple. Let’s not have to go through that again.

2. Greek Consonant Clusters

Greek consonant clusters, while not technically diphthongs, are best explained as really complicated diphthongs that the Greeks created to express their deep appreciation of the challenging, laborious nature of the universe. In the same way that there is something deeply rewarding about listening to an old blind man ramble for days about some guy who gets lost on his way home, just to hear the part where he kills everyone who’s been trying to sleep with his wife, so too is there something gratifying about having to pronounce p and n in direct succession every time you want to refer to the lungs.

Three of the most commonly used examples in medicine involve the letter n – gn, pn, and mn. People run into trouble with them because they’re involved in three words that sound very similar, and while no one would nor diamnose someone with gneumonia, when you throw mnemonic, pneumonic and pathognomonic at someone, you run into trouble. Trust me – looks these words up on Wikipedia and you’ll see mention of the difficulties people encounter when dealing with these words. Modern English speakers simply ignore those first consonants and focus on the n, but that’s no way to behave.

People also run into problems with the even more challenging pt. Once relegated to the nightmares of young students trying to translate passages from the works of Ptolemy, this linguistic stumbling block has now been thrust back into the spotlight by oncologists, who insist on constantly referring to apoptosis. Medical necessity, combined with the decline of American educational standards, means that every day, medical students and professionals speak of “ay-pop-toe-sis”, causing thousands of Greek warriors, long dead and buried on the shores of Ilion, to scream from the depth of Hades, “It’s aah-puh-pto-sis, you idiots!”

Here’s what it comes down to: the mountain crags and rocky soil of Attica are no place for frivolity. Food, water, money, and above all letters were conserved, and nothing was wasted. If the Greeks put a letter there, they did it for a damn good reason, so show some respect and pronounce it. Not only will you appease the spirits of red-haired Menelaus and the mighty Ajax, but it builds character too.

In Conclusion

A classical education isn’t all fun and games. Sometimes there were fun and games, for example on Exelauno Day, when we were treated to the delight of several hours of Greek and Latin declamations. But we also learned something: the past isn’t dead, it’s all around us. It’s in the language we speak (even everyday English), it’s in our government and society, it’s even in the food on our tables and herbs in our gardens. The fathers of modern medicine used the languages of the past to describe the world around them, because they knew that new discoveries were made because of old knowledge. As it says in the great seal of the Oldest School in Continuous Existence in North America, The One True School: Mortui vivos docent, The Dead teach the Living. We understand our world because they lead the way, and we who have inherited their legacy are in their debt.

Remember that the next time you bungle your way through pheochromocytoma. I mean, it’s just a growth of dusky-colored cells.