Richard G. Petty, MD

Grapefruits, Medicines and Medical Correspondents

Mark Twain once said:
“Be careful of reading health books, you might die of a misprint.”

I was thinking about that as I was watching a TV show earlier.

I have spoken before about the frustration of many of us about the quality and accuracy of some media medical correspondents. Though every show has a disclaimer about the importance of discussing any issue with a health care provider, it is really unfortunate to present inaccurate data that could needlessly alarm people.

I will immediately put my hand up and say that I have done more than my share of media work, not just in the United States and Great Britain, but also in countries from Finland to Australia and twenty or thirty more in between. And I may well have misspoken at some time or other. Even the most well intentioned people sometimes make slips, and it is especially easy when you are in a studio and you know that the clock is counting down.

But that stress makes it all the more important to have accurate material prepared in advance so that slip-ups don’t happen.

Today’s piece was about a story that pink grapefruit may not interact with some medications. The correspondent rightly said that any type of grapefruit may interact with some medications, but then said that there was an interaction in the stomach. This is not correct and could be very confusing.

The issue is that grapefruit juice may induce the enzyme complex cytochrome P450 3A4 in the liver and intestine. So if you or a medication that is metabolized by the enzyme, grapefruit juice may lower the plasma level of the drug, making it less effective. This is another example of the importance of telling your health care provider about ANYTHING that you eat or drink, in addition to listing any herbs and supplements that you take.

Here is a list of some of the more common medicines metabolized by cytochrome P450 CYP3A4:

Alprazolam
Amiodarone
Amlodipine
Aripiprazole
Astemizole
Atorvastatin
Buspirone
Cafergot
Chlorpheniramine
Cimetidine
Cisapride
Clarithromycin
Cocaine
Codeine
Cyclosporine
Dapsone
Dexamethasone
Dextromethorphan
Diazepam
Diltiazem
Domperidone
Erythromycin
Estradiol
Felodipine
Fentanyl
Finasteride
Fluconazole
Fluvoxamine
Grapefruit juice
Faloperidol
Hydrocortisone
Iindinavir
Itraconazole
Ketoconazole
Lidocaine
Lovastatin
Methadone
Midazolam
Mifepristone
Nefazodone
Nifedipine
Nitrendipine
Norfluoxetine
Ondansetron
Pimozide
Progesterone
Propranolol
Quetiapine
Quinidine
Quinine
Risperidone
Ritonavir
Sildenafil
Simvastatin
Tacrolimus
Tamoxifen
Taxol
Telithromycin
Terfenadine
Testosterone
Trazodone
Triazolam
Verapamil
Vincristine
Ziprasidone
Zolpidem

A Shocking Study

I have been teaching medical students and doctors since the 1970s. But there have recently been times when I have despaired about the way in which so many young doctors no longer engage in common courtesies with their patients.

I just spoke to someone who had visited a new family physician. She was fresh out of her residency, and her residency director has something to answer for. She did not make eye contact or shake hands, and could not remember the person’s name. When the patient extended her hand the doctor became confused because she was focused on her laptop.

I know that I can be accused of being old fashioned, but that shocked me, as did a recent report that medical students at a highly rated school are going to be getting classes in empathy and talking to people. This was announced with great fanfare. My question: why on earth do intelligent people need to be taught how to communicate? And if they have a problem in that area, first, how did they get accepted into that excellent medical school? During the years that I was involved in medical school admissions, I would have not have given a high score to someone with poor interpersonal skills. Second, why are the students’ teachers not modeling communication skills?

So first I heard about the extraordinary manner of the primary care physician. Then it was the self-congratulation that accompanied the announcement that students were going to be taught how to speak to people.

And then this.

A study in the Archives of Internal Medicine that left me shaking my head.

The researchers from Northwestern University's Feinberg School of Medicine found that Doctors do not address patients by name in half of first-time visits, even though nearly all patients want this common courtesy.   

There has been research on what doctors should wear but little about how they should greet patients or what patients actually expect. Most good physicians have relied upon empathy and common sense to guide them. This study focused on finding out what patients think is an appropriate greeting. He also analyzed a sample of interactions between doctors and patients during first-time visits.

The researchers collected information from 415 phone surveys in which people were asked how they expect to be greeted by a doctor. Researchers also viewed and analyzed more than 120 videos of primary care visits in which the doctor and patient met for the first time.

They found that 78 percent of survey respondents wanted the physician to shake their hands. Nearly all patients wanted to be greeted by name, including 50 percent by their first name, 17 percent by their last name and 24 percent by both their first and last name. Most patients, about 56 percent, wanted physicians to introduce themselves using first and last names, while 33 percent expected last name and 7 percent expected first name.

The researchers found a striking difference between expectations voiced in the phone surveys and the actual interaction between doctors and patients in the videos. While 83 percent of doctors shook hands in the videos, only half addressed the patient by name. 

Obviously everyone has their own communication style, but the researchers recommend that doctors should incorporate a greeting strategy that uses first and last names for both doctor and patient. Doctors also should plan to shake a patient's hand, but need to be sensitive to body language or other nonverbal cues that may indicate whether a patient does not want to or is not physically able to reciprocate or respond.

How we use names or handshakes will also change over time.

Why does this business of doctor-patient communication matter so much?

It is not simply a point of courtesy, though that would not go amiss. The real issue is that relationships are the heart of healing. Relationships might not be so important to the person performing some technical service, but for healing they are essential. If I need to get my car fixed, it is nice if the mechanic wants to talk, but it is not essential. He can treat my car as the hunk of metal and moving parts that it is.

But healing is different from treatment. Healing demands a relationship, intention and a shared vision. An interaction that will create something that is greater than the sum of the parts. A polite, personal greeting creates a first impression that can affect the chance of developing a therapeutic relationship. Ignoring the normal rules of social interaction sets the tone for everything that comes afterwards. It is respectful to use a person’s name and on a purely practical level, helps ensure that you are seeing the right person! More than once I have been given the wrong chart before meeting a person for the first time.

Interestingly, accrediting organization quite rightly emphasize that communication is a critical skill for physicians. Sadly many medical schools put such a huge emphasis on academic attainments that some people enter the medical profession without natural communication skills, and their training does little to help them get better at it. But this skill may not come naturally to all doctors, so it's important to offer guidance on different aspects of communication such as greetings

My students will tell you something that I have said a thousand times: “You have spent a lifetime developing people skills. You have learned how to talk to Aunt Mabel, how to feel when you are in a dangerous environment and how to deal with that guy at the bar who is becoming annoying. These are very valuable skills. Why did you check them at the door on the day that you entered medical school?”

One of my mentors once lamented, saying that 90% of medical students would have been better served by a technical college than a medical school, because they had no curiosity, no desire to move the field forward and no wish to engage with the people who came to see them. And that was in England, where there is socialized medicine. I did not want him to be right, but he probably was. In fact he was right about a great many things, which is why he was nominated for the Nobel Prize in Medicine on three occasions.

If medical schools want to turn out healers rather than technicians, then it is clear that medical students and doctors have to be helped to learn basic communication skills.

One of the many reasons that so many holistic therapists and practitioners of Integrated Medicine are popular is that they do understand the importance of good communication. Not because of research, but because that is their natural way of being.

What have your interactions with doctors been like?

How do you like them to greet you?

“True communication is remembering that everything is relationship --- that, regardless of the appearance, no one stands alone."
--Hugh Prather (American Spiritually-oriented Counselor and Writer in the Field of Personal Growth and Relationships)

“Once a human being has arrived on this earth, communication is the largest single factor determining what kinds of relationships he makes with others and what happens to him in the world about him.”
--Virginia Satir (American Family Therapist, 1916-1988)

How Doctors Think. Or Not.

I recently reviewed a fascinating book at the Amazon website. It is called “How Doctors Think,” and it was written by the ever-thoughtful Jerome Groopman from Harvard.

To save you having to look through all the reviews to find what I said, I thought that it would be useful to say something about the book and why I have some reservations about Jerome’s analysis.

Most doctors are highly educated, hard working people who most of the time try to do their best. Yet in our blame culture there are places in America where you can’t get a specialist to treat you: they have all been driven out of business by lawyers representing unhappy clients. The question of why this has come to pass has occupied the minds of the American medical profession for three decades.

Jerome believes that the key problem is that doctors make the same kind of errors in thinking that the rest of us do. We all – and not just doctors - jump to conclusions; believe what others tell us and trust the authority of “experts.” Clinicians bring a bundle of pre-conceived ideas to the table every time that they see a patient. If that have just seen someone with gastric reflux, they are more likely to think that the next patient with similar symptoms has the same thing, and miss his heart disease. And woe betides the person who has become the “authority” on a particular illness: everyone coming through his or her door will have some weird variant of the disease. As Abraham Maslow once said, “If the only tool you have is a hammer, you tend to see every problem as a nail.” To that we have to add that not all sets of symptoms fall neatly into a diagnostic box and that uncertainty can cause doctors and their patients to come unglued.

Up to this point the book is very good as far as it goes but I do not think that the analysis is complete.

I have taught medical students and doctors on five continents, and this book does not address some of the very marked geographic differences in medical practice and the book is “Americano-centric.”

The first point is that the evidence base in medicine is like an inverted pyramid: a huge amount of practice is still based on a fairly small amount of empirical data. As a result doctors often do not know want they do not know. They may have been shown how to do a procedure without being told that there is no evidence that it works. As an example, few surgical procedures have ever been subjected to a formal clinical trial. Although medical schools are trying to turn out medical scientists, many do not have the time or the inclination to be scientific in their offices. In day-to-day practice doctors often use fairly basic and sometimes flawed reasoning. A good example would be hormone replacement therapy. It seemed a thoroughly good idea. What could be better than re-establishing hormonal balance? In practice it may have caused a great many problems. Medicine is littered with examples of things that seemed like a good idea but were not. Therapeutic blood letting contributed to the death of George Washington, and the only psychiatrist ever to win a Nobel Prize in Medicine got his award for taking people with cerebral syphilis and infecting them with malaria. The structure of American medicine does not support the person who questions: consensus guidelines and “standards of care” make questioning, innovation and freedom very difficult. A strange irony in a country founded on all three.

The second major factor in the United States - far more than the rest of the world - is the practice of defensive medicine: doctors have to do a great many procedures to try and protect themselves against litigation. This is having a grievous effect not only on costs, but also on the ways in which doctors and patients can interact.

Third is the problem of demand for and entitlement to healthcare. We do not have enough money for anything: but what is enough if the demand for healthcare continues to grow as we expect? And if people are being told that it is their right to live to be a hundred in the body of a twenty year-old? Much of the money is directed in questionable directions. There are some quite well known statistics: twelve billion dollars a year spent on cosmetic surgery, at a time when almost 40 million people have no health insurance. There are some horrendous problems with socialized medicine, but most European countries have at least started the debate about what can be offered. Should someone aged 100 have a heart transplant? Everyone has his or her own view about that one, but it is a debate that we need to have in the United States.

Fourth is the impact of money on the directions chosen by medical students and doctors starting their careers. Most freshly minted doctors in the United States have spent a fortune on their education, so they are drawn to specialties in which they can make the most money to pay back their loans. In family medicine and psychiatry, even the best programs are having trouble filling their residency training programs. Many young doctors are interested in these fields, but they could die of old age before they pay off their loans.

Fifth is the problem of information. It is hard for most busy doctors in the United States to keep up to date on the latest research, and many are rusty on the mechanics of how to interpret data. So much of their information comes from pharmaceutical companies. Many of the most influential studies have been conducted by pharmaceutical companies, simply because they have the resources. But there have been times when data has therefore appeared suspect. Industry is not evil, but companies certainly hope that their studies will turn out a certain way, and the outcome of any study depends on the questions asked and the way in which the data is analyzed. And like any collection of people, it is easy to fall into a kind of groupthink. There are countless examples of highly intelligent individuals who all missed the wood for the leaves.

Another related problem is that many scientists are now also setting up companies to try and profit from the discoveries that they have made in academia. Most are working from the highest motives, but sometimes there are worries about impartiality. So once again, the unsuspecting physician may add data to the diagnostic mix without knowing its provenance. There have recently been a number of high profile examples of that.

I ended my review by saying that I hope that every doctor and patient in America should read it, and I stand by that, with the caveats and comments that I have added to the mix.

Medicine and Creativity

The Lancet medical journal has just published this year's themed issue on the topic of 'Creativity and Medicine'.

If you click on the link, you will be taken to a digital edition of the special issue. The digital edition is an exact facsimile of the print copy and is available for one month. You can turn pages just as you would with a print edition and even print off the pages for your own personal use.

The Lancet is one of the journals that you will find in the "Journal" listing on the left of this blog.

Many of the articles are extremely interesting and thought provoking: "Writing and healing;" "Development of children's creativity to foster peace;" "Healing through art therapy;" "Theatre - a force for health promotion;" "Hospital clowns;" "Healing architecture; " "Healing gardens;" "Chance favors the prepared mind" and "What can the arts bring to medical training?" were some of my favorites, and give you a good flavor of what's in store for you.

You will also see how this fits very precisely with a true Integrated Medicine.

One caution: it IS a medical journal and there are one or two articles near the back that are not for the squeamish.

With that caveat, there is much food for thought in these articles, and the Lancet deserves our thanks for making them available for free. Even if it is only for a month!

Predicting Response to Medicines

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

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

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

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

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

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

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

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

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

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

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

Advertising Medicines

Web Mistress (that still sounds a bit rude) Carol Kirshner has just alerted me to something very important.

It looks as if there is going to be more oversight of direct-to-consumer advertising of medicines.

She posted this on Thursday:

"According to an article published today by Reuters the General Accountability Office (GAO) has published a report that the Food and Drug Administration (FDA) needs to improve their monitoring of direct-to-consumer drug advertising. Specifically, the FDA should issue warning letters more quickly when misleading advertisements appear.

The GAO findings are based on an examination of 19 letters issued in 2004 and 2005 which took, on average, 8 months to send out. The GAO asserts that by the time the companies received the letters, most had already discontinued the ads. Additionally, the GAO found that even after the letters were received, some companies continued to break the rules on the same medications.

The GAO report found that the pharmaceutical industry spent 4.2 Billion dollars on DTC ads in 2005. This is almost double the amount spent in 1997. Breakdown of other spending includes 7.2 Billion dollars promoting directly to doctors and 31.4 Billion dollars spent on R&D.

Logic would seem to suggest that if spending on DTC advertising continues to grow exponentially, monitoring will become even more difficult. There will simply be too much volume to keep up with given the current resources of the FDA. In fact, the FDA has tried to proffer this as an explanation for the lapses. According to the article, the GAO is standing firm that the FDA could do more."

The first thing to say is that the vast majority of pharma companies do a great job of providing clear and accurate information, and I know of several for whom patient welfare always trumps the bottom line. But clearly there have been some problems.

Second, is that consumers need to be aware that the inofmration in the advertisements may no longer be 100% accurate, so check before you take anything. One of the reasons for creating this blog was so that I could be responsive to questions and quick to provide new information as it appears.

I also have a number three point, and it is something that surprises many of my friends and colleagues in the United States. Direct-to-patient advertising is prohibited almost everywhere else in the world. The rationale for that prohibition is most definitely not to disempower people! It is that careful prescribing of medicines is becoming an ever more complex art and science.

Regular readers may remember a report about the lamentable level of training of British doctors in how to prescribe and combine medicines. And British doctors do not have the added burden of patients asking for medications by name.

Some years ago I was at a meeting at which I was told a statistic that 92% of American doctors will prescribe a medicine if tha patient asks them to, while the figure throughout Europe was less than 20%. I've never been able to find any documentation for those figures, though they were given to me by a senior executive in a pharma company.

If those figure are anywhere near the truth they would worry me: there are just so many inter-individual differences in response to treatment and so many potential interactions between medicines, herbs and supplements. Explaining them all to someone who hasn't been trained in phamacology can be tough.

Trust me! I've been teaching medical students, residents, junior attendings, pharmacists and nurses since the 1970s. All have biomedical backgrounds, but teaching them all the ins and outs of modern pharmacology can be a Labor of Hercules!

So this is absolutely not a criticism of members of the public asking about things that they have seen on TV or the internet. Neither is it a criticism of 99% of the pharmaceutical industry.

I think that it's great for people to ask for what they want, the problem is this: How many doctors and nurses are able to say no?

And also to explain their reasons clearly?

Isn't it just an extra stressor for patients and prescribers alike?

Medical Terminology and Clear Communication

During the Second World War, there was so much worry about the possibility that Axis spies had penetrated the United Kingdom, that there was a whole campaign entitled, “Careless Talk Costs Lives.”

We sometimes see a similar problem in medicine, and in particular in psychiatric practice when we use terms that may cause great and unnecessary distress.

When somebody is unwell, it is hard for them and for their family to take everything in. research has shown that people only remember accurately 30-40% of what a doctor, nurse or therapist says to them. That is why I recently wrote the piece on clarity of communication.

Another problem is vocabulary. It is calculated that a medical student has to learn aorund 6,000 new words during his or her training. Young doctors and nurses often forget that what they mean by a word is often very different from what a non-medic may mean. That is why we try hard to define eveything on this blog.

You might be interested to look at an example on the Psychiatric Resource Forum blog. This one discusses paranoia. It's an important word, but one which means something diferent to the specialist from its common use in conversation.

I think that it is valuable for you to be armed with as much information as you can, and I plan to continue highlighting terms that can lead to distress and misunderstanding.

Irritable Bowel Syndrome, Mood Disorders, the Serotonin Transporter and Integrated Medicine

Whenever we run into two common conditions, it’s easy to imagine links where none really exists. Three years ago some colleagues from Oxford reported on a person with bipolar disorder and irritable bowel syndrome, and commented that the association was uncommon.

However there may after all be a genuine link between mood disorders and irritable bowel syndrome, that is a disturbance in the “third arm” of the autonomic nervous system. The first arm is the sympathetic nervous system, the second the parasympathetic and the third is the enteric or gut nervous system that is closely linked with key regions of the brain.

Not long ago there was an interesting report of a woman who had multiple problems including environmental allergies, atypical bipolar disorder, irritable bowel syndrome and Raynaud’s phenomenon. Such odd constellations of problems are quite familiar to anyone working in the major referral centers around the world, and some can be exceedingly hard to treat. Tough cases like this often stimulate further research. I once tried and failed to treat a woman with a chronic illness. When she came back a year later to see if I had any new ideas, I told her that I now had a shelf of books and over a thousand reprint of papers about her condition: I don’t like failing someone. And I’m not unique in that.

A new study from the Karolinska Institute in Stockholm, has found that chronic widespread pain, which, as I explained recently, is the cardinal symptom of fibromyalgia, is prevalent and co-occurs with other symptom-based conditions such as chronic fatigue syndrome, joint pain, headache, irritable bowel syndrome, and psychiatric disorders. There is more and more evidence of a link between fibromyalgia, irritable bowel syndrome and depression. It is not just that people are sick and get depressed: as we shall see in a moment, the link is more subtle than that. Another illness seemingly linked to these three is interstitial cystitis.

Now some colleagues at the National Institutes of Health have been looking at a serotonin transporter (SERT) that regulates the entire serotoninergic system and its receptors. This transporter is found throughout the animal kingdom, telling us that it must be important.

In humans the gene is located on chromosome 17, and disturbances in it have been found in people with autism, ADHD, Tourette’s syndrome and bipolar disorder. Experiments using genetic engineering suggest that SERT may be a candidate gene for several human disorders, from obesity to irritable bowel syndrome. People who have disturbances in SERT tend not to respond so well to the serotonin reuptake inhibitors (SSRI’s) antidepressant medicines.

SERT is not the whole story. Some geneticists from Los Angeles have found evidence linking irritable bowel syndrome, depression, migraine and inheritance of mitochondrial DNA.

Many approaches have been tried to help people with these groups of problems. I always find it remarkable that psychological treatments can be so effective in conditions with a genetic component, for this once again proves that biology is not destiny.

The best approaches to conditions like irritable bowel syndrome and coexisting mood disorders is to use medications and psychological approaches. Many of us have also found that the addition of nutritional, environmental and subtle energetic approaches have been of great help, together with some work to uncover the meaning and transpersonal value of a chronic illness. That last piece is not the first priority, which is to help the person gain control of his or her life. But if we don’t do something to work with the meaning and purpose of an illness, it will usually come back in some form or other. This comprehensive approach differentiates Integrated Medicine from many other types of therapy.

Black Cohosh and Liver Damage

After discovering that some of the Black Cohosh sold in the United States contains precious little of the active ingredient, we now learn that that may not have been such a bad thing.

In 2004, a Conference sponsored by National Center for Complementary and Alternative Medicine and Office of Dietary Supplements, National Institutes of Health indicated that Black Cohosh appeared to be safe. However, earlier this year, the regulatory authorities in Australia issued a policy statement about adding warnings about liver toxicity to all herbal products containing Black Cohosh. The European and British regulatory authorities followed suit.

This highlights a problem with which we’ve struggled before: are the reports of hepatotoxicity due to a “bad batch?” Adulterated perhaps, or collected incorrectly? Yet that highlights both the strength of natural remedies and also their Achilles’ heel. We have so little information about the purity of individual products.

The standardization of herbal medicines is difficult, particularly since herbals usually contain complex mixtures of constituents, some of which are active, and some not. We often do not know exactly which component of an herbal medicine is responsible for clinical effects. There are often also differences in the composition of herbal preparations among manufacturers and lots. There are also enormous variations in the identification of plants by the manufacturers, how they are handled and the presence of other chemicals. Just think of the variations in the taste of different types of coffee, and you will see the point.

This variation has important consequences in clinical trials, many of which have failed to address the question of whether the herbs that they were using were of high quality.

The information on the label does not always reflect the actual content of the preparation and it is difficult to give one standard dose for an herbal medicine.

I thought that I should give you the wording from The European Medicines Agency (EMEA) and the Committee on Herbal Medicinal Products (HMPC)”

“Following review of all available data, the HMPC considered that there is a potential connection between herbal medicinal products containing Cimicifugae racemosae rhizoma (Black Cohosh, root) and hepatotoxicity.

The EMEA therefore wishes to give the following advice to patients and healthcare professionals:

Advice to patients:

-- Patients should stop taking Cimicifugae racemosae rhizoma (Black Cohosh, root) and consult their doctor immediately if they develop signs and symptoms suggestive of liver injury (tiredness, loss of appetite, yellowing of the skin and eyes or severe upper stomach pain with nausea and vomiting or dark urine).

-- Patients using herbal medicinal products should tell their doctor about it

-- Advice to healthcare professionals:

-- Health care professionals are encouraged to ask patients about use of products containing Cimicifugae racemosae rhizoma (Black Cohosh, root).

-- Suspected hepatic reactions should be reported to the national adverse reaction reporting schemes."

Bipolar Disorder, Insomnia and Suicide

For many years now, I have advised on the treatment of many well-known people with all sorts of problems and illnesses. I always admire people who reveal that they have suffered from a problem in the hope of helping other sufferers.

The actor Stephen Fry has recently described his struggles with bipolar disorder and why he suddenly abandoned a play in London after developing stage fright. You may have seen him playing Jeeves to Hugh Laurie’s Wooster, or in the Blackadder shows.

Stephen was once described as a man with a “Brain the size of Kent.” He said that he became so knowledgeable because of terrible insomnia, which kept him up nights: he used the time to read enormous numbers of books. He also described a suicide attempt and a very serious plan to kill himself.

Though I've not examined Stephen, I can now explain several things to you:
1.    Bipolar disorder is not uncommon, and is rather more common in highly creative people. That being said, we must not romanticize an illness that carries a substantial mortality. The illness is frequently misdiagnosed, and when it is, there is an ever-present risk of suicide, as well as a host of other medical problems.
2.    Anxiety disorders occur in 80-90% of people struggling with bipolar disorder, and stage fright is one of these anxiety states
3.    Stephen may not have had insomnia as much as a reduced need for sleep, which is a classic symptom of one type of bipolar disorder. People with insomnia cannot sleep and usually go through the day feeling un-rested. People with a reduced need for sleep not only stay awake, but don’t get tired until they have been up for days at a time. Doing something like reading lots of books at night is another classic symptom.

Stephen Fry has just made a documentary for the BBC in which he talks about bipolar disorder with Carrie Fisher, Richard Dreyfuss and Robbie Williams.

They all deserve our gratitude for speaking out, telling their stories, and hopefully helping alleviate some of the stigma of mental illness, and helping more people get the diagnosis and treatment that they need.

Thank you Stephen!

P.S. There has recently been a rumor going round that your humble reporter was the model for Hugh Laurie's Golden Globe award-winning portrayal of Dr. Gregory House. I don't know where it started, but there's absolutely no truth in this vile calumny. I'm never irritable or curmudgeonly...

Technorati tags: Stephen Fry Bipolar disorder Stigma Hugh Laurie Blackadder Gregory House

Training Doctors to Use New Medicines

I was saddened to see a press briefing by four senior members of the British Pharmacological Society  at the Society’s 75th Anniversary meeting in London. They called for an immediate improvement in the training of medical students and doctors in pharmacology and clinical pharmacology. They lamented the reduction in the teaching of the basic and clinical principles underpinning the use of medicines, that was leading doctors to be less confident in prescribing. This at a time when medicines are becoming increasingly powerful and complex to use, and when patients are more likely to be taking a number of different drugs.

I have known all four of the people who made these statements, and none is given to hyperbole. Professor David Webb from the University of Edinburgh had this to say: “Patients are becoming ill and some are dying as a result of poor prescribing. There is no doubt about that. A substantial proportion of that is undoubtedly avoidable.”

I was in San Francisco earlier today, and I was shocked by one of the questions, “What is the P450 system?” This is one of the most important metabolic pathways for medicines in the liver and the intestines, and it was worrying that a prescriber did not know that. In my view if a student doesn't know something, it's the teacher's fault, so it means that we trainers are not doing as good a job as we should, and that the problems are not confined to the United Kingdom.

The discussion soon turned to the increasing evidence that some medicines may be associated with metabolic disturbances in some people who take them. We soon started talking about the broader issues of drug side effects. My view is that we don’t need to blame doctors or pharmaceutical companies, that have no interest in bringing unsafe medicines to market: the financial and legal consequences can be devastating. And in any case, I’ve met hundreds of people working in senior position in over thirty pharmaceutical companies and the vast majority of them are deeply committed to trying to improve the lot of humanity.

I think that the problem is not with medicine itself or with doctors or companies. The problem is inadequately trained and/or bad doctors and bad companies.

And fortunately all of those are uncommon. But if these pharmacological luminaries are flagging up a problem, we all need to re-double our efforts to ensure that everyone working in medicine is trained in the basics.

Technorati tags: Pharmacology Medical training Cytochrome P450

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 

Systemic Psychiatry

“Once a disease has entered the body, all parts which are healthy must fight it: not one alone, but all. Because a disease might mean their common death. Nature knows this; and Nature attacks the disease with whatever help she can muster.”
--Paracelsus (a.k.a. Theophrastus Phillippus Aureolus Bombastus von Hohenheim, Swiss Physician and Alchemist, 1493-1541)

It is usually a mistake to try and look at an illness in isolation.

We are all human beings, and physical challenges affect the whole organism, as well as our mind, our relationships and our spiritual connections.

There is currently a very hot area of research that is still unknown to most people: even to most people working in psychology and psychiatry. This hot new area proposes that schizophrenia, bipolar disorder, major depressive disorder and autistic spectrum disorders, are disturbances affecting the whole body, but with prominent effects in the brain and on emotion and behavior. This may help provide one part of the explanation for why people struggling with chronic mental illness - and their relatives - suffer from an array of physical illnesses that cannot be explained by stress or poor lifestyle choices alone.

You can find a brief review with a stack of references here.

This idea of psychiatric problems being generalized systemic disturbances that have their primary effects on the brain and on behavior is important to the general themes of this blog. We are always interested in looking beyond the obvious causes, to a dynamic integrated vision of a person that includes every part and every dimension of his or her being. If we want to help people recover from illness, to triumph over adversity, and to use challenges as springboards to transcend themselves and the limits placed upon them, it is only possible if we take account of the whole person.

Perhaps we can reduce mental illnesses to disturbances in cell membranes or a few chemicals in the brain. But I do not think so. It is more accurate for us to be thinking about a perturbation or disturbance in the Informational Matrix that underlies the subtle systems of the body, that in turn support the biochemical reactions that provide the structure for the external expression of life itself.

We live in very interesting times.

“Good timber does not grow with ease. The stronger the wind the stronger the trees.”
--Willard J. Marriott (American Businessman and Founder of Marriott Hotels, 1900-1985)

Technorati tags: Schizophrenia Bipolar disorder Diabetes mellitus Phospholipid Cell membrane Systemic illness Informational matrix 

A New Way of Looking at – and Treating - Inflammation

Diseases of both large and small blood vessels are two of the biggest problem facing people with diabetes. Not only is it a huge clinical challenge, but also nature sometimes does our experiments for us. The high rates of coronary and peripheral vascular disease in diabetes can be seen as a kind of experiment of nature: a recognizable set of chemical abnormalities that might shed light on vascular diseases in general. It was those twin factors: a huge clinical problem, and an experiment of nature, that lead me to pick the topic of my research doctorate. 

When I was working on my research doctorate in the mid 1980s, I came across a lot of old research that seemed to show links between inflammatory and autoimmune conditions like systemic lupus erythematosus and rheumatic fever, and the eventual development of coronary artery disease. There was also a lot of old and largely forgotten research about the link between some viral infections and the development of coronary artery disease and acute coronary artery occlusions, because some infections can make blood more “sticky.” Inflammation evolved as one of the body’s defence mechanisms.

So I made the proposal – revolutionary at the time – that diabetes, coronary artery disease and a range of other illnesses might be inflammatory rather than degenerative. I soon found inflammatory markers in people with diabetes, that helped predict when someone was running into trouble with their eyes, kidneys or heart.  Even with stacks of data, I had to spend a lot of time defending that position, because it also implied that some illnesses thought to be irreversible might not be.

With the passage of time, it has tuned out that I was probably correct. Chronic inflammation, wherever it starts, mat have long-term effects on the body and on the mind. Chronic inflammation increases the risk of diseases of many blood vessels, as well as causing anemia, organic depression and cognitive impairment. Here is a partial list of common conditions in which inflammation is a prominent factor:
1.  Rheumatoid arthritis
2.  Systemic lupus erythematosus
3.  Fibromyalgia
4.  Chronic infections
5.  Insulin resistance or metabolic syndrome
6.  Arteriosclerosis
7.  Diabetes mellitus
8.  Hypertension
9.  Asthma
10. Inflammatory bowel disease
11. Psoriasis
12. Migraine
13. Peripheral neuropathy
14. Alzheimer’s disease
15. Autism
16. Gingivitis
17. Cystitis

The reason for raising the issue is not to say “told you so!”

It is instead that we need to think about inflammation a little differently. There is a mountain of information about the physical aspects of inflammation. We can stop at the simple description of inflammation as a condition in which part of the body becomes reddened, swollen, hot, and usually painful, or we can look below the surface: we can examine inflammation not only as a physical problem, but also as a psychological, social, subtle and spiritual problem. Why bother? Because the deeper approach allows us to understand and to treat and transcend inflammation as never before.

I am going to write some more about specific ways to address inflammation and what it means in future articles. I would also like to direct you to the book Healing, Meaning and Purpose, in which I talk about specific approaches in more detail.

But I would like to start with this.

In Ayurvedic and homeopathic medicine, inflammation is a sign of an imbalance in the vital forces of the body, and the traditional Chinese system agrees: here inflammation is usually a manifestation of an excess of Yang Qi, or a deficiency of Yin Qi. Most of our lives are seriously out of balance: Yang Qi is like a rampaging lion that has been stimulated by:
Acidic foods;
Environmental toxins;
Unwanted sexual stimulation:
Noise;
Discordant music:
Constant demands from others:
Toxic relationships;
Years spent in front of television sets and limitless multi-tasking.

It should be no surprise to learn that all of these inflammatory conditions are increasing rapidly throughout the Western world. Not because we are getting better at identifying them, or we are living longer, but genuinely increasing.

It is wrong to put all the blame on poor diets or inadequate exercise. The problem is more subtle and is a reflection of distorted Information being fed to our bodies, minds, relationships, subtle systems and spiritual relationships.

The great news is that this simple conceptual shift gives us a whole load of new tools for handling these problems, and for using them as catalysts to growth.

In the next few weeks, I am going to drill down and give you some specific guidance that ties into the material in Healing, Meaning and Purpose and the next two that are on the launch pad.

Fasten your seat belt!

Technorati tags: Inflammation Aging Alzheimer's disease Arteriosclerosis Neuropathy Autism Arthritis Systemic lupus erythrmatosus Fibromyalgia Inflammatory bowel disease Gingivitis 

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

Understanding Attention Deficit Disorder as a Long-term Challenge

Regular readers will know that I am a huge advocate of natural and non-invasive methods of treatment whenever possible. But sometimes we reach an impasse, and the only option is to use pharmacological or other types of conventional intervention. But even then, it is a mistake to assume that physical treatment alone will be sufficient to help the individual and their family: it is only sensible also to address the psychological, social, subtle and spiritual dimensions of the person. And we must never lose sight of the positives: some people who have health challenges are transformed for the better, and some “illnesses” may carry gifts with them. I’ve talked about the creativity of people with bipolar disorder and schizotypy and the empathy and innovation that may accompany attention deficit disorder.

There is often a fine balance between the positives and negatives of an illness and the types of help that may be of greatest value.

I have just been involved in a common discussion at this time of year: a young person has quite bad attention deficit disorder (ADD). Since she started pharmacological treatment not only has she risen from being a failing student to getting all As and Bs, but the quality of her life has improved dramatically. Unfortunately, she has been told that she only needs to take her treatment when she feels that it is necessary to complete her schoolwork. Many healthcare providers continue to believe that ADD and ADHD are just academic problems. There is a very good new review article that discusses this misperception in some detail. Prescription patterns show that the majority of school-age children are only being treated from Monday to Friday, and from 7AM to 3PM. Why does this matter?

There is excellent and extensive research about the consequences of non-treatment, and most of it has nothing at all to do with school. If people with ADD and particularly with ADHD are left untreated, they are more likely to:
1. Develop substance abuse
2. Be involved in a serious accident
3. Engage in illegal activities
4. Contract a sexually transmitted disease
5. Have an unplanned pregnancy
6. Become separated or divorced

The article makes a point that we have often discussed with families: these consequences of non-treatment are events that primarily occur outside the school environment. So withholding medicine just when it is needed the most may be a risky business.

We are now seeing increasing evidence that successful pharmacological treatment reduces these consequences of untreated ADD/ADHD to the rates found in the general population. Simply using appropriate medications can protect people from adverse consequences of these problems both now and in the future.

I think that we should look at ADD in the same way that we look at an illness like diabetes. In diabetes, the high blood glucose and elevated lipids are not themselves the problem. They may cause symptoms, but the real danger lies in the long-term physical consequences of high glucose and lipids. It is these that can be so devastating to the person with the illness, causing the so-called complications of diabetes, such as retinopathy, kidney and heart disease.

Similarly ADD/ADHD may cause symptoms – such as problems in school – but it is the long-term consequences that can cause such problems. Children and adolescents, and for that matter some adults with both illnesses don’t realize that these are the main reasons for treatment.

There is a common myth that adults know that they need to take their medication, and so they do. Hands up anyone who has only taken half of a course of antibiotics!!

There is very striking study of adults with ADHD who were asked to do a simulated driving test while on and off their medicines. The people in the study rated their driving performance just the same whether they were on or off their medicines. Despite the fact that when they were off their treatment they were an astounding five “standard deviations” worse in terms of driving safety and responsibility! For people not used to looking at statistics this may not seem like much, but the difference is astonishing. You would not want to share the road with an untreated person with ADD.

We know that within the first three months of treatment 50% of children and adults will have stopped their ADD/ADHD treatment and most studies agree that by 18 months, the figure is around 80%.

We need to get the message out that:

1. ADD and ADHD can create some nasty long-term problems if not adequately treated.
2. For a host of reasons, most people will stop their treatment, so plan for it, and don’t just wait for it to happen.
3. Adequate treatment consists of a lot more than giving medication and hoping for the best.
4. People need psychoeducation.
5. They need to learn coping strategies.
6. The family needs to know how to help and how to deal with the problems that someone with ADD/ADHD may be causing them.
7. And people need to know how and when to use medications and how to integrate them with non-pharmacological strategies.

Technorati tags: Attention deficit disorder Attention deficit hyperactivity disorder Substance abuse Treatment 

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

Healia.com

Carol Kirshner, web mistress extraordinaire, has just alerted me to a great resource for anyone looking for information on health, wellness and healing, called Healia.com.

Carol's review is excellent, and now that I've tried out the website, I really do share her enthusiasm.

One of the reasons for creating my own blog is that the internet is full of medical misinformation. I have just been writing an article that I am going to post tomorrow. My initial reactions to some of the statements that I found on line would not have been fit for you gentle reader. Suffice to say that there were comments on some websites that betrayed a complete ignorance about the workings of the human body and recommendations that can best be described as bovine excreta.

Healia.com seems to be very different. I have been putting it through its paces, and I've so far not found a single problem or contentious area, despite throwing a lot of unusually tough questions at it. I fully anticipate that it's going to become one of my major research tools, and for matters pertaining to health, it seems to be better than any other search engine that I've found.

Technorati tags: Internet search engine Health Healing 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 

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 

Happiness and Resilience

For more than two decades, my main focus has been on ways to help people become more resilient to the slings and arrows of outrageous fortune. To enable people to withstand anything that's thrown at them: physically, psychologically, socially and spiritually. And not just to withstand them but to use adversity as the impetus for growth.

Adversity is a fact of life: it cannot be controlled. But we can control how we react to it.

This is such an important concept.

So many people try and make themselves stronger and stronger, yet there will always be something that can overwhelm the most powerful defenses. I knew of two martial artists in Hong Kong who claimed that they could defeat anyone. They were incredibly strong and had exquisite technique.

Which did not help them one bit when some villains shot them from behind by.

I have come across others who have spent their lives eating and exercising and still dying prematurely. What was the problem? They had not learned the arts of resilience, which include adaptability, flow and seemless integration with the Universe.

Over the next few days I am going to introduce you to some of the techniques that we have developed for enhancing psychological and physical resilience, before going on to reveal some of the secrets for strengthening the subtle fields of your body, and how to maintain dynamic relationships, not just with another person, but with your Higher Self.

One of the manifestations of resilience is happiness, so before we start, I would suggest that you try this small test that was published by the BBC by arrangement with Professor Ed Diener, from the University of Illinois who designed it.

Technorati tags: Resilience Happiness Flow Relationships

Human Evolution

For more than a century, the received wisdom has been that humans finished their physical evolution between one hundred thousand and fifty thousand years ago, and that there have been only minor changes in cognitive abilities over most of that time.

I have always found those assertions to be fundamentally flawed. Our bodies have changed beyond all recognition in the last few hundred years, as I’ve pointed out in my last book and CD series Healing Meaning and Purpose. Even more than that we have changed and are changing mentally. If we were to go back in time ten thousand or even one thousand years, we would find that people were cognitively, emotionally and morally quite different from modern humans. Not simply because of technology and the explosion of knowledge about the external universe, but because there is a dynamic relationship between our development as a species and our creations, with each feeding off the other.

It is only recently that a number of theoreticians, philosophers and psychologists have begun to look at the ways in which we are continuing to develop and what it means for all of us.

The German psychiatrist and philosopher Karl Jaspers first pointed out the great moral leap forward in what he called the Axial Period, between about 700-200B.C.E., during which the foundations of many of the world’s great religions first appeared, probably in response to the prevailing violence and unpleasantness of the time. More recently the Polish-born Swiss philosopher Jean Gebser started developing intriguing models of the transformations of human consciousness. In the United States, the psychologist Clare Graves developed a revolutionary concept of developing levels of development of the personality, that has evolved into Spiral Dynamics. (You may be interested to look at a review that I have just written about an excellent CD program detailing the latest developments in this field.)

And then there is Ken Wilber whose work in this field is remarkable, and whose creation of the Integral Institute promises great things. To these luminaries I now add Dudley Lynch a writer whose work I have only recently discovered.

Dudley recently wrote a very sensitive blog item about the efforts of a person with a mental illness trying to keep himself integrated in a sea of psychic chaos. He was kind enough to publish my brief response, which needs a little more detail.

The reasons for raising these points about continuing human development are these:

1.The manifest physical changes in people over the last few hundred years have enormous – and largely neglected - implications for clinical medicine.

2. It is likely not just peoples’ physical bodies that have changed, but also their subtle systems. I pointed out in my last book and CD series that the chakra system has developed to its current point only within the last few thousand years. This continuing development is also one of the reasons why some therapies that once only worked occasionally are now becoming more stable and predictable, and why some new forms of therapy – like the tapping therapies - are now being discovered.

3. It is because of these profound changes that new forms of therapy are now being developed. Not just using a supplement here, or a breathing exercise there, but precise combinations that help guide the healing of every aspect of an individual and his or her relationships and spiritual connections.

4. Some people who appear to have psychotic illnesses are moving into new developmental stages without having passed through the necessary intermediate stages. I have just read a first person account of an English journalist who could easily have been diagnosed with a manic illness, but was almost certainly undergoing a spiritual emergence.

5. Major emotional, cognitive, moral, conscious and spiritual shifts can be profoundly frightening to many people, and are doubtless one of the reasons for the profound feelings of social dislocation and violent reactions that we are observing throughout the world.

6. It is no surprise that new spiritual pathways are now emerging. Many will doubtless be very helpful to many of the thirty million Americans who count themselves as spiritual seekers, but have not yet found what they are looking for.

7. Taken together, these new understanding about the longitudinal development of people, relationships and whole societies are already having extraordinary effects on our ability to guide them all in more healthy and integrated pathways.

Technorati tags: Human evolution Axial period Ken Wilber Karl Jaspers Alternative medicine Complementary Medicine Integrated Medicine Chakras Subtle energy

Health Risks of X-Rays

There have been alarmist and often sensationalist stories about the health effects of ionizing radiation since it was first discovered. Wilhelm Conrad Röntgen won the Nobel prize in Physics in 1901 for his discovery of X-rays, and it was quickly discovered that over-exposure to X-rays was dangerous. Marie Curie – the Polish-born French scientist who won two Nobel prizes in 1903 and 1911 - died of leukemia. It has often been suspected that it was related to her long-term exposure to radiation.

As a child growing up in England, many shoe shops had primitive X-ray devices called fluoroscopes to allow kids and their parents to look at their little toes inside their shoes. Despite knowledge of the health effects of X-rays I reported in an article published fifteen years ago, that while working at a hospital in Nanjing, China, I was shocked that the ancient X-ray equipment had no shielding at all.

There is no doubt that X-rays and their more sophisticated progeny, like CT scans, have revolutionized medicine, and saved countless lives. So how do we weight the risks and benefits of diagnostic X-rays? The last thing that we want to do is to discourage people from having the medical help that they need.

Help has arrived in a new report Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2 from the National Academy of Science, published in September 2005. I think that this report should be considered the definitive and authoritative resource on the subject of radiation risk.

Dr. Richard C. Semelka has produced an outstandingly helpful summary of the report and its key recommendations.
1.    The report says that medical X-rays can cause cancer, and that there is no safe lower limit. The risk is very low, and, as one might imagine, is higher in children. It is also important to be aware that cancers are not uncommon and almost always have multiple causes, so claiming a causal link between a diagnostic X-ray examination and the subsequent development of a tumor is very difficult. The main tumors said to be associated with X-rays are leukemia, thyroid and breast. The time between exposure and tumor development can be very long.
2.    Therefore any use of X-rays, particularly CT scanning should be done judiciously. One of the problems in the United States is that many professionals have been forced to practice defensive medicine. They could be held legally liable if they do not do a test.
3.    Professionals already use the lowest possible dose of radiation.
4.    Professionals are already discussing whether there are any possibilities of substituting other types of diagnostic imaging.

Now I’m going to tell you a story. Some time ago I had a health problem that may well have been a result of exposure to radiation as a child. The health problem is now long gone, but it sensitized me to the issue. So what would I do now if a physician recommended that I have an X-ray or a CT scan? I would discuss the options:
How important is the test?
What would be the downside of not having it?
Is there any other way of getting the same answer without using X-rays?
If the answer to that one is “no, “ then what’s the lowest dose of radiation that we can use?
And how can we shield the bits of me that don’t need a dose of X-rays?
Then, even with my medical history, I personally would almost certainly go ahead and have the test. But every person would be well advised to have that discussion with their health care provider.

Many professionals read my articles, and for you, it would be worth considering getting the report, and going through Dr. Semelka’s thoughtful article.

I think it’s excellent that scientists have produced this report and that thoughtful radiologists around the world are working on the best ways of safe guarding the welfare of the public. I am going to continue to report the emerging scientific literature on this important topic.

Technorati tags: X-rays radiation carcinogenesis

A New Atlas Promises a Breakthrough in some Brain Disorders

The very first attempts to take pictures of the living brain go back to the 1930s, but it is only in the last 20 years that MRI, SPECT and PET studies of the brain have really moved the field forward. After thousands upon thousands of imaging studies, we are beginning to approach the time when we can start harvesting the data collected over these years.

We are on the cusp of an extraordinary advance in our understanding of the brain and how it can go wrong in a large number of neurological and psychiatric illnesses. But that is only a side show: being able to identify the neurological correspondences of, say a psychiatric illness, does not mean that we reduce the illness to the firing of a group of neurons. But it does mean that we are gong to be much closer to providing suitable treatment for the neurological component aspect of the illness.

There has been a dramatic demonstration of this with the publication of a new brain map of people living with a rare but important illness called William’s syndrome.

One of the biggest puzzles for those of us who look at brain scans, is why there is so much variability in the structure of the brain. In the rest of the body, veins and arteries can turn up all over the place, but nerves tend to be in pretty much the same position in everybody. This is not the case in the brain. I’ve looked at many thousands of MRI scans of the brain, and I’ve never found any two alike. It’s one of the reasons that I’m a little doubtful about some of the claims of imagers who say that they can diagnose someone by looking at a brain scan. Most of the time there’s just too much normal variation.

All over the world, there have practitioners who have claimed to derive all sorts of information from brain images. Most experts remain a bit skeptical: hundreds of experts and hundreds of millions of dollars have only enabled us to speak in generalities. Some private practitioners even perform scans for diagnosis.

Some time ago I met a psychiatrist who had an unusual theory about the causes of mental illness. He wanted us to do two MRI scans on a patient to prove his theory. When I told him that we were not yet able to do that in individuals, he was indignant, “But you’ve published all those studies showing abnormal brain structure in schizophrenia.” I explained that all the brain imaging studies have told us quite a lot about groups of people with mental illness, but little about individuals. I do not know of any academic psychiatrists anywhere in the world who think that we can yet use PET, SPECT, fMRI or MRI scans for diagnosis of mental illness. Maybe we’re just being a bit slow. Or perhaps the brain scan diagnosers haven’t got all the pieces of the puzzle just yet. Research is expensive and takes a great deal of time. Busy clinicians are eager to exploit new investigative tools for the benefit of their patients, and usually do not publish their results in peer reviewed journals. With this new research we are going to be able to see if these individual practitioners are correct.

Not only are there many inter-individual differences, but also the current state of the person can have a big impact on some types of imaging. I was recently asked to review a paper for a scientific journal in which the authors had enthusiastically explained the way in which they could now diagnose a certain illness by doing a brain scan. Sad to say, they had not asked a couple of basic questions, like the person’s mood when they were scanned. Depression reduces the flow of blood in regions of the brain, the patients turned out to be depressed, and the results were invalidated. It was a real shame, but it is so important that patients don’t get misled by investigations that cannot help them.

So the moral of the story is this. If someone wants to do any kind of investigation for diagnostic purposes, ask them first whether there is any published evidence that the test actually works: what are the sensitivity and specificity of the findings generated by the test? And who else is doing it?

“If the brain were so simple we could understand it, we would be so simple we couldn't.” --Lyall Watson (South African Biologist and Writer, 1939-)

Technorati tags: brain structure williams syndrome bipolar disorder PET scan

Crucial New Insights Into the Metabolism of Medications

When we examine the interactions of medicines with the body, we are interested in what the medicine does to the body, and also what the body does to the medicine: what we call pharmacokinetics and pharmacodynamics. But it has long been known that these two essential considerations are far from being the whole story: there are enormous differences in the ways in which people respond to medicines: some people need huge doses of a medicine, whilst there are others who cannot tolerate medicines at all. Though part of the explanation for those differences is clearly not just pharmacological – the same people who are super-sensitive to medicines are often also extraordinarily sensitive to acupuncture and homeopathy – there is a new kid on the block: a new factor in drug metabolism.

Men and women handle medicine differently, the time of day that a medicine is taken, as well as things like the food eaten in the last few hours can all impact the outcomes of taking a medicine. We have also known that there are many other variables in a person’s response to a medicine.

For more than two decades physicians and pharmacologists have wondered if the three pounds of bacteria living peacefully in our intestines might have a major impact on the metabolism of medicines. This question was first prompted by clinical observations: first, people with no intestinal bugs exhibited many oddities in how they handled medicine, and second, there are some rare situations in which overgrowth with unusual bacteria can chew up certain essential nutrients.

New research reported by the BBC confirms these clinical observations.

Researchers at Imperial College London and the pharmaceutical giant Pfizer have used a “pharmaco-metabonomic” approach that uses a combination of advanced chemical analysis and mathematical modeling to predict responses to drugs. Details of the research are published in the journal Nature.

The method is based on an analysis of the chemical products of the body's metabolism. We think that examining these patterns can help diagnose diseases, predict an individual's future illnesses, and their response to treatment.

The principle investigator is Professor Jeremy Nicholson and he has said the 'pharmaco-metabonomic' approach appears able to take account of individual differences in the way that drugs are absorbed and processed by the body. It differs from person to person depending on factors including the type and amount of bacteria found in the intestines.

These new techniques could be the first step towards the development of more personalized pharmacological treatments. For those of us practicing integrated medicine, this is a most welcome development.

Technorati tags: drug metabolism gender differences intestinal bacteria pharmacodynamicspharmacokinetics

Happy World Tai Chi & Qigong Day!

Saturday, April 29, 2006 is World Tai Chi & Qigong Day . The day is going to be celebrated in 60 countries around the world as well as all fifty states. The event has been recognized by the United Nations World Health Organization, and proclaimed officially for 17 US states by their governors, as well as senates, legislatures and mayors of various countries.

I taught Tai Chi and Qigong for several years, and had the privilege of studying with teachers in China and Malaysia whose methods were part of an oral tradition. Much of this material has still not been published. I recently reviewed a very nice book at the Amazon.com website. One of the things that impressed me about the book is that it contained exercises and techniques that I had been taught by Chinese Masters, but which to my knowledge have never been published anywhere else.

I thought that it might be a good moment to review the world literature on the medical effects of Tai Chi and Qigong. My search has turned up over 2,200 published reports, of which about a third are the reports of clinical trials. I have been able to analyze the data in about a half of those trials. The data now suggests that Tai Chi is genuinely useful for:

• Preventing falls in the elderly
• Improving functional mobility and some aspects of immune function
• Improving blood pressure and lipid profiles and subjective wellness
• Improving overall physical performance
• Stress reduction in HIV positive individuals

There are many other studies indicating the value of Tai Chi, but these give you a sense of some of the research that is going on at the moment.

As I mentioned in another post, qigong is both a personal practice and is used as a form of therapy. It has recently been shown to help:

1. Chronic pain
2. Cardiac rehabilitation in the elderly
3. Chronic fatigue syndrome
4. Overall immune function
5. Asthma

This is by no means a comprehensive list, but as you can see, this is an active area of research.

Learning some Tai Chi and Qigong could be one of the best investments that you ever make in your own health.

Technorati Tags: Tai Chi, Qigong, Wellness, Asthma, Chronic fatigue, HIV

Fungal Contamination of Pillows

I recently came across a study from colleagues at the University of Manchester in the United Kingdom, that was published in the journal Allergy.

Fungal contamination of bedding was first studied seventy years ago, but there have been no reports in the last seventy years. In this new study, researchers sampled ten pillows with between 1.5 and 20 years of regular use. Each pillow was found to contain a substantial fungal load, with four to 16 different species being identified per sample and even higher numbers found in synthetic pillows. One of the most worrying things was that the microscopic fungus Aspergillus fumigatus was particularly common in synthetic pillows. And fungi as diverse as bread and vine moulds and those usually found on damp walls and in showers were also found in the pillows. Aspergillus is a very common fungus, carried in the air as well as being found in cellars, household plant pots, compost, computers and ground pepper and spices. I have treated many people with invasive Aspergillosis, a sometimes nasty illness that occurs mainly in the lungs and sinuses, although it can spread to other organs including the brain. It can be very difficult to treat, and as many as 1 in 25 patients who die in modern European teaching hospitals have the disease. In France and Germany, this is one of the occasions when unorthodox medicine is often used at the same time as high doses of antibiotics: proper integrated medicine.

Aspergillosis is a particular problem in people with compromised immune systems. Hospital pillows have plastic covers and so are unlikely to cause problems, but patients being discharged home - where pillows may be old and fungus-infected - could be at risk of infection. Aspergillus can also worsen asthma, particularly in adults who have had asthma for many years, and it can cause allergic sinusitis in patients with allergic tendencies. Constant exposure to fungus in bed could be problematic.

The moral of this story is be extra aware that pillows may harbor fungi that can cause or exacerbate allergies and more serious problems in people with other illnesses. If you have allergies, it is best to use foam rather than feather pillows. If you have synthetic pillows, wash them regularly in warm water and with a non-allergenic detergent. Dip the pillow one small section at a time in the solution and squeeze through the pillow. Once the pillow is clean, rinse it out at least three times to remove all of the soap and residue. Then lie the pillow out flat to dry, and turn it frequently. To fluff the pillow, take a couple of tennis balls and put them in the dryer with the pillow and air dry for about 30 minutes.

Technorati tags: fungus, integrated medicine, allergies, asthma

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,

The Status Syndrome

I have recently seen some reports in the media about a connection between money and longevity: the idea being that the more money you have, the longer you live. Which presumably means that Bill Gates will live forever. Sadly this link between wealth and longevity is a false extrapolation from some very old research. Yes, extreme poverty is associated with excess mortality, not only because of poor lifestyle and lack of access to medical screening and care, but also because adults who were of low birth weight are more likely to develop diabetes and hypertension. And people born into poverty are more likely to have been malnourished before birth, and therefore to be of low weight at birth. This relationship between low birth weight and subsequent disease is likely the result of incomplete development of the liver and kidneys before birth.

A famous study of British civil servants has indeed shown that people who work in more senior positions are more likely to live longer than people working in the lower ranks. But it has nothing to do with money. Once people have passed a certain critical material threshold, lifestyle factors have progressively less impact. There are still more smokers amongst manual workers and hours of hard work means that they have to eat high calorie high fat foods to be able t keep working, and we have not done a good job of showing people how easy it is to eat healthily on a budget.

Sir Michael Marmot is an outstanding epidemiologist working in London, who has spent three decades examining the health consequences of differences in social standing. He has discovered that there is a social gradient that predicts health outcomes: the lower a person’s social rank, the higher their risk for heart disease, diabetes, mental illness, accidents and many other health problems. Once people have passed a certain threshold of physical and material well-being, something else comes into play: other kinds of well-being that have a massive impact upon life. These are autonomy - how much control you have over your life - and opportunities for social engagement and participation. The psychological experience of inequality has profound effects on multiple body systems. Sir Michael has summarized a lot of his research in an eminently readable book entitled, appropriately, The Status Syndrome.

There is an interesting corollary of the Status Syndrome. In his book The Pecking Order, Dalton Conley presents interesting research that indicates that our level of success relative to our siblings is less the result of birth order or genetics and more the result how much family resources – time, energy, money and love - we received while growing up.

There’s not much that you can do about your birth order, but all this research has some important implications.

1. Once you have crossed a threshold that allows you access to nutritious food, exercise, stress management and health care, there is no longer any link between health and wealth. In fact, working and working to get more and more money is associated with increased mortality!

2. The amount of time, energy, money and love that the family is able to give to each child will help shape and structure their future life. That is a hugely important responsibility.

3. Ensure that you feel and know that you are autonomous: that you are in control of your life. I really urge you to work on this. One of the reasons for being concerned about the ever-increasing demands being made upon all of us is that it can make us feel out of control. I spend a great deal of time in Healing, Meaning and Purpose discussing and demonstrating techniques for taking back control of your life.

4. Are you socially engaged and participating in life? Are you doing something for your community or your church? How often do you meet new people and engage with them? Is there someone whom you haven’t seen for a while that really needs a call from you? Please do think about this: it’s not just about socializing; it’s about protecting your health and well-being, and the health and well-being of those around you.

Technorati tags: status syndrome, Michael Marmot

Acupressure for Sleepiness

I’ve been using and teaching about the use of acupressure for boosting energy for a very long time. Since the early 1980s I’ve used pressure and tapping of some specific acupuncture points to give myself a quick jolt of energy. I’ve also had some success in helping patients with chronic fatigue by giving them some acupressure methods to use on a daily basis.

So I was very interested to see the publication of a small study involving 39 students in the Journal of Alternative and Complementary Medicine. The students were participating in three days of all-day lecture classes. They were taught to apply acupressure - either tapping or massaging – either five stimulating or five relaxing points. The students were not told the intended effects of the different points.

Acupressure stimulation points were:

1. The top of the head

2. The top of the back of the neck on both sides

3. On the back of the hands in between the thumb and forefinger

4. Just below both knees

5. On the bottom of the feet -- at the center just below the balls of the feet

Acupressure relaxation points were:

1. Between the eyebrows

2. Just behind the earlobes

3. On the front of the wrists

4. On the lower legs above the ankles and toward the midline

5. On the top of the feet in between the large and second toes

The methods that the students were shown consisted of applying pressure to these points with light tapping of the fingers and massaging with the thumbs or forefingers.

The study was a cross-over design: Half of the students applied the stimulation acupressure regimen at lunchtime during the first day of class followed by two days on the relaxation regimen, and the other half followed the reverse schedule.

The results showed that students reported significantly less sleepiness and fatigue on the days they used the acupressure stimulation regimen. This is a fertile area for research. People have also claimed to be able to fatigue with both Thought Field Therapy (TFT) and Emotional Freedom Technique (EFT), and I’ve certainly found them to be useful on some occasions. The challenge now is to replicate this acupressure research and also to try out TFT and EFT in a similar study design.

Technorati tags:Thought Field Therapy,  acupressure, sleep, complementary medicine, Qi, Emotional Freedom Technique

Adjunctive Homeopathy in an Intensive Care Unit

Although we normally try to get articles quickly, we are sometimes thwarted and they can be delayed in arriving. I have only just got my hands on a study abstract that was published by a research team from Graz in Austria last October. The investigators from the Ludwig Boltzmann Institute for Homeopathy examined the use of homeopathy in a group of severely ill people in an Intensive Care Unit.

This was a double-blind, placebo-controlled trial to see whether homeopathy would be able to influence the outcome of critically ill people with severe sepsis. Seventy people entered the study, and 35 received homeopathic treatment and 35 received placebo, in addition to their regular treatment. The main outcome measure was survival. At day 30 there was no difference between the survival rates of the people receiving homeopathy and placebo. But at day 180, the survival rate in the homeopathy group was 75.8% compared to 50% in the placebo group.

One study does not make a revolution, and it is still early days for this kind of experimental work. Yet two things stand out from this small investigation:

1. The homeopathy was being used as an adjunct to conventional medical care. I sometimes get worried when practitioners of unorthodox medicine say that they would ONLY use herbs or homeopathy. The best approach has to be to combine conventional treatments with those unorthodox ones that can be shown to be helpful.

2. Trained homeopathic physicians did the prescribing. This is important: some studies have foundered because the studies tried to test just one remedy. Yet homeopaths individualize each treatment. So two people may have the same infection, but because they have different personalities and constitutional make-ups, they will receive different treatments.

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Technorati Tags: homeopathy, complementary medicine, integrated medicine

Glucosamine and Chondroitin

A study has been published in last week’s New England Journal of Medicine that seems to show that there’s no advantage in taking the popular dietary supplements glucosamine and chondroitin. Indeed that’s what has been reported in the media . But notice that I said, “Seems to show,” for on closer examination there is more to this paper than it appears.

The investigators are to be congratulated for doing the study in the first place. What they did was to take a large group of 1583 patients who all had osteoarthritis of the knees, and divide them into five groups:

• A placebo group
• A group that took celecoxib (Celebrex) 200mg/day
• 1500mg of glucosamine/day
• 1200mg of chondroitin/day
• A combination of 1500mg of glucosamine/day and 1200mg of chondroitin/day

The study lasted 24 weeks, and the main outcome measure was pain in the knees. The study showed that although patients on Celebrex did very well compared with the placebo group, those on glucosamine and chondroitin did not do better than placebo, although the combination was better than using either supplement alone. But one of the odd things was that people with moderate to severe pain WERE helped by the combination, and in fact the combination out-performed Celebrex!

Not only does the combination seem to help people with the biggest problems with pain, but also there are some other important points:

1. The worse someone is, the bigger the room for improvement. If someone only has mild pain, you need a lot more patients to find a statistically significant improvement.

2. As in most studies, multiple measurements were done, and Celebrex was no better than placebo in 12 out of 14 of them. So if the “active comparison” failed on multiple measures, we need to be very cautious about how we interpret the study.

3. The placebo response rate in the study was 60%, while the average is 30-35%. This is a huge difference. This may be because the patients knew that they had a four in five chance of getting a treatment that might help them, so they went into the study with high expectations.

4. This is only one study, concerning one type of joint problem. There are more than 30 others that have in general been even more positive then the findings in the moderate to sever group, including a very long-term study that showed that over an eight-year period, the combination dropped the rate of knee replacement by almost 75%. It is crucially important to examine the results of any study in the context of everything else that has been known and discovered. Every type of study has to be checked, and verified.

5. The study was funded by the National Institutes of Health and is the first of two parts, with a second study of the impact of the treatments on X-rays of the knees still pending.

6. None of the groups had many side effects, but it is worth remembering that medicines of the Celebrex type are under intense scrutiny because of the possible association with cardiovascular disease.

7. Many specialists use anti-inflammatory medicines together with glucosamine/chondroitin, at least at the beginning of a course of treatment. And that makes good sense.

8. What about the dosing of the supplements? Although those are the doses used by most people, they may not always be enough. In patients who weigh more than 200 pounds, many experts recommend 2000mg of glucosamine and 1600mg of chondroitin. It is also wise to take the supplement in divided doses with food. (I have sometimes also found it very useful to add Methylsulfonylmethane (MSM), 1000mg/day to the glucosamine and chondroitin, though there is little research to support it.)

None of these treatments can be given to pregnant women or nursing mothers.

One other small caveat, if you are having surgery make sure that you tell you surgeon if you are taking these supplements. Chondroitin has minor anticoagulant activity , and so may glucosamine.

And remember that the maintenance of joint health is not just a matter of taking some supplements. It is a judicious mixture of taking the right medication when needed, together with supplements, a healthy diet containing some omega-3 fatty acids and antioxidants, exercise, management of posture, particularly of the spine, and weight management. To say nothing of ensuring that joint problems are not being compounded by psychological and relationship problems, and disturbances in the subtle systems of the body.

Technorati tags: glucosamine, chondroitin, knee pain, arthritis

Marital Conflict and Hardening of the Arteries

The Bible contains at least three references to the undesirability of hardening one’s heart:

“And the Lord said unto Moses, When thou goest to return into Egypt, see that thou do all those wonders before Pharaoh, which I have put in thine hand: but I will harden his heart, that he shall not let the people go.” -- Exodus 4: 21

The BBC is carrying a report of a paper presented to the American Psychosomatic Society meeting in Denver Colorado. Researchers from the University of Utah have added another piece of evidence that marital conflict bad for you. In a previous posting I discussed the evidence that marital conflict can compromise the immune system. Now we have confirmation that marital conflict can also have an adverse effect on the coronary arteries, leading to hardening and calcification of these crucial blood vessels.

The researchers studied 150 married couples, with at least one partner in their sixties. None of the people in the study had ever been diagnosed with cardiovascular disease. Each couple was asked to pick a topic that caused disagreements in their marriage: topics included money, disagreements about in-laws, children, vacations and household chores. They were then videoed while they discussed the topic, and the videos were watched by psychology students who coded comments as friendly or hostile, submissive, or dominant or controlling. Cardiac scans were then done to look for signs of disease.

Wives who made the most hostile comments during the discussion had a greater degree of calcification of their coronary arteries, indicating the build up of plaque in these crucial arteries. It is not just the behavior of one person: the highest levels of calcification were found in women who behaved in a hostile and unfriendly way and who were interacting with husbands who were also hostile and unfriendly. Husbands who were more controlling, or who were more dominating, or whose wives were controlling or dominating, were also more likely to have more severe hardening of their arteries than other men.

These findings are in line with everything that I have been writing about looking at all the five dimensions or domains of a person: physical, psychological, social, subtle and spiritual. If you ask most people what they are doing to protect themselves against heart disease, they will probably talk about not smoking, taking exercise and healthy eating. That response is correct, but inadequate. Toxic relationships are just as dangerous, as are certain psychological response styles. For many years it was thought that the so-called “Type A personality,” was a risk factor for coronary artery disease, but research has shown that it is just two aspects of this response style that are responsible for the increased risk of coronary artery disease: anger and hostility.

Disagreements are bound to come up in any relationship, but the way that we communicate gives us a great opportunity to do something healthier for both people. In my book Healing, Meaning and Purpose I discuss the wonderful work of Riane Eisler, and I talk a lot about methods of transforming relationships from an unhealthy dominator model into a healthy partnership model.

Particularly if you are in a relationship, I urge you to take some action today to move towards greater heart health.

Technorati tags: marriage, heart disease, Riane Eisler, bad relationships

Acupuncture for Migraine

It was frustration at being unable to help so many people with migraine, that first lead me to begin my training in acupuncture. At the time I was working as a young research fellow in the main migraine clinic in London and I quickly discovered that acupuncture could be a wonderful treatment for many people suffering from this illness. I did my advanced training in acupuncture in China and even there – working with some of the best practitioners in the world - I confirmed my observation that acupuncture is no panacea. But it is a very helpful addition to our therapeutic toolbox.

There is a most interesting article in this week’s Lancet Neurology, that was also picked up by the BBC. The study came from Germany, and involved 960 patients who were randomly assigned to normal migraine medication treatment, traditional acupuncture, and sham – or fake – acupuncture. People in all three groups got better, and there was nothing to choose between the treatments in terms of efficacy.

So what does that mean? That acupuncture was in this trial as good as medications. But it adds to the growing literature that indicates that the precise placement of needles is not always as important as we used to think. But we also need to know exactly where the “sham” needling was done. During my years with the Research Council for Complementary Medicine and Prince Charles’ Foundation for Integrated Medicine, I saw a great many studies and proposals for studies in which the “sham” needles had actually been placed in highly active acupunctures points.

When I was training in China, most of my fellow students had trained in classical acupuncture in Europe, and some were outraged when they heard Chinese professors of acupuncture say that only some acupuncture points were always in the same place, and that it was not necessary to follow all the classical teachings. Some of the Europeans felt that the Chinese were destroying an ancient legacy. The Chinese simply responded by saying that the practice of acupuncture was being evolved on the basis of clinical observations and empirical research. It looks as if they were correct!

Technorati tag: acupuncture, migraine

Migraine and Hormones

Migraine (can be a frightfully difficult problem to treat. It is such an interesting puzzle, that the first book that I ever wrote was on migraine and other types of headache. Migraine is a great deal more than just a severe headache. It is can also be associated with neurological symptoms, and people often become exquisitely sensitive to light and sound. Additionally, at the beginning of the attack, the stomach stops working properly, which can make the absorption of medicines very difficult. Then comes the vomiting and sometimes diarrhea.

Although migraine is usually described as a “vascular” headache, there are strong reasons for thinking that it is more than that. People who suffer from the classic type of migraine often have spreading visual problems or partial visual loss, which goes on for between ten and sixty minutes. These visual problems are likely the result of a spreading wave of neurological depression spreading over the visual cortex at the back of the brain. The sensitivity to light and sound suggests that something is going wrong in the neurological systems that normally filter sensations, and the gastrointestinal problems indicate that something is going wrong in some of the control centers of the brain. There are some real oddities about migraine: it is exceptionally uncommon in people with diabetes; appears to be slightly more common in people who are left handed and is one of the only illnesses that tends to gets better as we get older.

There are a number of well-known triggers to migraine attacks. Though the scientific literature on triggers is not conclusive, here are some of the more common ones, that if avoided, have helped a great many people:

• Stress (either during stress, or when the pressure comes off)
• Cheese
• Chocolate
• Coffee
• Citrus fruit
• Red wine
• Changes in the weather (especially when there are a lot of positive ions in the atmosphere)
• Mono-sodium glutamate (MSG)

One of the best-known features of migraine is that it is considerably more common in women and that there is often a relationship between headaches and phases of the menstrual cycle, in particular during the pre-menstrual days. There have been many small studies that have indicated that oral contraceptives might increase the risk of suffering from migraine. A new study from Trondheim in Norway, has confirmed a link between oral contraceptive and migraine. The Nord-Trøndelag Health Study was done between 1995 and 1997. It included 14,353 pre-menopausal women, of whom 13,944 (97%) responded to questions regarding their use of contraceptives. There was a significant association between migrainous and non-migrainous headaches and the women’s reported use of estrogen-containing oral contraceptives. An important finding was that there was no relationship between the number of headaches and the amount of estrogen in the contraceptive pill.

There is one more thing to factor into the equation. Over the last two decades, there have been many reports of an association between certain types of migraine and cerebrovascular accidents (“strokes”). In the largest analysis of the data, that was published in the British Medical Journal, there was indeed a higher rate of strokes in women who had migraine and who were taking oral contraceptives. These studies included some of the older ones done in the days when the doses of hormones were higher than they are today, but when making decisions, it is important to be aware of this rare association.

An editorial in the British Medical Journal made these recommendations, with which I agree:

1. In an otherwise healthy young person, there is little cause for concern because the absolute risk of stroke is very low.

2. People with migraine who are on oral contraceptives have another reason for not smoking

3. Use low dose estrogen or progesterone only contraceptives in young women with migraine.

4. Although there isn’t much good evidence, many neurologists suggest stopping oral contraceptive pills if the migraine becomes more frequent or changes in character.

5. The risk of stroke gradually increases over age, particularly in smokers, so a slightly older smoking woman with migraine, should probably not be taking an oral contraceptive, unless it is the only option for her.

Technorati tags: migraines,hormones, headache, womens health

Acupuncture Without Needles

There are, in the United States, over 7 million people who are partially or completely disabled by back pain and another 40-50 million people who suffer from chronic recurrent headaches. Frustrated with my inability to help all my patients with conventional treatments, I have been using acupuncture since 1981. But about ten years ago I started using more acupressure, particularly since I could teach a lot of people to continue treating themselves.

Last month we saw evidence from a study using magnetoencephelography (MEG) scanning equipment that acupuncture reduces the activity of regions of the limbic system of the brain. MEG is a relatively new technology that measures the very faint magnetic fields that emanate from the head because of brain activity, instead of measuring electrical activity itself, which is a fairly blunt instrument. This reduced activity only occurred with deep needling, and when the patient experienced what is known as de qi. In Chinese medicine it is normally considered that the needle has not been correctly positioned until the patient and the practitioner both get the sensation of de qi. By contrast, superficial needling just caused activation of sensory areas of the cortex. Many doctors trained in needling techniques ignore the de qi experience, which is, I think, a mistake. When you are able to elicit it, the efficacy of acupuncture increases enormously.

Keep in mind what I have said before: just because acupuncture is associated with neurological changes, does not mean that they are responsible for the effects of acupuncture.

In this week’s British Medical Journal is an article from Taiwan, showing the effectiveness of acupressure in 129 patients with chronic low back pain. Like every study ever done, it is possible to pick some holes in this one, but overall it appears to be sound.

Now I am interested to see a press release about a form of needle-less therapy. I have written before about Thought Field Therapy (TFT), and the subject of the press release is a development of it called Emotional Freedom Technique, or EFT. While TFT uses tapping at specific points, together with humming, counting and eye movements, EFT is much simpler. It combines gentle fingertip tapping on key acupuncture points with focused thought. It is claimed to effectively reduce – and often permanently eliminating – chronic pain. According to its practitioners, EFT is more than 80-percent effective in treating headaches, back pain, cancer pain, arthritis, and pain from other conditions.

There is the rub: I could find no published research when I did a Medline search. That being said, I have reported elsewhere that I went to California to debunk TFT and became a convert after being treated by its inventor, Roger Callahan. There is a small amount of research on TFT that appears to confirm its effectiveness in some conditions, and I have certainly found it to be very helpful for many people.

Whether the claims of EFT will be born out remains to be seen. I have seen the techniques work, and I have to give credit where it is due. In exchange for your email address Gary Craig, who developed EFT, allows you to download a EFT manual from his website. You may also purchase DVDs from his site to learn more about this treatment modality. As always, I do not suggest using EFT or any other method in place of tried and tested treatments, but it may be a good adjunctive treatment for mild conditions.

In future message and in my newsletter I shall share some of the precise techniques that I have found useful, as well as ones that did not work out for me.

Technorati tags: Emotional Freedom Technique, headaches, acupuncture, acupressure, chronic pain

Sheryl, Lance and Kylie

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

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

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

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

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

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

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

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

Technorati Tags: Sheryl Crow, cancer screenings, breast cancer

Interactions Between Drugs, Herbs and Other Therapies

The first reports this morning on the condition of Vice President Cheney suggested that he had developed mild heart failure as a result of being given medications for arthritis. We do not yet know if this is accurate: as I am writing this, it is only four hours since he was admitted to the hospital.

Update: He has been released from the hospital -- See article and Article #2.

But the reports remind us of the importance of interactions between medications: fluid retention with many anti-inflammatory agents is extremely well known, and can become very important in somebody who already has cardiac problems. I have seen countless people run into this particular problem. Every year, very many require hospitalization as a result of drug side effects, and a high proportion of those are due to drug interactions. Most pharmacies have access to databases detailing drug interactions, and there are a number of excellent reference books on the subject, including a huge, and highly recommended volume produced as a companion to the Physician’s Desk Reference, better known as the PDR.

Yet it is often forgotten that herbs and supplements may also interact with prescription medications and with each other. Some years ago I was on television program and upset many of my friends in the holistic health movement when I pointed out that just because something is natural, does not necessarily mean it is safe. After all, arsenic, Deadly Nightshade and hurricanes are all natural!

There are several useful resources on the topic of drug/herb, herb/herb and drug/herb/supplement interactions:

The first is a website (Ibis Medical) that sells some very good software, but is also a treasure trove of useful information.

Second is a book that I have found useful, though no book can ever produce the “final word”: things change too rapidly, and it is a huge job to try and keep up with everything.  However,

Lininger and colleagues book, A-Z Guide to Drug-Herb-Vitamin Interactions. Roseville, California: Prima Publishing, 1999 -- seems to be a good start.

Finally, I would also direct you to a program that I wrote for health care professionals, but it contains a very large number of references and summaries of the different types of interactions that can happen with some of the more common herbs and supplements.

Technorati tags: Herbal medicines, Drug interactions

The New Frontier in Brain Control

In the 1970s, many of us in the scientific and medical fields started becoming very interested in the burgeoning field of biofeedback, in which we used monitoring devices to measure certain biological processes, like skin temperature an blood pressure, so that we could then teach people to gain some voluntary control over previously involuntary functions. I remember being particularly impressed that some people seemed to be able to gain some measure of control over epileptic seizures. Much of this interest grew out of some extraordinary experiments conducted at the Menninger Clinic in 1969, when it was still in Topeka, Kansas. An Indian Yogi named Swami Rama was shown to be able to voluntarily stop his heart for between 16.2 and 20.1 seconds, and subsequently others were shown to be able to control temperature, pain and bleeding.

In 1981, I had the privilege of setting up the first biofeedback system in the Department of Neurology at Charing Cross Hospital in London. I was quite astonished when a teenager working on the staff was, in less than 30 minutes, able to learn to increases the temperature of one hand more than three degrees Celsius (5 over in degrees Fahrenheit), compared with her other hand. We tried to use biofeedback in painful conditions and migraine, with some benefit. During the intervening years, there has been continuing interest in the whole field, but we have not seen any real reproducible breakthroughs.

But now, with the advent of new technology, things may be changing. There is an interesting report on the use of functional MRI scanning and chronic pain that was highlighted on the Nightly News with Brian Williams.

The report refers to work being done on chronic pain at Stanford University. When a person with chronic pain imagines the pain to be as bad as bad can be, specific regions of the brain become activated. Then by using an array of relaxation techniques, including breathing, muscle relaxation and thinking pleasant thoughts, the person can watch the over-activity of the brain gradually calm down as their pain lessens.

This is important work for several reasons:

It may well help people with chronic pain to use non-pharmacological approaches to the control of their pain, even if they do not have access to fancy high-tech scanners.

The work is pushing the frontier of what is possible in terms of controlling one’s own body.

It is an amazing confirmation of the teachings of many schools of teaching about health, from yoga and qigong, to Science of Mind.

It raises very interesting questions about who or what is actually controlling the pain: it gets us straight back to the whole question of where is the mind and is it the same as the brain. (The answer to that is NO: a subject for many more entries)

It is important not to lose sight of the fact that pain is often a lot more than aberrant firing of neurons or an imbalance in the some of the serotonin and norepinephrine systems of the brain. It can be brought on or exacerbated by psychological and social factors, and I have seen many people in extreme spiritual crisis, who then began to develop pain in various part of their bodies, yet had no overt signs of depression or of any other psychological or psychiatric problem.

Chronic pain often develops into a “habit,” or what I term a “pain cycle.” This may have both a physical substrate (abnormal firing in circuits in the thalamus of the brain), and a strong psychological component (pain becoming “learned”). Interrupting a pain cycle for even a few hours can often have long-term effects.

There may also be other non-pharmacological approaches that can help an individual. When dealing with chronic pain, it is also important to sort out the effects of medications. However appropriately used, some may have long term effects on the body/mind complex.

Technorati Tags: pain control, chronic pain,

Mapping the Genes of Disease

Many of us have been wondering if the so-called genetic revolution is ever going to bear fruit? When are we going to see some practical benefit from billions of dollars and the years of research by thousands of scientists?

On December 13th 2005, Dr. Francis Collins, the head of the National Institutes of Health’s Genetics Program, announced a bold $100 million pilot project to try to begin to unravel the genetic makeup of some common cancers. The plan is to try and speed the understanding of the diseases, so that new treatments may be developed.

We have already discovered numerous genes that can play a role in initiating cancer: in causing a cell to become malignant, to keep it growing and then to spread. Some tumors run in families, but many do not. And even in families with strong histories of cancer, it is by no means inevitable that an individual will develop the disease. As I have said many times, "biology is not destiny."

This new program is to be applauded: understanding the genetic component of cancer is an essential step toward better treatment, but it is equally important to recognize that an understanding of the biochemistry of the disease is but one aspect of understanding it. We also need to consider environmental and psychological factors, which all come into play. I have known some of the more militant geneticists who insist that the whole of human health and wellness will be comprehensible in terms of genes: why some people smoke all their lives and do not get lung cancer, while some non-smokers die of the disease in the forties. Or why some people have high-risk cancer genes, but that these are balanced by genes that endow them with a robust psyche that prevents them from succumbing to the disease.

I have had endless discussions with some, and although I respect their position, I think that they have only half of the answer. One of the big breakthroughs in recent years has been the understanding that genes in the brain do not so much determine your personality, but instead they give you a predisposition to how you react to changes in your environment. Genes are a lot less fixed than we used to be taught.

So this initiative is great, but don’t think that it is going to come up with all the answers.

For this we also need to be aware of the psychological, social, subtle and spiritual aspects of illness. For it is by considering all of these and understanding that illness has meaning and purpose for us, that we can achieve health and healing.

Technorati tags: genetics, cancer, healing and meaning

What's in Your Blood?

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

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

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

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

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

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

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

Technorati Tags: laboratory tests,  medical diagnosis, disease

Addiction, Learning and Genes

Many of us have been mourning the death of George Best at the age of just 59. Arguably one of the most skillful players ever to kick a soccer ball, he finally succumbed to the slow suicide of alcohol abuse. Yet in the midst of all the opinion pieces that have tried to unravel the reasons for his alcohol abuse, all seem to have missed out on something very important. It has been missed because so many people have become wedded to the simple notion that there is one cause for one problem.

We have all seen so many television programs on which people have tearfully recounted the traumas that have befallen them, and we are then told that their current problems, whether of addiction, or of an inability to trust, or of serial infidelity, are all the result of having learned these behaviors, usually in childhood. So a person becomes an alcoholic because they saw their father drinking. An awful lot of therapy, and self-help is based upon that faulty premise. Why is it faulty? Because these people also share the same genes, and because, try as we might, we cannot reduce the whole of human behavior to ONLY learning, or ONLY genes. Most of the genes in the brain do not so much force you into behaving in a certain way; they instead predispose you to the way that you will handle something in your immediate environment.

So in the case of George Best, virtually all the tributes have said that the poor man become an alcoholic because he could not deal with all the fame, adulation and pressure that accompanied becoming soccer’s first real superstar. And doubtless, those were factors. But there is something else: his mother also died of complications of alcoholism, when she was 58 years old. Her drinking was attributed to watching her son succeed and then crash and burn. Possibly. But it is far more likely that it happened because they were both genetically predisposed to alcoholism.

When we try to understand a problem like this, it is essential not just to focus on the obvious cause: stress, or trauma, but also to look at the physical predisposition to reacting to the stress or trauma. Some people can be assailed by the most dreadful events, and come out smiling, while others have their lives ruined. It is also essential to look at the social context. George Best was brought from Belfast to Manchester when he was only 15 years old, and went home after two days because he was so homesick. He was persuaded to return to Manchester, and everyone tried to create a surrogate family for him, but it was obviously very difficult for him. It is also important to know that alcohol and substance abuse can cause havoc in the subtle systems of the body. That is why, when we treat people suffering form these illnesses, we encourage them to do some work, like Qigong or Yoga, to strengthen their subtle systems. Finally there is often a spiritual component to these problems. It is no coincidence that “spirits” as in alcohol and “spirit” as in spirituality, come from the same Latin root, in recognition of the ancient worship of the god Bacchus. Bill Wilson and Bob Smith recognized this link when they founded Alcoholics Anonymous in 1935. Many people who have struggled with addictions have been able to achieve sobriety once they discover and acknowledge the spiritual aspect of their lives, or in some cases that their substance abuse has been a reaction to a deep spiritual hunger.

Newsweek has an excellent article on the progress being made in our understanding of the physical components of addiction. The article highlights the complexity of the illness and the extraordinarily high relapse rates of sufferers.

There is only one quibble that I have with the article, and that is that it perpetuates the idea that substances of abuse hijack the “reward systems” of the brain. The reason why this is not quite correct is that it is a bit of a misnomer to talk about “reward systems.” These days we prefer to talk about salience systems. What does this mean? If something pleasurable happens to you, then the dopamine and GABA systems of the brain are indeed stimulated. And it appears that in substance abusers this system does not respond properly. So that they self-medicate because they have a form of sensory deprivation in these systems and that is the only way to get the dopamine levels that they need. But we now learn that dopamine also rises in the self same regions of the brain in response to threat. So what this system is doing is deciding what is salient, or important in the environment, and then focusing on and responding to it. It is these salience systems that seem to be under some genetic control, and can predispose someone to becoming a substance abuser.

Technorati tags: George Best alcoholism energy medicine

The Rigors of Science: Finding Research You Can Trust

"All that glisters is not gold; Often have you heard that told."

This famous quotation from Shakespeare’s The Merchant of Venice, Scene 2, Act 7, is a suitable title for something that we need to discuss. I have been becoming more and more disturbed by the constant flow of advertisements and infomercials that attempt to buttress their claims by saying that "scientific studies have shown that…" When in reality the scientific support just isn’t there. How can such a thing happen?

The first thing is that reading scientific articles is a skill. Often when studies are being quoted, it is pretty obvious that some folk have only read the title or the abstract of the paper. Yet someone with experience of reading papers does not do that at all: they start with the sections of the paper describing the methodology. When I am looking at a research paper, whether it is on a new medicine, or on a study of intercessionary prayer, I will be armed with a pencil, notepad and calculator. Just because something has been published does not mean that it is true!

For more than five years I spent at least one day each week in some of the finest libraries in the world, trying to track down the original reports of odd or strange observations. I was doing this, not out of idle curiosity, but because I was determined to find out the truth behind many of the claims made in popular books and sometimes repeated in textbooks. What I found shocked me. Countless things repeated from one book or article to another had no basis. If you look hard enough you will find all sorts of reports that never stood the test of time.

In 1927 the Nobel Prize in Physiology or Medicine was awarded to the Austrian Neurologist and Psychiatrist Julius Wagner-Jauregg. The prize was awarded for his "treatment" of advanced cerebral syphilis by inoculating the patients with the organisms that cause malaria. It may be that the fever would have helped some of the symptoms, albeit transiently. But at what a cost! Over the years, good, hard working, compassionate health care providers around the world have done all sorts of things to patients that have turned out to do more harm than good.

Going back through my files, I have seen an astonishing number of reports in the media about scientific and medical breakthroughs that later turned out to be incorrect. That is okay: sometimes we advance by trial and error, but the trouble is that not everyone is aware that knowledge has advanced, and that yesterday’s ideas have been overtaken by new information. I was recently at a conference about a new form of treatment. A neurologist was explaining why it was safe and why certain side effects did not occur. The only trouble was that his explanation was twenty years out of date. He simply did not know that an old theory had been overturned by new research. He is a top-notch neurologist, but somehow the research had slipped in under his radar. It shows how difficult it is for even a professional to keep up with new information.

The problems of providing accurate information are being compounded in our Internet age, because of two issues. The first is premature reporting, and the second is the rapid promulgation of information, without checking. As an example of the perils of premature reporting, remember back to the fiasco during the 2000 U.S. Presidential election, when the constant desire of news programs to be first with the results, lead to some awful problems for the media.

There is an interesting example of the second problem. There is a beautiful quotation by Marianne Williamson, which begins with the words:

"We fear that we are inadequate, but our deepest fear is that we are powerful beyond measure. It is our light, not our darkness, that most frightens us."

If you Google it, you will find several hundred websites saying that this quotation was used by Nelson Mandela in his inaugural presidential address in 1994. Except that he did not. His office has confirmed that he never used the quotation. Yet the story continues to be spread. There are countless other examples.

These twin problems are constantly cropping up in reports of clinical trials. I recently had the privilege of contributing a brief article about the painstaking steps involved in getting to the truth about a new treatment. You can find it at: 

http://psychiatricresourceforum.blogs.com/

Taking single studies out of context, and not evaluating all the information in them, may sell a lot of supplements or books, but is just not fair to the public. It also makes it hard for us to trust information from the really high quality studies that are out there.

Technorati tags: Marianne Williamson  More blogs about Scientific rigor.

Some New Research on Acupuncture

Acupuncture has been in use for at least three thousand years and some evidence that our ancestors were first exploring this amazing form of healing seven thousand years ago. We now have several forms of acupuncture being practiced: Traditional Chinese, that operates on a system of yin and yang, of five elements, of Qi and channels along which it flows. It was this system that I studied in China almost fifteen years ago. There are many schools and styles of traditional acupuncture, and distinct forms of treatment have grown up in many parts of the Far East, including Japan, Korea and Vietnam. There is also something called "medical acupuncture," that ignores the principles and precepts of traditional Chinese medicine, and instead focuses on stimulating tender spots and using simple "recipes" for treating people. This stimulation might be with needles, lasers of electricity. Both types of acupuncture have been subjected to a great deal of research.

It may be that medical acupuncture works simply by stimulating the release of endorphins, or modulating some other chemical transmitters in the brain and spine. But the situation with traditional acupuncture is more complex. Every competent practitioner has seen clinical responses that cannot be explained on that basis alone. I have personally treated people paralyzed by strokes, and have seen them recover far more than we would ever expect in Western medicine. Other odd things too, like the cartilage being restored in people with arthritis. The frustrating thing is that none of the treatments works every time. But when it does, it can be amazing.

Recent studies that have been published in major journals have extended the list of conditions that may improve with acupuncture to include:

• Fibromyalgia
• The side effects of HIV medicines
• Arthritis of the knee
• Overactive bladder in women
• Itching associated with dialysis

On the other hand, I was surprised to see a large study of people with migraine, who failed to obtain much benefit. More than 20 years ago I reported good results using acupuncture for migraine at a conference in London. An esteemed colleague from Chicago immediately disagreed, saying that he had tried acupuncture and it had not worked for him. I think the message here is that it is not just the therapy, but also who is doing it.

Technorati tags:  acupuncture Energy medicine Qi

Lupus Question

I had a very nice letter from a gentleman who posed the following question, which I have slightly edited in order to maintain confidentiality:

"A friend of mine, a 36 year old female has been diagnosed with Lupus.Healing by her doctors is not an option. Treatment yes. That's not good enough. Any recommendations on how to heal it, who to see, what to read?"

It is always difficult for a health care practitioner to make precise recommendations about an individual whom they have not seen. That’s why we get so frustrated by some of the people who sell “cure alls” on their websites or infomercials. And when they are challenged say “but I’m not a doctor.” In which case, why are you giving advice??

Let me first say something about lupus. Systemic lupus erythematosus (SLE) is one of the so-called non-organ specific autoimmune diseases. What that means is that it can attack virtually any organ that has a DNA “command center.” And immune complexes can attack the skin, joints, kidneys, lymph nodes and so on. The autoimmune diseases show us how unwise it is for folk to advise us to “boost” our immune systems. SLE is an example of an overly boosted immune system. We should aim to balance our immune systems.

There is a lot of evidence that SLE has been becoming more common in recent years. Though we always have to be careful when we are told that an illness is becoming more common. That apparent increase may also be accounted for by other factors:

1. More physicians may be becoming familiar with the illness: I saw this happen some years ago after I published an account of the first British case of a very rare type of headache. Within months, several other cases had been found. In each case doctors wrote to me saying that they had been treating the sufferer without success for many years, but after my report, understood what the problem had been, and, following my rules, had cured their patients.
2. Diagnostic tests are becoming more sensitive, so more cases are turning up.
3. Specialists are very good at changing the diagnostic criteria for an illness, or the level at which treatment is required: the “when is a difference a disease?” issue. Skeptics are forever saying that the only reason for doing so is so that drug companies can sell more drugs. But that’s a real misunderstanding: it’s actually the other way round. We change criteria once we have evidence that treatment may do some good. A good example is blood pressure. The levels at which we recommend treatment have been falling in recent years, because we now know that even minor hypertension can increase the risk of heart disease. Or diabetes mellitus, where the diagnostic blood sugar levels have been reduced for this reason: even small elevations of blood glucose increase the chance of damage to some blood vessels. It’s not the glucose itself that’s the problem, but the consequences of an elevated glucose level.

The reason for this preamble is this: if SLE is becoming more common, it is difficult to explain using conventional medical models. Some years ago, there was a report that more than half of all sufferers carried an organism called mycoplasma, and that this might be the cause of the illness. Nobody was ever able to replicate that finding, so the idea of an infectious cause is firmly on the back burner.

So let’s look at the illness from the perspective of physical, psychological, social, subtle and spiritual factors, for all come into play in someone dealing with SLE. The key to treatment is to have a healing synergy between all of the interlinked aspects of our lives.

On the physical front, conventional medicines have a great deal to offer, but as you said, for treatment rather than cure. They are also used to help protect organs against damage. One potential reason for the increase in the prevalence of SLE, is that there is a close link between the amount of fat in the abdomen and the production of some classes of inflammatory mediators. So question one: does the sufferer have an excess of intra-abdominal fat? If yes, diet and much gentle exercise as the illness will allow. What kind of a diet? Balanced, and following the principles which I outlined in the final part of the Healing, Meaning and Purpose.

There have been countless reports of people with SLE and other forms of inflammatory arthritis, especially rheumatoid, having food sensitivities particularly to dairy or to alfalfa. The research base is weak, but it is always worth exploring. There has been growing interest in the use of DHEA and foods high in omega-3 fatty acids. Some people have also reported some benefit from Vitamins C and E, and selenium. The treating physician can help with doses. There are also some herbal and homeopathic remedies that may be helpful. I quite like The Arthritis Bible by Craig Weatherby and Leonid Gordin as an overview of some of these approaches.

Next is psychological. Sunlight, stress, fatigue and lack of sleep can all make the condition worse, and I would urge the person to follow some of the plans that I outline on the CDs and in the book. An awful lot of people suffer from illnesses like this as a consequence of psychological factors. So it is a really good idea to use the approaches to see if there are any emotional, cognitive or relationship problems which have triggered or are perpetuating the autoimmune process.

Next is the subtle systems that underlie the physical and psychological. These may need to be re-programmed using acupuncture, or Reiki, or Thought Field therapy, or even high potency homeopathic remedies.

Finally the spiritual. I cannot over-emphasize the importance of this in all our lives. Again, I have made some suggestions in the program. It would not be right for me to tell others what or how to practice, but keeping in touch with, and strengthening the contact with your spiritual essence provides a wellspring of healing energy and support.

There is a final point that I would like to make. Not all illnesses can be made to disappear, and sometimes our focus has to change to one of helping the individual understand, learn from and coexist with the illness.

Who to see? Any health care professional that will respect all five domains, and help the individual to help themselves.

Now, back to you: does that help?

+ Are there others out there who would like to share their experiences?

Technorati tags  Lupus  Thought Field Therapy  Healing