Richard G. Petty, MD

Fast Foods, Exercise and Your Liver

We have known for many years that insulin resistance can cause non-alcoholic fatty liver disease (NAFLD). Now a new study published in the journal Gut reports that too much fast food and too little exercise can harm the liver in a matter of weeks.

In an experiment looking a lot like Morgan Spurlock’s Super Size Me, Swedish researchers selected 18 thin, healthy volunteers - 12 men and 6 women - to attempt a 5 to 15% body weight increase by eating at least two fast-food-based meals per day for four weeks. The participants in this intervention group also restricted their level of physical activity to no more than 5000 steps a day. A comparison group, matched for age and sex, ate a normal diet and maintained normal exercise levels.

The plan was to see if doubling calorific intake and increasing total body weight had any impact on participant's liver health.

Changes in major liver enzymes, such as alanine aminotransferase (ALT), and in hepatic triglyceride content (HTGC) were used to indicate liver damage. Abnormally high ALT levels are frequently seen in people who consume a lot of alcohol or who have been infected with the hepatitis C virus. HTGC measures fatty acid levels in the liver; too much fat in the liver leads to a condition called fatty liver disease.

At the end of the four weeks, the researchers found that:

• Fast-food consumers had put on an average of 6.5 kg (14.3 lbs.)
• Five participants increased their weight by 15%
• One person gained 12 kg (26.4 lbs.) in two weeks
• Sharp increases in ALT occurred after just one week on the fast food diet
• The average ALT level increased four-fold from 22 U/l to of 97 U/l over the 4 weeks
• ALT rose to liver damage levels in 11 participants
• No changes were seen in levels in the comparison group
• The increases in ALT levels were linked to weight gain and increased sugar and carbohydrate intake. One subject developed fatty liver disease, and there was a large rise in liver cell fat content in the other participants

Although nobody should be surprised that gorging on junk food and becoming a couch potato is bad for the body, the speed and extent of the liver damage is alarming.

“Don't dig your grave with your own knife and fork.”
--English Proverb

“I saw few die of hunger; of eating, a hundred thousand.”
--Benjamin Franklin (American Author, Inventor and Diplomat, 1706-1790)

Nutrigenetics: A Peak Into the Future

At any given time only about ten percent of you genes are thought to be active. They are switched on and off in response to all kinds of internal and environmental changes. This is particularly true in the metabolic pathways, where gene activation is an essential part of the normal response to dietary changes. We also know that many of us have genetic reasons for varying in our nutritional requirements.

Anybody who has looked into diet and nutrition knows that there is no one approach that works for everyone, and the Holy Grail of weight management is to be able to identify which diet will work for whom.

This goal has just come a little closer with the publication of a report from researchers in Greece, London and Colorado that has been published in the Nutrition Journal.

The paper, “Improved weight management using genetic information to personalize a calorie controlled diet” is available for free download.” The study population consisted of 50 patients who had failed to lose weight. They were offered a nutrigenetic test screening 24 variants in 19 genes involved in metabolism. 43 patients attending the same clinic were selected for comparison using algorithms to match age, sex, frequency of clinical visits and BMI at initial clinic visit. The second group of 43 patients did not receive a nutrigenetic test. BMI reduction at 100 and over 300 days and blood fasting glucose were measured.

The results are very promising. After 300 days of follow-up individuals in the nutrigenetic group were more likely to have maintained some weight loss (73%) than those in the comparison group (32%). Average BMI reduction in the nutrigenetic group was 1.93 kg/m2 (5.6% loss) vs. an average BMI gain of 0.51 kg/m2 (2.2% gain). Among patients with a starting blood fasting glucose of >100 mg/dL, 57% (17/30) of the nutrigenetic group but only 25% (4/16) of the non-tested group had levels reduced to <100 mg/dL after >90 days of weight management therapy.

The paper concludes by saying that the addition of nutrigenetically tailored diets resulted in better compliance, longer-term BMI reduction and improvements in blood glucose levels.

This is a small “proof of concept” study, and the effects are not enormous, but there is easily enough here already to vigorously pursue this genetic approach.

Folic Acid: Too Much of a Good Thing?

If you believe everything that your read in the media or hear on those infomercials, you would think that you should spend all day munching pounds of fruits and vegetables while taking megadoses supplements chasers.

While that may sound good in theory, in practice things are not so simple and this approach may actually do you harm.

A good example has just come to light in a report from the Institute of Food Research in the United Kingdom that has just been published in the British Journal of Nutrition.

We have talked before about the potential value of fortifying food with folic acid. Apart from reducing the risk of neural tube defects in babies, it may also reduce the risk of depression.

The new report suggests that fortifying flour with folic acid may lead to a range of health problems.

Folic acid is a synthetic form of folate, a B vitamin found in a wide variety of foods including liver and leafy green vegetables. Folates are metabolized in the intestine, whereas folic acid is metabolized in the liver. The liver is an easily saturated system, and at doses of half the amount being proposed for fortification that could lead to significant unmetabolized folic acid entering the blood stream.

This excess folic acid could cause a number of problems:
It may interfere with some treatments for leukemia and arthritis
Women being treated for ectopic pregnancies
Men with a family history of colon cancer
People with blocked arteries being treated with a stent 
In women undergoing in-vitro fertilization, it may increase the likelihood of conceiving multiple embryos
Unmetabolized folic acid accelerates cognitive decline in the elderly with low levels of vitamin B12 (If they have normal levels of B12, folic acid may slow brain aging)
While dietary folates have a protective effect against some cancers, folic acid supplementation may increase the incidence of colon cancer
Folic acid may increase the incidence of breast cancer in postmenopausal women, though other studies have shown the opposite

The trouble is that it could take 10-20 years for any potential harmful effects of unmetabolized folic acid to become apparent.

The latest study follows a letter to the Food Standards Agency from Sir Liam Donaldson, the Chief Medical Officer of England, requesting further expert consideration of two recent studies linking folic acid to bowel cancer before the government gives the final go-ahead for mandatory fortification of food with folic acid. However the Food Standards Agency has stuck to its position that fortification is safe. Mandatory fortification has already been introduced in the US, where it has been required since 1998, Canada and Chile, where it has cut neural tube defect rates by up to half.

Professor Nicholas Wald, director of the Wolfson Institute of Preventive Medicine, said:

“Fortification would prevent many cases of spina bifida and would also benefit the health of the country as a whole. Further delay in this public health measure will result in hundreds more babies being disabled by this serious disorder, or pregnancies being needlessly terminated due to a neural tube defect."

When it comes to analyzing risks and benefits, one of the most important things is to realize that more is not necessarily better, and that folate and folic acid are not the same thing at all.

Second is the point that we discussed before: some people have the right genes to be able to metabolize folic acid with impunity, while others may get a range of problems from taking it.

Red Meat and Breast Cancer

There is an important study that was published in the April issue of the British Journal of Cancer, but which I haven't seen reported in the United States.

The researchers did a survival analysis to assess the effect of meat consumption and meat type on the risk of breast cancer in the UK Women's Cohort Study. Between 1995 and 1998 a cohort of 35,372 women was recruited, aged between 35 and 69 years with a wide range of dietary intakes, assessed by a 217-item food frequency questionnaire. The researchers also took into account smoking, weight, fruit and vegetable intake, class, education and use of hormone replacement therapy.

The results showed that eating even small amounts of red meat daily can increase the risk of breast cancer by 56 per cent in older women.

As little as 2oz (57g) of beef, lamb or pork a day showed an effect. Post-menopausal woman who ate larger amounts, 3.6oz (103g), of processed meats such as sausage, bacon or ham had an increased risk of 64 per cent.

Even younger, pre-menopausal women had a slightly raised risk if they ate red meat daily.

Earlier analysis from the study found that pre-menopausal women who had the greatest intake of fibre cut their breast cancer risk by half.

The Leeds work supports other studies. In November, a study from the United States found that women who ate the largest amounts of red meat had a rising risk of breast cancer. But different studies have presented conflicting views.

One reason why red meat may contribute to a raised risk of breast cancer is that it is a rich source of saturated fat. The women who ate the most meat were also more likely to be fatter.

The publication of the study in the United Kingdom generated a great many negative comments from the meat industry.

One spokesperson, on hearing that as little as two ounces may be enough to increse the cancer risk said,

"Two ounces is absolutely tiny. I have never heard such rubbish. It's a tiny amount. This is ridiculous, it's silly."

I doubt very much that it is "silly," though it is a surprise that the study has not attracted more attention.

The best way to look at this data is not to say that everyone should become vegetarian, but to recommend that women should:

• Eat a balanced diet
• Limit alcohol consumption
• Exercise regularly
• Keep and maintain a healthy weight
• Try to maintain a regular sleep schedule

Non-pharmacological and Lifestyle Approaches to Attention-Deficit/Hyperactivity Disorder: 1. Diet

You can find some articles on Attention-Deficit/Hyperactivity Disorder (ADHD) here, and also some of the evidence that ADHD is a “real” illness and not just a label for socially unacceptable behavior. That being said, it is essential to take extra care when making the diagnosis. Mud sticks, and diagnostic mud sticks like glue. It can be hard to “unmake” a diagnosis.

As with any problem, the most effective way of helping it is to address the physical, psychological, social, subtle and spiritual aspects of the situation.

Medicines can definitely have a place in the management of ADHD, and the reason for treating ADHD is not so that people get better grades in school or do better at their jobs. It is to prevent the long term problems that may follow from inadequately treated ADHD.

There is a large and growing body of research on non-pharmacological approaches to treating ADHD. A literature search has turned up over two hundred papers, over half of which report some empirical research. Some of the research is summarized in a short paper aimed at health care professionals.

Research has shown that more than 50% of American families who receive care for ADHD in specialty clinics also use complementary or alternative medical (CAM) therapies, if you include things like modifying their diet or other aspects of their lifestyle. Despite that, only about 12% of families report their use of CAM to their clinician. Despite that low rate of families reporting the use of unorthodox therapies, a national survey of pediatricians showed that 92% of them had been asked by parents about complementary therapies for ADHD. The trouble is that many pediatricians have not been taught very much about the pros and cons of these approaches.

The most commonly used CAM therapies for ADHD are dietary changes (76%) and dietary supplements (> 59%). I have talked about food additives and one type of diet in the past. Now let’s look in a little more detail.

The 3 main dietary therapies for ADHD are:

• The Feingold diet,

• Sugar restriction, and

• Avoiding suspected allergens.

Sometimes these diets are used in combination.

The Feingold Diet
The Feingold diet is the most well known dietary intervention for ADHD. It aims to eliminate 3 groups of synthetic food additives and 1 class of synthetic sweeteners:
Synthetic colors (petroleum-based certified FD&C and D&C colors);

Synthetic flavors;

BHA, BHT and TBHQ ; and

The artificial sweeteners Aspartame, Neotame, and Alitame.

Some artificial colorings such as titanium dioxide are allowed.

During the initial weeks of the Feingold program, foods containing salicylates (such as apples, almonds, and grapes) are removed and are later reintroduced one at a time so that the child can be tested for tolerance. Most of the problematic salicylate-rich foods are common temperate-zone fruits, as well as a few vegetables, spices, and one tree nut.

During phase 1 of the Feingold diet, foods like pears, cashews, and bananas are used instead of salicylate-containing fruits. These foods are slowly reintroduced into the diet as tolerated by the child.

The effectiveness of this diet is controversial. In an open trial from Australia, 40 out of 55 children with ADHD had significant improvements in behavior after a 6-week trial of the Feingold. 26 of the children – 47.3% -  remained improved following liberalization of the diet over a period of 3-6 months.

In another study, 19 out of 26 of children responded favorably to an elimination diet. What  is particularly interesting is that when the children were gradually put back on to a regular diet, all 19 of them reacted to many foods, dyes, and/or preservatives.

In yet another study, this one a double-blind, placebo-controlled food challenge in 16 children, there was a significant improvement on placebo days compared with days on which children were given possible problem foods. Children with allergies had better responses than children who had no allergies.

Despite this research many pediatricians, particularly in the United States, do not believe the evidence regarding the effectiveness of elimination diets or additive-free diets warrants this challenging therapy for most children.

There is an interesting difference in Europe. In 2004 a large randomized, blinded, cross-over trial of over 1800 three-year-old children was published. The results showed consistent, significant improvements in the children's hyperactive behavior when they were on a diet free of benzoate-preservatives and artificial flavors. They had worsening behavior during the weeks when these items were reintroduced. On the basis of this and other studies, in 2004 schools in Wales banned foods containing additives from school lunches. It has been claimed that since the ban, there has been an improvement in the afternoon behavior of students.

The biggest problem with the Feingold and other elimination diets is that they are hard to follow and to maintain. But for some children and families, the inconvenience and stricter attention to food have worthwhile results.

It is also essential to ensure that children on any kind of diet maintain adequate nutrition: there have been many examples of that simple rule not being followed.

Sugar Restriction
The notion that sugar can make children “hyper” entered the mainstream over twenty years ago, and is now on the list of things that “everyone knows.” But happily it is not true. At least 12 double-blind studies have failed to show that sugar causes hyperactive behavior. Some researchers suggest that sugar or ingestion of high-carbohydrate "comfort foods" is actually calming, and that children who seek these foods may be attempting to "self-medicate."

There are plenty of very good reasons for children to avoid candy, but hyperactivity is not one of them.

Food Allergies
There is clear evidence that children, and perhaps adults with ADHD are more likely to have allergies. That lead to the obvious question whether children with ADHD allergic or sensitive to certain foods. (It is useful to differentiate “allergies” that are the result of abnormal reactivity of the immune system to proteins in food, from “sensitivities” that are the direct result of substances in food: the two have different treatments.)

It is certainly true that food allergies and food sensitivities can generate a wide range of biological and behavioral effects. Gluten sensitivity (celiac disease) is known to be linked to an increased risk of ADHD and other symptoms.

In an open study of 78 children with ADHD referred to a nutrition clinic, 59 improved on a few foods trial that eliminated foods to which children are commonly sensitive. For the 19 children in this study who were able to participate in a double-blind cross-over trial of the suspected food, there was a significant effect for the provoking foods to worsen ratings of behavior and to impair psychological test performance.

For more than 30 years one of the tests used to track allergies has been the radioallergosorbent test (RAST). It is not much used these days since technology has moved on. In an allergy testing study of 43 food extracts 52% of 90 children with ADHD had an allergy to one or more of the foods tested. Over the next few years several researchers carried out open-label studies in which children with ADHD and food allergies were treated with a medicine called sodium cromoglycate, that prevents the release of inflammatory chemicals such as histamine from mast cells. Some of the reports suggested that it could help in some children.

Other popular dietary interventions include eating a low glycemic index diet to avoid large swings in blood sugar. Another strategy has been to “go organic” to reduce the burden of pesticides, hormones, antibiotics, and synthetic chemicals in the child's system. These diets need more scientific study but they are probably safe if expensive.

There are plenty of practitioners and commercial entities who claim to be able to identify food sensitivities with all kinds of methods from blood and muscle testing to electrical and energetic techniques. Some may be helpful, but few have been proven to be effective.


What Should Parents do About Diet, Nutrition, Allergies and Sensitivities?
It is very difficult to predict whether an individual child will be helped by changes in diet. However, as long as the child’s needs for essential nutrients are met these diets should be safe.

It is an extremely good idea for parents to keep a diet diary for one to two weeks to see if anything obvious jumps out. Then trying an additive-free diet, low in sugar and avoiding foods that are suspected of exacerbating symptoms. You will normally find the answer - yes or no - within a few weeks.


What is the Evidence for Food Sensitivities and ADHD in Adults?
Not a lot!

There are plenty of people who have reported that dietary restrictions have helped them, but there is very little evidence. One of the problems about looking for food sensitivities is that there is a high placebo response rate. But if you have adult ADHD, it may be worth investigating. Just make sure that any diet that you use is nutritionally sound. And if you don't find anything reconsider another approach.

Half the Population Has Genes to Make Them Fat

I have talked a bit about my skepticism concerning the genetic contribution to obesity, insulin resistance and diabetes.

I was fascinated to see a huge fifteen year study that has just been published in the journal Science. I felt a touch of pride: back when the earth was new, I helped train more than one of the authors.

The study involved over 42,000 people and found an association with body mass index at every age [from seven to 70] in populations throughout the UK and Europe.

Unlike previous work, it shows a very common genetic link with mild obesity rather than a rare genetic link with extreme obesity.

There were 42 scientists in the group and they found that if people carry one copy of a variant in a gene called FTO, as does half of the general population, it will lead to a gain in weight of 2.6lb or put just over half an inch on their waists and raise their risk of being obese by one third. People with two copies of this variant in the FTO gene, which is the case in one in six of the population, then they will gain almost 7lb more than those who lack the variation and are at a 70 per cent higher risk of obesity.

The researchers then tested a further 37,000 people from Bristol, Dundee and Exeter as well as a number of other regions in Britain, Italy and Finland. In every case the same variant in the FTO gene - which is mostly present in the brain and pancreas, among other key tissues - was associated with type 2 diabetes and obesity.

They also showed that in children, this particular FTO variant was associated with increased body weight.

We hope that in the future, once we have found additional obesity genes, it may be possible to offer advice based on a person's genetic make-up. We all know that folk are eating more and doing less exercise, but some people gain more weight than others. Similarly two people on the same diet and exercise plan lose different amounts of weight. There are undoubtedly some unrecognized factors in weight gain, but genes remain in the mix.

Never be disheartened if your first attempt at diet and exercise is not crowned with success: they are only two of a dozen factors that play into weight control.

Do not fall into the fatalistic trap of thinking that biology is destiny.

We are talking about a factor that may modulate the way in which we control out weight.

As promised, I shall soon be publishing a book detailing specific methods for dealing with whichever ones are important in your life.

Your future lies in your hands: not in a string of chemicals.

 

Race and Diabetes

It’s another one of those, “Everyone knows that…” facts. For forty years we have all been taught that some ethnic groups are at higher risk of developing insulin resistance and type 2 diabetes mellitus. So now “everyone knows that” African Americans, Native Americans and people from the Indian sub-continent are all genetically predisposed to these medical maladies.

Now it looks as if "everyone" might have been wrong.

James Neel first proposed the theory of the "thrifty genotype" in 1962. He suggested that cycles of feast and famine early in human history created a gene that helps the body use scarce nutrients - a gene that leads to obesity and diabetes in sedentary modern populations with ready and continuous access to food.

Several months ago I pointed out some of the problems with the thrifty genotype theory, and why many of us have become more convinced about the concept of the “thrifty phenotype.” I have many friends, colleagues and former trainees who have dedicated themselves to hunting for diabetes genes. As early as the mid-1980s I was worried that they were going to vanish down a rabbit hole.

It seemed illogical that a gene or genes could “explain” an illness that was, until recently, very rare. It would have to be a gene that was somehow switched on and off by diet or some other environmental factors. It is certainly possible but seemed implausible, given that there are dozens of genes designed to control food intake and metabolism. But my friends the gene jockeys had the louder voice, and it was good for them to see what they could find. Now, twenty years later, more than 250 genes have been studied as possible causes of type 2 diabetes, but together these genes explain less than 1 percent of diabetes prevalence worldwide.

There is an interesting piece of research published in the journal Perspectives in Biology and Medicine by a team of researchers from the United States and Australia, that supports what I was saying. The study was co-authored by UC Irvine anthropologist Michael Montoya, an anthropologist at the University of California at Irvine, together with an epidemiologist and population geneticist. Together they analyzed existing genetic studies published across a variety of disciplines. The team found no evidence to support the thrifty genotype theory.

They also found that in most existing studies of the suspected genes that contribute to diabetes in ethnic minorities, researchers had failed to control for the potential impact of social and environmental factors. If those factors are taken into account, other factors - such as poverty, housing segregation or poor diet - were stronger indicators of diabetes than genes.

As Montoya said,

"Our study challenges the presumption that Native American, Mexican American, African American, Australian Aborigine, or other indigenous groups are genetically prone to diabetes because the evidence demonstrates that higher rates of diabetes across population groups can be explained by non-genetic factors alone. Our study shows that by focusing on genes, researchers miss the more significant and alterable environmental causes of diabetes."

One of Montoya’s co-authors, Stephanie Malia Fullerton, a population geneticist and bioethicist at the University of Washington added,

"When it comes to diabetes, we're finding that genes are no more important for ethnic minorities than for anyone else."

This new critique of genetic and ethnic studies will need to be replicated, and it is a little bit of a surprise that such important work was published in Perspectives rather than one of the journals dedicated to epidemiology.

I have no inside knowledge about why the study was published where it was. But it often happens that it can be very difficult to get new research published if it contradicts the mainstream. There have been examples of experts squashing data that contradicts their own, but it is uncommon. Most of the time the difficulty in getting revolutionary new data published is not because of some conspiracy, but because any kind of evidence, particularly if it is radically different, attracts the most concentrated scrutiny by independent reviewers.

If this new data analysis is confirmed, it is going to mean a radical re-think about the ways in which we screen, manage and advise people from different ethnic groups.

It also confirms something that I've said a hundred times: Biology is Not Destiny.

Fats, Inflammation and Depression

We have talked before about the associations between inflammation and psychiatric illnesses.

There is yet more evidence in the shape of a study just published in the journal Psychosomatic Medicine. by Janice K. Kiecolt-Glaser and her colleagues from Ohio State University College of Medicine in Columbus.

The study involved 43 older adults with a mean age of 66.67 years, and the results suggests that the imbalance of omega-6 and omega-3 fatty acids in the typical American diet could be associated with the sharp increase in heart disease and depression seen over the past century. The more omega-6 fatty acids people had in their blood compared with omega-3 fatty acid levels, the higher their levels of the inflammatory mediators tumor necrosis factor-alpha and interleukin-6, and the greater the chance that they would suffer from depression. These are the same inflammatory mediators associated with insulin resistance, type 2 diabetes and coronary artery disease, all of which are more common in depression. And depression is more common in diabetes, arthritis and coronary artery disease than expected.

Our hunter-gatherer ancestors consumed two or three times as much omega-6 as omega-3, but today the average Western diet contains 15- to 17-times more omega-6 than omega-3. There were 6 individuals in the study who had been diagnosed with major depression, and they had nearly 18 times as much omega-6 as omega-3 in their blood, compared with about 13 times as much for subjects who didn't meet the criteria for major depression.

Depressed patients also had higher levels of tumor necrosis factor alpha, interleukin-6, and other inflammatory compounds. And as levels of depressive symptoms rose, so did the omega 6 and omega 3 ratio. So it seems as if the effects of diet and depression enhance each other. People who had few depressive symptoms and/or were on a well-balanced diet had low levels of inflammation in their blood. But when they became more depressed and their diets became worse – which is very common when people are depressed – then the inflammatory mediators in the blood surged.

Omega-3 fatty acids are found in foods such as fish, flax seed oil and walnuts, while omega-6 fatty acids are found in refined vegetable oils used to make everything from margarine to baked goods and snack foods. The amount of omega-6 fatty acids in the Western diet increased sharply once refined vegetable oils became part of the average diet in the early 20th century.

Depression alone is known to increase inflammation, the researchers note in their report, while a number of studies have found omega-3 supplements prevent depression.

So this more evidence for the value of eating fatty fish like salmon, mackerel or sardines two or three times a week, but be sure to avoid fish that may contain a lot of mercury. If you add more fruits and vegetables to your diet, you will also reduce your levels of omega-6 fatty acids.

I have just finished analyzing all the new literature on using fish oils for the prevention and treatment of psychological and psychiatric problems, and I am going to post my findings in the next couple of days.

Anti-inflammatories and Colon Cancer

I just had a very good question after I published my list of Twelve Tips to Reduce Your Risk of Colorectal Cancer.

Dear Dr. Petty,

“That’s a great list, but I am wondering why you haven’t included aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs)? I thought that they had been shown to reduce the risk of colon cancer.”

This is an excellent question, and I deliberately omitted mention of anti-inflammatories because the research suggests that they may cause more harm than good.

There is a report in today’s edition of the Annals of Internal Medicine from the United States Preventive Services Task Force, a highly regarded and independent panel of experts in primary care and prevention, that confirms that screening for colorectal cancer is still important and everyone over 50 should have it. But they urge caution on taking preventive drugs, saying that on balance the health risks of aspirin outweigh the benefits when it comes to preventing colon cancer. This advice holds even for those people with a family history of the disease, as long as they have only an average risk of colon cancer. (20 per cent of people who get colorectal cancer also have a close relative with the disease, with proportionally more cases among African Americans than other races.)

They found good evidence that high doses of aspirin (i.e. 300 mg a day or more) and possibly ibuprofen protect against colorectal cancer but this comes with increased risk of intestinal bleeding, stroke and kidney failure.

In low doses - under 100 mg a day - the Task Force says that good evidence supports the notion that aspirin protects against heart disease. However, at this dosage it will have no preventive effect on colorectal cancer.

The US Preventive Services Task Force regularly reviews the available research evidence and issues advice based on what they regard the strength of the evidence to be. They use a grades to help guide practice. For example a grade A recommendation is equal to "strongly recommends", while a B is just "recommends", and C is "no recommendation for or against".

In this case the Task Force has issued a grade D "recommends against" to the routine use of aspirin and NSAIDs to prevent colorectal cancer.

So for now I recommend following the Twelve Tips that I published yesterday.

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.

Do Healthy Foods Taste Bad?

There is a valuable study in the Journal of Marketing, which I must confess is not normally on my overloaded reading list. At least it wasn’t until I discovered an astonishing number of articles that are highly relevant to our basic themes of Health, Integrated Medicine, Meaning and Purpose.

We are all constantly puzzled by the way in which so many people seem to enjoy unhealthy foods. This is a matter of enormous importance: countries like China and India are now getting fattest the fastest, partly because of their peoples’ craving for Western junk food, coupled, in many cases, with a metabolic inability to process the food in the same way that most Europeans do.

Well, according to this study, foods that we think are healthy taste worse. This is the "unhealthy = tasty intuition." In one of the experiments, test subjects were offered a mango lassi, an Indian yogurt drink that has the consistency of a thick milkshake. Those who were told that the lassi was "unhealthy" liked the drink significantly more than those who were told the drink was "healthy.”

When I was a young student one of my teachers told me that patients always believe that if something tastes foul then it must be doing them some good. A lesson that I had learned from my grandmother when still a small child. By the age of five I already knew that any rash or snivel would mean having to take some pungent and disgusting potion: some secret recipe that had been in the family for generations. Even then I wondered how it was that so many family members had lived to great ages. It didn’t seem possible.

This research fits in with the teachings of my grandmother and my professor. People assume an inverse relationship between tastiness and healthiness. In the study people believed that what they were consuming was unhealthy, they guessed that it would taste better, be more enjoyable to eat and that they would be more likely to choose it in a test.

This is important research and has a number of practical implications for helping people to adopt more healthy eating patterns.

This reminded me of a salutary lesson. Some years ago I spent a very happy year doing a part time course in wine tasting. Fascinating topic taught by Masters of Wine who said that they could tell incredible things about a wine after the smallest taste. A couple of years ago such claims were put to the test in Bordeaux in France, which is, of course, famous for its wines. In the first experiment 54 acknowledged wine experts were asked to give their impressions of two glasses of wine: one white and one red. The wines were actually the same white wine, one of which had been tinted red with an odorless food coloring. But here it gets interesting: the experts described the "red" wine in language typically used to describe red wines. For instance one said tat the colored wine had a “flavor of crushed red fruit.” Not a single one noticed it was actually a white wine.

In a second experiment an inexpensive wine was presented to the experts in two different bottles, one fancy and one plain. The experts gave the two bottles completely different evaluations. The experimenters described their results in terms of the interaction between vision of colors and odor determination. But we can also interpret the data in terms of expectation and perspective. If we expect something to taste good it tends to do so. Yes of course you can get a nasty surprise, but there is a powerful subjective component in how we interpret sensations.

I strongly suggest that you analyze your own reactions to food. Do you believe that healthy foods have to taste awful?

This may be an important key to changing your own eating patterns.

"Life expectancy would grow by leaps and bounds if green vegetables smelled as good as bacon.”
--“Doug Larson”



“As for food, half of my friends have dug their graves with their teeth.”
--Chauncey M. Depew (American Politician and, from 1899-1911, Senator from New York, 1834-1928)

“To lengthen thy life, lessen thy meals.”
--Benjamin Franklin (American Author, Inventor and Diplomat, 1706-1790)

“If you have formed the habit of checking on every new diet that comes along, you will find that, mercifully, they all blur together, leaving you with only one definite piece of information: french-fried potatoes are out.”
-- Jean Collins Kerr


(American Author and Playwright, 1923-2003_

Tea and Milk

Growing up in England, tea is a great deal more than a drink.

Always drunk hot, of course. No normal person would want it served cold.

It is a major social lubricant and is considered by most to be a separate food group. And the health benefits conferred by a nice cup of tea are now known to just about everyone in Britain.

But from an early age I knew that one day I would have to leave the country.

Why?

Because I could never abide the way in which the vast majority of tea drunk in England is destroyed by the addition of milk and sugar. There are even long technical debates about whether to add the milk before pouring in the tea or after? How fast to add the white stuff? How to stir it in?

Since I was knee high to a puppy I was always the odd one out, wanting nothing to do with this wanton destruction of a sublime beverage.

Which should always be enjoyed au naturel. The only thing that might ever sully a cup of fine Earl Grey or Darjeeling might be a little lemon. Anything else?

Yuk.

Well, it now transpires that this isn’t just a matter of taste buds.

A study just published in the European Heart Journal says it all in the title, “Addition of milk prevents vascular protective effects of tea.”

Tests on sixteen healthy postmenopausal female volunteers showed that black tea significantly improved the ability of the arteries to relax and expand, but adding milk completely blunts the effect. The research was supplemented by tests on rat blood vessels. Tea caused the muscle in the vessel wall to relax by producing nitric oxide from the endothelial cells that line blood vessels. Adding milk blocked the production of nitric oxide and the relaxation of the muscles.

Now bear in mind that they were testing black tea. The researchers are now looking at the potentially more potent green tea to see whether its effects are also blocked by milk.

The villain of the piece is a group of proteins called caseins, which they found interacted with the tea to decrease the concentration of catechins in the beverage. Catechins are the flavonoids in tea that mainly contribute to its protection against cardiovascular disease.

The moral of the story? Tea can be wonderful on so many levels. Not only does it taste good, but also it can do wonders for your health.

But please, please, please don’t lose all the benefits by sloshing in a load of milk!

Raw, naked tea is the way to go...

"Thank God for tea! What would the world do without tea? How did it exist? I am glad I was not born before tea."
--Sydney Smith (English Clergyman and Essayist, 1771-1845)

Dogs, Diet Pills and Healthy Eating

Pfizer Animal Health announced today that the Food and Drug Administration (FDA) has approved Slentrol(TM) (dirlotapide) for the safe and effective management of canine obesity, making it the first and only veterinary-approved obesity drug for dogs in the United States.

Because of our intense interest in metabolism, we have been tracking the rise in canine obesity since 2001. Wild dogs do not get fat, but under-exercised canines given the wrong food rapidly do. Many owners think that they are too busy to exercise them and many neighborhoods either have no side walks or are simply not safe for a walk. Having just received multiple bags and boxes of food, I can also attest to something else: we often equate food with love - without being aware of the potential adverse health consequences.

According to 2002 data from the American Veterinary Medical Association 40 percent of dogs - around 17 million - are considered overweight (5 percent to 20 percent over ideal weight) or obese (20 percent or more over ideal weight).

Depending on the species, our canine friends get many of the same problems that we associate with overweight in humans: arthritis, heart disease, respiratory conditions and some cancers. Obesity can also worsen the signs associated with pre-existing diseases such as osteoarthritis. In addition, obesity can affect a dog's quality of life by making exercise and play more difficult or even impossible.

The medicine is, quite rightly, designed to be used with a diet and exercise plan.

This new medicine does appear to be a real advance, and its mode of action very interesting. Indeed I am at this moment looking at a dog who might benefit!

But I also notice that a number of news outlets have reproduced the Pfizer press release verbatim, and presented it as a news item.

What Pfizer said is 100% accurate, but when the media reporduce something without comment I worry that this is an example of "fake news."

It is interesting to me that this story was released two days after the release of a report from researchers at the University of Alberta Hospital that has just been published in the Lancet.

Their conclusion? That we need better data on the long-term effects of anti-obesity drugs before more widespread use of the therapies. We need to know not just if a medicine leads to weight loss, but whether it leads to clinical benefit. We saw this with the recent tragedy with the medicine torcetrapib. This was a medicine designed to increase levels of HDL-( "good") cholesterol. Indeed it does, but more people taking it died in a clinical trial, which was then stopped.

I am often asked, "Wouldn't it be great if we could do anything that we wanted and then to take a pill to cancel out the effects?"

The answer to that one is surely a big, "No!"

Fortunately such a solution - which would destroy personal responsibility - seems to be years in the future.

If ever.

We MUST take responsibility for the things that we do.

To do anything less is to accept the fantasy that we are no more than machines at the mercy of our brain cells.

We are all far more than that.

And deep down we all know it.

Healthy Aging

I have talked about the small number of simple steps that can dramatically reduce your risk of getting congnitive decline as your get older and some new evidence to show the benefits of non-drug treatments for dementia. I am pleased to say that my conclusions have just been supported by an editorial in the Journal of the American Medical Association.

I would like to let you know about another great resource: the International Council on Active Aging (ICAA) which has produced a great package of action items that are all rooted in good quality scientific research. The list is very similar to the ones that I have created for you here, and are very precise.

1. Invest in good shoes and socks
2. Play games
3. Walk
4. Increases your physical activity
5. Do exercises to improve your balance
6. Get regular eye checks, not only for corrective lenses, but to be checked for early evidence of diabetes or high blood pressure
7. Seek out friends family and neighbors
8. Modify your diet toward a "Mediterranean" one
9. Laugh
10. Get enought sleep

Whatever your age, I urge you to spend a few minutes working on a simple plan that will fit your schedule: your mind and body, family and friends will thank you forever.

Reducing Your Cancer Risk

“The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.”
-- Thomas Alva Edison (American Inventor, 1847-1931)

I am sure that you will agree that prevention is better than cure. And this is a good time of the year to review where you are in your life and what you want or need to do for yourself and your loved ones.

According to a study reported in the Lancet in November 2005 more than one third of cancer deaths are attributable to nine modifiable risk factors.

To evaluate exposure to risk factors and relative risk by age, sex, and region, the investigators analyzed data from the Comparative Risk Assessment project and from new sources, and they applied population-attributable fractions for individual and multiple risk factors to site-specific cancer mortality provided by the World Health Organization.

Of the seven million deaths from cancer worldwide in 2001, approximately 2.43 million (35%) were attributable to nine potentially modifiable risk factors. Of these deaths, 0.76 million were in high-income and 1.67 million in low- and middle-income nations; 1.6 million were in men and 0.83 million deaths were in women.

Smoking, alcohol use, and low consumption of fruits and vegetables were the leading risk factors for death from cancer worldwide and in low- and middle-income countries. In low- and middle-income regions, Europe and Central Asia had the highest proportion (39%) of deaths from cancer attributable to the nine risk factors studied.

For women in low- and middle-income countries, sexual transmission of human papilloma virus (HPV) was also the leading risk factor for cervical cancer. Smoking, alcohol use, and overweight and obesity were the most important causes of cancer in high-income countries.

Between 1990 and 2001 mortality from cancer decreased by 17% in those aged 30 to 69 years and rose by 0.4% in those older than 70 years, according to the authors, but this decline was lower than the decline in mortality rates from cardiovascular disease for men and women. The decline in mortality in men was largely due to reduction in mortality from lung, prostate, and colorectal cancers, while in women, lung cancer increased in the 1990s, and death rates for breast and colorectal cancer decreased. An article published almost ten years ago in the journal Cancer Epidemiology, Biomarkers, and Prevention, it was estimated the worldwide attributable risk for cancer to infectious agents as 16%.

The nine factors were:

1. High body mass index
2. Low fruit and vegetable intake
3. Physical inactivity
4. Smoking
5. Alcohol abuse
6. Unsafe sex
7. Urban air pollution
8. Indoor use of solid fuels
9. Injections from healthcare settings contaminated with hepatitis B or C virus

This all makes good sense, but it is good to see high quality research in reputable journals confirming what we suspected. The research also gives us further compelling reasons for taking a good look at our lifestyles and hopefully the motivation to do something to improve them. And in the case of air pollution and injection of contaminated products, to be active in getting things cleaned up.

“Keep your own house and its surroundings pure and clean. This hygiene will keep you healthy and benefit your worldly life.”
-- Sathya Sai Baba (Indian Spiritual Teacher, c.1926-)

“Length of life does not depend so much on a good physical constitution as it does on the best use of the six non natural things, which if we rule aright, we shall live long and healthy lives: to divide the day properly between sleep and waking; to adjust our air to the needs of the body; to take more or less food and drink according to our age, our temperament and whether we live an active or inactive life; to take exercise or rest according to the quantity of food and whether we are lean or fat; to know ourselves and be able to rule our emotions and subject them to our reason.  Whoever handles these wisely will live long and seldom need a doctor.”
--Giorgio Bagliivi (Italian Physician, Pathologist, Researcher and Author of De Fibra Motrice, 1669-1707)

“The best doctor prevents illness, a mediocre one treats illnesses that are about to occur, and an unskilled one treats current illnesses.”
--Chinese Proverb

Exercise Beats "Dieting" in Managing Obesity

An important report was presented at the Scientific Meeting of the United Kingdom Society for Behavioural Medicine in Cambridge earlier this month.

A team of researchers from Leeds Metropolitan University and the University of Hull studied 62 women aged 24 to 55. They all had a Body Mass Index (BMI) over 30, which is classed as clinically obese. (Regular readers will know that most experts have moved away from using BMI to evaluate metabolic and cardiovascular risks).

The program encouraged women not to diet but to take part in exercise classes. They were required to do four hours a week of exercise, such as t'ai chi, aqua aerobics or circuit classes.  So it was not necessary to become a hard core exercise freak!

The researchers found significant improvements in health and mental well-being.

The women in the study were also taught about good eating habits, including how to read food labels and cook food, and they received social support and behavioral therapy to help them respond to body cues such as hunger and feeling full.

After a year, the women had only lost a little weight but were significantly fitter and happier with themselves. Their blood pressure, heart rate and cholesterol fell and respiratory fitness increased. And the women also felt better in terms of general well-being, body image, self-perception and stress.

This small, simple study re-emphasizes what we have said to tens of thousands of people: fad diets will only help in the short term. For all practical purposes you can eat what you want, but in moderation. But try gradually to change the composition of your diet. I have written some advice on doing that. In Healing, Meaning and Purpose we also provide a number of tactics to help you tackle some of the psychological and social hurdles that may stand in the way of weight management. Which include something not often discussed: the twelve ego-fears that can be the hidden drivers to a lot of our behavior.

Understand them and you can gain a remarkable degree of control of your thinking and your emotions.

And it is exercise that should be the centerpiece of a weight management strategy.

This was re-inforced by a study published last week in the Archives of Internal Medicine: people who lost weight by restricting calories lost bone mineral density. Those with exercise-induced weight loss did not.

And as you doubtless know, loss of bone mineral density is one of the key risk factors for osteoporosis.

So please don't buy in to some new "miracle" diets: they simply don't exist.

Instead:

• Gradually increase your level of exercise
• Slowly change the composition of your diet
• Keep your internal organs - especially your intestine - in balance
• Develop your food awareness (I am going to do a whole post/article about that!)
• Learn how to deal with the psychological, social subtle and spiritual aspects of suboptimal eating (Check out the reources that I have already provided + a new eBook in the New Year)
  

And before you know it, you will be exactly where you want to be.

Promise!

 

Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.”
--Plato (Athenian Philosopher, 428-348 B.C.E.)

“The way to cheerfulness is to keep our bodies in exercise and our minds at ease.”
--Sir Richard Steele (English Dramatist and Essayist, 1672-1729)

Intestinal Microbes: A Hidden Cause of Obesity

It is no secret that many famous people swear by colonic irrigation. The late Princess Diana used to say that it helped her stay fit and keep her weight steady, though personally I always thought that good genes and regular exercise were the real explanations.

In previous posts I have talked about some of the emerging lines of evidence suggesting that there are at least four previously little recognized causes of obesity:

1. Stress
2. Salt intake
3. Pesticides
4. Viruses

Following a paper in today’s issue of the journal Nature, it looks as if we shall have to add a fifth: the intestinal microbes that are collectively known as “gut flora.” 

We have within us vast communities of microbes that outnumber our own body's cells by 10 to 1, and may contain 100 times more genes than our own human genome.

We have known for many years that we each contain pounds of these microbes and that they are doing a great deal more than simply sitting there. We have known since the 1950s that many of the microbes are involved in digestion, absorption and immune function. That is one of the reasons why most doctors worry about the unnecessary use of antibiotics: some can knock out the gut flora, sometimes with serious consequences.

It is the first of these – digestion and absorption – that has been attracting attention. Under normal circumstances our bacteria break down many complex molecules like polysaccharides into simple sugars that we absorb and use for energy.

Colleagues from the Washington University School of Medicine in St. Louis have made a remarkable discovery. It seems that the balance of two major families of intestinal bacteria: Firmicutes and Bacteroidetes have a major impact on digestion and obesity. Together these two families constitute 90 per cent of the bacteria in the intestines of humans, and, coincidentally, white mice.

The researchers conducted two parallel studies. In the first they found that as obese people lose weight, the balance between the Firmicutes and the Bacteroidetes changes - the latter increasing in abundance as an overweight person gets slimmer.

The second study used white mice. Here, researchers discovered that the bacteria in the lower intestines of obese white mice were more efficient at extracting calories from complex carbohydrates than the bacteria in the intestines of slimmer mice.

In an earlier study the researchers had shown that the intestines of obese mice had the same depletion of Bacteroidetes as found in the innards of obese humans.

The practical consequence of this finding is immense: it means that if two people are on the same diets and doing the same amount of exercise, one may gain weight and the other stay the same weight. Simply because the person who stayed the same had more Bacteroidetes in his large intestine, extracting fewer calories from the same amount of food. The main reason why his friend gains weight is because he has more Firmicutes and fewer Bacteroidetes.

The researchers suggest that intestinal bacteria could become "biomarkers, mediators and potential therapeutic targets" in the fight against obesity.

I find it impressive that some advocates of natural healing had predicted something along these lines in the early days of the 20th century. I am not too keen on colonic irrigation, though I have many colleagues who use it routinely. But there are many other ways of changing your intestinal flora, including probiotics and prebiotics. You may be interested to look back at a few words that I wrote about them in late August.

I would be happy to detail some other evidence-based strategies that we have used for normalizing intestinal flora.

“A man is not rightly conditioned until he is a happy, healthy, and prosperous being; and happiness, health, and prosperity are the result of a harmonious adjustment of the inner with the outer of the man with his surroundings.”
--James Allen (English Author and Mystic, 1864-1912)

“You cannot poison your body into health with drugs, chemo or radiation. “ Health" can only be achieved with healthful living.”
--T.C. Fry (American Writer on Natural Healing and Originator of the Life Science/Natural Hygiene Course, 1926-1996)

Aerobic Exercise, Diet and Abdominal Fat

Most of us are probably aware of the difference between fat inside the abdomen – “intra-abdominal,” also called visceral fat – and fat on the hips or the outside of the abdomen. The fat inside the abdomen is associated with insulin resistance, diabetes and at least a dozen other medical problems. This fat is also covered in cortisol receptors and breaks down and reforms extremely rapidly. By contrast the fat on the outside of the body has relatively few metabolic consequences until the amount of it becomes extreme.

Excess fat in general is not a good idea, but it is the intra-abdominal fat that is the best target for treatment.

New research has shown that the addition of aerobic exercise to a standard dietary weight loss program can preferentially reduce abdominal fat in overweight people.

The investigators did a twenty week prospective study in which looked at 45 obese women with an average age of 58 years. During the study the participants bought their own breakfast in consultation with a dietitian, but had their lunch and dinner prepared by the kitchen staff of the hospital. They were either told to continue with their normal routine of daily activities, or to do low-intensity or high-intensity aerobic exercise. The investigators not only did all the standard measurement on their volunteers, they also did fat biopsies and measured the size of the fat cells.

They all lost weight, but in the people who did the high-intensity aerobic exercise, they also had a reduction in the size of the fat cells in subcutaneous tissue taken from the abdomen.

This is interesting, but it’s necessary to sound a note of caution about the experiment: the investigators were measuring subcutaneous fat cells rather than the all important intra-abdominal fat cells. The trouble with measuring those is simply getting at them. It is not easy trying to get fat out of the abdomen without some invasive procedures.

Food, Reward and Weight Gain

There's a short review with a link to an online research paper that you might find interesting.

Although the paper has to do with the mechanisms of weight gain in people with schizophrenia, many of the same principles apply to many people with weight problems. The systems of the brain involved in salience - deciding what is important in the environment - appear to be disrupted.

Gene-Jack Wang at the Brookhaven National Laboratory has discovered that the brains of morbidly obese people seem constantly to be turned toward finding food: The regions of the brain connected to the mouth lips and tongue are overly active, and, like the addicts who get the biggest rush from drugs, they seem to have fewer dopamine receptors in the reward systems. Perhaps like the addict, the morbidly obese eat to compensate for an underactive dopamine system.

In Healing, Meaning and Purpose, we coined the term, “Salience Disruption Syndrome,” to describe a group of problems that are normally thought of as separate entities, but which are inextricably linked. They include not just over-eating, but:

• Impulse control disorders
• Substance abuse disorders
• Pathological gambling
• Pathological shopping
• Attention deficit with ot without hyperactivity
• Bipolar disorder

The list is a long one and the reason for highlighting it is that we have been able to devise new treatments based on this new principle of a disruption in salience. If there is interest, I shall post some more about the methods that we have devised.

The Epigenetic Code

In Healing, Meaning and Purpose I reveal some of the extraordinary changes that are occurring in our understanding of genetics and inheritance. Even if you are currently learning genetics in college, it is quite likely that some of what your professors are teaching may already be out of date. I say that with the greatest possible respect: I find that in some of my fields of expertise, I am often having to update my teaching materials every week.

One of the remarkable discoveries that is generating huge amounts of new information is what we call epigenetics. This is the study of a form of inheritance that can occur without fundamental changes in gene sequences. This has to do with the idea that there is a second layer of programming on top of our DNA. A code that can change over our lifetimes in response to environmental change. Diet, hormones, chemicals in the environment, stress and even thought, emotion and behavior, can all change the ways in which our genes are expressed. Some of these epigenetic changes can be passed on to other generations. In other words, there can be an inheritance of acquired characteristics. Something that has been denied for over a century.

Let me give you a simple example. Studies of a particular species of mouse have shown that maternal diet has an effect on the coat color of the offspring. This was the result of what is known as methylation that altered gene expression. These changes in coat color were carried on to the next generation: the grandchildren of the mouse given the special diet. This created quite a stir, because it had been thought that epigenetic changes in cells are erased each time that a cell divides. Obviously that was not happening. We now have many examples of epigenetic changes being passed on to the next generation and the next. There are literally hundreds of scientific papers on the subject.

As I have written before in my last book and CDs, in articles and in reviews at Amazon and elsewhere, the traditional view of genetics has been one of genetic determinism. That we are all little robots whose entire lives are dedicated to nothing more than passing our DNA from one generation to the next. And the genes even dictated how we did that. I still know many gene jockeys who are convinced that the whole of human behavior will ultimately be explained by our genes, and that free will is therefore a myth.

I’m just as sure that they are wrong.

Let me give you an example. Identical twins have identical DNA, yet we have known for fifty years that one twin may get a genetic illness that the other does not. And the brains of identical twins, though they start out identical, quickly become quite different from each other because of the impact of the environment. Twin studies of mental illness have been going on at the Institute of Psychiatry in London since 1960. Every patient coming to the hospital is asked by the clerical staff if he or she is a twin. And there has been groundbreaking research on mentally ill twins at the National Institute of Mental Health for decades. And what have we learned? Though there may be a genetic component in schizophrenia, when we look at people with schizophrenia who have identical twins, only half of the twins have the illness, despite having the same DNA. The key difference is at the epigenetic level.

Marcus Pembrey from the Clinical and Molecular Genetics Unit at the Institute of Child Health, part of University College, London, has been at the forefront of the work on epigenetics. Marcus has had the opportunity to study the unusually detailed historical medical records of the isolated northern Swedish city of Overkalix. He and his colleagues found something astonishing. The grandsons of men who experienced famine during mid-childhood went through puberty earlier and had longer life spans, while the grandsons of men who were well fed in early childhood had an increased likelihood of diabetes. For females, the effect was similar but it was tied to the grandmother, rather than the grandfather. Presumably these responses are designed to adjust our early growth and reproduction to be ready for unpredictable changes adverse events in the environment. I would call this epigenetic resilience.

In a separate study done in Bristol in England, Marcus studied two generations of families, and found that fathers who had started smoking before age 11 had sons who were significantly heavier than average. There was no similar effect on daughters.

There is already some evidence that epigenetic factors may play a role in the development of bipolar disorder and schizophrenia.  Many of us are becoming excited about the potential benefit that may flow from a better understanding of genetic and epigenetic mechanisms in major psychiatric disorders.

There is a new journal called, appropriately, Epigenetics that contains a treasure trove of important information. The editor is Moshe Szyf, form McGill University in Canada, and he recently pointed out that one single gene could have as many as 700 epigenetic programs associated with it.

His own research has linked epigenetic change to social interactions: the way in which we behave toward one another can lead to a change in how our genes operate.

Rats whose mothers groom and lick them when they are young grow up to be much calmer than rats whose mothers neglected them. There is, of course, nothing surprising about that. We all understand the importance of good child rearing. But what was surprising was the finding that epigenetic changes are the cause. By nurturing their young, the rat mothers activated a gene that suppressed the creation of cortisol, one of the stress hormones.

Pups who were neglected did not have that gene activated, so they produced more cortisol and were therefore more stressed out.

Knowing this, the researchers were able to increase the well-nurtured rats' stress by injecting them with methionine, an amino acid commonly found in food supplements.

Here we have proof that the link between food and mood is not just due to transient chemical changes in the neurotransmitters of the brain, but that a chemical in our diet could cause fundamental changes in the way in which our genes work. In this case a rat’s emotions and state of mind. The implications for all of us are extraordinary.

Since 2003, a consortium of public and private firms in Europe has been working on the first Human Epigenome Project (HEP), and it hopes to have completed 10% of the map by the end of this year. As you can see, it is a lot more complicated than mapping the human genome, and epigenetic codes are constantly moving targets. The first reports from HEP have indicated that at least 20% of the genes studied so far can have their behavior modified by the environment. The food that we eat, the chemicals that we ingest and the attitude of our parents and peers can all change the way in which our genes function. As Marcus Pembrey has said, “Child care has a whole new meaning.”

This is all crucially important, because one of our most important discoveries has been that human beings have been undergoing extremely rapid physical as well as psychological and social change, and that is one of the reasons why the Laws of Healing have been changing over the last century.

Curry and Cognition

During a visit to Singapore a couple of years ago, I heard about some interesting research that's just been published in the American Journal of Epidemiology.

The authors did something fairly simple. They took a group of 1,010 people with no evidence of dementia aged 60-93 years, and correlated their consumption of curry with their cognitive performance. Studies like this are not easy: what if more intelligent people like eating curry to begin with? What if sick people can't get out to the local curry house? And so on.

But the researchers did this all very carefully: they took into account all the known sociodemographic, health, and behavioral determinants of performance on a simple cognitive test. So they controlled for many of the other factors that can accelerate cognitive decline, like depression, smoking, drinking alcohol, high blood pressure, glucose and lipids.

The result was that people who occasionally or often ate curry had significantly better cognitive function than people who "never, or rarely" ate curry.

Is there any logic to this?

Well in fact there is. Curcumin, from the curry spice, turmeric, has been shown to possess potent antioxidant and antiinflammatory properties and to reduce beta-amyloid and plaque burden in experimental studies. There have been serious suggestions about using active constituents of tumeric to try and prevent the development of Alzheimer's disease.

This research is all very encouraging. The amount of curcumin used in the experimental studies is similar to the amount ingested by having a couple of curries a week, and now the epidemiological study from Singapore suggest that those couple of curries may have a clinically measurable effect.  That's not to say that eating curry three times a day is going to be even better.

All things in moderation: too much curry can play havoc with your digestive processes.

And your relationships....

Probiotics: Caveat Emptor

You may well have heard the advice that we all need to keep the bacetria in our intestines healthy. Countless experts have recommended that, as long as we are not lactorse intolerant, we should regularly take some live yoghurt to "re-colonize" our intestines with nice friendly bacteria.

There has just been a briefing in London to warn the public that as many as half of the "probiotic" or "friendly bacteria" products on sale in the United Kingdom could be ineffective and some may even be harmful.

The experts on the panel included Professor Glen Gibson from the University of Reading who is an expert in food microbiology, and recommended sticking to products made by major manufacturers. Too many of the other productsmight not contain the numbers of bacteria advertised, and the icrobes might not survive long enough in the intestines to do much good.

The evidence that probiotics help is still far from settled, as discussed in a recent review. But there are enough reports to think that probiotics may be helpful for irritable bowel syndrome and perhaps inflammatory bowel disease.

An even newer area or interest in the use of "prebiotics:"  short-chain carbohydrates that alter the composition, or metabolism, of the intestinal organisms in a beneficial way.

Make sure that if you are using a product, it comes from a reputable manufacturer, and that it contains at least 10 million bacteria. And as I said in my title, "Caveat Emptor," "Let the buyer beware."

How Does Fiber Help You?

Unless you’ve been living on Mars (!), you will doubtless have heard of the advantages of increasing the amount of fiber in your diet. A high-fiber diet reduces your risk of colon cancer, constipation, hemorrhoids hypercholesterolemia and insulin resistance syndrome.

We have always wanted to know how fiber does so many magical things at once, and now we may an answer. In a paper published in the open-access Public Library of Science Biology today, by a group from one our local institutions – the Medical College of Georgia in Augusta – collaborating with a researcher from Josai University, Sakado, Saitama in Japan.

The epithelial cells lining the intestine have a life span measured in 1-5 days. They spend their short life times working to process enormous amounts of food residue on its way past. It is this layer of cells that acts as the barrier between the body and items floating past on the inside of the intestine.

Long before it became the topic of some popular books are over-enthusiastic magazine articles, we became very interested in the idea of the “Leaky gut:” the concept that some illnesses are a result of breakdown of the normal integrity of this protective barrier. Over 20 years ago, a friend and colleague at Northwick Park Hospital - Ingvar Bjarnason - did some pioneering work on this important issue. Several recent studies have indicated that a breakdown of this barrier may be involved in several childhood illnesses including allergies and asthma. There is also some early information suggesting that “leaky gut” may be involved in some autoimmune processes involving the intestine. Both zinc supplementation and oats may prevent gut leakiness under certain very specific circumstances.

When the epithelial cells in the gut wall encounter indigestible fibrous foods, the outer covering of the cell ruptures, releasing a coating of cell-protecting mucus. In a matter of seconds, the cell begins to repair itself, in the process releasing yet more of the beneficial mucus. Not only does it lubricate, but also it may keep some carcinogens and allergens out of your system.

The constant buffeting of the cells causes mild damage that increases the level of lubricating mucus. Injury at the cellular level promotes the health of the gastrointestinal tract as a whole.

Here we see a basic principle of nature: many of the same things that apply in the cells of the body apply equally in the life of someone trying to achieve success. Without the buffeting, the cells of the intestine could not produce the mucus on which your life depends.

Without some occasional adversity, you will find it more difficult to grow as a human being.

“Storms make oaks take deeper root.”
-- George Herbert (English Religious Poet, 1593-1633)

“He who knows no hardships will know no hardihood. He who faces no calamity will need no courage. Mysterious though it is, the characteristics in human nature which we love best grow in a soil with a strong mixture of troubles.”
--Harry Emerson Fosdick (American Clergyman, Writer and Broadcaster, 1878-1969)

Insulin Resistance, Polycystic Ovarian Syndrome and Sleep Apnea

Polycystic ovarian syndrome (PCOS) is a common endocrine disorder that affects between 5-10% of women in the Western World. It is a leading cause of infertility, and although the underlying cause is still speculative, it is very heavily associated with insulin resistance.

There was an International Consensus Workshop sponsored by the European Society of Human Reproduction and Embryology and the American Society of Reproductive Medicine came up with this set of criteria. PCOS is present if a woman has at least two out of three of:

1. Oligoovulation and/or anovulation (ovulating only occasionally or not  at all)
   
2. Excess androgen (male sex hormone) activity
3. Polycystic ovaries (which needs a gynecological ultrasonography) and other causes of PCOS are excluded

There is still a great deal of debate about the precise way to define the syndrome. We are currently preparing a scholarly article on the subject and our literature review has included over three thousand papers.

The combination of an excess of the male (androgenic) hormones and insulin resistance can cause an array of symptoms apart form the menstrual disturbances and infertility, including:
Central obesity
Acne
Hirsutism, while at the same time experiencing alopecia
Skin flaps and dark patches of skin, usually on the neck or in the armpit
Sleep apnea

It is the last of these that I would like to highlight today.

A new study by Dr. Esra Tasali and her colleagues from the University of Chicago has found that in women with PCOS, sleep apnea is, as expected, associated with high fasting insulin levels. Sleep apnea might worsen the metabolic consequences of insulin resistance.

Regular readers may recall that I highlighted the association between insomnia, insulin resistance, weight and diabetes a couple of months ago. Here we have yet more confirmation of this link.

Not getting enough sleep – for any reason - can play havoc with your metabolism. It seems that in women with PCOS, it’s really easy for a vicious circle to become established:
Insulin resistance -> weight gain -> sleep apnea -> insomnia -> more insulin resistance -> more weight gain and so on.

It is important for everyone to know about this association, because chances are that you know someone with PCOS and/or sleep apnea.

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

Cannabinoid Receptors and Cardiovascular Risk Factors

Clinicians throughout the world are looking forward to being able to use a new medicine for obesity called rimonabant, which will be marketed as Acomplia by Sanofi-Aventis. It was launched in the United Kingdom yesterday, after being given official European Union marketing approval last week. We do not expect to get it in the United States until sometime in 2007, assuming that the FDA gives it approval. The medicine is not cheap, but interestingly there is also some data to suggest that it may help some people stop smoking.

So why the interest? The original idea for the compound was based on the observation that many people become very hungry if they use cannabis and specific cannabinoid receptors were found in the brain that are responsible for many of the actions of the drug.

A recent and important study involving a two-year investigation of 3045 obese or overweight individuals was published in the Journal of the American Medical Association. It indicated that treatment with 20 mg/day of rimonabant plus diet for 2 years promoted modest but sustained reductions in weight and waist circumference and favorable changes in metabolic and cardiac risk factors.

Only about half of the people in the study completed it, so we must interpret the data cautiously. The idea of using a pill to manage weight is appealing as a weight-loss aid for some patients. But as I have pointed out before, the control of weight is highly complex, and it is highly unlikely that a pill will be successful on its own. What are needed are long-term, comprehensive lifestyle changes, together with careful attention to the psychological and subtle aspects of weight control.

We have had a great many requests to publish our own comprehensive weight management strategy – The Atlanta Approach – that we have been using with great success for almost two decades. If there is interest in me doing so, I shall put our notes together into a downloadable eBook.

Technorati tags: Rimonabant Acomplia Cannabinoid receptor Weight management The Atlanta Approach

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

The Genetics of Eating

The BBC has just run a story about the latest installment of some fascinating work being done by Professor Jane Wardle, of Cancer Research UK's health behavior unit.

Two years ago she published data on genetic predispositions to unhealthy eating behaviors. This new study involved more than 200 pairs of same-sex twins, about half of whom half were identical, so sharing all their genes. Based on questions given to the childrens' mothers, it now appears that a taste for high protein foods like meat and fish are largely inherited. By contrast, a liing for vegetables and sweets are less likely to be fixed and more a reflection of the menu provided by parents. Interestingly, girls were found to be more likely to enjoy vegetables than were boys.

It's not clear why there should be this separation: genetic predisposition toward protein eating and environmental toward vegetables and sweet things. The researchers though that it might have something to do with variety of choices of vegetables and little choice in types of proteins.

I think, though, that this all makes good sense from an evolutionary prespective. We are going to be exposed to different fruits, vegetables and sweet things throughout the year and particularly as our ancestors migrated. Copying what foods to eat would make sense. The trouble arises when the availability of food throws the system off.

In Healing, Meaning and Purpose, I point out that as recently as ten thousand years ago, is someone wanted something sweet, it would mean sucking a sweet vegetable or risking a raid on a beehive. Oh how things have changed! In 1905 The average annual intake of refined sugar was 60 pounds per person, up from 7 pounds per person in 1805. (It is estimated to be an average of about 150 pounds for each person in the United States in 2005. A twenty-fold increase in just 200 years.)

This research indicates that parents could have a profound impact on their children's dietary preferences - and help steer them toward healthy options. That being said, there are so many children who develop all manner of likes and dislikes for no readily apparent reason. We have recently been taking a great deal of interest in the oversensitivity to taste and texture of food in many girls with attention deficit disorder. I shall write more about that soon.

But the research also reinforces what I have said so many times: genes are important, but biology is not destiny. There are millions of vegetarians who presumably still have those meat-liking genes on board.

“Give me the children until they are seven and anyone may have them afterward.” --St. Francis Xavier (Spanish Jesuit Missionary and Co-Founder, in 1534, of the Jesuit Order, 1506-1552)

Technorati tags: Genetics Dietary preference Evolution

Add Years to Your Life and Life to Your Years: The Power of Small Changes.

I want to tell you about a mind bogglingly important study that many professionals have known about, but somehow hasn’t popped up on most people’s radar. The story  was broken by the BBC last month. It is about an exceptionally important study that has been running in Norfolk, in Eastern England, as well as other parts of Europe since 1992. The British section is directed by Professor Kay-Tee Khaw who is Professor of Clinical Gerontology at the Department of Public Health and Primary Care at the University of Cambridge. The main focus of the Clinical Gerontology Unit is the maintenance of health in aging populations, with a particular emphasis on the combined role of lifestyle, environmental and genetic factors in chronic diseases.

The UK arm of the study has been following 25,663 men and women aged between 45 and 79 years old, looking at their diet, environment, lifestyle and health. The latest results from the study have confirmed several things that we already suspected: 1. Eating five portions of fruit and vegetables a day can give you the life expectancy of someone three years younger.
2. Not smoking turns back the clock by four to five years.
3. Even increasing exercise by a moderate amount can increase your life expectancy by three years. But the amount of exercise someone would need to do to achieve that depends on their job. A sedentary office worker would need to do one hour of exercise, such as swimming or jogging every day. By contrast, a person with a moderately active job, such as a hairdresser, would need to take 30 minutes of exercise a day. Here’s some more good news: People with very active jobs, including nurses and bricklayers, do not need to do any extra exercise - as their work is strenuous enough.

I think that just about anyone can take those baby steps toward a longer and healthier life

There's an old Yugoslavian Proverb:
“Grain by grain a loaf, stone by stone, a castle.”

That seems about right!

Technorati tags: Health Longevity Preventative medicine Wellness

Attention Deficit Disorder, Allergies and Membranes

There has been a long-running debate about the relationship – if any – between allergies and attention deficit disorder (ADD).

As long ago as 1991 a paper seemed to indicate that there were higher rates of hyperactivity in the parents of children with allergies as well as increased rates of allergies in children with ADD. Recently a study from New York seemed to show higher rates of allergic rhinitis in children with ADD. The problem with all this is that we are looking at two common problems and trying to sort out a genuine connection can be tricky.

I started thinking about this problem again, after a recent report that some children had symptoms of hyperactivity, inattention, attention-deficit/hyperactivity disorder, and excessive daytime sleepiness as a result of sleep-disordered breathing. But what was remarkable was the number who improved after they had their tonsils taken out. The tonsils are one of the first lines of defense in the immune system, which is why they so often become enlarged with infections, or for that matter in any kind of immunological reaction. Now I’m not much of one to take out tonsils unless there’s a really good reason, but it is certainly an important observation for anyone who has a child with behavioral or cognitive difficulties: he or she may not be sleeping properly.

I have seen quite a number of people who had physical and psychological problems, including headaches, depression and attentional problems, who turned out to have either allergies or environmental sensitivities, and when those were addressed, the symptoms resolved. I have also seen some people who followed the notoriously difficult Feingold diet with some success, even though the research doesn’t seem to be very supportive of elimination diets. And I've seen just as many people who got no relief at all from elimination diets.

I have just done a detailed literature review on the topics of allergy and attention, and I don’t think that we have enough evidence to suggest that everybody with attention deficit needs to see an allergist. But what this highlights is that not all people with attentional problems or hyperactivity have ADD. They may have attentional problems because of sleep disturbance, depression, anxiety, obsessive compulsive disorder and a range of other problems.

There is some exciting research indicating that one of the problems in many cases of ADD is a disturbance in the normal functioning of cell membranes. If that is correct, it may be that there are disturbances in the membranes of both neurons in the brain and membranes of cells in the immune system. That link is not entirely proven. But it has received further credence by the finding that some children and adults with ADD seem to show improvements of both attention and immune function when they take omega-3 fatty acids. I have recently been hearing some encouraging reports from people who have used the Omega-3 Formula made by Omegabrite (And no, I have no link with the company!)

Technorati tags: Attention deficit disorder Allergy Atopy Hyperactivity Tonsils Cell membrane Omega-3 fatty acid 

Farmer P.

Well today your humble reporter is like a dog with two tails.

He has never tried growing anything other than roses and herbs, but She Who Must Be Obeyed wanted vegetables. So I was dispatched to create a vegetable garden. Being in the American colonies, we decided to use the old Native American method, planting corn, squash and beans in the same hole in the ground, so that the corn grows, providing a climbing structure for the beans, and the two together provide shade for the squash. Being originally of an English persuasion, I hadn't seen squash, except as an occasional import in exotic stores, so I didn't know what to expect.

Well here is my first crop.

Thank you to Morgan Wenner for providing her hand!

I am now in the market for squash recipes: I think that we're going to be living on them for a while....

Technorati tags: Gardening Cucurbita Squash

Sleep, Weight, Insulin Resistance and Diabetes

I am often asked why there seem to be such close links between food and mood. Not just comfort eating, or the sudden shock of lots of carbs when we need an energy jolt, but why drugs that alter mood so often alter appetite?

You will probably not know this, gentle reader, but I only learned of it from reading scholarly papers. Apparently many people report that using marijuana makes them very hungry. On the other hand, cocaine and amphetamine affect not just the metabolism, but also appetite. The link has to do with the evolutionary development of feeding behaviors with the motivation to find food and to be satisfied by it.

Another link that has interested me for many years is the connection between metabolism and sleep. We have always presumed that this link has to do with hibernation: even humans have maintained some hibernation responses.

There is extremely good evidence that there is an inverse relationship between the number of hours that you sleep and an increase in your weight. There have been a great many studies on this, but one of the best was published by a group of researchers from the Mood and Anxiety Disorders Program, at the National Institute of Mental Health, the Psychiatric University Hospital, Zurich, Switzerland; University of Pittsburgh School of Medicine and the Department of Psychosocial Medicine, Zürich University Hospital, Switzerland in the Journal Sleep in 2004.

A report from the BBC concerning a study presented to the American Thoracic Society International Conference in San Diego provides yet more evidence of this link between sleep and weight. Researchers from Case Western Reserve University in Ohio, followed nearly 70,000 women for 16 years. They found that women who slept five or fewer hours a night were a third more likely to put on at least 33lbs (15kg) than sound sleepers during that time. It also found that compared with women who slept for seven hours a night. lighter sleepers were 15% more likely to become obese (have a Body Mass Index (BMI) of 30 or more. {BMI is calculated by dividing your weight in kilograms by the square of your height in meters}).

Previous studies, some of which I have reported before, have shown that after just a few days of sleep restriction, the hormones that control appetite cause people to become hungrier. However the women in the study appeared to eat less. I say “appeared to,” since the use of personal evaluations of food intake are notoriously inaccurate.

In dozens of countries arond the world, I am regarded as an authority in the fields of endocrinology, metabolism and nutrition. But when a group of us tried to estimate our daily intake and compare it with meticulous diaries, we discovered that we – a group of internationally renowned experts – were off by around 500 calories per day.

All kinds of explanations have been advanced, from people who didn’t sleep getting up and binge eating; to the effects of sleep-deprived people craving high carbohydrate, high fat food; to insomnia being a result of anxiety or depression that releases hormones that cause us to lay down fat in our tummies.

For all kinds of complex biochemical reasons, I have always felt that a lack of sleep would lead to an increase in insulin resistance, that may cause an increase in the deposition of fat in key regions of the body.

Some new research suggests that I may have been right on this one. A group based at Yale University School of Medicine, in New Haven, Connecticut has just published a report that should be of interest to all of us, and in particular you multi-tasking insomniacs out there.

The investigators studied a cohort of men from the Massachusetts Male Aging Study who did not have diabetes at baseline (1987–1989) and who were followed until 2004 to look for the development of diabetes mellitus. They came to the conclusion that BOTH very short and extra long sleep durations increase the risk of developing diabetes, independent of confounding factors.

The take home message?

If you do not get 7-8 hours sleep each night, you are vulnerable to a great many problems, and perhaps the biggest of all is the risk of weight gain, insulin resistance and diabetes mellitus.

I do not recommend using sleeping tablets unless absolutely necessary, and then for just a few days at a time. Instead follow all the sleep strategies that I have talked about in earlier blog entries.

During a recent visit to Danville, Virginia, I was delighted to learn that one of the non-pharmacological approaches that I have found helpful – putting a cold compress on the abdomen – was used by General Stonewall Jackson who used this very technique that I had to learn by going all the way to China.

The bottom line? Before your sleep gets disrupted by being  overweight and you develop sleep apnea, try some simple sleep hygiene, and a few of these novel techniques.

Technorati tags: Insulin Insulin resistance Insulin resistance syndrome insomnia alternative medicine resilience 

More on the Neurology of Obesity

The last year has seen a mass of new obesity research linking intestinal hormones and the brain.

Over the last 25 years, there has been increasing evidence that many people with significant weight problems have problems in a region of the brain called the hypothalamus that is involved in the control of appetite, feeding, temperature and a range of other bodily functions. On April 18th, I mentioned the intriguing possibility that viruses could be one previously unrecognized explanation for the obesity pandemic. It is hypothesized that these viruses might alter the normal functioning of the hypothalamus, causing an increase in feeding, and perhaps also of appetite and inactivity.

A study from Albert Einstein Medical College in New York, published in this month’s Journal of Clinical Investigation provides further evidence that there may be something wrong with the normal functioning of the hypothalamus.

We normally have a sensitive mechanism in the hypothalamus for sensing fats, which provide a strong signal to stop eating and also to start normalizing blood glucose. There are strains of obese rats, and in these little creatures the fat sensing mechanisms do not work properly. Not only do they keep eating, but also they cannot control their blood glucose properly. Those two things together conspire to produce yet more obesity. What was so interesting in this study, was that the researchers found that if they inhibited a single enzyme involved in fat metabolism, the levels of fatty acids rose in the hypothalamus, the animals were once again able to sense fat levels, and both their feeding and glucose levels normalized.

This is one of the first times that it has been possible to find a single enzyme that would normalize metabolism. The next question is to see whether this might constitute a viable treatment for obesity, or if the body would quickly work around the treatment and return to its old ways.

Technorati tags: weight control hypothalamus obesity

More Advances in Understanding Weight Control

I have on many occasions discussed the problem of over-simplifying the mechanisms controlling our weight and appetite. They are complex and have multiple fail-safes and multiple levels of redundancy, which is why most weight loss programs only last for short periods of time. The body gets used to the diet, believes that it is starving, and immediately gets to work to conserve energy: our metabolism slows and our physical activity levels begin to fall.

We can tinker with leptin, cortisol or insulin to our hearts’ content, and each will probably help for a while. But if we ignore the body’s starvation-protection mechanisms, to say nothing of the psychological, social and subtle aspects of weight, our efforts will usually be fairly short-lived. Most of us now understand that food intake is only part of the equation; we also need to maximize our metabolic rate and increase our level of physical activity. One of the problems has been how to help someone exercise whose body wants to go into starvation mode.

Steve Bloom’s group at Imperial College and the Hammersmith Hospital in London has published another valuable report helping to elucidate some of the complex mechanisms involved in appetite, weight and metabolism. Steve has been working in this area since the early 1970s, and is one of the most highly cited scientists in the world. In a field that constantly sees new discoveries replacing the old, he is unusual in that that virtually all of his work has stood the test of time.

This report concerns the intestinal hormone oxyntomodulin, which has a dual action, increasing energy expenditure as well as reducing food intake. It appears that oxyntomodulin may let the brain know it has an adequate energy supply and that it can afford to do productive things rather than just concentrating on food seeking behaviors or energy conservation. The hormone signals the brain that it can increase exercise by letting it know that the energy is available to do so.

At the moment oxyntomodulin has to be given by injection, and, given the complexity of the weight maintenance systems it is unlikely to be the whole answer.

Technorati tags: weight control obesity oxyntomodulin energy expenditure weight management

Predicting Responses to Supplements

The other day I was being asked about the use of S-adenosyl methionine (S-AME) for depression and the same day somebody was asking me about some of the supplements – mainly creatine - being taken by body builders.

The research data for each of these is patchy. When S-AME is injected, it seems to help with mild to moderate depression. But oral S-AME is a different issue, because the compound is about a soluble as sand. Not that much is absorbed, which is why we give fairly large amounts so that some gets into the body. Some research has been positive and some not. Similarly, when we look at creatine, there is a limit to how much can be taken up into the intestines or into muscles.

These are not nit-picky observations: When we take a supplement, it is good to know the chances that it will help. You don’t want to waste money on something that has little chance of getting into your body. It is always possible that a supplement works by some unknown mechanism, and we don’t want to dismiss that possibility: if you take a large dose of Vitamin C, most of it will be out of your body and into the plumbing within two hours. But that does not exclude the possibility that during those two hours it is doing something useful inside your body.

This is why we look at five things:
1.The research data, and also who did the research? With pharmacological agents as well as herbs and supplements, there have been countless examples of research funded by the manufacturer, generating glowing testimonials that don’t hold up to independent scrutiny
2. Individual accounts of benefit. Though they don’t carry the same weight as controlled studies, they can’t be minimized
3.The origin, purity, dose, concentration and expiration of the supplement. With many herbs and supplements there is a great deal of variability in quality control from one company to another and sometimes even from one batch to another
4.The plausibility that a treatment could be helpful. If a medicine cannot get into the body, it is not that likely to be helpful.
5.The possibility that a herb or supplement may be acting by some entirely novel mechanism

Rest assured that when we write our articles, we always check out all of these five things, as well as analyzing all the data in the reports of the research. I have mentioned before that when I read a paper, I sit down with a notepad and calculator so that I can check everything in the study. Many journals now post all the raw data online, and we check through that as well.

There are countless magazines and websites that try to bring you all the latest and greatest information. When you read their material it is a great idea to see if they have checked all of these five points as well as analyzing the data in the studies. Many of them do, but not always.

Some of us have been pulling our hair out every time that we see a well-known marketer present more of his infomercials. He is one of that band of people who quote research without really understanding it, perhaps in the hope that nobody will check up on them!

If you are interested in some herb or supplement, let me know and I shall see if I can help you. And if I do not know, I promise that I shall tell you!

Technorati tags: dietary supplement S-adenosyl methionine creatine intestinal absorption

Viruses and Weight Gain

Another discussion in Healing, Meaning and Purpose revolved around the evidence that in addition to toxins, viruses have been attracting a great deal of attention as causative agents of obesity in humans. There are currently seven viruses known to cause obesity in animals and three in humans. This work began almost twenty years ago when a Dr. Nikhil Dhurandhar was working in India and discovered that viruses could cause obesity. It started with a chance observation: thousands of chickens were dying, and when they did, they were found to be abnormally heavy. He then discovered that people who had been exposed to a chicken adenovirus called SMAM-1 were consistently fatter than those who had had no exposure. He later moved to the U.S., and has collaborated with other researchers to study whether human adenoviruses, which are common throughout the human population, could be having a similar effect. This led to the discovery that the human adenovirus Ad-36 caused significant fat increases in animals, and furthermore was associated with obesity in humans. Now we have a new report from Leah Whigham and her team at the University of Wisconsin in Madison who tested several human adenoviruses for their ability to increase fat in both live chickens and in cell culture.

It is not at all far-fetched to suggest that there may in the future be vaccines to prevent one of the many causes of obesity. But for now, follow simple rules of hygiene and do everything that you can to improve your own resistance to infection. Which gets us straight back to Healing, Meaning and Purpose!

Technorati tags: weight gain, Nikhil Dhurandhar, virus,

Calcium, Vitamin D, Diabetes and Schizophrenia

There are some odd puzzles in medicine. For more than 100 years it has been known that diabetes is more common in people suffering from schizophrenia, bipolar disorder and probably also depression. There has also been data indicating that some children with ADD and autism have metabolic disturbances that may underlie some of the cognitive difficulties. It has also been observed in Europe that dark skinned immigrants - whose skin coloring makes them less able to make Vitamin D - are more likely to develop diabetes. Some dark skinned immigrants are also far more likely to develop schizophrenia compared with their families that stayed in sunny tropical regions. Children – particularly boys - who are breastfed and/or have Vitamin D supplements in the first year of life are less likely to develop schizophrenia in later life. Vitamin D is not only involved in calcium absorption, but also in maintaining the integrity of cell membranes. So the link between diabetes and schizophrenia may have something to do with Vitamin D.

A new study just published in the journal Diabetes Care indicates that women with high intakes of vitamin D and calcium appear to have a lower risk of developing type 2 (maturity onset) diabetes. The study from Tufts-New England Medical Center looked at data on 83,779 women enrolled in the Nurses' Health Study. The women had no history of diabetes, cardiovascular disease or cancer when they enrolled in the study. Vitamin D and calcium intake from foods and from supplements were evaluated every 2 to 4 years. Over the 20 years of follow-up a total of 4843 new cases of diabetes were discovered. The lowest risk of diabetes was observed among women with the highest combined intakes of calcium and vitamin D compared with those with the lowest.

These are important findings, because interventions to raise both vitamin D and calcium intake and quick, cheap and easy, and may significantly reduce the risk of developing type 2 diabetes.

So how much should we take? Although we should be able to make enough of our own Vitamin D by spending even ten minutes in the sun, not everyone can do that, the sun is not without its risks, and the mechanisms for making Vitamin D become less effective as we become older. Though a balanced diet should also help provide some vitamin D and enough calcium, the data indicates that we should take in at least 1200mg of calcium each day, and 400 International Units (10 micrograms) Vitamin D each day. It is possible, though uncommon for people to take too much Vitamin D, and that can have all manner of health consequences.

Technorati tags: vitamins, diabetes, schizophrenia, calcium, Vitamin D,

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,

Hunger and Memory

It’s always a good idea to see how new findings fit in with previous knowledge, and also to see if they make sense. We have previously met the hormone leptin, which is involved in decreasing appetite. Its twin is the hormone ghrelin. Discovered in 1999, ghrelin comes from some of the cells lining the stomach and acts in the hypothalamus to increase appetite. When the stomach is empty it is released into the circulation and travels to the brain where it activates receptors in many different regions. Some research has indicated that one of the reasons why gastric bypass surgery may be effective is because it reduces levels of ghrelin and therefore reduces appetite.

Research published in December 2004 showed that in healthy young men, sleep deprivation caused a decrease in leptin levels and an increase in ghrelin levels, which, as expected, was associated with an increase in hunger and appetite. This is one reason why getting less sleep than you need may cause you to gain weight.

A new study published in the journal Nature Neuroscience, has found an intriguing link between ghrelin and memory. I noticed that the BBC also picked up on this interesting story. Researchers at Yale have discovered that ghrelin acts in an ancient part of the brain known as the hippocampus: so named because it is shaped like a sea-horse. (As an amusing aside, the old German pathologists thought it looked like a silk worm, so that’s what they called it!) The hippocampus has a number of functions, but is most of all essential for learning new material.

The researchers showed that mice who lack the ghrelin gene had 25% fewer synaptic connections between their hippocampal neurons. They then did the next step, and injected normal mice with ghrelin. They promptly increased the number and density of their synaptic connections, which correlated with significant improvements in the animals’ performance on several tests of learning and memory.

So that means that a hormone produced by the stomach can control some brain functions, and this may represent a link between metabolism and the ability to learn. The more that we discover, the more we see the intimate interactions between the brain, intestines and heart.

This link makes good sense: we know that memory can be switched on and off by a range of factors. In order to help us come up with options for handling the environment and for remembering things to avoid, memory is often switched on at times of stress. Hunger is a form of stress, and it makes good biological sense that we might be more alert and better able to remember and to recall information when hungry. It stands to reason that this has enormous survival advantage. If our early ancestors had not had this hunger/memory link, they might well have died out in the competition for food.

This gives some credence to the old advice that it is best not to try to study or to take an exam on a full stomach. Just have enough food to make sure that you have ample fuel, and that you are not distracted by hunger pains.

Technorati tags: hunger, memory, stress, study habits

Satiety: Another Kind of Gut Feeling

According the World Health Organization, there are currently over one billion overweight people in the world today. The ever-increasing prevalence of obesity in young people promises that this pandemic is likely to worsen in the coming years, putting an intolerable strain on healthcare systems. I have frequently commented on the problems of using a reductionist approach to weight management. You probably know from personal experience that any diet works for a while and then, unless something drastic happens, the weight usually returns. Similarly some of the drugs available for treating obesity may indeed work, but usually only in the short term and their usefulness is limited by side effects.

I want to say more about why the problems of weight can be difficult to manage and why the solution is not another fad diet aimed at modulating one hormone, such as leptin, or one neurotransmitter like serotonin or dopamine. I have mentioned before that there are multiple systems involving at least 260 tightly interconnected hormones and chemical transmitters coordinating the control of body weight. There are so many because weight is critical to survival and, with the possible exception of the brain, the more critical a system, the larger the number of fail safes and backups: the greater the degree of redundancy. Imagine a tent being secured by 260 ropes. But not just any ropes, these are intelligent cooperative ropes. Cut one, and the tent will stay in place because there are still hundreds left in place. Give it a little time, and the remaining 259 ropes will take up the slack, and the tent remains unmoved. Professor Steve Bloom from the Hammersmith Hospital and Imperial College Faculty of Medicine in London, has been a world leader in research into intestinal hormones and weight management for over thirty years, and he has just published a brief overview that focuses on just a few of the hormones known to be involved in the maintenance of body weight, and highlights the reason why some of them are attracting the interest of pharmaceutical companies. As well as holistically-oriented physicians.

It is now known that the regulation of appetite and food intake involves a complex series of interactions between higher cognitive centers in the brain, more primitive brain regions that we share with birds and reptiles, and the rest of the body. Amongst the key players in this whole vast orchestra are the endocrine systems of the gut, that play an important role in inducing and maintaining feelings of satiety.

The list of gut hormones involved in the maintenance of weight is a long one, that can be confusing to people who are not expert in the field. Here are just a few of them:

• Cholecystokinin
• Glucagon-like peptide 1
• Peptide YY
• Oxyntomodulin
• Ghrelin
• Pancreatic polypeptide

This is by no means the whole list, but you get the idea. At least one model for obesity suggests a breakdown or deficiency of some of the gut hormones that normally signal satiety. In effect, people do not know when they are full. In addition, disturbances of some of these hormones may lead to fat being deposited in some of the danger areas of the body, particularly inside the abdomen.

If I were to give you a breakdown of all the recognized weight control systems in the brain, I think that both of us would probably fall asleep

Yes, these understandings will enable drug manufacturers to produce new drugs to help with obesity. But that is only part of the story. We have found time and again, that the most effective way to normalize weight and eating habits is to deal with it from five different directions:

1. Physical
2. Psychological
3. Social
4. Subtle
5. Spiritual

In previous articles I have already given some broad brush strokes about what constitutes healthy eating. Strategies that work WITH rather than against systems that have been evolving for millions of years. In future articles I shall also share some of the weight management techniques that I detail in my book Healing, Meaning and Purpose.

Technorati tags: satiety, weight loss, weight control, diet, holistic diet, healthy eating

Green Cheese Claims and Needless Dietary Chaos

The front cover item of today’s Newsweek Magazine concerns the confused and confusing state of dietary advice in America, and indeed around the world. So much of the advice on offer is based on political considerations and a fundamental misunderstanding about the way in which knowledge grows.

People outside the academic world are often astonished to discover that it is not a world of quiet painstaking investigation and careful intellectual deliberation, but is instead a hot bed of neo-Darwinian competitive frenzy. Every academic is under constant pressure to publish or perish. There are constant and intense demands to bring in grant money. This pressure can lead to huge problems. Data is often published before it is ready.

As regular readers of my columns know already, I have been vigorous in exposing scientific misconduct, but I am also concerned about raising false hopes or giving false guidance on the basis of single studies. Any study, however well designed and executed and however many subjects it contained, still needs to be confirmed and confirmed again. If somebody at NASA produced evidence that the moon was made of green cheese, I doubt that they would be believed. Not unless the observation could be confirmed by hundreds of independent investigators around the world.

Yet every day I see people who have fallen victim to green cheese claims. People who have been persuaded to part with millions of dollars to buy supplements to help them lose weight, on the basis of very limited data and sometimes wild extrapolations. Often they are just not needed. As an example, people are usually not told that ten minutes in the sun and a glass of low fat milk will give them all the calcium and vitamin D that they need for a day.

The Newsweek article does a great job of teasing apart many of the competing claims.

A year ago Mike Johanns, the Secretary of Agriculture, launched the new MyPyramid initiative to highlight the 2005 Government Guidelines for healthy eating, which for the first time emphasized the importance of individualizing any approach to diet and exercise. Although there were all the usual allegations that the guidelines were simply a confection designed for the health of American farmers rather than the health of the American population, I really cannot agree with those comments. The guidelines represent a considerable advance on the old food pyramid, but as I have pointed out in previous postings, the problem with weight management is not just what you leave out, but also what to include in any healthy eating plan. I really do suggest that if you haven't already, you look back at some of the suggestions that I've made previously on this blog.

Let me also direct you to another resource: The Psychiatric Resource Forum's article “Nutrition for Americans” will point you toward other good sources of information that we have carefully vetted for accuracy. Although this blog was created for healthcare professionals, it also contains a lot of information of value to readers of this blog.

Later this year, we plan to publish a short book on the precise approach to healthy eating that I have been using with great success for many years now.

Technorati tags: green cheese, diet advice, MyPyramid, Newsweek

Integrated Health and Aging

An important principle of the emerging laws of health and healing is that anything helpful should help more than one system of the body at a time. So a diet that might help mitigate the effects of aging in the skin should also have beneficial effects on the major organs of the body.

So I was encouraged to see a new report indicating that cardiovascular health and a healthy lifestyle are associated with maintaining the health of our brains as we age. This is, of course, intuitively obvious, but it is always nice to see such things confirmed by empirical research.

The new report is from a multi-Institute collaboration of the National Institutes of Health (NIH) published online in Alzheimer's & Dementia: The Journal of the Alzheimer's Association. The chair of the committee was Hugh Hendrie, the Scottish-born professor of psychiatry from the University of Indiana, and the committee members were many of the most eminent people in the fields of aging and Alzheimer’s disease.

What is encouraging about this new report is that many of the factors associated with cognitive decline as we get older are eminently remediable: we have within our reach a set of potential interventions that could significantly reduce our personal risk of developing cognitive problems later in life. These are the things that we need to work on if we want to reduce our risk of developing cognitive decline later in life:

1. Hypertension: There is excellent evidence that inadequately treated hypertension correlates strongly with cognitive decline.
2. Physical activity: There is good evidence that elders who exercise regularly are less likely to experience cognitive decline. This is over and above the general improvement in quality of life that accompanies regular exercise. The earlier in life that we start, the easier it is to continue.
3. Increased mental activity throughout life, including learning new things and going through higher education may benefit the health of the brain.
4. Moderate alcohol use and the use of vitamin supplements also seem to be brain protectors, though the report does not specify which supplements.
5. Social disengagement and depressed mood are both associated with poorer cognitive functioning, so it is important to be alert to signs of depression, and to maintain a social network. I discuss this in more detail in my book Healing Meaning and Purpose.

There are doubtless some genetic and environmental factors about which we can do little. But the idea that we now have a list of things that we can do to protect our brains is very exciting.

This report also signals another important change. In recent years we have seen the growth of Positive Psychology, the study of how to improve ourselves rather than the constant focus on psychopathology. This report calls for the research community to study health maintenance of the brain with the same energy that it has brought to bear on the study of diseases of the brain. To which I would add, that we must not just focus on how to maintain the health of the brain, but how we can enhance it’s function so that we can all reach and exceed our full potential.

Technorati tags: aging, Integrated health, Positive Psychology, healthy lifestyle,

Fat Facts

I was very pleased to see that Dean Ornish is now writing a column for Newsweek magazine, and that Andrew Weil will be contributing to Time. This is good news: both of them have made original contributions to holistic health care, and have always been very reasonable in their pronouncements.

Dean’s debut column has just come out. As you might expect, given his long history of making valuables contributions to the diet debate, he has called his article The Facts About Fat, and he reports on an important article published earlier this month in The Journal of the American Medical Association. The study presents some of the results of the Women's Health Initiative dietary modification study, which followed nearly 49,000 middle-aged women for more than eight years. The study compared those on a regular diet to those on a low-fat diet, to see if dietary modification could help prevent heart disease and cancer. The women in the “dietary change” group were asked to eat less fat and more fruits, vegetables, and whole grains each day to see if it. The women in the comparison group were asked to continue on their usual diets.

The results of the study have caused some consternation, because low-fat diets did not appear to protect against heart disease, or stroke, or breast cancer, or colon cancer. But here we come back to a point that I have made in other articles. We must not take studies at face value, but instead analyze the data in detail. It is hard work to extract the real message from published data, but it is incredibly important to do so.

So what were the limitations of this study?

1. The reduction in dietary fat was very small.

2. People are not good at keeping diet diaries, and often think that they are eating more healthily than they are. (Some years ago we did an experiment in which we estimated our daily calorie intake and also kept diet diaries. We were all experts in human nutrition, but each of us under-estimated out intake by about 300-500 calories per day)

3. The increase in consumption of fruit and vegetables was small.

4. The control group that was supposed to stay on their regular diet actually did not. Most of us know something about healthy eating, and most people are making some changes toward better diets.

5. Eight years is actually quite a short duration for a cancer prevention study.

Dean then returns to a favorite and important theme: the study didn’t distinguish between beneficial and harmful fats. Several previous studies have shown that the omega-3 fatty acids found in salmon, halibut, mackerel, walnuts, and flax seed oil may reduce your risk of a heart attack by 50 percent or more, as well as perhaps reducing the risk of inflammation and some forms of cancer.

I am certainly persuaded by the data on omega-3 fatty acids, as well as recent evidence indicating that reducing overall dietary fat to around 33 grams of fat per day, reduces the risk of breast cancer recurrence by 42%.

Dean also endorses another comment that I have made in previous posts: what you include in your diet is as important as what you leave out.

Technorati tags:  Dean Ornish, Newsweek, Nutrition, low-fat diet

Lectins, Leptin and the China Study

I have just reviewed a most interesting book called The China Study at Amazon.

This book, touted as the most comprehensive study of nutrition ever conducted, is indeed a treasure trove of useful information. The first point that I particularly liked is that the author is not a reductionist. He understands that the idea of trying to reduce the value of foods to one food type or one nutrient is deeply flawed. Let me give you an example: there is some good evidence that tomato-derived lycopene has a great many health benefits, but that does not mean that the solution to all that ails us is a diet consisting solely of tomatoes. I was once asked to see a person who had a genuine problem with a series of food sensitivities: a well-meaning but poorly educated practitioner had put her on a diet of lettuce leaves, rice and spring water. Several months later I saw her because of profound weight loss and malnutrition. The problem was a lack of balance in the dietary approach, and failing to see the big picture.

T. Colin Campbell is definitely one who sees the big picture, both in terms of his own research, and the broader context. He rightly points out that trying to divorce nutrition from the whole diet and lifestyle is a fundamental mistake.

I noticed something rather interesting, which I have just seen picked up by another reviewer: there seems to be a strongly positive correlation between wheat consumption and the risk of sustaining a myocardial infarction.

The reason that I perked up on seeing this is that I have just been analyzing a paper from Lund in Sweden. The investigators’ fundamental premise is that the rise of agriculture and the consumption of cereals might be the underlying explanation for many of the diseases of affluence. The researchers did a study of pigs, and showed that by putting them on a cereal-free diet, the pigs’ insulin resistance, blood pressure and C-reactive protein all fell, which are excellent markers of cardiovascular health. They went even further and provided a biochemical explanation, pointing out that for all its many benefits, agriculture is exposing our bodies to novel lectins: plant proteins that bind to specific carbohydrate groups on cell membranes. (We met lectins in my previous posting on blood types). These lectins seem to have the worst type of biochemical properties that enable them to block the action of a key metabolic hormone called leptin. First discovered in 1994, leptin produces a satiety signal, telling your brain to stop eating. In some animals it may also cause insulin resistance. Leptin was very hot news a few years ago, because if an animal or a person is resistant to leptin, they become morbidly obese. So a number of pharmaceutical companies tried to develop obesity treatments based on leptin. Sadly, to date all of them have failed. It is not surprising that nutritional interventions based on modulating leptin have also been disappointing. At last count there were over 260 hormones and neurotransmitters involved in the maintenance of body-weight. So trying to manipulate just one of them is hardly likely to be crowned with success.

As I have said in other posts, there will always be someone, somewhere, who will respond to any kind of eating or life plan. The trick is in predicting who will respond to what, and in that we are still scratching our heads. So if you want an approach that has the highest overall chance of success at maintaining and improving your health, rather than just focusing on pounds, I’m going to repeat my advice from an earlier posting:

1. It is important for you to maintain your energy balance, between input and output

2. Calories do count

3. What you include in your diet is as important as what you exclude: we are designed to consume not just rice and lettuce, but an array of other nutrients.

4. Make only moderate dietary changes at any time: making big dietary changes can be a pretty violent attack on your body and your mind

5. Avoid the “trans-fatty acids”

6. Try to consume some omega-3 fatty acids every single day

7. Eat fewer simple carbohydrates

8. Use weight management and exercise strategies that enhance your overall health and well-being

9. Take more exercise: even small amounts can have a big effect.

And now I am going to add a tentative number 10:

10. If your weight and metabolic parameters are still not as they should be, discuss a gradual reduction of cereal intake with your health care provider, and how to ensure that you still get the amount of fiber that you need. Depending upon your own genetic make-up that may be the missing piece.

Technorati tags: The China Study, T. Colin Campbell, diet, lifestyle change, nutrition

The Four Percent Solution

In this week’s edition of the Journal of the American Medical Association, is a study of 11,701 American over the age of 50, who participated in a national health survey in 1998 funded by the National Institute on Aging. The researchers analyzed participants' outcomes during a four- year follow-up and examined the health characteristics that seemed to predict death within four years.

These were the questions that were asked, and this is a bit like golf: you want to have the lowest score possible. Zero would be best. The score is supposed to tell you your chance of dying within the next four years.

1. Age: 60-64 years old = 1 point; 65-69 = 2 points; 70-74 = 3 points; 75-79 = 4 points; 80-84 = 5 points; 85 and older = 7 points.

2. Male or Female: Male = 2 points.

3. Body-Mass Index: Less than 25 (normal weight or less) = 1 point. (BMI = weight in pounds divided by height in inches squared, multiplied by 703.)

4. Diabetes: 2 points.

5. Cancer (excluding minor skin cancers): 2 points.

6. Chronic lung disease that limits activities or requires oxygen use at home: 2 points.

7. Congestive heart failure: 2 points.

8. Cigarette smoking in the past week: 2 points.

9. Difficulty bathing/showering because of a health or memory problem: 2 points.

10. Difficulty managing money, paying bills, keeping track of expenses because of a health or memory problem: 2 points.

11. Difficulty walking several blocks because of a health problem: 2 points.

12. Difficulty pushing or pulling large objects like a living room chair because of a health problem: 1 point.

Score:

• 0 to 5 points = less than a 4 percent risk of dying;
• 6-9 points = 15 percent risk;
• 10-13 points = 42 percent risk;
• 14 or more points = 64 percent risk.

So what should we make of this?

The first thing is that the study is just looking at the physical aspect of life. It asks nothing about diet or family history. It also says nothing about psychological and spiritual factors that can buttress health and well-being.

So what should it mean if somebody gets a high score? Does it mean that they should expect the end and stop reading long novels? Absolutely not! A high score should be a very good indicator that you should have a talk with your health care provider and get to work on all the reversible factors on the list. And as I have pointed out before, a positive psychological outlook and regular spiritual practice have been shown to extend the length and quality of your life.

It is not given to us to know the length of our lives and plenty of people live on and on despite breaking all the rules while others die young despite a lifetime of temperance. I had an aunt who smoked heavily throughout her adult life, yet lived to be well over ninety, while one of my former students died of lung cancer in his thirties, having never smoked a single cigarette.

Genes and lifestyle are important in determining our life span, but so are the quality and integrity of our relationships, our own sense of meaning and purpose, the clarity of the subtle systems of the body and our spirituality.

So use this study not as a death sentence, but as a wake-up call.

Technorati tags: health quiz, aging, longevity

Diet and Blood Types

One of my earlier posts entitled “What in Your Blood?” elicited a most interesting and important question from a reader:

“Does any of this have to do with the research that Dr. Peter D’Adamo has in his "Blood Type Diet" book? I have had clients tell me diseases and pains vanished when they followed his diet, while others had no effect. I would be interested in hearing your take on it all.”

This is a great question that gives me the opportunity to comment about this whole issue. I think that many of us have made similar observations to the reader who asked the question.

For people not familiar with this theory, D’Adamo’s notion is that our ancestors originally all had type O blood group, and that the appearance of agriculture was associated with the appearance of type A blood group, and then as recently as 10,000 B.C.E. – A.D. 1000, types B and AB started to evolve.

In this scheme, people with Type O blood group are the descendents of Hunters, the dominant, hunter-caveman types that require meat in their diet and should avoid wheat and beans. They are supposed to be most likely to suffer from asthma, hay fever, and other allergies. People with Type A blood are originally the Cultivators, and they should eat a vegetarian diet since they are predisposed to heart disease, cancer and diabetes; Type B blood group people were allegedly Nomads, and are dairy-eating omnivores who are susceptible to chronic fatigue and autoimmune disorders, such as systemic lupus erythematosus and multiple sclerosis. The rare individuals who have the AB blood group require a mixed diet, but should avoid chicken. They are supposed to be at risk of heart disease, cancer, and anemia, but tend to have the fewest problems with allergies. So D’Adamo decided that we should eat according to our blood types.

Like a lot of simple models, it is attractive and can be seductive. Yet the underlying concepts are deeply flawed. There are some weak associations between some blood groups and some physical ailments: to name just two, blood type A and coronary artery disease, and type O and gastric ulcers. That second one we now understand: people with blood group O are not able to mount a strong immune response to the usual causative organism: Helicobacter pylori. I did a literature review and dug up over 700 research papers on the subject of blood groups, disease and lectins (the adhesion molecules found, amongst other places, on red blood cells). There was nothing whatsoever to confirm D’Adamo’s claims. Indeed I think that some of his claims are potentially risky. Few people would agree with the idea of feeding some people high fat diets, and the theory takes no account of ethnic differences in food tolerability. For instance the high rates of insulin resistance amongst most people of Indian heritage, or the dairy intolerance common in much of the Asia-Pacific rim.

D'Adamo's theory of blood group evolution is not correct. Far from having developed new blood groups with the arrival of agriculture, there is solid molecular evidence that the different blood groups were already present at least 5 million years ago. Gorillas and chimpanzees possess similar blood groups. One of the scientists quoted on the D’Adamo website is Winifred Watkins, who was one of the team that first described the structure of the molecules determining blood group types. She was only 29 at the time, and later she became a Fellow of the Royal Society and a mentor of mine. She passed away about three years ago. She was the person who first told me about the evolution of blood groups, and there’s now a fair bit written about it. The last great African Diaspora occurred long before the development of agriculture, and the migrants took their diverse blood groups with them. That is one of the ways in which migration patterns have been tracked. So there is no link between blood groups and “professions.” It is still possible that there is some other arcane link between optimum nutrition and blood groups, but it is now ten years since D’Adamo’s book came out, and we have to ask why there is no published research to support the claims. His website contains a lot of references to research papers on blood groups. Many are quite old, and there is no critical evaluation of the papers.

Yes, some people will benefit from any kind of diet or intervention, which is why some of your clients have benefited, but the predictive value of the four major blood group types is clearly very low.

Technorati tags: blood type diet,

Coffee and Sex

These two may seem strange bed fellows(!)

But a study published in November 2005, was picked up by a lot of the news media, and probably lead a lot of people to encourage their wives and girlfriends to have an extra cup of coffee. The reason? Because this study, from Southwestern University had the title “Coffee, Tea and Me: Moderate doses of caffeine affect sexual behavior in female rats.” The research showed that at least in rats, coffee stimulated regions of the brain regulating arousal. It was immediately reported around the world that coffee drinking would raise a woman’s libido.

I don’t know what the report did for sales of coffee, but sadly, once again, the devil is in the details. Not only is human sexuality a lot more complex than it is in rats, but there is also this. In order for an adult woman to get the same amount of caffeine, she would have to drink at least ten large cups of coffee at once.

And coffee is a pretty good diuretic.....

Technorati tags: coffee, sex drive, human sexuality

Some Suggestions for Dealing with Insomnia

I have received an interesting question from a 50-year-old professional woman, who has had sleep problems that are especially severe during times of stress. As she says:

“I seem not to have the shut down switch in my brain.” She is worried about taking medications, and wonders if there is anything else that she can do to help herself.

____________________________

It is always unwise to make specific recommendations about someone without seeing them face-to-face, and the evaluation of a problem like this will normally take several hours. But the points that she raises have a great deal of relevance for so many people that I thought that a few comments would be helpful and equip everyone reading this with some information to discuss with their healthcare providers.

As usual, I think that it is a good idea to look at the question from the multiple dimensions of physical, psychological, social, subtle and spiritual. They are all inter-related, so dividing them up is simply a convenient way to help us think through the problem.

Before we do anything, we have to try and find out why someone has problems with sleep, and that may need investigations up to and including a sleep study.

The first thing is that my correspondent is female and likely either menopausal or perimenopausal. That is important, because as most women know, hormones have potent effects on sleep. It is not just that uncomfortable hot flashes can wake a person; it is also a direct effect of estrogen and probably of some of the releasing hormones in the hypothalamus. Hormone replacement therapy alone, does help some women but by no means all. Even at the physical level we see the general principle that there is rarely one cause for one problem. Typical menopausal sleep disturbances include a difficulty in falling asleep, and around 20% of menopausal women report that they sleep less than six hours a night. There is also some degradation in what we call sleep efficacy and an increase in deep slow wave sleep. Estrogen has effects on nasal mucosa, and when estrogen levels fall obstructive sleep apnea is more likely to occur. A major physical and psychological issue is that insomnia may become a learned habit that can persist even in the face of the best treatments.

This leads me to the second dimension, and that is psychological. The writer of the letter mentioned that she couldn’t turn off her thoughts. You would be amazed at how frequently I have been asked to consult on someone with a sleep problem and the individual has never been asked the question, “What is it that stops you falling asleep?” I have seen countless people prescribed sleeping tablets, when the real problem was anxiety or some other nasty problem that needed to be tackled first. In a moment I am going to make some suggestions that will try and help with both sleep and the ruminations and anxieties that may be contributing to its disturbance. Similarly, I have known a great many people whose sleep problems were the result of relationship difficulties or of something as simple as one person being a night owl and the other an early morning riser.

I always start with some simple sleep hygiene:

1. Stress management
2. Exercise a couple of hours before retiring
3. Keeping mentally stimulated until it is time for bed
4. Don't go to bed until you are tired
5. No caffeine, alcohol or nicotine after 6pm. (Preferably, of course, no nicotine ever!!) {Remember that many over the counter painkillers contain caffeine, as does chocolate}
6. There are some specific dietary recommendations for helping with sleep, and I shall write about those on a future occasion
7. Try to keep the bedroom atmosphere relaxing, and establish a sleep ritual
8. If you cannot sleep, get up and do something relaxing: struggling to go to sleep is virtually impossible.
9. Always get up at the same time in the morning, to try and re-set your brain, and as soon as you get up, be exposed to as much bright light as possible.

Now let me give you a few tricks that work on the five dimensions.

1. Start by lying on your left side for 5-10 minutes and then roll onto your right side. This appears to work by exploiting the so-called nasal cycle, which I shall write more about on a future occasion.
2. Still on the subject of the nose, one of the reasons that aromatherapy can be helpful, is because smell is unique amongst our senses, in that it is the only one that is not filtered by the thalamus. The regions of the brain that respond to smells are also directly related to some of the memory centers. The result is that smells can evoke memories extremely rapidly. You will probably have had the experience of smelling a perfume or cologne and instantly remembering someone who wore it in the past. This close linkage of smell and memory has enormous survival advantages: the smell of a predator can cause us to respond extremely rapidly. We can also use this knowledge to our advantage. Lavender has been used as a sleep aid for centuries. You can try putting a few drops of lavender oil on a cloth on your night-stand. Or you can use an electric diffuser or aromatherapy lamp. When I was growing up, we grew lavender and would put sprigs of it in the bed linens. It certainly seemed to help.
3. Some people have found that melatonin can be very helpful, and it is readily available. Discuss it with your health care provider.
4. Here is an old trick from traditional Chinese medicine. If you cannot sleep, soak a washcloth in cold water, lie down and put it on your abdomen for about ten minutes. I was taught that this works by pulling excess energy out of your head and neck down into the abdomen. There’s not a shred of scientific evidence that the technique works, but it does surprisingly often.
5. If people who are good at visualization, some have reported great success by creating a picture of a warm, calm and relaxing place. And not just a picture, but also a five senses experience. It has to be personal, and perhaps even a place to go back to on a regular basis. When I first learned to do hypnotherapy I was put into a light trance by one of my teachers. To this day, more than 25 years later I can still vividly recall the experience of being told that I was drowsing on a grassy knoll on a warm summer’s day on the Downs of Southern England, and actually feeling that I was there. I can still evoke the memory at will and I’ve made it more detailed over time. If you are a visualizer, try that.
6. Another technique that I learned from an early teacher, is to review the day backwards. Remembering what you did immediately before going to bed, and before that and so on. A simpler and often effective technique is just to start slowly counting backwards from 100.
7. Herbs: There are three that are widely used, and for which there is some research base. There is good evidence that the herb Valerian can induce drowsiness, and it is widely used – even by doctors – in France and Germany. An important point about valerian is that it is poorly absorbed and chemically and thermally unstable. So it needs to be kept cool, and used fairly soon after it is prepared. As with all herbs, Valerian has side effects and can interact with prescription medications and alcohol, so it really is essential to discuss its use with your health care provider. The same goes for the other two widely used herbs: Hops and Passionflower.
8. There is some evidence, though it’s not that strong, that taking a combined calcium/magnesium supplement (500mg calcium and 250-500mg magnesium) an hour before bed helps some people.
9. I recommend massaging your facial muscles before lying down to sleep. Not only does this reduce muscle tension, but also the face is covered in acupuncture points, and so that may be another reason why it can help.
10. Do not read or watch television in bed, but listen to a little calming music before retiring.

I do hope that will help you in your discussions with your health care provider. And I am always interested in hearing other suggestions, particularly if there is some research to back them up.

Technorati tags: Insomnia, menopause, herbal medicine, sleep hygiene, insomnia remedies, women's health

Brazilian Diet Pill

My colleagues over at the Psychiatric Resource Forum just got this FDA warning and asked me what I thought. I am reproducing in its entirety:

“MedWatch - The FDA Safety Information and Adverse Event Reporting Program The FDA warned consumers not to use two unapproved drug products that are being marketed as dietary supplements for weight loss. Emagrece Sim Dietary Supplement, also known as the Brazilian Diet Pill, and Herbathin Dietary Supplement may contain several active ingredients, including controlled substances, found in prescription drugs that could lead to serious side effects or injury. They contain chlordiazepoxide HCl (the active ingredient in Librium), and fluoxetine HCl (the active ingredient in Prozac). Emagrece Sim and Herbathin were also found to contain Fenproporex, a stimulant that is not approved for marketing in the United States. Consumers are advised not to use the Emagrece Sim and Herbathin products and to return them to the suppliers. There may be other manufacturers or suppliers of imported Emagrece Sim and Herbathin, and consumers should exercise caution in using any of these imported products.

Read the complete MedWatch 2006 Safety summary, by using the following link: FDA news release

My Comments: Sadly this sort of thing is not uncommon. An unknown but clinically significant proportion of the Ayurvedic and Chinese herbs that are imported into the United States and Europe contain steroids and other drugs. I once diagnosed two cases of Cushing's syndrome that were the result of people taking imported Indian herbs. One of them was an Indian man who was referred for weakness of his proximal muscles, which prevented him from walking up the stairs. He also add other classic symptoms of Cushing’s syndrome: he had gained weight, particularly in the face and around the abdomen, he had high blood pressure and diabetes mellitus. The other had a less florid presentation. There have been quite a number of publications on the subject of adulteration of herbal remedies.

Several years ago I became involved in an investigation of some apparently miraculous cures of eczema with Chinese herbal remedies, and sadly some of these had also been adulterated with corticosteroids. This was a real shame, because some of the herbal remedies actually helped eczema even if they did not contain steroids. These cases are all the more sad, because there are also large numbers of companies that make Indian and Chinese herbs to the highest possible standards, yet the bad apples have put even these under scrutiny.

The message must be that just because something is natural does not guarantee that it is safe. I have said before, but it bears repeating that arsenic, deadly nightshade and hurricanes are all natural. It is essential to obtain any herbals from a reputable source and to ensure that your health care provider knows exactly what you are taking: apart form the topic of adulteration, there are hundreds of potential interactions between herbal and prescription medicines.

Within the last three months, I have written an educational program for professionals that explores these issues in considerable detail, and makes recommendations about reliable suppliers of herbs.

Technorati tags: brazilian diet, diet pills, herbal medicines

Appetite Suppression

Appetite is a complex phenomenon controlled by many neurochemical and hormonal signals, as well as psychological and social factors.

An article by a group of investigators lead by Gilles Mithieux from the French research body, INSERM, published in the journal Cell Metabolism, may explain why many people on high protein diets, like Atkins, report a reduction in their hunger pangs.

The study was done in rats that were fed a high protein diet. It was found that this diet increased the activity of genes involved in glucose production in the animals’ small intestine. This increased glucose production was sensed by the liver and then chemical signals were relayed to the brain indicating that the stomach was full, and thus causing the animals to reduce their food intake.

Previous research has indicated that high protein diets do not seem to do anything magical to metabolism, but may work by reducing the overall intake of calories. The same effect on intestinal glucose production can be achieved with a low carbohydrate diet, showing us that both types of diet are probably working by the same mechanism. There are some interesting points here:

1. This study re-affirms the importance of calorie reduction as the key to weight loss, and it answers the “how” question: how do some of these diets work?

2. It illustrates something that is not widely known: glucose is produced in many parts of the body and glucose is a key regulator of appetite. The vast majority of the glucose circulating in your blood has come from the liver, and not directly from what you eat. It is only if you soak yourself in simple carbohydrates, as might happen if you drink something containing a lot of sugar, that your blood glucose may rise. But in most people who have healthy metabolism, the body rapidly corrects the elevated glucose.

3. The types of genes being stimulated to work in the intestine cannot be stimulated indefinitely. Eventually they will stop responding. You can only fool the body for a limited amount of time. That would explain why so many people who lose a lot of weight on one of the popular diets, find that the weight does not stay off. The lesson must be to make small but significant dietary changes, with the emphasis on keeping your food intake balanced. (You might like to have another look at my entry from January 6th)

Technorati tags: appetite, diet, high-protein