Richard G. Petty, MD

Testing for Diabetes in Children

Diabetes mellitus can be a devastating illness, especially when it comes on suddenly in a child or adolescent. In young people it is usually so-called Type 1, or insulin-dependent diabetes, an autoimmune disease in which the immune system attacks the insulin-producing beta cells in the pancreas. The disease can have a major impact on the whole family, and sometimes people forget the way in which it can affect siblings whose needs often need to be subordinated to the needs of the newly diagnosed young person.

And here is an important point: even when it appears suddenly, the disease process may have been going on for some time before the clinical symptoms appear. By the time that blood glucose levels begin to rise, it usually implies that the damage to the insulin-producing cells in the pancreas has reached a critical point, and the chance of recovery is low. Anything that we can do to prevent the disease from progressing to the point of producing symptoms would be immensely helpful, and that starts with early recognition before the pancreatic damage has reached critical.

Although we now understand a great deal about the interplay of genetic, environmental and immunological factors that may lead to the illness, this knowledge has so far not helped us very much. There has been a tremendous need to try and identify the early stages of the disease, but that goal has been elusive.

In a study published in the Journal of Immunology researchers from the University of Queensland's Diamantina Institute for Cancer, Immunology and Metabolic Medicine, are developing a simple test that may predict whether a child will develop Type 1 diabetes. They have identified a cellular pathway known as NF-kappa B that is activated in certain blood cells – monocytes and dendritic cells - of people with Type 1 diabetes.

In healthy people monocytes remain quiescent unless they are activated by an infection or other stressor. Then the NF-kappa B pathway gets activated.

In people with Type 1 diabetes things work the other way round: monocyte NF-kappa B was already activated in the blood, and when exposed to infection the pathway shut down. This tells us that there is a problem of immune control that may cause diabetes to develop in children. It is this monocyte abnormality that will hopefully form the basis of a diagnostic test.

This work is assuming more urgency since there are several trials of diabetes vaccines underway, and if successful, it may become possible to identify and intervene in children at risk of Type 1 diabetes before it occurs.

In addition, understanding why the immune system loses control before the disease starts should open up a number of new options for prevention and treatment.

Attention-Deficit/Hyperactivity Disorder: Diagnosis and Complications

I have had a great many requests to talk more about attention-deficit/hyperactivity disorder (ADHD): what it is, and what it is not; when is it a problem and when is it just “normal” childhood or adolescent behavior? And what evidence is there for non-pharmacological approaches?

Although there is a lot of information about ADHD available in books and on line, some is better than others, and some is misleading. I have recently had the privilege of giving a series of lectures on each of these topics, and many people have thought that I had a different take on the issue, so I an going to summarize some of the lectures here.

First I would like to direct you to a short article on the diagnosis on ADHD. The most important point is that we have to tell the difference between kids being kids and a problem that needs treatment.

Second is an article that talks about some of the problems that may follow if someone has ADHD and it is not diagnosed or treated.

Over the next two days I am going to follow up with articles that I have written on "Non-pharmacological and Lifestyle Approaches to Attention-Deficit/Hyperactivity Disorder":
Diet, nutrition, allergies and sensitivities
Herbs and supplements
Movement, exercise, sleep and environmental design
Massage, qigong, tapping therapies and acupuncture
Mind-body approaches to treating ADHD
Homeopathy and flower essences in ADHD
Using Integrated Medicine in ADHD


“Thoughts of themselves have no substance; let them arise and pass away unheeded. Thoughts will not take form of themselves, unless they are grasped by the attention; if they are ignored, there will be no appearing and no disappearing.”
--Bhikshu Ashvaghosha (Indian Playwright and Master of Buddhist Philosophy, c. A.D. 1st Century)

“The true art of memory is the art of attention.”
--Samuel Johnson (English Biographer and Essayist, 1709-1784)

“Attention makes the genius; all learning, fancy, and science depend upon it. Newton traced back his discoveries to its unwearied employment. It builds bridges, opens new worlds, and heals diseases; without it taste is useless, and the beauties of literature are unobserved.”
--Robert Aris Willmott (English Author, 1809-1863)

Twelve Tips to Reduce Your Risk of Colorectal Cancer

Colon cancer, or, more accurately colorectal cancer, includes cancerous growths in the colon, rectum and appendix. It is the third most common form of cancer and the second leading cause of death among cancers in the Western world. Colorectal cancer surpasses breast and prostate cancers as a leading cause of cancer deaths in both men and women.

And the key point is that with early screening and a few simple dietary modifications, you can dramatically reduce your risk of getting it.

These are the 12 Tips to Slash Your Risk of Colorectal Cancer

1. Receive regular colorectal cancer screenings beginning at age 50 if you are at normal risk
2. If you are at higher risk due to a personal or family history of colorectal cancer, other cancers or inflammatory bowel disease have a discussion with your health care provider about screenings before age 50
3. Eat between 25 and 30 grams of fiber each day from fruits, vegetables, whole grain breads and cereals, nuts, and beans
4. Eat a low-fat diet: colorectal cancer has been associated with diets high in saturated fat, particularly fat from red meat
5. Eat foods with folate, such as leafy green vegetables
6. Try to drink at least 80 fluid ounces of pure water a day unless you have a medical reason for not doing so
   
7. Drink alcohol in moderation: 2 units of alcohol or less each day
8. If you smoke, here is another good reason for quitting. Alcohol and tobacco in combination are linked to colorectal cancer and other gastrointestinal cancers
9. Exercise for at least 20 minutes three to four days a week. Moderate exercise such as walking, gardening or climbing stairs may help reduce your risk
10. If you get any persistent symptoms such as blood in the stool, a change in bowel habits, weight loss, narrower-than-usual stools, abdominal pains or other gastrointestinal complaints, it is essential to report them to your health care provider
11. Maintain a healthy weight. Obesity may increase the risk of colorectal cancer
12. Maintain a good intake of calcium and vitamin D:  this combination has been shown to reduce the risk of colorectal cancer

For more information, I recommend visiting the Web site of the American Cancer Society.

I keep their details in the "Resources" section on the left hand side of this blog.

Predicting Response to Medicines

Much as we would all like to rely upon natural and non-invasive approaches to treatment, there are times when pharmaceuticals also have their place.

A common question is whether there are any good ways to predict who will respond to what treatment and whether we can predict the risk of side effects. Unfortunately the answer is that although we are getting better, and the research base if growing rapidly, there is still a lot of trial and error in prescribing.

An exciting and relatively new area is called pharmacogenetics: using our genetic make-up to allow us to tailor treatments to each of us individually. Over the last few months there have been a lot of media reports about being able to use simple blood tests to predict who will respond to antidepressants. (As an example, see this report from the Washington Post).

Unfortunately these reports, though undoubtedly well meaning, have not told the whole story. You might be interested to see a brief article about this interesting topic that helps put things in perspective.

Though there are some highly reputable institutions that are trying to help provide genetic testing not only for drug responses but also to predict the risk of developing certain illness, unfortunately there are also plenty of rogues who prey upon the worried and unwary. I was recently shown pages and pages of all kinds of tests on an individual: genetic tests; biochemical tests; allergy tests and all kinds of unorthodox tests using every imaginable type of gizmo, from magnets to devices claimed to measure the aura.

Not surpringly, the individual was thoroughly confused by this vast morass of information. The best thing to do was to tear it all up and to start again with the simple question: "What do you think is wrong?" Deep down inside, she knew the answer.

I have spent years working in and running laboratories, so I am not shy about using science and technology.

Science and technology must be our servants and not our masters.

“During my eighty-seven years, I have witnessed a whole succession of technological revolutions. But none of them has done away with the need for character in the individual or the ability to think.”
--Bernard Mannes Baruch (American Financier and Government Official, 1870-1965)

“We must learn to balance the material wonders of technology with the spiritual demands of our human race."
--John Naisbitt (American Futurist and Author, 1929-)

“Humanity has passed through a long history of one-sidedness and of a social condition that has always contained the potential of destruction, despite its creative achievements in technology. The great project of our time must be to open the other eye: to see all-sidedly and wholly, to heal and transcend the cleavage between humanity and nature that came with early wisdom.”
--Murray Bookchin (American Ecologist, 1941-)

Eye Color

“The eye is the jewel of the body.”
--Henry David Thoreau (American Essayist and Philosopher, 1817-1862)

In November we had a look at new data suggesting that eye color may have developed as a kind of “instant paternity test.”

Now scientists in Brisbane, Australia are reporting that they have uncovered the genetics of eye color, and that they are surprisingly simple. Which is just what we would expect if something were biologically important.

The research is published in the current issue of the American Journal of Human Genetics.

After studying 3,839 individuals, it turns out that of the six billion or so “letters” that make up the human genetic code, a handful of "single nucleotide polymorphisms" (SNPs - pronounced "snips") are largely responsible for the color of your eyes. These SNPs consist of a change in just one “letter” in the genetic sequence. All the SNPs are located near a gene called OCA2. This gene produces a protein that helps give hair, skin and eyes their color. And mutations in OCA2 cause the most common type of albinism. So these gene mutations modify the amount of pigment in the iris: people with brown eyes have more pigment than people with blue. The odd one out is people with green eyes. In them the changes in the genes seems to have produced a functional change in the pigmentation protein itself.

This is interesting for another reason. There are a small number of medicines and clinical conditions that are associated with changes in the color of the iris. But I have also seen some people whose eye color has changed very rapidly in response to changes in mood, attention or concentration. I have also sometimes seen it happen when people have achieved some altered state of consciousness through prayer or meditation. Yet there is hardly any scientific research into this odd but uncommon phenomenon.

I did find two studies from Korea that attempted to associate a gene for angiotensin converting enzyme and the apolipoprotein e gene with iris type. The trouble with these studies was that they were very small and started with the assumption that iridology could be used to diagnose a physical problem, even though the research (1. 2. 3. 4.) has shown that it cannot.

I had assumed that these rapid changes in eye color had something to do with changes in blood flow in the eye, and that does remain the most likely explanation. But the question now is whether the SNPs associated with eye color are themselves modulated by mood, cognition or spiritual insight.

If you have ever observed changes in iris color in yourself or other people, I would be very interested to hear from you.

“All our souls are written in our eyes.”
--Edmund Rostand (French Poet, 1868-1918)

Screening for Breast Cancer

An important report came out in the middle of October that doesn't seem to have been reported in much detail by the mainstream media in the United States.

It concerns screening for breast cancer. This is a most important issue: breast cancer is the most common form of malignancy in women and it carries a high morbidity and mortality. Though there can be a genetic component, there are also a number of important environmental factors. Some of those for which there is decent evidence include:

• Circulating levels of estrogens and androgens
• Late first pregnancy
• Having no children
• Not breast-feding
• Alcohol consumption
• Post-menopausal weight gain
• Exposure to artificial light

There is an array of other potential risk factors, but the point is that with so many potential risk factors, it is difficult to idenify everyone at high risk of developing the disease. 

Therefore mass screening for breast cancer has been the accepted practice for many years now, and it has undoubtedly saved many lives.

But the new research - a review of studies covering half a million women - raises some important questions for women as well as clinicians.

The investigators found that for every 2,000 women who had mammograms, one would have their life prolonged but 10 would have unnecessary treatment due to false positive tests and over-dagnosis.

Dr. Peter Gozsche the director of the Nordic Cochrane Center, who led the research, said that the new research indicated that many women were being treated for slow-growing tumors that might never have affected them if they had not been picked up during the screening.

There remains no question that screening does save lives, but the new research indicates that - if it is replicated - we need to re-think the risk/benefit ratio about screening and the actions that we take if screening turns up an abnormality.

But it also should not scare people away from being screened.

It is also a good reminder that there are many potentially modifiable risk factors for breast cancer, and that is the best place to direct your attention.

Carpal Tunnel Syndrome and Diabetes

Carpal tunnel syndrome is a relatively common neurological problem in which the median nerve is compressed in the wrist.

The classical symptoms are:

• Tingling, numbness or burning in the fingers or hand, especially thumb, index, middle or ring fingers, but not your little finger. It is most typically present on waking, but can occur after using the hands. Some people "shake out" their hands to relieve their symptoms.
• Pain radiating or extending from the wrist up the arm to the shoulder or down into you’re the palm or fingers, especially after forceful or repetitive use.
• A sense of weakness in the hands and sometimes a tendency to drop things
• Numbness, especially in the tips of the thumb, index, middle and ring fingers.
• Eventually the small muscles that control the thumb, index and middle fingers can weaken and atrophy.

In many people there is not obvious cause, although it is more common in women approaching menopause, and these days it can be one of the problems associated with using a computer mouse of keyboard for long periods. Every student of health care learns that there is a great long list of causes including:

• Pregnancy
• Rheumatoid arthritis
• Trauma
• Hypothyroidism
• Diabetes
• Amyloidosis
• Acromegaly
• Myeloma
• Tumors

Although I was taught about carpal tunnel syndrome not just as a cause but also as a predictor of diabetes more than 30 years ago, it has been forgotten by some non-specialists.

There is some new research from King’s College in London that has suggested that carpal tunnel syndrome may be a harbinger of diabetes.

As many as 20% of people with diabetes have a compression neuropathy such as carpal tunnel syndrome, and in people with limited joint mobility – a complication of diabetes - the incidence may be as high as 75%. The new research indicates that carpal tunnel syndrome may precede the diagnosis of diabetes by up to 10 years. The work was based on an analysis of 2,655 people who were diagnosed with type 2 diabetes in 2003-2004. The researchers excluded people with other known risk factors for carpal tunnel syndrome. The relative risk for subsequently developing diabetes was 1.63.

This research shows once again that diabetes can sometimes make its presence felt years before it has been formally diagnosed. A study published in 2003 found that 56% of people with peripheral neuropathy of unknown cause actually had abnormal glucose tolerance tests.

Earlier this year, researchers form the Netherlands did a retrospective review of 516 people with carpal tunnel syndrome, and found only two people with diabetes. They therefore recommended that routine screening for diabetes was not worthwhile in otherwise typical carpal tunnel syndrome.

I disagree with them.

I think that it would be wise to screen people with carpal tunnel syndrome for any disturbances of glucose metabolism, including insulin resistance, and if they are at a particularly high risk of developing diabetes, it would be worth going ahead and doing a glucose tolerance test. We don’t often do them these days, but this would be one of those times.

A Possible Test for Alzheimer's Disease

I was very pleased for some of my former colleagues from the Institute of Psychiatry at the Maudsely in London.

Years of work by the researchers and unstinting support from pateints and their families seems to be bearing fruit.

Professor Simon Lovestone and his team have published an important paper in this month's edition of the journal Brain, which is commemorating the centenary of the first description of Alzheimer's disease. It is very hard to get a paper in to the journal, and the fact that the researchers did, speaks volumes about the quality and importance of their work. The entire article is available online. That was made possible by the Alzheimer's Research Trust who also funded this work: kudos to them for backing this work and for publicizing the results.

What they have done is to develop a blood test that may be able to pick up signs of Alzheimer's disease before people start to show symptoms. They used a process called proteomics - the study of proteins - and found levels of two types of protein in the blood that were only present if people had the condition. We do not yet know exactly what the proteins are.

The researchers are quite rightly being cautious at this point. Nobody wants yet again to raise false hopes. There is also the knotty ethical problem of being able to test for people with the earliest stages of the illness. There is the theoretical risk that medical insurers may deny coverage if someone's test is positive.

But if confirmed, this is of enormous importance: we already know that the earlier that treatment is started the better. And by treatment I certainly do not simply mean medications: controlling blood pressure, glucose and lipids; maintaining optimal nutrition; and taking physical and mental exercise may all slow progression of the illness.

It's wonderful to have some good news about this often devastating illness.

The CSI Effect

Over the last three or four years, American lawyers and law enforcement have been struggling with something that has become known as the CSI Effect.

Following the phenomenal success of the TV show CSI and its spin-offs, a major problem has been developing in courtrooms across America. Jurors are drawn form the ranks of television viewers, and they may have unrealistic expectations about the nature and quality of the evidence that they will be asked to examine. It is being claimed that cases are being lost because the evidence offered might fall far short of what the television-trained jurors have learned to expect.

I have not been able to find any god evidence for the CSI effect, and it may just be a case of attorneys who are upset about losing a case, but I don’t think so. I’ve spoken to quite a number of lawyers as well as physicians who do legal work, and there does seem to have been quite a shift in the courtroom. Most jurors now appear to rate scientific evidence much more highly than eye-witness accounts and confessions by defendants.

Even allowing for artistic license, I’m constantly astonished by the largesse of whoever is funding the CSI laboratories! I spent years working in basic research, and know only too well how hard it can be to make ends meet. Many of the reagents that they slosh around on the set would cost thousands of dollars in the real world.

One very good consequence of CSI is that it seems to be enhancing the status of scientists. At least it is in the United States. The idea of the super-smart well equipped team being able to out-fox the villain is very popular. I’ve recently had to spend a bit of time in England, and the difference in the cops and robbers shows is remarkable. The current crop of English detectives seem to be conflicted and charismatic, and it is they with a combination of street smarts and intuition who solve the crimes, with only an occasional nod toward the backroom boffins. (And yes, I know, “boffin” is a Britishism. Guilty as charged M’lud.)

I recently read that all over the United States, young people are flocking to enroll in science courses. So long as they have something to do with forensic science. A University in West Virginia now boasts 500 students studying forensic science, compared with only four in the 2000-2001 academic year. Another positive for CSI and for science is the key role of female and minority investigators, who all play equal roles in bringing the guilty to book.

The jurors’ demand for scientific evidence reflects a broader trend in society. In these uncertain times, people like to have certainty: The kind that you can get from a printout or a picture. It’s the same in medicine, where people demand certain diagnoses where none might be available. The combination of defensive medicine and the patient demand for certainty have between them fueled an unprecedented rise in the number of tests being ordered, to the exclusion of common sense and clinical skills. I’m a huge fan of what the new technologies are helping us do for people. But it is essential for us to remember that tests are meant to complement and not replace clinical skills.

There is still no good way of understanding a person and his or her distress by doing a scan, inserting a scope or taking a blood test. They all need to be used together. But even when we do that, medical decision making, just like weighing the evidence in court, remains a balance not just of objective data, but also of experience and intuition.

And we need to continue to explain that not all in this world is certain and predictable.

“Uncertainty and expectation are the joys of life. Security is an insipid thing, though the overtaking and possessing of a wish discovers the folly of the chase.”
--William Congreve (English Playwright, 1670-1729)

Hearing Voices

In 1973, there occurred a notorious episode in the history of psychiatry. A psychologist named David Rosenhan did an infamous experiment in which he had a group of eight people present themselves to twelve hospital emergency rooms claiming that they were hearing the words, “Empty, “Dull” or “Thud.”

Most were admitted and given psychiatric diagnoses. The second part of the experiment consisted of asking staff at a psychiatric hospital to detect non-existent 'fake' patients. They did rather badly. A paper about this was published in the journal Science, with the title, “On Being Sane in Insane Places.”

 
In its day, this paper was considered a damning critique of psychiatry and a plank in the ant-psychiatry movement that was in full swing at the time. In truth, it tells us only that if you lie to doctors and nurses you may deceive them. And second it is only a criticism of bad psychiatry. The idea of diagnosing schizophrenia or any other mental illness on the basis of hearing a single word is absurd. At least 40% of the population will at some time hear their name being called, particularly in times of stress or after bereavement. And very many people in the general population will occasionally hear a word being spoken. It is diagnostic of nothing.

I sincerely hope that none of the people that I’ve taught in 45 countries around the globe would EVER diagnose schizophrenia or any other mental illness simply on the basis of hearing voices, a.k.a. auditory hallucinations. As I’ve stressed time and again, the only purpose in making a diagnosis is to guide treatment and prognosis. Simply hearing voices can guide neither.

This topic came up during one of the things that I was doing to advocate for patients, because September 14th 2006 was World Hearing Voices Day, and I received some very interesting information from a UK based organization, the Hearing Voices Network. (There's also a nice article here as well.)

There is some excellent research on people who hear voices yet are not mentally ill. Many of these people do not feel the need for any treatment and not only peacefully coexist with them, but regard them as a blessing. Most of the research has been done by Professor Marius Romme and Sondra Escher from Maastricht University in the Netherlands, Richard Bentall from the University of Manchester, and Gordon Claridge at Oxford.

About 4% of the general population hears voices, and most of them are not mentally ill. It is essential for us to understand the notion of dimensional rather than categorical diagnoses. I’m mentioning it again, because it prevents us falling into the error of labeling people for no readily apparent reason. For some people their voices are supportive and comforting.

One of several studies has shown that the form and content of auditory hallucinations is much the same whether someone has been labeled with a mental illness or not. Trauma and abuse can reactivate voices, or make them threatening.

The key to the hearing voices is whether or not they are causing distress to the individual or to those around them. There are four major coping strategies typically used by people who hear voices: distraction, ignoring the voices, selective listening to them, and setting limits on their influence.

The biggest danger for people who are hearing voices and are suffering from cognitive impairment or a mental illness, is that the voices may form the basis for delusions. As people are trying to make sense of their experiences, they may develop highly creative explanations.

I once worked with someone who was not hearing voices, but feeling odd sensations coursing along her limbs. She got a textbook of Chinese medicine, and became convinced that she was feeling the flow of Qi in her body. But because she also felt the sensations in places that were nowhere near the channels and meridians, she became convinced that it was her mission to redefine not just the courses of the channels, but to re-write the whole of Chinese medicine according to the sensations in her body.

Her attempt to make sense of her experiences made her grandiose and delusional. She became unable to care for herself, eventually became very distressed and was grateful to have some treatment which eradicated the sensations, which in turn caused the delusions to evaporate.

So treat each person as an individual and forget the unhelpful and stigmatizing labels.

Recognizing Restless Legs

I've recently written a couple of articles about restless legs syndrome (RLS), following which I got this question:

"Dear Dr. Petty, I've thought that I've got RLS, and so did my doctor, but I've just heard about something called akathisia, and another doctor has told me that I might have that instead. Is there any way to tell them apart? The doctor seemed to think that they were the same thing. Have you heard of akathisia, and are there any tips for working out what I've really got?"

Yes, I do indeed know what akathisia is, and this is a good question. I've seen  many experts who have mixed up the two conditions. Both may be present in the same person, and there may be some small degree of overlap, but an experienced neurologist should be able to tell them apart without too much trouble.

Akathisia is most commonly seen in people taking certain types of medication that act on the brain. However something indistinguishable from akathisia was described three hundred years before we had any of these medicines. So medications are most certainly not the only cause.

I'd like to direct you to a new article by our friends over at Psychiatric Resource Forum, where you will find an article that goes through the clinical features and causes of akathisia and the nine classical features that distinguish akathisia from RLS.

Let me know if that does not give you the answer that you need, and I'll happily write a more detailed account of how to distinguish the two.

Good luck, and let me know if I can help you further.

Predicting Osteoporosis

Osteoporosis or thinning of the bones, is an extremely common problem that may lead to bone fractures, particularly in older, postmenopausal women. But sadly we are not good at predicting who will get a fracture. Simply measuring bone density is a long way from being a perfect predictor of who will go on to break bones because of osteoporosis.

A new research study from Melbourne, Australia has just come out in the journal Radiology. The researchers have devised a mathematical formula that is quite good at predicting who will get a fracture over a two-year period. The formula calculate's a woman's risk of developing a fracture with 75% accuracy. The fact that it misses 25% may not sound good, but it's actually a big advance.

The researchers examined 231 women with osteoporosis who had suffered bone fractures and 448 women who had not.They discovered that several factors including bone density levels in the spine and hip, weight, and the number of previous fractures were related to the likelihood of sustaining another fracture. By taking all these measurements into account, the team was able to develop a predictive formula. The formula itself is enough to make your head spin, but it will be very easy to use in practice.

We do have a number of effective treatments, including hormone replacement therapy, vitamin D and calcium supplements, and non-hormonal medicines including the bisphosphonates like sodium alendronate (Fosamax®) 10 mg a day or 70 mg once a week, risedronate (Actonel®) 5mg a day or 35mg once a week or and ibandronate (Boniva® once a month)and parathyroid hormone. There are several other medicines in the pipeline, and there have been claims that homeopathy may also help.

The trouble has been knowing which patients to target. Nobody wants to give everyone medicines if we can avoid it. Hence any form of accurate prediction about who might benefit from what, is to be welcomed.

Remember that there is good evidence that several small lifestyle adjustments can reduce your risk of osteoporosis:

1. Exercise
2. A diet rich in calcium, omega-3 fatty acids and green vegetables. Reduce sodium and refined sugar.
3. Supplemental calcium with vitamin D, magnesium and boron
4. Do not smoke
5. Avoid excessive amounts of alcohol

There are seveal medicines and illnesses that can increase the risk of osteoporosis, and a health care provider will know to be particularly careful about monitoring bone mineral density and applying this new formula.

Psychiatric Diagnosis

Several months ago I wrote about the advantages of seeing psychiatric problems on a spectrum rather than independent categories. And that it is also essential to look at the whole person: there is currently a terrible tendency in medicine and in psychiatry to reduce people to the neurotransmitters in their brains, which is not just a very limiting way of seeing an individual, it’s just plain rude.

One of the reasons why it is essential to look at the whole person is that the agenda of a physician and of a person asking – or being sent – for help may be entirely different. A doctor may want the voices to go away, and for the person to stop being fearful about the things that the TV is saying to them. The person may want help with making sense of their experiences. If someone believes that they are feeling this way because they’ve been abandoned by God, you can pour medications into them until you are blue in the face: they will not help the core problem. Yes, of course you can re-balance their dopamine, serotonin, GABA and acetylcholine receptors. But if their core belief has to do with abandonment, your efforts are unlikely to be crowned with success.

These issues came up again when I had the privilege of speaking to a meeting of the National Alliance of the Mentally Ill in Natchez, Mississippi last week.

There were all the usual questions about advances in mental health, and on the chances for recovery. My answer to that one is always the same: the chances for recovery from any mental illness - including schizophrenia and bipolar disorder - are better than they have ever been. The largest single barrier is expectation. If doctors, psychologists and therapists assume that nothing can be done apart from controlling symptoms, then it is unlikely that people will get better. We all know what will happen if we start the day assuming that’s it’s going to be terrible.

I’d like to highlight two blogs – here and here - that were started by the same person after she had recovered from a psychotic episode. She contacted me after my earlier posts. She has an excellent website which she started after an exchange with two psychiatrists who said essentially the same thing: “If the person can be cured, then it is NOT schizophrenia. Schizophrenia is a chronic mental illness that has no cure.”

This is not true: but rather than being an indictment of psychiatry, it’s an indictment of bad psychiatry. We have a great deal of evidence that the brain is a highly plastic organ, and that many of the typical changes seen even in unmedicated people with the illness can return toward a normal pattern. This shouldn’t be a surprise: it has been known for many years that at least a third of people who carried a diagnosis of schizophrenia recover completely. To say that the recovery indicates that the original diagnosis was wrong is an extraordinary piece of circular reasoning.

The statement also implies that the writer doesn’t see a difference between healing, treatment and cure, which for me are three different interactions.

There is also another point that I made in Natchez: psychiatric diagnoses are still descriptive and are therefore largely at the level of the rest of the medicine of 100 years ago, when a person might be diagnosed with “dropsy,” “anasarca” or “icterus.” Terms now rarely used because we understand the underlying pathology. In the same way terms like schizophrenia will eventually give way to descriptions based on the biological, psychological, social and spiritual issues going on in a person.

Because the diagnoses are descriptive, getting too worried about the precise one is unlikely to be helpful. I once had a family become very angry with me. Their son had seen many specialists, who had all offered different diagnoses. After many day’s observation and exhaustive investigations, the one that I came up with did not please them. Because I wanted to treat their son as a human being with a problem that had responded to an antipsychotic and therapy, but they wanted him to have a less intimidating diagnosis. I tried in vain to explain that these were all just descriptors, and the important thing was that he was getting better with our treatment.

The reason for making a diagnosis at all is so that we can communicate, that it may guide treatment and allow us to offer some advice about prognosis. If someone has a heart attack, it is usually not too difficult to diagnose it. The reason for the diagnosis is not so that we can write it on a form or so that we can label someone, but because it can help guide us.

I certainly don’t agree with every one of points made in the articles that he’s posted, but that’s just fine. Active debate is always better than ignoring each other. Or as Winston Churchill once said, “Jaw, jaw, is better than war, war.”

On the main points in these blogs, I think that we are in complete agreement:

1. Even without drugs it is possible to induce mania and psychosis in just about anyone: sleep deprivation, arousal and sensory overload will usually do it in a few days. If someone has a family history of psychiatric problems it will likely take half as long. If they have a personal history it might take a quarter as long.
2. Recovery should be the aim for anyone with a psychiatric problem.
3. Recovery is not necessarily the same as cure.
4. Not all people diagnosed with “psychiatric problems” have them: some are having genuine spiritual experiences: I’ve seen many people going through kundalini and other types of spiritual awakening who had been given psychiatric diagnoses. I used to get some raised eyebrows when I had a string of referrals from clergy and spiritual teachers that usually read something like, “I don’t know if this person is psychotic or possessed. Please could you see them and advise me.”
5. The quest for meaning and purpose is essential to our humanity. I have seen some of the most damaged of people with large traumatic holes in their brain trying to extract meaning and purpose from what had happened to them. Psychotic, manic, depressed and cognitively impaired, but still trying to work out the meaning for them personally.

The major psychiatric illnesses can be very hard to help: I regularly see everyone else’s problems when I travel: 45 countries and 47 states at last count. But it’s very unusual to find someone for whom we can do nothing.

But I never let clinicians give up: the people who come to us for help deserve better than that.

And for people who got through the process on their own, I congratulate you. But I beg you, please don’t suggest to everyone that they can do the same thing. Many need outside help that addresses all five dimensions of their being.

When Is It An Illness?

There’s been a very worrying trend in recent years, and that is constantly to medicalize every kind of behavior: we are no longer allowed to be shy, we have to be “socially phobic;” many things once regarded as vices, like excessive gambling, drinking or eating are now being re-cast as impulse control disorders and adolescent temper tantrums could be “Intermittent explosive disorder.” And I now read a report about giving selective serotonin reuptake inhibitors (SSRI) antidepressants to people with emotional lability.

In April of this year the Public Library of Science published a series of articles on the important topic of “disease mongering,” which two authors define as “the selling of sickness that widens the boundaries of illness and grows the markets for those who sell and deliver treatments.” The authors made the point that some of the medicalization of human behavior is being driven by some pharmaceutical companies. They picked on several conditions or illnesses in which claims of prevalence and severity have been inflated in order, they claimed, to generate a need for medicines. One of their targets was female sexual dysfunction, where there has been a serious attempt to convince the public in the United States that 43% of women live with this condition. Many experts have heavily contested those figures.

One of the big worries about expanding the boundaries of an illness is that it is easy to throw out the baby with the bathwater. To use this last example: saying that the figures for female sexual "dysfunction" are inflated can lead some clinicians to dismiss everyone who has a problem, and then not to treat people with genuine organic difficulties. It is tragic to see people referred to a psychiatrist for a physical problem like low testosterone or undiagnosed diabetes or thyroid disease.

There can also be marked differences of opinion about the nature of illness. “Premenstrual dysphoric disorder,” (PMDD), is a particularly severe premenstrual syndrome, with some additional mood features. The American Psychiatric Association has precise diagnostic criteria for PMDD. The regulatory authorities in the European Union decided that this was not a real illness and declined to let a pharmaceutical company market a medicine for it.

I’m all for doing anything that I can to help people and to alleviate suffering. Part of the problem is that it is acceptable to have a “disorder.” The prevailing attitude is that no one can be blamed for being sick. The reality is that by most estimates, 70% of human illness is caused by lifestyle choices. By turning everything into disorders we take away our responsibility for our actions.

Most people are not looking for the causes of their troubles, they want a quick fix. Changing is hard, it is inconvenient and it is much easier to believe a pill will make everything better.

The second issue is that “better living through chemistry” may not be. There’s been a question rumbling round for some time now: has the over-exposure of young people to antibiotics, analgesics and sleeping tablets, been partly responsible for the rise in asthma and in substance abuse in later life? We don’t know the answer but it is important for us to think about.

The third point is that we need to think about what we are doing to ourselves if we want to medicate our way to happiness. Do we really want to deny ourselves the opportunity for becoming happy by our own actions rather than relying on a pill and being told what is normal?

P.S. Four years ago the Nuffield Council on Bioethics produced an important report entitled Genetics and Human Behaviour: the Ethical Context. It looked at some of the ethical challenges that are coming with the constant new discoveries in biology, and warned against the dangers of widening diagnostic categories, to encourage the use of medication by people who would not necessarily be thought of as exhibiting outside the normal range. It is well worth reading.

How Many Angels Can Dance on the Head of a Needle? Moving Beyond the Metabolic Syndrome

I have written a great deal both on this blog and in scholarly articles, about insulin resistance and the insulin resistance and metabolic syndromes.

You will have noticed that I’ve always used the term insulin resistance syndrome.

This is not a matter of semantics. For years now I’ve been worried about the splitting that’s been going on in the field: we currently have six sets of definitions of the metabolic syndrome. And apart from the fun of going to all those conferences in exotic parts of the world, you have to ask what’s been achieved by these ever more divisive attempts to “define” the medical consequences of insulin resistance.

The American Diabetes Association has begun to promote the concept of “cardiometabolic risk.” The Association has established a national Cardiometabolic Risk Initiative (CMRI) to stress the association between diabetes, heart disease and stroke. The idea of introducing this umbrella term is to help people better understand and manage all diabetes and cardiovascular risk factors, and to side-step some of the controversy surrounding the definition of insulin resistance or metabolic syndrome and which cluster of variables are in and out.

A new Cardiometabolic Risk (CMR) Calculator to help us evaluate an individual’s risk of diabetes or vascular disease should be available by the end of the year.
The formula already includes factors such as:
1.    Body mass index
2.    Waist circumference ratio
3.    Fasting plasma glucose
4.    HDL-cholesterol
5.    LDL-cholesterol
6.    Triglycerides
7.    Apolipoprotein B
8.    Blood pressure
9.    C-reactive protein
10.  Age
11.  Sex
12.  Race/ethnic origin
13.  Family history
14.  Tobacco use

Part of the reason for this new initiative is the discovery that pre-diabetes, or impaired fasting glucose, where plasma glucose levels are 100-125 mg/dl, is associated with a high prevalence of cardiovascular disease risk factors such as obesity, hypertension and dyslipidemias.

The person who first proposed the insulin resistance syndrome, a.k.a. syndrome X, a.k.a. metabolic syndrome, is Gerald Reaven who first recognized the syndrome in a landmark paper in 1988. He recently gave a lecture entitled; “Insulin Resistance Versus Metabolic Syndrome: Different Names, Different Concepts, Different Goals.” I am in complete agreement with his basic proposition, which is that insulin resistance explains the clustering of all of the components that make up the metabolic syndrome. So Gerry’s position is that there’s no point in trying to make a diagnosis of metabolic syndrome: everything is due to insulin resistance.

So instead of wasting time and resources in trying to diagnose metabolic syndrome, it is much better to understand the pathophysiology: what is going on at the molecular level, how these processes produce risk factors, and whether we can predict others. We should identify and treat each of the underlying processes and the complications of insulin resistance. If we are going to have a syndrome, it should be called insulin resistance syndrome.

And let’s stop these academic debates and get on with the job at hand: there is a 600% variation in peoples’ ability to have insulin transport glucose into cells. More than half the US population is destined to develop at least some degree of insulin resistance, so we need to look for better ways to identify people who have it, and to apply the principles of integrated medicine to keeping them healthy.

Technorati tags: Insulin resistance Insulin resistance syndrome Metabolic syndrome Cardiovascular disease Hypertension Inflammation Hyperlipidemia Weight gain Integrated medicine

Insulin Resistance, Insulin Resistance Syndrome and Race

I often hear clinicians say that they are not too clear about the differences between insulin resistance and insulin resistance syndrome. Let me define them, and then tell you why they are so important, and why everyone needs to be informed about them.

First, insulin is a hormone produced primarily in the cells of the Islets of Langerhans in the pancreas. It has over 500 functions in the human body, but its main actions are on the regulation of the metabolism of carbohydrates and fats. Insulin enables glucose – one of the major sources of energy - to move into many of the cells in the body. Insulin is also involved in the conversion of glucose to glycogen. These two actions lower the blood glucose level.

Insulin resistance is defined as an impaired biological response to insulin. It is a condition in which many of the cells of the body - mainly in the liver, fat and muscle - become resistant to the effects of insulin. The normal responses to a given amount of insulin are reduced. As a result, higher levels of insulin are needed in order for insulin to have its effects. There are many potential causes of insulin resistance: genetic; an increase in intra-abdominal fat; smoking cigarettes; being of low birth weight; and there are some prescription medicines that can cause insulin resistance. Insulin resistance is one of the underlying causes of type 2 (maturity onset) diabetes mellitus, as well as an array of other illnesses including polycystic ovarian syndrome. Most studies have suggested that around a third of people living in the United States and Western Europe have insulin resistance, and there are marked ethnic differences.

The insulin resistance syndrome has several other names: Metabolic syndrome; (Metabolic) Syndrome X; Dysmetabolic syndrome; Reaven’s syndrome; multiple metabolic syndrome. There are several sets of criteria for defining the insulin resistance syndrome. In the USA it is usually defined as the presence of 3 or more of the following:
1. Abdominal obesity (Waist circumference >40 inches in men; >35 inches in women
2. Glucose intolerance (fasting glucose ≥110 mg/dL)
3. Elevated blood pressure ≥130/85 mmHg
4. Triglycerides >150 mg/dL
5. Low HDL (Men: <40 mg/dL; women: <50 mg/dL)

There is a constant debate in the medical literature about whether insulin resistance syndrome is an illness, and what should be included in it. It is important, because it appears to predict the development of diabetes and coronary artery disease, and between 20 and 25% of the population of the Western world has it. So what normally happens is that a person develops insulin resistance, which eventually evolves into the insulin resistance syndrome, before diabetes and heart disease appears. There can be as long as twelve years between the development of insulin resistance, and the diagnosis of diabetes, and we have very good evidence that lifestyle changes can dramatically reduce the risk of moving from insulin resistance to the insulin resistance syndrome and diabetes.

It has become quite well-known that people of African and Asian Indian heritage are at increased risk of developing insulin resistance, and some of the sequelae of insulin resistance: insulin resistance syndrome, diabetes mellitus, hypertension and gout. These may in turn lead to increased rates of myocardial infarction and strokes. A study presented last Monday at ENDO 2006, the annual meeting of the Endocrine Society in Boston helps further clarify some of these ethnic differences. Researchers analyzed data from the Insulin Resistance Atherosclerosis Study (IRAS), designed to assess relationships between insulin resistance and cardiovascular disease in a large multi-ethnic population.

The investigators divided data from female IRAS participants into different groups based on body mass index (BMI), a measure of body fat based on height and weight. A BMI of less than 25 is usually considered "normal." The analysis revealed that 47 percent of black women of normal weight had insulin resistance, compared to less than 20 percent of the Hispanic or White women. Both insulin resistance and the likelihood of developing type 2 diabetes increase as obesity increases. It had long been suspected that there was an independent effect of race, but this study not only shows that race alone may influence insulin resistance, but that we may therefore need to change the definition of obesity in women of African heritage.

The news reports on this important finding failed to mention that previous research has found something very similar in Asians from India, China and Japan. Each of these ethnic groups may develop insulin resistance, insulin resistance syndrome and diabetes without being obese, though obesity dramatically increases their risks of running into trouble.

It is relatively simple and inexpensive to measure insulin resistance, and many metabolic experts, including your humble reporter, have, for more than a decade, been measuring it in high-risk individuals. Clearly we cannot do anything much about an ethnic or genetic risk, but we can alter the way in which the body responds to that risk. If a person is insulin resistant, diet, exercise, specific nutritional and herbal interventions and occasionally medications, may all reduce the risk of developing diabetes and heart disease.

Technorati tags:Insulin Insulin resistance Insulin resistance syndrome Metabolic syndrome Diabetes mellitus Obesity Hypertension Racial differences

Diagnosing Illnesses

I am pleased to say that my recent item about Categorical and Dimensional ways of looking at illnesses has provoked some spirited correspondence and questions. Far from indicating that the art of diagnosis is arbitrary and vague, it reflects clinical reality. I get a great many magazines and articles from supporters of alternative medicine, and some have so misunderstood the principles of diagnosis that they think that illnesses don't exist! One of the reasons for this flawed thinking is that we all have a bad case of physics envy. The success of Newtonian physics and Humean philosophy has seduced us into thinking that everything has a single cause, and that every item and every event has clearly defined boundaries.

We are complex and ever-evolving individuals and we are also members of of constantly changing groups, so we have to be seen not only as "objects" wth diagnostic labels, but also as people with a time and developmental dimension: you and your life challenges will change over time as you continue to develop and evolve. As the great Scottish poet Robert Burns said: “Nature's mighty law is change.”

I think that is important to let you know how this field is developing, and why it is that we cannot always come up with a cut and dried answer to the question "Well, what has he got then?"

On May 24th, I wrote a short article about the inter-relationships between schizophrenia and bipolar disorder that you may find interesting. It develops some of the points that I made in my previous article.

Technorati tags: Diagnosis Category Bipolar disorder Schizophrenia

Categorical and Dimensional Diagnoses

I recently had the great pleasure and privilege of speaking to a group of health care providers in Monteagle Tennessee, and an interesting question came up. The sick citizens of Tennessee are having a hard time now because of the problems with TennCare. This problem is not new, and is not only happening in Tennessee. There is no malice or lack of compassion involved, it is simply a matter of $$$.

And because we need to have a diagnosis in order to apply for reimbursement, the discussion soon turned to the matter of psychiatric diagnosis. It’s pretty well known that I have lectured on the subject of psychiatric diagnosis all over the world: it was actually one of the reasons that I was first invited to come to the United States. The problem is this. When we classify an illness, we can either think of it as a “category,” like strep throat or a heart attack: an illness that has clearly defined margins. Or we can think about it as a “dimension.” So instead of seeing illness as a separate entity, we think of health and illnesses as lying on a spectrum, running all the way from being healthy and well, through mild degrees of just not feeling “right,” to being severely ill. Reimbursement requires categorical diagnoses, even if they do not reflect clinical reality.

This second – dimensional - way of thinking is particularly useful when we are thinking about psychological problems. The world is full of people who are a little bit obsessive, or who get bad mood swings. But they are not bad enough to be called an “illness.” In fact, having some of these traits can be enormously beneficial: they have continued in the population because they have a survival advantage. If I need to have surgery, I sincerely hope that my surgeon will be mildly obsessive, rather than discovering a few weeks later that he had forgotten to do something he should have!

When I am teaching about schizophrenia and bipolar disorder, I discuss how they lie on a spectrum that passes through so-called schizoaffective disorder, cluster A personality disorders – schizoid, schizotypal and paranoid – to schizophrenia. (You may be interested in looking at the blog entry for May 24th here). I also make the point that I can make just about anyone psychotic. Come and live in my research center for a week, where you will not be allowed to eat or sleep; you will have to drink 30 cups of coffee a day and take up smoking. I can guarantee that most people will develop some symptoms. If you have a family history of mental illness it would not take a week, but perhaps 3-4 days. And if you have a personal history of mental illness, it could take no more than a day or two. The key is arousal. People experiencing high levels of arousal may well start to experience manic, depressive or psychotic phenomena. The types of symptoms that are experienced are determined by background, environment and genes. This sort of “reactive” psychosis is completely different from the other end of the spectrum, where, particularly in males, there are demonstrable abnormalities in the brain – shifts in laterality and progressive loss of grey matter in specific regions, with swelling in other – many of which are present before the onset of full-blown psychosis, and before exposure to medications. Though some of the older antipsychotic medicines may make the situation much worse.

In January of 2005, some of my colleagues in Edinburgh, Scotland, published an important paper after studying people at high risk of developing schizophrenia. Many of these high-risk people did not develop the illness, although some had transient and partial symptoms. We know that some family members – the carriers of the genes – may also suffer from some symptoms of the illness. This shows us how genes do not control everything: many people suffer from mild cases because their environment or personality helped protect them from developing a full-blown illness. In other words: biology is not destiny. These findings also give us important clues as to how we may be able to reduce the risk of an illness expressing itself.

Diagnoses are not always cut and dried. Medical professionals are sometimes unable to reach a definitive diagnosis, needing to wait and see how things develop. Having specialized in the diagnosis and treatment of tough cases, family members sometimes become very upset because their loved one does not have a clear diagnosis. Psychiatric diagnosis is still primarily clinical and often needs time to clarify. Although there are many demonstrable neurological disturbances in people with schizophrenia and bipolar disorder, even the most sophisticated brain scans are still not at the stage where we can make diagnoses.

If we think in terms of dimensional diagnoses that reflect clinical reality, it helps us to understand the range of symptoms that people can experience. It also speaks to the point that I have made time and again: symptoms are signs, and they are signs that can be generated in the body, in the mind, in relationships (not just because some might be stressful), and they may have subtle system or spiritual origins. Successful treatment needs us to identify the origins in an individual and to work with all the five main dimensions of the individual.

And by the way, we have succeeded in helping virtually all of our seriously mentally ill patients back to living the kind of lives that they want: jobs, relationships and so on. So this is not an academic discusssion, but instead something supremely practical

Technoratic tags:diagnosis category dimension bipolar disorder schizophrenia schizotypal personality disorder recovery spirituality

Sick Building Syndrome

Sick building syndrome (SBS) was first recognized in 1982, and is a combination of symptoms associated with an individual's place of work - most often an office building -though there have also been instances of SBS in residential buildings. A 1984 World Health Organization report into the syndrome suggested up to 30% of new and remodeled buildings around the world might be linked to symptoms of SBS.

Many symptoms have been associated with SBS, including:

• Headache
• Dry or itchy skin
• Chronic fatigue
• Irritation of the eyes nose or throat, sometimes with a dry coughs
• Dizziness
• Nausea
• Difficulties in memory and concentration
• Extreme sensitivity to smells or bright lights

For SBS to exist, these symptoms must disappear soon after the occupants go outside.

There have been many explanations for these symptoms, primarily related to environmental pollutants. But I have something to add to that list. Some time ago I spent a happy year working at the Charing Cross Hospital in London during which I made an odd observation. On days that I worked in the laboratory on the tenth floor, I would be exhausted by the middle of the day, while on days when I worked in the outpatient clinic in the basement, I could easily get through a 5 hour clinic without difficulty. I mentioned it to a neurophysiologist friend who told me something very interesting: it had been discovered that on days when the wind blew at 5-10 miles an hour, the building began to vibrate like a giant tuning fork, and that the vibration was at its worst between the tenth floor and the top of the hospital. The vibration was imperceptible to most people, but I clearly had the misfortune to be sensitive to it. Yet without this experience, I might never have known of the potential adverse effects of vibration of the human body.

I have been consulted by a number of corporations and government organizations that have had trouble with people getting sick in certain buildings. Until now we have thought that it was all environmental, and that it could be anything from vibration to poor ventilation, chemicals, molds and many things in between. So I was very surprised to see a report published in the journal Occupational and Environmental Medicine from a first rate research group at University College London.

The British Inland Revenue Service demolished an entire 19-storey building in Bootle, Merseyside, after almost half of the employees had developed illnesses compatible with SBS. In a study published two and a half years ago, it was claimed that adding ultraviolet light to ventilation systems to kill microbes could vanquish the symptoms of SBS. But this new research suggests that the cure may actually be better management.

The new study included 4,052 civil service workers between the ages of 42 and 62 who were enrolled in a larger general health study. The men and women in the study worked at 44 different office buildings around London. The workers completed surveys designed to assess their general health and whether they had symptoms linked to SBS. They were also asked questions about the physical properties of the offices that they worked in and the stresses associated with their jobs.

As in earlier studies, women tended to have more symptoms associated with SBS than did men. Younger workers also had more of the symptoms than older workers. Almost one in five women and one in seven men reported five or more symptoms associated with sick building syndrome.

Now here was the surprise: the authors found little association between physical work environment and the symptoms. But there was a strong association between the symptoms and feelings of having high job demands and little support in the workplace. They also found that the more control people have over their workstation, the fewer symptoms were reported.

Though the findings fail to support "sick buildings" as a common cause of worker illness, the study should not be interpreted as meaning that the physical quality of the workplace is unimportant. It is most likely that we are dealing with a combination of physical and work related factors.

As I was reading the report and reviewing the rather vague but often quite severe symptoms, I was reminded of some recent work that I have been doing on burnout: I’ve just published an article about it. My interpretation of this study is that many cases of SBS are likely a form of burnout that is partially modulated by physical factors in the environment.

Technorati tags: sick building syndrome, workplace, occupational medicine, burnout, Stress

Personal Evaluation of Wellness

As a physician, I am trained to know what questions to ask in order to diagnose health problems and understand what course of action needs to be prescribed to alleviate or cure the problem.  I can be a nightmare for my secretary if she makes my schedule tight because I can spend over an hour with a patient on a first visit.  She would argue that it is more like two hours, but I will admit that I take whatever time I need to gather the pertinent information.

I recently wrote an article that allows one to conduct a personal evaluation of his or her own wellness.  Click here to be taken to it.  It is based on my many years of experience and research.  You will notice that the questions cover the 5 main areas (Physical, Psychological, Social, Subtle and Spiritual) that are key to achieving an overall feeling of wellness and good health.

Keep in mind that this is a bit of a shortened version, there are many more questions that can be helpful.  However, this should get you started about thinking of ways to improve your own sense of health, meaning and purpose.

Technorati tags: wellness, health survey,

Sheryl, Lance and Kylie

I was very sorry indeed to hear that the amazingly gifted singer Sheryl Crow, who is only 43 years old, is facing a challenge with cancer. She is, of course, by no means the first. Cancer is not something that just hits the older people in the population. Two recent examples: Lance Armstrong who even now, after years of treatment and triumph is only 34, and Kylie Minogue, who is 37. Those two are apparently doing very well indeed, and have used their celebrity to publicize the importance of health screening and of looking at all the options in treatment.

Because of the kind of work that I do, I know of many other well-known people who have dealt with similar problems, and are doing extremely well, but who have chosen to maintain their privacy. Most forms of cancer are no longer the death sentence that they once were.

For more than two decades, I have been heavily identified with holistic medicine, which has gone through more names than the artist formerly known as Prince: alternative, complementary, integrative and integrated. So people are often surprised that I am also an expert in conventional medicine. “After all,” I am asked, “If integrated medicine is so great, then why bother with conventional medicine at all?” The answer is that the best way to treat anyone is by an integrated approach that treats the five principle dimensions of a person: physical, psychological, social, subtle and spiritual.

I regularly receive mailings from people and organizations claiming that they can cure all types of cancer using all sorts of unusual approaches, from nutrition to detoxifications and methods for getting rid of parasites. I have never recommended these approaches because the evidence is so flimsy, and we have data to show that there are indeed treatments that can improve survival and quality of life. But what I am very keen on is using conventional treatment as well as these less orthodox approaches, which are precisely tailored to the individual.

The United States Department of Health and Human Services has Task Forces that make screening recommendations, and I thought that it would be a good idea to make a note of some of their recommendations:

• Breast Cancer: Mammography every 1-2 years over age 40. Interestingly, the Task Forces don’t recommend routine breast self-examination, although many European countries do.
• Cervical Cancer: Screening every three years after age 21 or after becoming sexual active.
• Colon Cancer: “Regular” screening for everyone over age 50
• Prostate Cancer: They do not recommend routine PSA screening, but certainly clinical examination.

All of these recommendations get ramped up if an individual has a family history of a specific cancer and breast and colon cancer screening should start earlier in African Americans.

So I wish the very best to Sheryl, Lance and Kylie. And if you have been following my posts about spirituality and healing, it is, I think, highly likely that if enough of us think kindly of them, it will help them heal.

Technorati Tags: Sheryl Crow, cancer screenings, breast cancer

What's in Your Blood?

I am sure that you have seen all those credit card advertisements with the tag line: "What’s in you wallet?"

I was thinking about this a couple of days ago when I heard about the husband of a friend of ours who had been in a really nasty motor vehicle accident which left him with several broken bones. After a few days he started to develop problems with his breathing and the family noticed that he was bruising and hemorrhaging from his scars. Yet some of his lab values appeared to be "normal." Fortunately, I was able to offer some advice, and his recovery is now back on track.

But the case reminded me that many physicians have not been taught the value of looking at laboratory values as a whole. Too often we see computer-generated sheets that highlight the "abnormal" values. Yet this is not quite right. First, however good the equipment, laboratory values are never totally accurate. There is always an associated measurement error. This is like those political opinion polls where the expert tells us that the error is + 3%. So if candidate A has 47% and candidate B has 50%, you cannot tell who is winning. Maybe candidate A really has 50% and candidate B really has 47%. Let me give you two clinical examples. I have seen a young doctor who wanted to give someone a blood transfusion because their hemoglobin had fallen by one gram, without realizing that the lab error was + 0.5. So when I asked him to repeat the measurement, there had actually been no change. And I have seen countless people get worried because someone’s temperature has gone up by a degree or two, even though this is within the normal measurement error, and is, by itself, quite meaningless.

And that leads me to the second point: an elevated temperature, or a low hemoglobin, is simply a guide; it is one part of the whole gestalt that we use for diagnosing and monitoring illness. It is wrong to treat a lab value.

Third, when we look at lab values, we are interested in the overall pattern, rather than one result here or there. So I might have a sheet of results in front of me without a single highlighted value, and yet be able to discern a pattern that points toward a specific illness. An individual’s blood chemistry can tell an eloquent story: if you know how to read it.

A fourth point is that for many laboratory tests, there is no such thing as "normal." We use what are known as "reference ranges." Blood levels that have been measured on a lot of apparently healthy people, that are lumped together and used as average reference value for that population. Any deviation is regarded as "out of range," but it does not necessarily mean that it is abnormal. If we go and do another reference range in China or Africa, we may get entirely different results. I once dealt with a large number of patients from some islands in the Caribbean who had two apparent problems: many of them has been misdiagnosed with a condition called acromegaly, a condition in which adults begin to produce large amounts of growth hormone. It can be a nasty illness, and it was apparently responsible for the death of Earl Nightingale, one of the early leaders of the personal development movement. The thing was that amongst these islanders, elevated growth hormone levels were normal and caused no ill health. Second, many ran high levels of an enzyme called creatine kinase that is commonly used to diagnose myocardial infarctions or heart attacks. So we could not use the enzyme for diagnosis in these people unless we saw an extra big change. And that’s an important reason for measuring hormones, chemicals and temperatures: not just to get one-off values, but to monitor change. Once again bearing in mind that any measurement will likely have some level of inaccuracy associated with it.

This last point about reference ranges is exceedingly important. I have seen countless people who have been diagnosed with "subclinical" thyroid or adrenal problems because the treating clinician was not familiar with the interpretation of endocrinological investigations. In a later entry, I am going to discuss why many endocrinologists have become a little skeptical about so-called illnesses like "adrenal exhaustion" and "sub-clinical hypothyroidism."

Technorati Tags: laboratory tests,  medical diagnosis, disease