The Twinkie Diet

“Heya?|where did those cupcakes go?”

Like a never-ending western North Carolina climb where each switchback reveals another uphill, and the finish is shielded by tall pines, the struggle to lose weight and to stay lean is incessant.

In wrestling weight gain, competitive cyclists share the same mat as “regular” Americans. Like jockeys, all competitive bike racers strive for maximal leanness. It’s physics: Weigh less and the same number of watts push you farther and faster, especially when going uphill or accelerating from a slow speed. Remember those velocity problems in Physics 101?

But is it conceivable that losing weight a?? even if accompanied by lower cholesterol levels??a?? could be detrimental to long-term wellness? Obviously, the question answers itself.

Unless your Internet connection has been interrupted in the last few days, you have probably heard of the “Twinkle diet.” Kansas State University nutrition professor Mark Haub tested the hypothesis that if he reduced his daily calorie consumption from 2600 to 1800 he would lose weight.

Here’s the cool part: To amplify his findings that calorie restriction is all that is required to lose weight, he primarily ate a convenience-store diet. Calories came from processed food, high in trans fat and high fructose corn syrup a?? the worst of the worst. Oreos, Hostess cakes, Little Debbie snacks, sugary cereals and Doritos were his staples. (He ate vegetables in the presence of his kids.)

The results were incredible. It worked. Not only did he lose 27 pounds, but he also markedly improved his cholesterol level and lowered his total body fat percent.??Stunning.??Despite the high-calorie inflammatory content of his food, faithfully adhering to a daily calorie restriction resulted in weight loss.

The message is that potato chips do not cause fatness, regularly eating the whole bag does. A few M&M’s are okay, just not hundreds of them.

A master of the obvious is Professor Haub. He isn’t saying he is any healthier, no one would argue that. He just makes it harder for the dietary perseverators, the nutritional elite, the peddlers of weight loss scams, to make a simple solution complex. Sorry.

It’s a quandary isn’t it: We want our obese patients to lose weight, but we cannot advocate junk food as the main entree. We want both — fewer calories and more nutrients.

Reducing inflammation is the key to heart health. Keeping blood vessels healthy comes from good sleep, regular exercise and a good diet. Regularly eating inflammatory trans-fats and insulin-spiking high??glycemic snack foods will surely negate the positive effects of weight loss.

But at least Dr. Haub has helped doctors shorten the coaching session part of an office visit with an obese patient. To the commonly heard phrase,??”Doc, I really don’t eat that much,” we can respond — compassionately — that studies show that if you eat fewer calories you will lose weight.

In discussing “these studies” with our patients it will be best to omit the methodology section of Dr Haub’s experiment. No worries — we are now a headline-only society anyways.

Seriously. Who ate those cupcakes?

JMM

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Improving Health For Older Adults

New clinical trials and published research??are giving us information on how to improve health in elderly patients. Here are some brief points from the??Cleveland Journal of Medicine that were surprising to me:

– Each year 30 percent??of people age 65 or older fall and sustain serious injuries so preventing falls and fractures is important.??Vitamin D prevents both falls and fractures, but mega doses of Vitamin D (50,000 mg) might cause more falls. A better dose is 1,000mg a day in people who consume a low-calcium diet.??

– Exercise boosts the effect of influenza vaccine.

– The benefits of dialysis in older patients is uncertain, as it does not improve?? function in people over age 80.??We don’t even know if it improves survival.??Older patients who receive dialysis for kidney failure had a decline in function (eating, bed mobility, ambulation, toileting, hygiene, and dressing) after starting treatment.

– Colinesterase inhibitors (Aricept, Razadyne and Exelon) are commonly used to treat Alzheimer disease, but they all can have serious side effects.??Syncope (fainting), hip fractures, slow heart rate, and the need for permanent pacemaker insertion were more frequent in people taking these drugs.??The benefits of these drugs on cognition is modest.

– A new drug called Pradaxa (dabigatran) will likely prove to be safer than Coumadin (warfarin). Over two??million adults have atrial fibrillation and the median age is 75. The blood thinner warfarin is critical for prevention of strokes but it caries a high risk of bleeding and drug levels have to be monitored frequently.??Dabigatran will probably replace warfarin, but it will probably also be a lot more expensive.

As I often say, medicine and science are constantly changing and evolving. As new evidence comes forth, physicians and patients need to re-evaluate they way we do things.

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Thanksgiving And Your Priorities

Here is my column in??[the November 21st]??Greenville News:

This Thanksgiving we will have 32 guests at the table. Rather, at the tables we scatter about the dining rooma?|and living rooma?|and kitchen. At our house, food is practically a sacrament. And obviously Thanksgiving is the high holiday of American eating. So we will be honoring the tradition by feeding everyone as much as we can.

Because the guests are all beloved to us, we will also have a variety of foods, in a variety of presentations. For instance, there will be fresh cranberries for organic purists, as well as a maroon gelatinous mass of cranberries for those who feel that cranberries indeed spring from aluminum. The turkeys will be divided perfectly among dark and light meat lovers. And for the carb-loving, there will be sweet potatoes, mashed potatoes, and potatoes soft, but cut into chunks. (In deference to the texture-challenged.)

We will have assorted dressings, casseroles and vegetables. And more types of sweets than any of us really need. All of it because we love one another, friends, family, young and old. And we want everyone to have something that they love. The sheer pleasure of eating is one (but not the only) reason that we love the holiday so much.

I think we also love it for a few other reasons. For instance, we (and I mean all Americans) love it because it slows us down, just a bit, before the Christmas madness sets in. Yes, the day after Thanksgiving ita??s “game on.” But on Turkey Thursday we stop, if only because we are too full to move. So much of our lives involve rushing, hurrying, competing. Thanksgiving is a food-stuffed, sleep-inducing speed bump in the frantic activity of the season.

We also love it because it is tangible. Today so much is virtual. So much of our lives are borne on the airwaves, across cell-towers or satellites. Our pleasures are so often intangible, insubstantial — distant sounds and images on movies, television shows, or the Internet. Even our work is often virtual. Thanksgiving is a time when we can touch and taste, listen and embrace.

The things which delight us that day are material and substantial. We may watch the Macya??s Parade or football, but ita??s all background to the chill air, the wind and blowing leaves, the warm food, the laughter; and best of all, the presence of people who matter. And if our loved ones are far away, and we can only reach them by phone, by Skype or e-mail, we do it because we crave their touch, their voice so deeply. At Thanksgiving, as we cook and carve, eat and talk, we celebrate our humanity. It is an appropriate preparation for the Christmas season, which addresses our souls so beautifully and with such hope.

I also think that we love Thanksgiving because of its stated purpose. Humans naturally worship; so humans naturally crave order. That may be a controversial statement, but it isna??t really insulting. We all, on some level, elevate certain things to higher levels than ourselves. Whether ideology, science, power or God, worship (by any other name) is what we do.

Therefore, I believe we desire a kind of hierarchy in our lives. On Thanksgiving, we pause from our self-adulation, our self-absorption, the certainty of our own self-determination and seem to say: “I should be thankful.”

We may disagree about who it is we should thank, but the day gives us a chance to put things in some priority. Many of us will pray thanks to God for His gifts; others may simply say, to those they love: “Thank you for being here, thank you for being mine.”

Hopefully all of us will feel a sense of gratitude towards those who came before us, who established our republic, who built the road from the past to where we are today. Thanksgiving removes us, briefly, from the centripetal motion of our lives and forces us to look outward at the gifts and sacrifices of others, and for many, upward to the Creator. At the very least, it makes us remember that most of what is ours was not our own doing, whether we are talking about turkeys, countries, planets, or life itself.

So dear friends, enjoy the simple delights of food, laughter, the touch and the sound of others. Put your loves in order. And remember to look around at all the things of value, of worth, of beauty, that you did not produce, did not create, but are blessed enough to enjoy.

Especially the family snooring by your side in turkey-induced comatose states.

                       

Protecting Your Kid’s Brain

Neuropsychologist Kim Gorgens spoke at the last TEDxDU about issues surrounding children’s safety and what parents can do to prevent concussions — and it’s probably not to wrap the little ones in bubble tape. Watch for yourself:

(Hat Tip: Scope)

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New Recommendations For Vitamin D

Vitamin D has been talked about as the vitamin a?? the one??that might help fend off??everything from cancer to heart disease to autoimmune disorders, if only we were to get enough of it.

a??Whoa!a?? is the message from??a committee of experts assembled by the Institute of Medicine (IOM) to update??recommendations??for vitamin D (and for calcium).

The??IOM committeea??s report, released??this morning, says evidence for??many of ??the health claims for??vitamin D??is a??inconsistent and/or conflicting or did not demonstrate causality.a?? The exception is the vitamina??s well-documented??(and noncontroversial) benefits on??bone growth and maintenance.

The IOM panela??s report also??says most North Americans (Canadians as well as Americans)??have more than enough vitamin D in their blood to achieve the desired effect on bone. The??committee said??a blood level of 20 nanograms per milliliter (ng/mL) is sufficient for most people.

The??panel??set 600 International Units (IU) as??the recommended daily??intake??for children and??for adults ages 19 to 70. People ages 71 and older are supposed to??get an additional??200 IU,??or 800 IU a day.

Thata??s??a fairly sizable??increase over the??previous recommendations of??200 IU per day through age 50, 400 IU for people ages 51 to 70, and??600 IU for people ages 71 and older.

The safe upper limit on daily intake had been 2,000 IU for most age groups. Todaya??s committee report??increased that to 4,000 IU.

Here is the conclusion of a??four-page summary of the??full book-length report:

Scientific evidence indicates that calcium and vitamin D play key roles in bone health. The current evidence, however, does not support other benefits for vitamin D or calcium intake. More targeted research should continue. However, the committee emphasizes that, with few exceptions, all North Americans are receiving enough calcium and vitamin D. Higher levels have not been shown to confer greater benefits, and in fact, they have been linked to other health problems, challenging the concept that that a??more is better.a??

The new vitamin D recommendations are??bound to kick up some??controversy??because many researchers,??led by Dr. Michael F. Holick,??have argued that??Americans should be consuming a lot more vitamin D than they are now,??with??800 to 1,000 IU a day??being the??bare minimum and??over 2,000 IU a day??as??being??closer to the??optimum.

Vitamin D proponents have also said the goal for??blood levels should be??30 ng/mL. The??IOM panel says??levels that high are not associated with any health benefit and adds that levels above 50 ng/mL a??may be reason for concern.a??

The committeea??s calcium??recommendations are not likely to be nearly as controversial as??its advice on vitamin D.

The summary of the panelsa?? report??says??national surveys show that most people in the United States and Canada get enough calcium, the notable exception being??girls ages 9 to 18.??The panel warns that postmenopausal women who take calcium supplements may be increasing their risk for kidney stones by getting too much of the mineral.

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A New Superbug?

Scientists have discovered a new, highly-transmissible gene that could, quite easily in fact, open a frightening new front in the ongoing global war against superbugs.

The antibiotic-resistant gene, NDM-1, was first identified in 2008 a Swedish patient that had received hospital care in New Delhi. NDM-1 produces an enzyme that allows bacteria to destroy most antibiotics. It exists on plasmids, which are pieces of genetic material that are easily shared between bacteria including E coli and other species that can cause pneumonia, urinary tract infections, and blood stream infections.

NDM-1 probably evolved in parts of India where poor sanitation and overutilization of antibiotics provide a perfect environment for the creation of??antibiotic-resistant bacteria.

The gene has been identified in??three U.S. patients. All had received medical treatment in India, and all recovered from their infections. It has been found sporadically in Britain, Australia and nearly a dozen other countries as well. Most affected patients were a??medical touristsa?? — that is, people seeking less expensive medical care in India.

a??We need to be vigilant about this,a?? said Arjun Srinivasan, an epidemiologist at the CDC told the Washington Post. a??This should not be a call to panic, but it should be a call to action. There are effective strategies we can take that will prevent the spread of these organisms.a??

The NDM-1 gene does not appear to be transmitted by coughing or sneezing, but rather through exposure to contaminated sewage, water and medical equipment. Inadequate handwashing also likely plays a role. The CDC has advised doctors to look for it and isolate patients that have it.

The scientists who discovered NDM-1 warned that it had become endemic in many areas of India and Pakistan.

a??What we saw (in south-Asian hospitalized patients) is the tip of the iceberg,a?? Timothy Walsh, a Cardiff University professor of microbiology told the Post. a??For every person in the hospital, you can imagine there are a vast majority of people out there carrying NDM around.a??

Meanwhile, the Indian government denounced the news as a??scare tactic designed to discredit the nationa??s exploding medical tourism industry. That industry??attracts 450,000 patients per year and will likely generate $2.4 billion in revenue in 2012.

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Treatment-Resistant Depression: New Insights

Only one-third of people with major depression achieve remission after trying one antidepressant. When the first medication doesna??t adequately relieve symptoms, next step options include taking a new drug along with the first, or switching to another drug. With time and persistence, nearly seven in 10 adults with major depression eventually find a treatment that works.

Of course, that also means that the remaining one-third of people with major depression cannot achieve remission even after trying multiple options. Experts are hunting for ways to understand the cause of persistent symptoms. In recent years, one theory in particular has gained traction: that many people with hard-to-treat major depression actually suffer from bipolar disorder. However, a paper published online this week in the Archives of General Psychiatry suggests otherwise a?? and the findings provide new insights into the nature of treatment-resistant depression.

Researchers at Massachusetts General Hospital (MGH) and colleagues analyzed outcomes for roughly 4,000 participants in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, which was conducted both in primary care and psychiatric settings in order to mimic real-world treatment of major depression. The STAR*D investigators had used a simple questionnaire to ask participants about symptoms characteristic of bipolar disorder (such as mania or hypomania) as well as those suggesting psychosis (the inability to recognize reality, such as false beliefs or false perceptions). All participants initially received the antidepressant citalopram (Celexa), followed by up to three additional treatments as necessary.

The MGH researchers did find that many participants in the STAR*D study had multiple symptoms associated with bipolar disorder rather than major depression. Contrary to common wisdom, however, these symptoms did not significantly worsen chances of attaining remission after taking antidepressants. Instead, the researchers found that participants who said they experienced one or more unusual beliefs or experiences in the past two weeksa??symptoms that can indicate psychosisa??were significantly less likely than other STAR*D participants to attain remission.

a??We found that about one-third of participants in the STAR*D study reported strange or unusual experiences,a?? explains Dr. Roy H. Perlis, medical director of the Bipolar Clinic and Research Program at MGH and lead author of the paper. a??That doesna??t mean that one in three participants were psychotic, but that unusual thinking is common in people with major depression. As such, it is important that clinicians are on the alert for these symptoms, because they are associated with poorer response to antidepressants.a??

In recent years, both scientific review papers and continuing medical education courses have advised clinicians to re-evaluate a diagnosis of major depression and instead consider bipolar disorder when a patient does not respond to multiple antidepressants. But Dr. Perlis and others are growing concerned that bipolar disorder is now overdiagnosed as a result. a??We were seeing an increasing number of patients diagnosed with bipolar disorder, or bipolar spectrum disorder, simply because they had a family member with bipolar disorder or hadna??t responded well to antidepressants,a?? says Dr. Perlis. (In a 2008 paper, researchers at Brown University estimated that more than half of bipolar diagnoses might be wronga??partly because clinicians attribute symptoms like agitation or racing thoughts to mania rather than to major depression.)

When people with major depression dona??t benefit adequately from a first antidepressant, Dr. Perlis advises that ita??s wise to take several steps before deciding on the next treatment:

Review the diagnosis. Major depression can be difficult to diagnose because symptoms vary from one person to the next. a??Ita??s critical to revisit the diagnosis any time a treatment isna??t working, and this should include consideration of bipolar disorder,a?? Dr. Perlis explained. a??Risk factors such as a family history of bipolar disorder certainly increase my concern, and cause me to look even more closely. On the other hand, treatment resistance does not automatically equal bipolar disorder.a??

Consider other illnesses. Ita??s also important to consider whether another medical illness, such as anemia or obstructive sleep apnea, might be causing fatigue and other symptoms of depression.

Consider comorbidities. Major depression frequently occurs in conjunction with other psychiatric disorders, such as anxiety or substance use disorders, which can also affect antidepressant responsiveness. In such cases, ita??s important to treat the co-occurring mental health problem in addition to major depression.

Double-check dose. Ita??s always wise to double-check whether someone is taking the drug at the dose prescribed.

Give it more time. Although the standard advice for patients is to take an antidepressant for six weeks to see if symptoms improve, earlier findings from the STAR*D trial suggest that many people need more time to respond. The STAR*D investigators recommended that people with major depression take an antidepressant for at least eight weeks before considering another strategy.

                       

Skin Cancer Where The Sun Dona??t Shine

Not all skin cancers are from sun exposure. Viruses such as human papilloma virus (HPV), the virus that causes genital warts, also cause skin cancer. Skin cancer from HPV develops on genital skin in both men and women. It’s rarely talked about, but ita??s important and can be deadly.

Did you know that half of all deaths from skin cancer other than melanoma are from genital skin cancer???You probably also didna??t know that women are more likely to die from genital skin cancer as they are from skin cancer that developed from sun exposure (again, excluding melanoma).

We dermatologists are inexhaustible when it comes to warning people about the dangers of sun exposure, but we should also be warning people about the dangers of genital warts. HPV protection, which includes??HPV vaccines, is as important as sun protection in preventing death from non-melanoma skin cancer.

Genital warts can lead to deadly skin cancer. If your dermatologist has not checked your genital skin, be sure your primary care physician or gynecologist does. This is especially important, because unlike other sexually-transmitted diseases (STDs) which often have symptoms, HPV or genital warts often dona??t. It may be??embarrassing, but it could save your life.

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Snoring During Pregnancy: A Risk For Gestational Diabetes?

A recent medical study reported a fairly unique finding:?? Pregnant women who snore frequently are at an increased risk for developing gestational diabetes.

The Associated Professional Sleep Societies (TAPSS) reported that 24 percent of habitual snorers had an official diagnosis of gestational diabetes as opposed to 17 percent of nonsnorers. As gestational diabetes affects 4 to 6 percent of all pregnant women, this study is significant according to Louise Oa??Brien, Ph.D. who is associated with the department of neurology at the University of Michigan in Ann Arbor.

Snoring is nothing new among women but it becomes more pronounced with the onset of menopause or weight gain. Approximately one-third of all women in the U.S. are obese and at risk for snoring and sleep apnea. Being overweight can cause bulky throat tissue which then physically blocks air flow.

Up until the publication of the University of Michigan study, the health risks associated with snoring included greater than??ten seconds of interruptions of breathing, frequent waking from sleep, potential strain on the heart which then results in hypertension, increased risk of heart attacks, and stroke. Now the tide has changed.

A study involving 1,221 pregnant women were questioned as to whether they snored three or more times a week and nearly 31 percent of women were habitual snorers in their third trimester. The snorers had formal diabetic screening tests that confirmed the diagnosis of gestational diabetes. So, what does this mean clinically?

Ideally, pregnant women who are snorers should receive patient education literature that discusses the importance of the one-hour glucose screening. Obese pregnant women who snore three or more times per week should be tested sooner rather than later for gestational diabetes. A confirmed test of gestational diabetes should prompt a visit to the high-risk maternal-fetal specialist at the patienta??s earliest convenience.

As medicine continues to advance, so does the opportunity for greater patient awareness and education. Remember:??A healthy pregnancy doesna??t just happen. It takes a smart mother who knows what to do.

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Your Hydration Needs Monitored By An Intelligent Water Bottle

Imagine a water bottle that knows how hard and how far you are running, how much you’re drinking, what’s the outside temperature, and, based on all these variables, the device calculates when you need to have a drink. Cambridge Consultants have developed the i-dration bottle that does just that.

From the press release:

Intelligent sensors in the i-dration bottle can be used to monitor the external temperature, drinking frequency and quantity, and this data is then sent via Bluetooth to its usera??s smartphone. The phonea??s inbuilt accelerometer and gyroscope can measure exercise levels, and by “fusing” the data from a heart rate chest-band and information pre-entered using the smartphone interface (such as height, age and weight), the application can perform an assessment of a usera??s hydration levels. The i-dration bottle then responds accordingly by flashing a blue light if the athlete needs to drink more.

i-dration demonstrates the work that Cambridge Consultants is currently undertaking in bringing mobile applications to life. a??Most people still perceive an a??appa?? to be something that performs a certain task, whether ita??s checking the weather or the latest sports results, in a virtual world. However, we believe that in the next 12 to 18 months we will see a plethora of new dedicated a??hardware apps,a?? such as the i-dration drinks bottle, that will work in tandem with a smartphone to enhance a range of consumer products and services ,a?? said Rachel Harker, Business Development Manager at Cambridge Consultants.

Press release: Real-time hydration advice from new ‘smart’ drinks bottle …