Richard G. Petty, MD

Blood Pressure and the Seasons

High blood pressure may be more difficult to control in winter, according to research reported to the American Heart Association, at its meeting in Orlando last week.

A five-year study by a team from the United States found Department of Veterans Affairs analyzed data on 443,632 veterans treated for hypertension at 15 VA hospitals in cities throughout the US found that blood pressures during the summer were on average 7.76% lower than during the winter. The researchers found the same pattern emerged from each hospital they studied, regardless of whether it was based in a warm or cold climate, in locations that ranged from Anchorage, Alaska to San Juan, Puerto Rico.

This is an intriguing finding, and there are a load of potential explanations for it:
A more active summer lifestyle may be the key
It is also possible that people might eat more salty foods in winter, and salt is strongly linked to raised blood pressure
There may also be a link with sunlight. Which can trigger a number of metabolic changes

But I also need to sound a note of caution: blood pressure changes all the time throughout the day. Although the study was all done correctly, it is important to realize that many subtle variations in blood pressure could be lurking within the data.

Nonetheless, people should be aware of the possibility that their blood pressure may be harder to control in the winter, and to be more vigilant at this time.

“For everything there is a season, And a time for every matter under heaven: A time to be born, and a time to die; A time to plant, and a time to pluck up what is planted; A time to kill, and a time to heal; A time to break down, and a time to build up; A time to weep, and a time to laugh; A time to mourn, and a time to dance; A time to throw away stones, and a time to gather stones together; A time to embrace, And a time to refrain from embracing; A time to seek, and a time to lose; A time to keep, and a time to throw away; A time to tear, and a time to sew; A time to keep silence, and a time to speak; A time to love, and a time to hate, A time for war, and a time for peace.”
--The Bible, Ecclesiastes, 3:1-8

“Each new season grows from the leftovers from the past. That is the essence of change, and change is the basic law.”
--Hal Borland (American Writer, 1900-1978)

“Live in each season as it passes; breathe the air, drink the drink, taste the fruit, and resign yourself to the influences of each. Let them be your only diet drink and botanical medicines.”
--Henry David Thoreau (American Essayist and Philosopher, 1817-1862)

Television and High Blood Pressure in Overweight Children

After learning that watching too much television may cause behavior problems in children, a new report in the American Journal of Preventive Medicine indicates that watching too much television may push up a child’s blood pressure, but only if he or she is overweight.

Researchers from the University of California, San Diego; the Rady Children's Hospital - San Diego; the University of California, San Francisco; and the University of South Alabama collected data on 546 young people, aged 4 to 17 years, who were evaluated for obesity at pediatric subspecialty weight management clinics in San Diego, San Francisco and Dayton, Ohio, from 2003 to 2005. Children and their parent(s) were given a written questionnaire, which was used to estimate the average daily time spent watching TV, and then a physician verbally reviewed and confirmed the time estimate. The height and weight of the children were measured to determine a Body Mass Index and their blood pressures were recorded.

The investigators found that TV time was positively correlated with the severity of obesity. After controlling for race, site, and BMI score, both the severity of obesity and daily TV time were significant independent predictors of the presence of hypertension. Children watching 2 to 4 hours of TV had 2.5 times the odds of hypertension compared with children watching 0 to 2 hours. The odds of hypertension for children watching 4 or more hours of TV were 3.3 times greater than for children watching less than 2 hours of TV.

Yet more evidence that as wonderful as the television can be, too much of anything is not a good idea.

Well, almost anything...

“I find television very educating. Every time somebody turns on the set I go into the other room and read a book.”
--Groucho Marx (American Comedian, 1890-1977)

Acupuncture for Hypertension

In China and Japan I have seen acupuncture used to treat just about everything, with varying degrees of success.

Researchers from Erlangen in Germany have published a randomized single blind trial comparing acupuncture with sham needling in the journal Circulation. The results suggest that acupuncture may decrease blood pressure in hypertensive patients by a similar amount to that achieved using medication.

The investigators randomized 160 outpatients (mean age 58) with uncomplicated, mild to moderate hypertension to six weeks of acupuncture performed by Chinese medicine practitioners (trained in China), or to a sham procedure. Those on hypertensive medication continued taking it.

Patients were assigned to one of four patterns of hypertension, based on TCM diagnosis. Those in both trial arms underwent 22, 30-minute treatment sessions over a six-week period. During each session, three acupuncture points were needled bilaterally for 20 minutes. In the active treatment group, the points were chosen according to traditional Chinese medical diagnosis. Sham treatment consisted of needling points that according to Chinese medical theory would have no effect on blood pressure

Twenty-four hour ambulatory systolic and diastolic blood pressures were significantly reduced from baseline in the acupuncture-treated patients (by 5.4 mmHg and 3.0 mmHg, respectively). No significant decrease was seen in the sham-treated patients. The extent of blood pressure reduction observed was comparable to that seen with ACE-inhibitor monotherapy or aggressive lifestyle changes. However, blood pressure returned to pretreatment levels within 12 weeks of treatment cessation, leading investigators to conclude that ongoing acupuncture treatments would be required to maintain the beneficial effects.

This in an interesting study, but I agree entirely with some of the comments made in an accompanying editorial by Fiona Turnbull and Anushka Patel from the George Institute for International Health in Sydney, Australia.

Randomized trials of acupuncture have been conducted since the 1970s, but many were of poor quality, and did not even include control groups. In 1995 the World Health Organization published clear guidelines for clinical research on acupuncture, which included detailed information relating to the nature of control groups and blinding in randomized controlled trials. More recently, a National Institutes of Health Consensus Development Panel stated that the acceptance of acupuncture as a reliable therapeutic choice would depend on its evaluation using study designs that could withstand careful scientific scrutiny.

The whole issue of “sham” acupuncture remains problematic. Not only are we doing something physical. But the people administering the acupuncture know whether or not they are needling an “active” point, an even if they say nothing, they may well communicate what they are doing. There is also a more subtle point that is not raised in the editorial. A good acupuncturist does not just stick in a needle. He or she waits for the appearance of a characteristic and subjective needle sensation that tells him or her whether the needle is in the correct position.

Acupuncture studies are, simply for logistical reasons, usually fairly small and this one was no exception. And that brings us to the other point. Most forms of alternative and complementary treatment are very time consuming, and need a lot from a patient who has to show up for multiple treatments, for which he may be paying himself.

If a course of acupuncture treatment can bring about some long-term change or re-balancing in a person that might be worthwhile, but in this study the blood pressure went back up once the treatment was discontinued.

T’ai Chi Chih and the Sympathetic Nervous System

One of the problems about getting older is that the activity of the sympathetic nervous system may increase, bringing with it an increased risk of metabolic problems such as insulin resistance, hypertension and cardiovascular disease.

The sympathetic nervous system  is a branch of the autonomic nervous system. It is always active at a basal level, which is called sympathetic tone. It becomes more active during times of stress. Its actions during the stress response comprise the classical fight-or-flight response.

There is a very interesting study from the Norman Cousins Center for Psychoneuroimmunology at the UCLA Semel Institute for Neuroscience & Human Behavior in Los Angeles.

There were 32 people in the study aged 60 or over. There were 19 people who were T’ai Chi Chih (TCC) practitioners and 13 who were not. The practitioners had completed a 25-week training in TCC the 13 others just had health education classes. T'ai Chi Chih is a simplified  type of T'ai Chi that emphasizes the development of qi, a.k.a. chi.

TCC practitioners performed the breathing and movements for 20 minutes, while HE participants passively rested for the same time. Investigators measured various cardiovascular parameters before and after the task. A subsample of participants returned for a second evaluation and performed videotape-guided stretching for 20 minutes to evaluate the cardiovascular effects of slow-moving physical activity. TCC performance was found to significantly decrease sympathetic nervous system activity as measured by cardiac pre-ejection, blood pressure and heart rate. In contrast, there was no change in sympathetic activity following passive rest or slow-moving physical activity.

This shows us that there is something different about T’ai Chi. Practicing it leads to a decrease in activity of the sympathetic nervous system to levels that are not achieved by performing comparable physical activity alone.

Can a Pain in the Neck Raise Your Blood Pressure?

A chance discovery at the University of Leeds in the United Kingdom may give credence to longstanding claims by chiropractors that treating pain and stiffness by adjusting the neck can also lower blood pressure.

In a study published in the Journal of Neuroscience Jim Deuchars and his team report finding connections between rats’ neck muscles and a specific region of the brain. Their findings indicate that the neck muscles could play a key role in controlling blood pressure, heart rate and respiration. 

They found that nerves run from receptors in the neck muscles to a region in the brainstem called the nucleus tractus solitarius that is known to be involved in the control of autonomic nervous system. It seems likely that signals from the neck could play a key role in ensuring an adequate supply of blood to the brain as we change position, for instance standing up suddenly. If the signaling system fails we may run into problems with low blood pressure (postural hypotension) and difficulties with balance.

Although it is early days, and it is a long way from a rat study to understanding human physiology, the finding may do more than provide a tentative explanation for the chiropractic reports. It may also explain another puzzle: why some people with whiplash injuries get trouble with their blood pressure. On the other hand, there have been a number of studies that have shown that the practice of yoga may help control blood pressure. It had been assumed that it was simply a consequence of generalized relaxation, but perhaps it is more specific than that: could a soft flexible neck be important in maintaining a healthy blood pressure?

The best research studies are the ones that suggest more questions than answers: on that criterion this is a most important study.

Successful Aging

One of the most promising changes in psychology is the ever-greater emphasis on what makes us healthy, rather than constantly looking at the things that make us sick. There is an important approach called Behavioral Activation (BA) Theory, which emphasizes environmental and behavioral factors as determinants of our overall well-being. According to the theory, reduced engagement in pleasurable activities may be an important precursor of reduced well-being. This makes good sense: it is estimated that as much as 90% of our higher cortical functions are designed for social interactions.

This is something that I wrote in Healing, Meaning and Purpose:

"Nothing in the Universe exists in isolation: We live in a Universe of relationships. It is inconceivable that anything can exist except in relationship to something else. The entire Universe is made up of integrated systems that function, develop and evolve together. A failure to construct and maintain healthy relationships can be a cause of much distress.

Several years ago I reported some interesting observations. At the time, I was doing a lot of research on diseases of blood vessels. I had developed a laboratory method for taking some of the cells that line blood vessels from volunteers and then growing them in a cell culture dish. We discovered that if we did not have enough cells in the dish, they would all die of “loneliness.” The exception is cancer cells, which in culture will grow on their own, like weeds."

As an example in a paper published in February in the Archives of General Psychiatry it was shown that lonely individuals may be twice as likely to develop the type of dementia linked to Alzheimer's disease in late life as those who are not lonely. The theory has been shown to predict psychiatric well-being in a number of populations, including the caregivers of people with Alzheimer’s disease, people with chronic pain, cancer patients and community-dwelling older people.

It is also known that psychiatric well-being, particularly emotional well-being, may play an important role in cardiovascular health. This may be due to an increase in the activity of the sympathetic nervous system that increases not only blood pressure, but also the levels of inflammatory mediators and coagulant factors in the blood.

In research from the University of California at La Jolla that was presented on Monday at the 2007 Annual Meeting of the American Psychiatric Association in San Diego, California, twenty two people with a mean age of 70 were studied, to see if there was a link between their behavioral activation, i.e. how satisfied they were with their leisure activities, their affective well-being and their blood pressure.

The findings were as expected: the less satisfied and engaged people were, the higher was their blood pressure.

This is only preliminary data, but it confirms something that we have said before: as we get older it is as important to stay socially engaged as it is to do mental exercise.

And if you known someone who is older and isolated, you might want to go and see them.

“The most terrible poverty is loneliness and the feeling of being unloved.”
--Mother Teresa of Calcutta (Albanian-born Indian Nun, Humanitarian and, in 1979, Winner of the Nobel Peace Prize, 1910-1997)

“What makes loneliness an anguish is not that I have no one to share my burden, but this: I have only my own burden to bear.”
--Dag Hammarskjöld (Swedish Statesman, Secretary-General of the United Nations from 1953-1961, and, in 1961, Winner of the Nobel Peace Prize, 1905-1961)

The Causes and Consequences of Insulin Resistance

I have spent so much time talking about insulin resistance becuase it is one of the greatest medical threats facing the world.

It is estimated that approximately 33% of the adult population of the United States is insulin resistant, and if left untreated many will develop diabetes, hypertension and an array of other problems. It is an epidemic that is expected to swamp most health care systems around the world, yet sadly it may in most cases be preventable.

There is an enormous literature on insulin resistance. As of this afternoon there are almost 33,000 scientific papers on the subject.

I created this graphic to try and summarize the key points about insulin resistance: the main factors that may cause it, as well as the most important medical consequences.

(Click on the graphic to expand it.)

The Main Causes of Insulin Resistance are:

• Aging
• Intra-abdominal obesity
• Inactivity
• Glucose intolerance
• Genetics
• Fetal malnutrition
• Cigarette smoking
• Some medications

The Main Consequences of Insulin Resistance are:

• Type 2 diabetes mellitus
• Hypertension
• Arteriosclerosis
• Polycystic ovarian syndrome
• Non alcoholic fatty liver disease
• Disturbances in the function of the vascular endothelium
• Elevations of triglycerides and cholesterol
• Disturbances of clotting
• Disturnaces in kidney function
• DIsturbances in one type of heart rhythm
• Elevated uric acide levels
• Some malignancies

This is probably not a complete list, but it gives you a very good idea of the reasons for looking for insulin resistance. Many - but not all - experts now recommend measuring insulin resistance in people at high risk of developing any of these medical problems.

We have good evidence that lifestyle changes can prevent the development of many of these dire consequences, so it is certainly something worth discussing with your health care provider.

Blood Pressure and the Brain

We have known for almost a century that regions of the brain are involved in the control of blood pressure.

Yet over the last three decades most of the emphasis in research into hypertension (high blood pressure) has focused on blood vessels, the heart and kidneys.

Now research from Bristol University in England has been published in this month’s issue of the journal Hypertension, and it may put the brain back into the center of research into the causes and treatment of high blood pressure.

Working with rats, the researchers isolated a protein called JAM-1 (junctional adhesion molecule-1), that is located in the walls of blood vessels in the brain. It appears to trap white blood cells causing obstruction of blood flow in some of the smallest blood vessels. This can cause inflammation and result in poor oxygen supply to the brain, which may in turn trigger events that raise blood pressure.

Though this work is in its early stages, this is exciting stuff: if confirmed, it might be possible to treat hypertension with drugs that reduce blood vessel inflammation and increase blood flow within the brain.

It also ties in with other recent research from Imperial College, London and Oxford University, in which a team of neurosurgeons and physiologists discovered changes in blood pressure while fitting brain electrodes to 15 patients for pain control.

Deep brain stimulation involves placing very thin electrodes on very exact locations in the brain and is already used to relieve pain and to help Parkinson's disease patients with their movement.

The researchers found that they could make patients' blood pressure increase or decrease by stimulating very specific regions of the brain with the electrodes. Regions that have been associated with blood pressure control in the past. If they stimulated an area deep down in the midbrain called the ventral periventricular/periaqueductal gray matter, blood pressure went down, and if they stimulated the dorsal periventricular/periaqueductal gray matter it went up.

Nobody is suggesting that we should start sticking electrodes in peoples’ brain, but this chance observation may have profound implications, particularly for people who drop their blood pressure too far when they are treated with standard medicines.

These two pieces of research may also help explain why a balanced inflammation–reducing diet and relaxation may both reduce blood pressure.

Hot Flashes and High Blood Pressure

Many women experiencing hot flashes do feel as if their blood pressure is going up.

Well, there is some new research linking hot flashes and hypertension.

A hot flash (sometimes also referred to as a "hot flush" or, incorrectly a "night sweat") is a symptom of changing hormone levels considered characteristic of menopause.

Hot flashes are typically experienced as a feeling of intense heat with sweating and rapid heartbeat, and typically last from two to thirty minutes on each occasion. The event may be repeated a few times each week or up to a dozen times a day, with the frequency reducing over time. Excessive flushing can lead to the skin problem rosacea.

The study from Weill Cornell Medical College was published in the March/April issue of Menopause: The Journal of the North American Menopause Society.

The researchers used portable monitors to record the blood pressure of 154 New York City women, aged 18 to 65 (mean age of 46). The women had no previous cardiovascular disease and either mild hypertension or normal blood pressure. Fifty-one women reported experiencing hot flashes. These women were found to have an age-adjusted mean systolic awake blood pressure of 141 and a mean systolic sleep blood pressure of 129 -- compared to 132 and 119, respectively, for women not reporting hot flashes. The results were highly significant. For people whose lives are not complete without a little "p," the values were: p=0.004 and 0.007. The group differences for systolic blood pressure remained statistically significant after controlling for conventional hypertension risk factors, race/ethnicity, age and body mass index (BMI).

This is important research: High blood pressure is a major risk factor for heart disease, with the latter being responsible for half of all deaths among American women 50 and older.

We need to understand more about the mechanism linking blood pressure and hot flashes, but this research already suggests that women with flashes are at especially high risk. So if you know someone who ishaving them, make sure that they are having their blood pressure monitored on a regular basis.

Diseases of Discipleship

You will not find them listed on WebMD, but “Diseases of Discipleship” are nonetheless very real. I have mentioned them in Healing Meaning and Purpose and also here. They are the result of sudden access to spiritual energies that can upset the balance of the body, mind and spirit. The great value of having a teacher is to help you balance and work with these energies without being harmed by them.

Several of my own teachers talked a lot about these diseases of discipleship, but I would particularly like to single out Douglas Baker and the writings of Roberto Assagioli, Del Pe, Torkom Saraydarian, Stan Grof and Alice Bailey.

I have also had a great deal of experience with people undergoing spiritual crises. Many have been referred to me by priests, clergy and intuitives, because many of the individuals thought that they were “going crazy,” and some had ben given psychiatric diagnoses. That extensive experience has helped me and some of my students to describe some of the “symptoms” in more detail.

Roberto Assagioli identified five critical points where problems may arise:

1. Just before spiritual awakening begins
2. Crises caused by spiritual awakening
3. Reactions to spiritual awakening
4. Phases of the process of transmutation
5. The “Dark Night of the Soul”

Today I am just going to focus on the crises caused by spiritual awakening, because a great many people are experiencing them at the moment.

Here are some of the more common signs and symptoms include:

• Visual disturbances
• Extreme sensitivity to light and sound
• Paradoxically they often also find a raised pain threshold
• Increased metabolic rate, which may cause a slight increase in body temperature and a little weight loss
• Variable libido: some people lose all interest in sex, but most experience an increase in sexual desire, which can take them and any partners by surprise
• Disturbances in circadian rhythms
• Disturbances in thyroid and adrenal function: the thyroid often becomes slightly – or sometimes more than slightly – overactive and the adrenal glands slightly less responsive to stimulation
• Hypoglycemia
• Hypertension
• Chronic fatigue
• Anxiety and a feeling of “butterflies” in the region of the solar plexus
• Inexplicable sensations roughly corresponding to the channels identified in Chinese and Ayurvedic medicine
• Irregular breathing patterns, usually hyperventilation
• Something that feels like electricity under the tongue and under the palate
• Crying for no readily apparent reason
• As peoples’ consciousness rises, it is quite common to experience “Synesthesia” in which senses overlap: people may taste sounds, feel colors and “hear and see” with different parts of the body
• Psychic abilities often begin to appear: clairvoyance, clairaudience, spiritual intuition and the ability to heal
• Many begin to feel and see their own Inner Light and the Inner Light of other people

Not everyone gets all of these symptoms and they may come and go for a while. Some people don't get any at all, but they are unusual. There are two books by Hazel Courteney that detail some of what happened to her, and they are well worth a read.

It is important to emphasize that all of these signs and symptoms can also be caused by illnesses. So although most people who are going through all this want to avoid doctors, it is a very good idea to ensure that everything is okay. I once saw someone who had been told that she was having a kundalini experience, even though she did not have any of the usual features. She became very unwell, but felt much better when an insulin-producing tumor was removed from her pancreas.

The most important thing is to help people remain grounded. I have seen many people become extremely grandiose and even fanatical after going through a rapid spiritual awakening. It is also important to ensure that any physical symptoms - such as thyroid or blood pressure problems - do not continue unchecked.

Helping people who are going through spiritual change or crisis needs the help of a person or persons who understand physical and psychological problems, as well as being some way along the path of spiritual development. By “crisis” I do not mean crisis of faith, but a critical turning point in an individual’s personal development.

There are plenty of good ways of grounding using some physical, psychological and subtle system exercises. I have dozens of excellent techniques that I can publish if you are interested. Sometimes it is also a good idea to eat some heavy food.

It can be very helpful to get away form other people for a while. This doesn’t mean becoming a monk or nun, but just to avoid a bad case of people poisoning. In their overly sensitive state they can pick up a lot of negative things from the people around them. I have known a good many people who would begin to experience all the physical and psychological symptoms of the people around them.

Once we have confirmed that the person does not have all this as a result of thyroid disease or anxiety, it is essential to show them what is going on and the best way to approach and conceptualize it.

Next we help people to control some of the impulses that can otherwise swamp them. One of the many reasons for development of the sophisticated mind control techniques developed by Tibetan Buddhism was to help people watch their spiritual unfoldment without being overwhelmed by it.

We also try to help people to transmute psychological energies so that they can be used constructively.

Everybody is different, but in some people acupuncture, qigong, Reiki and homeopathy have all been helpful. Several of the flower essences can be very useful, in particular:
Vervain
Star Tulip
White Yarrow
Pink Yarrow

Every expert that I know in the field of spiritual development agrees with my observation that there are currently more people having major spiritual changes than ever before. It is essential for us all to know how to protect, support and birth them.

“To penetrate into the essence of all being and significance, and to release the fragrance of that inner attainment for the guidance and benefit of others, by expressing in the world of forms - truth, love, purity and beauty - this is the sole game that has any intrinsic and absolute worth. All other incidents and attainments can, in themselves, have no lasting importance.”
--Meher Baba (Indian Spiritual Teacher who, from July 1925 maintained Silence, 1894-1969)

“You knock at the door of Reality. You shake your thought wings, loosen your shoulders, and open.”
--Jalal al-Din Rumi (Afghan Sufi Poet, 1207-1273)

“Life is a series of awakenings.”
--Sri Swami Sivananda (Indian Physician and Spiritual Teacher, 1887-1963)

“What we usually call human evolution is the awakening of the Divine Nature within us.”
--“Peace Pilgrim” (a.k.a. Mildred Norman, American Peace Activist, 1908-1981)

Another Nail in the Coffin of BMI

In August I outlined some of our reasons for believing that the most common measure of overweight and obesity – the body mass index (BMI) – can be very misleading and should probably be abandoned, or at least consigned to the back burner.

A team at the Hammersmith Hospital in London led by Professor Jimmy Bell has been using a novel type of MRI scan to locate the distribution of fat in the body. The problem is that 40% of the population has "bad" fat around some of their internal organs including the heart, liver or pancreas, even though many appear thin. So even though they may look slim, they may still be at risk of conditions like insulin resistance, diabetes and hypertension because of this hidden fat.

As we have said before, from a health perspective, it is the distribution of fat that is all important, rather than just the amount of it. This study confirms what metabolic physicians have been saying for years: BMI gives you the wrong idea about how much fat you have.

Once you know about the distribution of your fat, we can design precise lifestyle changes to work on it. As an example, the strategies that we use for overall weight management are not the same as the strategies that we use for reducing intra-abdominal fat. There are very good physiological reasons why diet does little to reduce the fat around organs. It is there to provide fuel during exercise, so specific exercises are the way to rid yourself of this internal fat.

At the moment there are very few centers that can do this kind of scanning, but with the growing evidence of its importance, that is likely to change. In the meantime, be aware that aerobic exercise and strength training, particularly if it involves the large muscles of the back trunk and lower limbs is the quickest way to rid yourself of these dangerous fat deposits.

Fat in itself is essential for normal health, but fat in the wrong places can be a killer. And BMI tells you nothing about the fat lurking in the hidden parts of your anatomy.

Hidden Harbingers of Weight: Salt Intake and Obesity

In Healing, Meaning and Purpose, I discuss some of the evidence for four previously little recognized causes of obesity:

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

Each of these has been widely discussed in the professional literature, but little has percolated out into the general population except in advertisements for agents like Cortislim. I remain skeptical about these products. Tinkering with just one of the 260 hormones and neurotransmitters implicated in the control of weight is unlikely to be crowned with success. And their ingredients may also have the potential for causing problems. Recent advertisements have also mentioned that one of these products may elevate mood. Sad to say, in the last year we have seen two people who developed manic symptoms after taking one of the supplements. We are urging colleagues to see if there are any other cases, or whether these two were just coincidental.

I recently mentioned some of the evidence for viruses as a cause of weight gain.

Now a new publication from the Universities of Helsinki and Kuopio is out in this month's journal Progress in Cardiovascular Diseases, that provides powerful support for the salt hypothesis.

The researchers report that an average 30-35 % reduction in salt intake during 30 years in Finland was associated with an extraordinary 75 % to 80 % decrease in both stroke and coronary heart disease mortality in the population under 65 years. During the same period the life expectancy of both male and female Finns increased by 6 to 7 years.

As expected, reducing salt intake has a beneficial effect on blood pressure.

But in my view the most interesting finding of the study is the close link between salt intake and obesity.

As bartenders, pub landlords and tavern owners have known since the beginning of time, increasing a person's intake of sodium produces a progressive increase in thirst. (You didn't think that those peanuts on the bar were put there out of the goodness of the establishment's heart did you??!)

The progressive increase in the average intake of salt explains the observed increase in the intake of sugar-containing beverages which, in turn, has caused a marked net increase in the intake of calories during the same period in the United States.

Here is an extraordinary statistic: Between 1977 and 2001, energy intake from sweetened beverages increased on the average by 135 % in the United States. During the same period, the energy intake from milk was reduced by 38 %. The net effect on energy intake was a 278 kcal increase per person a day. The American Heart Association has estimated that, to burn the average increase of 278 kcal a day and avoid the development or worsening of obesity, each American should now walk or vacuum 1 hour 10 minutes more every day than in 1977. As we all know, that has not happened.

In the decade from 1976-1980 to 1988-1994 the overall prevalence of obesity increased 61 % among men and 52 % among women. During 1999 to 2002, the prevalence of obesity was 120 % higher among men and 99 % higher among women as compared with the 1976 to 1980 figures. The increased intake of salt, through induction of thirst with increased intake of high-energy beverages has clearly made a significant contribution to the increase of obesity in the United States.

It is also of note that until 1983 the use of salt did not change or even showed a continuous decreasing trend in the United States. The prevalence of obesity was relatively low and remained essentially unchanged from early 1960s to early 1980s.

This new study suggests that a comprehensive reduction in salt intake, which would reduce the intake of high-energy beverages, would be a potentially powerful means in the so far failed attempts to combat obesity in industrialized societies.

There is now conclusive population-wide evidence that indicates that we could achieve powerful beneficial health effects simply by reducing our overall salt intake. These benefits include a decrease in obesity.

As an aside, the population-wide long-term experience from Finland indicated that a remarkable decrease in the salt intake has not caused any adverse effects.

A number of years ago we were engaged in some experiments in which we replaced regular table salt - sodium chloride - with potassium chloride. For the first three weeks food seemed rather tasteless. But then we all suddenly discovered a new universe of flavors that had previously been hidden under a thick coating of salt. So a dietary change does have a temporary effect on your taste buds.

Although the paper doesn't say so, there is also some data that salt may itself increase cortisol release.

The bottom line?

We now have clear, empirical data to support three out of the four points that I made in Healing, Meaning and Purpose, and there is some less robust data for the fourth.

I urge you to try gradually to reduce your personal intake or salt, and to encourage your family and friends to do the same. I mentioned that food may initially seem a little less flavorful, but then things change rapidly and for the better.

And your body will love you for the change!

Update on Pramipexole

I have mentioned pramipexole before. In the United States it is approved for the treatment of the signs and symptoms of idiopathic Parkinson’s disease.

I’m always on the look out for medicines that can be part of a package of healthcare, and we need to learn both the pros and cons of new medicines. This looks to be a medicine that can be incorporated into Integrated Medicine. And before you ask, I have no links at all with the manufacturer, Boehringer Ingelheim.

There have been a number of interesting papers presented at the 10th International Congress of Parkinson's Disease and Movement Disorders in Kyoto, Japan this week.

New data presented have shown that people taking pramipexole (Mirapexin®/ Sifrol®) can experience significant improvements in a broad range of symptoms associated with Restless Legs Syndrome (RLS). 

In all studies presented at the meeting, people taking pramipexole reported clinically meaningful improvements in both their night and day-time symptoms, as measured on the International Restless Legs Scale (IRLS). The IRLS measures several aspects of the condition, ranging from discomfort, the need to move around, relief by moving around and then more specific RLS symptoms such as sleep disturbance, day-time tiredness, mood disorder, as well as addressing overall severity, weekly frequency, daily severity, and impact on daily activities.

One of the big problems in the treatment of RLS is that people who have it frequently have other problems as well, such as hypertension, arthritis, gastroesophageal reflux disease, depression, anxiety, and diabetes. So it is essential that the physical component of treatment should not cause any deterioration in associated illnesses. One of the papers presented in Kyoto indicated that pramipexole could be used in people with RLS who are also taking an array of other medicines. That claim is going to have to be checked by the FDA, but the data look very encouraging.

Still, when using medications, there’s no such thing as a free lunch: The most commonly reported adverse reactions in clinical trials for RLS were nausea, headache, and tiredness.

In people with Parkinson’s disease, pramipexole may cause them to fall asleep without any warning, even while doing normal daily activities such as driving. This is obviously very serious, and before the medicine gets an RLS indication in the USA, the FDA will really check this out in great detail. When taking pramipexole hallucinations have been known to occur and sometimes patients may feel dizzy, sweaty or nauseated upon standing up. In Parkinson’s disease, there is also a warning that as with many other medicines used to treat it, including pramipexole may be associated with impulse control disorders/compulsive behaviors.

So we need to keep an eye on safety, but so far the data is very encouraging, and we may soon have something else to add to an integrated treatment program for people with RLS.

___________

Here's a P.S. On November 10th, 2006, pramipexole was approved for use in RLS by the FDA. Here's the announcement:

Ingelheim/Germany, 10 November 2006 - Boehringer Ingelheim announced today that the U.S. Food and Drug Administration (FDA) has approved pramipexole, a non-ergot dopamine agonist, for the treatment of moderate to severe primary Restless Legs Syndrome (RLS).1 This is an important milestone for pramipexole (Mirapexin® / Sifrol® / Mirapex®), which was already approved throughout the European Union in April 2006 for this second indication.

Handedness and Immunity

In 1982, one of my mentors, the late Norman Geschwind, and two colleagues – Al Galaburda and Peter Behan - proposed an extraordinary hypothesis. It was that the levels of testosterone to which a baby is exposed before birth influence the development of both the cerebral and immune systems. According to this theory, high levels of testosterone result in greater incidences of left-handedness, deviations from the standard distribution of cerebral functions and increased autoimmune dysfunction. If the theory is right, then male brains should mature later than female brains, and the left hemisphere should mature later than the right.

It is certainly true that if a boy gets a head injury or infection involving the brain, he is less likely to recover than would a girl, and boys are far more likely to have some types of neurodevelopmental problems like dyslexia.

For a while it seemed as if there was also a strong association between left-handedness and certain types of allergy, and also with inflammatory bowel disease. This association with immunity also seemed to be present in mice: those who had left paw preference had more reactive immune systems, and they were thought to be more likely to produce auto-antibodies, suggesting that the central nervous system was involved in the genesis of some autoimmune diseases. Over the years the data has become less clear-cut, but the idea of an association between anomalous cerebral asymmetry and autoimmune disease never completely went away.

Recent data has again found an association between inflammatory bowel disease and laterality. And left-handers really do have more autoimmune disease.

The Geschwind-Galaburda hypothesis proposes that there should be a four-way association among neurodevelopmental disorders, special talents, non-right handedness, and immune disorders. In a huge study of 11,578 children, less than 1% had all four.

So where does this leave us?

The original theory was half right:

1. There is indeed a link between testosterone and early brain development
2. People who are left-handed or have a strong tendency toward left-handedness do seem to be at slightly increased risk of several autoimmune conditions
3. People who are left-handed or have a strong tendency toward left-handedness may have a slightly increased risk of high blood pressure, asthma and migraine
4. People who are left-handed or have mixed handedness are more likely to excel in certain disciplines: creative arts, music, computer programming and mathematics. What we don’t know is whether people with these special skills are more likely to have autoimmune diseases
5. Amongst very successful tennis players,  there are far more left-handers than would be predicted by chance. This supports the idea that support the notion that left-handed people have neurological advantages in performing certain tasks, such as visuospatial visuomotor cognitive tasks.

I was reminded of the way in which Nature seems to like to balance things out a bit: with some notable and famous exceptions, many successful athletes have not done so well academically and many academics would be unlikely to survive on the plains of Africa. Only some of these differences can be explained in terms of early direction and encouragement in school or while growing up: it seems that most of us cannot hope to become the kind of superman that Nietzsche used to dream about.

Perhaps it’s a way of stopping us from getting too full of ourselves.

Medicine and the Transformation of Illness

Something important has been happening in the medical field over the last century. And like most important concepts, once I mention it, everyone says, “Oh, that’s obvious.” Yet I have seen little discussion of it except in an occasional book or speculative paper.

The concept is this: modern medicine has been transforming the nature of illness in far-reaching ways. There are many illnesses that once were fatal, and which have now been transformed into chronic problems. Yet most conventional health care providers are still wedded to the short-term resolution of symptoms.

Let me give you three examples:

1. The first is diabetes mellitus. There are two main types, and at least ten subtypes. Type 1 diabetes is what used to be known as juvenile onset diabetes or insulin-dependent diabetes. It usually comes on in childhood or adolescence, is associated with severe damage to the beta cells in the pancreas that produce insulin. People with this problem usually become very sick very quickly and need insulin to keep them alive. Until 1922, when the first patient was treated with insulin derived from cows, the illness was usually fatal. Insulin transformed it into a chronic illness. People were kept alive, but now we saw the emergence of diabetic eye disease (cataracts and retinopathy), disease of the blood vessels supplying the limbs, heart and kidneys, kidney failure, infections and many other chronic problems. In 1935 Sir Harold Himsworth, the father of a friend of mine, identified a second type of diabetes. He published a classic paper on his discovery of insulin resistance in 1936. This is what is now known as Type 2 diabetes, and used to be called maturity onset diabetes. This is a more chronic illness, but carries many of the same complications. The point about these two types of diabetes is not just that they have disturbances of glucose and lipid metabolism. That on its own matters little. It is the long-term consequences of the elevated glucose and lipids that causes all the problems.
2. The second is hypertension. Again, this often used to be a fatal illness. Until the invention of the sphygmomanometer most people did not know that they had high blood pressure, and most often would die of strokes. Hypertension is now also a chronic illness. The problem is not the blood pressure itself, but the long-term consequences of an elevated blood pressure. That is why most physicians are now trying to prevent the damage to the heart, eyes and kidneys, instead of just focusing on the blood pressure numbers themselves.
3. The third is Lyme disease. This is a bacterial illness that is acquired by being bitten by a tick. It is said to be the fastest growing infectious disease in the United States, primarily because we are spending more time venturing into the wilderness, and the deer population – a major carrier of the tick – is increasing in most Eastern states. Lyme disease can make people very ill. We identify acute and chronic types. The acute can usually be treated if identified quickly and if the correct treatment is given. But sometimes identification can be very difficult, and inadequate or even inappropriate treatment may lead to the chronic form. We have even seen people who have been treated exactly as the experts say, but have still developed the chronic form of Lyme disease. The biggest problem with Lyme disease is that it is a great masquerader: it can look like so many other illnesses, from multiple sclerosis and rheumatoid arthritis to chronic fatigue syndrome and syphilis.

We could pick out other examples. I have mentioned some of the problems of thinking that attention deficit disorder is just a problem with getting good grades in school. When in reality the problem is that inadequately treated ADD is associated with a range of long-term problems that occur outside of school hours.

For many years now some practitioners have been warning about the long-term consequences of symptomatic treatment alone. One of the most eloquent critics of this way of treating people is the Greek homeopath and teacher George Vithoulkas. I like and respect George, but he takes a militant view, saying that conventional treatment simply suppresses illnesses, rather than treating them. His solution is to use homeopathy for everything. He is a genius and also a natural healer, so he can probably get away with that. Most of us cannot.

So the fundamental tenets of Integrated Medicine include medical treatment to deal with the acute problem, but a combination of approaches to prevent the problem from becoming chronic. Or if it has become chronic, then how to change its course over time.

As I’ve said before: Combinations are Key. Not randomly giving an antibiotic as well as a homepoathic remedy, but precisely tailoring the combination to the individual.

Shock Waves and Diabetes

A psychiatrist friend once called me to say that he knew that he had to change his job. He was in the second year of his Freudian training analysis, and as he was driving to work he experienced a severe pain in the back. He told me that it felt as if someone had put a knife in his back. This, he told me, was a psychosomatic reflection of the mean back stabbing environment in which he was working. “Tell me more about the pain,” I said. “Just like a knife,” he said, “it’s the most obvious example of my body telling me what’s going on here.” I suggested that he should come over for me to give him a physical check up, but he was having none of it.

The following day he passed a large kidney stone.

It’s important to listen to your body, and to try and understand its message. It’s also important to respect every aspect of your being: physical, psychological, social, subtle and spiritual. A physical pain may be telling you about something in your environment or it may just be telling you that there’s something wrong with your body. Sigmund Freud once famously remarked that “Sometimes a cigar is just a cigar.”

I was reminded of this story as I was reviewing a new report about an association between the use of sound waves – lithotripsy - to shatter kidney stones and the eventual development of diabetes. Approximately 10 percent of men and 5 percent of women under the age of 70 will experience a kidney stone.

Surgery for kidney stones used to be horribly traumatic. As a very young student and junior doctor I assisted in more than one operation to remove them. The invention of the lithotripter – a device that uses ultrasound to break up stones, so that they can be passed out of the body – was a big advance. Though the treatment itself is far from being painless, it is much better than major surgery, It is a shame to learn that the treatment is not as innocuous as we thought. This is important, because about 1 million people in the United States have had shock wave lithotripsy (SWL).

In a study published in the May issue of the Journal of Urology, researchers at the Mayo Clinic followed up on a group of 630 patients who had been treated with SWL in 1985. The Mayo was one of the first centers to use the technique, the hospital keeps wonderful records, and so it was one of the few places in the world where it was possible to follow people 19 years after treatment.

Almost 60 percent of the patients responded to a questionnaire and were matched to an equal number of patients whose kidney stones had been treated by some other method. Among the SWL group, 16.8 percent had developed diabetes, compared with 6.7 percent of the control group, and 36.4 percent had high blood pressure compared with 27.9 percent of the control group. According to the study, the development of hypertension was related to the treatment of stones in both kidneys, while the onset of diabetes bore a relationship to the number of shocks administered and the intensity of the treatment.

This makes sense: the kidneys are key controllers of blood pressure, and it has long been known that stones, inflammation, infection or vascular disease in the kidneys can cause elevated blood pressure. Perhaps the treatment scars the kidneys. And it is not surprising that sound waves powerful enough to shatter a stone might also cause damage to the tissues through which they are passing; which include the pancreas.

These findings will need to be replicated, particularly with newer model lithotripters. But even before that, I’m sure that the criteria for gets the treatment will be modified, and it will also be necessary to re-think how the treatment is done. As an example, instead of shooting one powerful burst of sound waves at the stone, it may be necessary to fire several low intensity burst from different directions that all crisscross in the vicinity of the stone.

For now, if you are one of the unlucky ones who gets a kidney stone, discuss this new research with your doctor before having lithotripsy. And if you have access to a good acupuncturist, naturopath or homeopath, ask them if they have had any success in treating kidney stones, and if “Yes,” whether they would be prepared to work with your physician to help you.

Thrifty Genes, Thrifty Bodies and the Barker Hypothesis

“They have sown the wind, and they shall reap the whirlwind.”
--The Bible (Hosea, 8:7)

In 1962, a geneticist named James Neel first proposed a “thrifty gene” theory to explain why 60% of adult Pima Indians living in the United States have diabetes, and 95% are overweight. Neel’s theory was that populations like the Pimas, that have for millennia relied on farming, hunting and fishing for food, would experience alternating periods of feast and famine. Neel hypothesized that in order to adapt to these extreme changes in caloric needs, people developed a “thrifty gene” that allowed them to store fat during times of plenty so that they would not starve during times of famine.

A similar theory was advanced to explain the high rates of diabetes in people from the Indian subcontinent, once they are exposed to plentiful supplies of food. These was traced by the great Diaspora from central Asia at the end of the last age, when the ancestors of modern Indians and Pakistanis made the great trek through modern Afghanistan into the Indus valley. A journey that had been impossible at the height of the Ice Age and which was still difficult. The idea was that people who could quickly lay down a lot of intra-abdominal fat would have a huge survival advantage.

This is an attractive hypothesis, but here have always been some problems with it:

1. The gene or genes would have to be able to work with the environment: the Pimas of Mexico and people living in rural India do not have the high rates of diabetes and obesity
2. Despite looking for over 40 years, no such gene has yet been found
3. If the thrifty gene is so advantageous, why doesn’t everyone have it?
4. Until recently, famines were rare and usually occurred every 100-150 years. As John Speakman has pointed out that would mean that most human populations have experienced at most 100 famine events in the course of their evolutionary history
5. Famines do increase mortality but only in about 10% of the population
6. In famines most people die of disease rather than starvation, and the worst affected are the young. Having a “thrifty gene” would not help them survive starvation OR disease
7. Simple genetic models would suggest that famines would not provide enough selective advantage and there has not been enough time for a “thrifty gene” to have penetrated the population

There could yet be some complex genetic model involving “reserve” genes that appear when needed, or some epigenetic inheritance, but we have no evidence for that either.

A second concept is gaining a lot of traction. It is what is known as the “Thrifty phenotype,” and is part of a larger theory called the “Barker Hypothesis.” I’m going to stick my neck out, and predict that David Barker may receive the Nobel Prize in medicine for his discoveries. They are that important.

Essentially the Barker Hypothesis suggests that in addition to genetic, epigenetic and environmental factors in disease, there is another, and that is the intrauterine environment. The idea is that if a mother is malnourished, she can modify the development of her unborn child. From an evolutionary perspective, her body is preparing the unborn child to survive in an environment where food is in chronic short supply, resulting in the “Thrifty phenotype:” smaller body size, lower metabolic rate and a propensity to be less active.

The problem is this. If you are born with the thrifty phenotype and actually grow up in an affluent environment, you are more likely to develop obesity, diabetes and vascular disease later in life. If true – and virtually all the evidence suggest that it is – then it has serious implications for countries that are transitioning from sparse to better nutrition, and may have contributed to some of our current health problems. Many of us were born to mothers who had poor nutrition, either because of the Great Depression, the Second World War, poverty, or just plain poor information about good nutrition during pregnancy. And now we are reaping the whirlwind.

The hypothesis has become sophisticated. If you are born small or premature, then your liver and kidneys may not have completed their final growth spurt, which might predispose you to metabolic problems and hypertension.

The story of how this all came to light would be worthy of Sherlock Holmes himself. English counties used to have people who were responsible for providing midwifery services. In the county of Buckinghamshire a single midwife collected data for almost thirty years. Information about the mother, the length and weight of the baby and the weight of the placenta. Information that would be impossible to collect these days. Some civil libertarian somewhere would probably dream up some way of hiding this enormously important information.

David Barker discovered these extraordinarily good records, and then set about finding the adults that these babies had become. And what he found has changed medicine: babies who had small placentas – a good measure of being small or premature – were more likely to develop obesity, diabetes or hypertension as adults. Then he and others turned their attention to other early physical characteristics and found correlations with health later in life. The highest risk of coronary heart disease was seen amongst people who were born small and became heavier during childhood.

The practical implications?

Find out your own birth weight and anything else that you can about your early development.

If you were a very large baby (bigger than nine and a half pounds), it implies that your mother may perhaps have had a metabolic problem. If you were small (less than five and a half pounds), then you should get the regular health checks that we recommend for anyone in a “high risk” group.

BMI R.I.P.

For experts in metabolism, we have long worried about the over-emphasis on the use of body mass index (BMI) as the arbiter of a "healthy" weight. It is one of those measurements that is in some senses too easy, and the results are deceiving. I regularly see people claim that a certain BMI will "predict" the risk that someone will develop cardiovascular disease or diabetes. The truth is very diferent.

There are two ways to calculate your BMI:
1. Metric system - Kilograms and Metres
[Your weight] divided by [Your height squared]

2. Imperial System - Pounds and Inches
[You weight] divided by [Your height squared] times 703.5

A person is said to be healthy if his or her BMI is between 18.5 and 24.9.

The trouble with this is that the calculation lumps together fat and muscle: a muscular six foot tall football player weighing 300 pounds and with 3% body fat, would have an "unhealthy" BMI of 26.3. That is clearly absurd, and one of the reasons that most experts use BMI only as one part of an evaluation of health.

Our scepticism has been confirmed by an important study from the Mayo Clinic in Rochester, Minnesota, and published in this week's issue of the medical journal The Lancet.

The researchers looked at 40 studies involving 250,152 patients. Their analysis revealed that people with a BMI of 30-35 were at lower risk of cardiovascular disease than those whose BMI was below 20.

BMI does not correlate well with fat. A better way to distinguish between fat and muscle is to take a cross-sectional view of the abdomen, and to focus on the waist-hip ratio.

A separate study by researchers at the London School of Hygiene and Tropical Medicine of 14,833 people over the age of 75 was published in the American Journal of Clinical Nutrition. They also came to the conclusion that BMI is a poor indicator of health in both men and women in this age group. These researchers also agreed that waste-hip ratio was a better indicator of mortality risk.

This is all music to my ears. For almost three decades we have been teaching about the importance of  different stores of fat and the limitations of the BMI calculation. It has been known since the 1940s that gaining weight on the hips, or developing "lover's handles" are only very weak predictors of diabetes and vascular disease: it is the intra-abdominal fat that is the problem.

There are particular problems with using BMI in the elderly and in some ethnic groups, especially people from the Indian sub-continent and Japan.

The bottom line?

BMI is misleading, and in some age groups and races, grossly misleading.

Much better to use weight and waist-hip ratio.

And BMI only if there is a space on the medical forms where they still need to have it filled in.

 

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

A New Warning from the FDA about Some “Sexual Enhancers”

On Wednesday of this week the Food and Drug Administration issued a warning to consumers not to purchase or consume Zimaxx, Libidus, Neophase, Nasutra, Vigor-25, Actra-Rx, or 4EVERON. These products are promoted and sold on web sites as "dietary supplements" for treating erectile dysfunction (ED) and enhancing sexual performance, but they are in fact illegal drugs that contain potentially harmful undeclared ingredients. Chemical analysis by FDA revealed that Zimaxx contains sildenafil, which is the active pharmaceutical ingredient in Viagra. The other products contain chemical ingredients that are analogues of either sildenafil or a pharmaceutical ingredient called vardenafil, which is the active ingredient of Levitra.

These undeclared ingredients can interact with some prescription drugs, in particular nitrates. In combination with nitrates, they can cause a catastrophic fall in blood pressure. You may have seen Keanu Reeves warn Jack Nicholson about that in the 2003 movie Something's Gotta Give.

We have seen so many examples of adulteration of herbal remedies and supplements, and I’ve written a previous item about this huge problem. Huge, not in terms of numbers of cases, but in terms of the potential for harm.

I always recommending reading the label whenever you buy anything. The problem with the products mentioned in this latest FDA warning, is that there was no indication that the products contained drugs. Also be careful about whose advice you trust. Several years ago, a study done in health food stores in the United Kingdom showed that most of the staff knew very little about the products that they were promoting. Things have improved in recent years: we have a couple of health food stores in Atlanta with very knowledgeable staff. But it’s always a good idea to check before accepting the advice of someone in a store. Be doubly careful if you are buying things online: it’s you body.

So Caveat Emptor!

Technorati tags: Food and Drug Administration Sexual enhancers Herbal remedies Viagra Sildenafil Vardenafil Levitra Keanu Reeves Jack Nicholson 

The Risks of “Pre-hypertension”

It often seems as if treatment guidelines change every year. The levels at which experts recommend treating cholesterol, glucose levels and blood pressure have all changed recently. Some cynics say that it’s all a device by drug companies to get more people on treatment, but that’s not really true. The guidelines change as we get more evidence that not treating something leads to bad consequences in the future. A good example would be the level at which experts recommend treating elevated blood glucose. The recommendation was changed when it was discovered that even small elevations of glucose could have a dramatic impact on the development of coronary artery disease.

We now have another change, this time with blood pressure. Everyone knows that high blood pressure can be dangerous. But researchers have recently defined something that we call pre-hypertension (a systolic blood pressure 120 to 139 mm Hg or diastolic blood pressure 80 to 89 mm Hg). What was not known for sure was what impact pre-hypertension would have on the incidence of cardiovascular disease.

A study published in the journal Hypertension has clarified the issue. The research involved 2629 people participating in the twelve-year-long Strong Heart Study. Pre-hypertension was more common in people with diabetes. And as expected, from the link between blood pressure and insulin resistance, impaired glucose tolerance or impaired fasting glucose in pre-hypertensive people greatly increased the risk of developing cardiovascular disease risk. We now need to do more research to see if interventions, such as drug treatment for blood pressure control for pre-hypertensive individuals are warranted. This is particularly important if people also have impaired fasting glucose, impaired glucose tolerance, or diabetes is warranted, because risk factors for coronary artery disease are cumulative: the more risk factors, the bigger the risk.

What this means is that your health care provider should help you keep your blood pressure lower than we thought, particularly if you have a personal or a family history of problems with blood glucose or of heart disease.

Technorati tags:Hypertension Insulin resistance Diabetes mellitus Coronary artery disease

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

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,

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