Pay for Performance

Generally, people will work harder or make more of an effort at a given task if it is in their best interest. That, I believe, is part of human nature. While maintaining a healthy lifestyle is in our best interest and that of our families by itself alone, sometimes we need a small (or large) extra push. Incentives come in many forms, however, money may create the most significant results since it enables additional positive reinforcements (e.g. a nice vacation, new clothes, etc).

Pay for performance is a concept that continues to be discussed as far as our U.S. health delivery system. The idea is that physicians and hospitals should be paid for providing quality care, not necessarily quantity. For example, physicians that demonstrate improved diabetes control in their patient population may receive a higher reimbursement, etc. As for hospitals, those that reduce inpatient associated infections or blood clots may receive additional compensation. The specifics regarding these types of incentives are still mostly under discussion on a national level but certain hospital systems have enacted this principal with success. Fundamentally, I have always thought this idea makes sense from a patient-physician-health care system perspective. We all want the same thing, in theory, which is for the people of this country to live healthy and long lives.

Since the insurance companies, and the employers who pay for benefits, want their customers/employees to remain healthy (for many reasons) a few pioneers have adopted a similar pay for performance health incentive. An article on March 28th in the NY times business section "Carrots, Sticks and Lower Premiums by Steve Lohr described the success of some of these programs including General Electric and Safeway. One of the models used for these companies is based on the Virgin formula which focuses on promoting physical activity. Personal physical activity is measured using pedometers, accelerometers or heart-rate monitors and the data is uploaded into an individual account on the web. One of the participants interviewed in the article stated that the financial reward of a $100 decrease/month in health insurance premiums for her and her husband if she maintained her activity goal was a huge selling point (50-80% of eligible employees participate). Currently, she has lost 40 pounds and intends to lose 14 more.

Executives in these companies believe that the "carrot works better than the stick." The article explains that there are no penalty payments, only encouragement to convert to healthy habits. Some companies are offering cash carrots to smokers, some paying up to $500 for smokers to quit. It is not hard to fathom that there may eventually be "cash carrots" for participants who give up sodas, excessive alcohol and fast food. Sean Forbes, president of Virgin Health-Miles stated, "We're trying to create the good-driver discount for health but one reason that's been so difficult is there's never been a way to really measure things before, but that is changing because of technology."

One of the take home points for me is that we need objective information regarding our health to have lasting effects. I recently started using a polar heart-rate monitor (thanks to my wife, Alexis) that tracks my heart rate and calories burned during exercise. I know I need to achieve about 85% of my maximum heart rate during exercise for beneficial results and now I can keep track. Also, it has been rewarding to see that in a 1 hour spin class I have burned over 500 calories. While these devices are helpful, they are not essential. Find objective ways to track your health such as weighing yourself once per week, have your cholesterol checked and then re-checked, monitor your blood pressure at home, etc.

Opponents of health care reform have made the argument that we all should be responsible for our own individual health on some level. Many have asked why they should pay for others health care if they don't take it upon themselves to remain healthy. Well, I hope with wellness education and objective data we can all reach our individual health goals so we can continue to live fulfilling and productive lives.

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Spring Forward

The phrase "Spring Forward" is one of my favorite phrases of the year. This phrase is classically related to advancing our clocks by one hour at the onset of spring, hence "spring forward." Other than the initial threat of a lost hour of sleep, this is generally a welcomed change for most people since it corresponds with the longer days of spring/summer. The concept of daylight savings was initiated during World War I with the intention of saving energy for war production. While it remains unclear whether daylight savings actually saves energy (in the form of electricity), I am always happy to welcome this time of year since it defines the end of the "fall back" period.

The Winter is probably a season of "fall back" not only in terms of changing our clocks backwards by an hour but also maybe a step back in our overall approach to health (probably more so in the cold climate regions). At least for me, I have always found it more difficult to make it to the gym and stay away from the comforts of sweets and alcohol (red wine/hot cider/chocolate, etc). The common New Year's resolution of losing weight/getting back in shape comes at the inopportune time of the heart of winter, football season, etc. Do people feel compelled to make these resolutions after the holiday season because of the excess weight/guilt related to all the parties? Maybe we can all start a new movement called the "Spring Forward Resolution."

The first entry of this blog titled "Knowledge is Power" describes my rationale for beginning this process. Basically, I felt I was not living by my own advice as a physician, I had accumulated excess weight that I wanted to lose and I was on the brink of a milestone birthday. The feelings related to these 3 things caused me to spring forward. Over the last few months I have regained my love for exercise through spinning (I now have the shoes/dri-fit shirts/heart monitor, etc.) and I have reached my previous level, if not best, level of fitness. Additionally, I am close to reaching my optimal weight. The challenges of changing my diet and getting back into shape continue to exist but have become much more of a way I choose to live my best life.

I propose that if you have not done so already please take the time to evaluate your individual health. The sun will continue to shine later in the day, the warmth will bathe our souls and the trees/flowers will be in full bloom for the next 6-7 months. This is an incredible time to have your spring forward moment. Walk home from work a few times per week, run in the park, find a nearby basketball/tennis court-the sky is the limit!

The opportunity to hear from patients, family and friends what spurred their lifestyle changes is always incredible. Most recently I have heard that a friend made drastic changes for his children, an older women wanted to feel better about herself, a middle aged man was scared about the onset of diabetes...

Daylight savings may not actually save energy but it may save lives! A reminder to learn your vitamin D level (maintenance 1000-2000 mg/day), have your cholesterol checked and get your daily dose of Omega 3 fatty acids.

We have previously discussed the effectiveness of positive reinforcement on diet and exercise, well, the same has been true for me writing this blog. The genuine praises and comments that reading these entries have made a difference in your lives is my main objective and means the world to me. All of this medical knowledge is useless without the opportunity to share it with others. I have loved using this avenue to spread health related wisdom. Thank you for reading and sharing! Please subscribe by email if you haven't done so and sign up as a follower of the blog at the top right corner of the page.

For the Love of Aging

With my birthday right around the corner I decided to write an entry that focuses on the aging process. For the majority of us the period around our birthday is a time of reflection and analysis of our lives. Everyone hopes that their future is bright and good health is a huge component of this wish.

For all of us that have spent time around women going through peri-menopause and menopause, or for those that have lived it, it is apparent that this is a difficult process. The initiation of hot flashes, mood swings, and weight gain are likely not pleasant symptoms of one of life's natural courses. For years, we all heard about hormone replacement therapy (HRT) with the replacement of estrogen that is lost during menopause. However, it has been revealed that HRT is a potentially dangerous therapy since it has been correlated with increased breast cancer, blood clots and heart disease in women. For the purpose of this blog I will discuss potential new therapies on the horizon to manage the weight gain that many women struggle with while getting older. Men, you are not in the clear from this whole estrogen as we age phenomenon and I will get to that soon so keep reading.

The hypothalamus is the region of the brain that controls energy regulation, thirst, hunger, etc. Remember that from high school science? Well, it is no surprise that this area of the brain is the focus of ongoing research to combat the battles of menopause. Research by Deborah Clegg at the University of Cincinnati demonstrated that is ESTROGEN receptors in the hypothalamic region of the brain that control energy regulation and body fat distribution. When these ESTROGEN receptors were destroyed in animals they began to eat more food, burn less energy and gain more weight. Therefore, it is reasonable to draw the parallel to the decrease in estrogen levels during menopause.

Estrogen receptors called ER-alpha are now being investigated in the ventromedial region of the hypothalamus (also involved in temperature regulation). Since we now realize the potential adverse reactions of supplementing estrogen in all receptors of the body researchers are hoping to determine a way to only stimulate the receptors in the hypothalamus. By achieving this goal, essentially the hypothalamus will still function at its pre-menopausal level. Thereby, helping to alleviate some of these difficult symptoms that women face during menopause. While many men experience these struggles of menopause vicariously through our partners we are not free from our own fight against hormonal changes with aging.

Men have the benefit of testosterone, at least while we are young. Testosterone helps to maintain muscle and aids metabolism. However, just as women have decreasing levels of estrogen as they age, testosterone levels also diminish in men. Interestingly, it is not just about this drop in testosterone but the mismatch with estrogen in older men that may cause problems. Yes, men have estrogen. At younger ages the testosterone levels are peaking so estrogen levels are lower in comparison.

The main active estrogen metabolite is estradiol. The main source of estradiol in men is aromatization, which is the conversion of testosterone to estrogen. The issue is that despite decreased production of testosterone from the adrenal glands and testes as men age the aromatization process continues which can result in a higher estrogen to testosterone ratio. One of the reasons that aromatase activity is persistent with age is an increase in belly fat. Estradiol levels correlate with subcutaneous abdominal fat. Some of the symptoms of excess estrogen in men include development of breasts, fatigue, having too much abdominal weight, loss of muscle mass and emotional disturbances. Research has always demonstrated (some conflicting) that excess estrogen in men may increase the incidence of stroke, heart attacks and prostate cancer. As always, I want to inform you all of possible solutions that exist to these problems.

As we have previously discussed, abdominal fat (visceral) is never protective. So first things first, try to lose the mid-section abdominal fat via methods that we have discussed in previous entries.

Estradiol is not the only culprit that may cause health problems. Specific estrogen metabolites may also initiate and promote hormone related cancers. Daily consumption of cruciferous vegetables such as broccoli, cauliflower and brussel sprouts convert dangerous estrogen metabolites to safer ones (always good to eat your greens). For those that actively avoid eating these types of green vegetables there are supplements that contain similar constituents to aid this process called indole-3-carbinol and sulphoraphane.

Just as there is estrogen hormone replacement for women there is also testosterone replacement for men in the form of an absorbable cream. Testosterone levels can be checked in the blood and if the level is much lower than the age matched average supplementation can be used. However, a follow up blood test within 30-45 days is required for dosing and also to ensure that the PSA (prostate specific antigen) has not increased. Estradiol levels can also be checked in the blood but this is definitely not routinely done by most doctors (as far as I know).

There are also now medications that are aromatase inhibitors (e.g. Arimidex) that lower the level of estrogen produced from testosterone. These medications are used primarily in breast cancer patients and I don't feel there is enough research out there yet to support using them in aging men.

Life is about balance and these hormones are no different. Too much estrogen can lead to heart attacks, stroke, etc. and too little can lead to osteoporosis and weight gain. It seems like there are some exciting research studies on therapeutics currently being done in this area so maybe aging will become even more pleasant in the future.

As always, comments and questions are appreciated. Don't forget to recommend the blog to your friends and family.

The Gut Brain

The brain is the organ responsible for our higher functioning in day to day life. The nervous system is obviously a highly complex unit that requires the coordination of many components. In order for the stimuli that we encounter to be incorporated into a functional signal we must ABSORB and translate that information into a language we can use. Well, the brain is not the only organ that functions in this manner. In fact, the body has another nervous system called the enteric nervous system. This is basically the brain of our guts.

In basic biology, physiology, etc. we all learn about this so called gut brain. This is essentially a system of neurons (long wires that transmit signals through chemicals). This system is the basis for digestion but also makes use of more than 30neurotransmitters. A few of these familiar neurotransmitters are serotonin and dopamine which are also found in the central nervous system.

These principles are basic facts that provide the background for the rest of this topic. I have been fortunate to spend time in the office of an integrative internist/cardiologist over the last few months and have learned a tremendous amount about how the function, or malfunction, of our digestive system plays a huge role in our daily lives.

The "leaky gut" is a theory that I had never heard much about in my traditional medicine training but I think it will start getting more attention. The hypothesis is that dysfunction in the barrier that lines the intestinal cells of the gastrointestinal tract creates a leaky gut (hyperpermeable) which can cause a widespread array of consequences. A few of the hypothesized consequences include irritable bowel syndrome, type 1 diabetes, asthma, and autism.

The million dollar question is, why would my gut be leaky? Possible infectious etiologies include viruses, bacteria and parasites (basically anything possible). Infectious sources appear to disrupt the tight junctions of the cells that form the intestinal barrier, specifically by altering the cytoskeleton. Many of us may not remember having this kind of infection but most of us have had some kind of "stomach bug." Also, the NY times editorial by Thomas Friedman this weekend illustrated the excessive amount of antibiotics used in our food supply due to the set-up for infections based on factory farming (another reason to consider eating organic when possible).

Alcohol consumption also induces a leaky gut which results in an inflammatory cascade (cytokines) and reactive oxygen species that can result in chronic diseases such as cancer. The majority of alcohol is yeast which I have learned is probably one of the largest causes for this phenomenon. Many of us may actually be allergic to the foods we eat in some way or another which successfully feeds this process. Symptoms such as blotting, gas, loose stools, etc. may indicate a yeast problem or food allergy such as gluten.

The common end point for most of these factors is that the gut is not able to absorb and function at its optimal level because of flattened villi. The main results that the doctor I was working with focused on were Vitamin D deficiency, low levels of serotonin and the resulting high epinephrine/low dopamine/low GABA. We have previously discussed the widespread Vitamin D deficiency in our society today and this may be a common reason. We simply are not able to absorb the Vitamin D that we are consuming in our diet.

Additionally, as I mentioned above, serotonin (the happy hormone) is produced by the intestines. If the intestines are not functioning at a high level, then clearly serotonin deficiency may exist. The result of low serotonin is a reflex elevation in epinephrine which may produce an anxiety state at baseline. A low level of dopamine may make it difficult to concentrate and a low GABA level will likely influence our sleep patterns. These are symptoms that many of us have and it would be nice to find out not only why, but also how we can improve them through lifestyle changes.

The current problem is that not many doctors are aware of this phenomenon and if they are not many evaluate for food allergies. The intestinal permeability blood test evaluates for up to 120 different possible food allergies (IgG mediated). Upon receiving the results, the doctor I was working with would go over it with the patient and advise the necessary dietary changes. The initial blood test also included a Vitamin D level (almost always deficient) and Homocysteine level (measures the amount of green vegetables consumed, also a marker for inflammation). Most doctors will screen for celiac disease (gluten allergy) so if you have any of these symptoms you should request this blood test.

The second million dollar question, how can I make my gut less leaky? Probiotics have hit the mainstream in foods such as yogurt (Activa) and are certainly available in most supplement shops. While the verdict had previously been out on the use of probiotics I think there may be more benefit then harm. Look for probiotics with colony forming units (CFU's) in the billions and that contain Lactobacillus GG and/or Bacillus Coagulans. I have started putting a 1/4 teaspoon in my protein shake in the morning. Also supplement your GI tract with L-glutamine which has both anti-inflammatory and anti-oxidative properties. Lastly, if your Vitamin D level is not increasing with oral Vitamin D (2000 units/day) then you may need to supplement with Vitamin D drops.

While this is certainly not a concept that we hear discussed frequently the results I witnessed in patients were simply astounding. The patients stated that their moods and energy levels were improved and the majority of them lost a significant amount of weight. One women in her late 60's had lost about 100 pounds in 1 year just by diet and people had thought she had undergone bariatric surgery.

I hope you all are continuing to learn from this blog. I am trying to provide a mix of more traditional information as well as things that we may find new and interesting. Thank you for reading and please pass the blog onto your friends and family. As always, you can subscribe by email at the top right corner.