Hard work is generally motivated by the reward of the end goal (bonus, promotion, recognition, etc). As I have alluded to repeatedly in these blog entries, remaining healthy is hard work (especially these days). The majority of us probably enjoy eating fatty, salty and sugary food while lying on the couch but unfortunately the end point for this lifestyle is likely far from a reward.
The last few weeks I have been the senior resident on an inpatient general medicine service. It is always an interesting transition from outpatient medicine to inpatient medicine since there are often different goals. The acuity of a hospitalized patient requires a standard work-up (usually featuring many tests and blood work, anyone who has been hospitalized can attest to this) and establishing a discharge plan once stabilized. The most common hospital admissions on our service are pneumonia secondary to underlying lung disease (COPD), heart failure, chest pain, and uncontrolled diabetes. One common link exists between the majority of these patients and their ailments, lifestyle choices have negatively effected their health (smoking/poor nutrition).
On rounds the last couple of days, I have become focused on the breakfast trays of our various patients, specifically the types of carbohydrates the hospital was feeding these people. My focus was heightened since earlier in the week I heard an outstanding lecture by a leading physician in the field of obesity, Dr. David Ludwig from Children's hospital in Boston. The lecture focused primarily on obesity, specifically in children, and the toxic environment that in large part has perpetuated this decline in health in this country and across the globe. A large focus of the talk was on the benefit of the glycemic index, something we have continued to hear a lot about through various diets (South beach, nutrisystem, etc.).
The Glycemic index was created in the early 1980's by Dr. David Jenkins in order to determine the best foods for diabetics. The concept was to determine a score for carbohydrates based on their effects on blood glucose. Foods that are digested quickly, and thus lead to a rapid elevation in blood glucose, are given a higher score on the glycemic index. The standard foods used as a reference number are 50 grams of pure glucose (sugar) or 50 grams of white bread and these equal a score of 100. While this tool was initially created with diabetics in mind, studies have indicated that this approach to nutrition may help prevent cardiovascular disease and cancer.
After attending this lecture, I was extremely distraught that our patients were basically consuming trays full of high glycemic index foods. There has been a large movement over the last decade to control patients blood sugar levels while they are in the hospital because studies have shown better overall outcomes (specifically post-surgery) so there are protocols to use insulin for inpatients. The rationale for elevated sugars in the hospital is many times explained by a stress response based on illness, steroids, etc. but a large component may be that we are feeding this captive audience products instead of food.
Food politics continues to be an uphill battle for the public in this fight against obesity. It is hard to know what is good for us and what is not. As I have said previously, read the labels and if you don't know what some of the ingredients are then don't eat it. Are Cheerios good for me since on the box the cereal is in a bowl depicted as a heart or if it says low fat is it good for me? I plan to start using the glycemic index as a guide for myself and my patients to provide more meaningful information on carbohydrate choices since they are unavoidable (nor do I want to avoid them, as stated by my one of my entry titles "To carbs, I love you).
Here are some examples:(low GI <55, medium GI 55-69, high GI 70 and above)
Bakery products: pound cake (54), croissant (67), Doughnut (76)
Beverages: apple juice (41), grapefruit juice (48), orange juice (52)
Breads: multi grain (48), rye bread (64), baguette (95)
Breakfast cereal: Muesli (56), puffed wheat (74), rice crispies (82), corn flakes
(83)
Here is a link with a complete list: http://www.lowglycemicdiet.com/gifoodlist.html
By the way, the breakfast trays for many of my pre-diabetics/diabetics in the hospital on the pre-ordered diabetic diet was comprised of corn flakes/rice crispies (both high GI), a white roll (also high GI), a banana and orange juice (also both high GI). There has been a movement, rightly so, to prevent hospital re admissions through better discharge planning and follow up with physicians. Nutrition is a necessary entity in these patients health that needs to be prioritized and taught while they are in the hospital.
I plan on finding a way to address this with the people making the food choices for the patients in the hospital. Let us all begin to think about the glycemic index when we are making food choices so we can maintain the right direction or reverse a potentially dangerous course.
Thank you all for reading. Please continue to provide feedback and pass this on to those who may find it useful. Until next time...
Thursday, May 13, 2010
Monday, April 26, 2010
More Than Beach Muscles
How many of us still lift weights in the gym? I personally gave up this activity years ago when I became more focused on a good cardiac workout. My focus has been to stay in shape and lose/avoid excess fat deposition. Also, I always feared that once I stopped lifting weights all the muscle I had developed would inevitably turn to fat so my thinking (stupid as it sounds) became not to build up excessive muscle. This rationale was completely wrong for me and for all of you based on a concept called sarcopenia.
Sarcopenia is the degenerative loss of skeletal muscle mass and strength that occurs with aging. It is associated with the frailty syndrome common in the elderly, however, this process unfortunately starts early. Beginning at around age 25, skeletal mass begins to diminish at 0.5-1% per year (or 10%/10 years). Based on these numbers by the time the average adult is age 70 their body is composed of comparatively more fat than muscle. This reversal in body composition predisposes people to falls secondary to poor balance and coordination. Additionally, skeletal muscle serves as a metabolic reservoir of proteins and metabolites so people with sarcopenia often have poorer outcomes from trauma and surgery.
With the loss of skeletal muscle there is a higher risk of osteoarthritis since the bones and joints carry more of the body weight. Osteoporosis (thinning of bones) is a condition that physicians have become more adept at screening and treating. Since bones and muscles work hand and hand the concept of sarcopenia is being realized as a crucial component to preventive health.
The goal, as always, is to prevent disease or at least prepare the body in the best way possible to do battle. Are those men and women at muscle beach in Venice or in the weight rooms at the gyms around the country "healthier" or fighting the aging process? In terms of preventing osteoarthritis (from wear and tear on joints/bones) and improving balance these people are likely doing their bodies a great service.
Much like many of you, I am sure, I was bored with running on a treadmill and lifting weights in the traditional manner. If you have been reading this blog since its creation you have learned about my new found love for spinning (a great cardiac workout). Now, I have been on a search for the anaerobic equivalent to spinning to build my overall muscle tone. Hopefully, with this information regarding skeletal muscle loss, sarcopenia, we will all be determined to prevent this condition's complications. Here are some tips that I have, and will, be using for anti-aging (as cliche as it sounds).
Resistance training appears crucial to prevent osteoporosis and osteoarthritis, probably in large part to building skeletal muscle. Balance exercises (standing from a seated position, walking on tip toes, etc.), floor exercises for building lower-body and abdominal strength (sit ups), and free weights are all beneficial to longevity. Personally, I have been doing half my cardiac work out then some strength training followed by completion of the cardiac exercise. This has kept the gym more "entertaining" since it includes much more variety.
Nutrition is another key component to maintaining a good balance of skeletal muscle to fat (it basically is always about diet and exercise). As we get older, our protein requirements will increase due to a reduction in the absorption. It is important to continue to maintain a well rounded diet high in fruits, vegetables and good sources of protein. Whey protein and the supplement glutamine are excellent sources of nutrition that are relatively easy to incorporate into everyday nutrition. I continue to have a protein shake (whey protein base) with a scoop of L-Glutamine every morning (I add a banana or other fruit for extra flavor).
Since it is baseball season I figured I should include some final comments on hormones, specifically steroids. As we age, our testosterone and growth hormones decline. With below baseline testosterone/growth hormone (matched against the same age group) it is difficult to build and maintain skeletal muscle. Blood tests are available, most routinely testosterone, which can be supplemented if deficiency exists. Testosterone may also play a role in cardiac health among other things (including the obvious).
Two links for you to check out:
1. www.cdc.gov/features/musclestrengthening (guide to various exercises, also can google resistance training and likely get some good exercise routines).
2. http://www.masssuit.com/ (some good friends of mine have developed and are selling this body suit specifically for resistance training). They have shown some incredible results.
My wish is that this knowledge is power. Now, time for us all to pump some iron. Your comments/questions on the entries is always encouraged. Please continue to share with your friends and families.
Sarcopenia is the degenerative loss of skeletal muscle mass and strength that occurs with aging. It is associated with the frailty syndrome common in the elderly, however, this process unfortunately starts early. Beginning at around age 25, skeletal mass begins to diminish at 0.5-1% per year (or 10%/10 years). Based on these numbers by the time the average adult is age 70 their body is composed of comparatively more fat than muscle. This reversal in body composition predisposes people to falls secondary to poor balance and coordination. Additionally, skeletal muscle serves as a metabolic reservoir of proteins and metabolites so people with sarcopenia often have poorer outcomes from trauma and surgery.
With the loss of skeletal muscle there is a higher risk of osteoarthritis since the bones and joints carry more of the body weight. Osteoporosis (thinning of bones) is a condition that physicians have become more adept at screening and treating. Since bones and muscles work hand and hand the concept of sarcopenia is being realized as a crucial component to preventive health.
The goal, as always, is to prevent disease or at least prepare the body in the best way possible to do battle. Are those men and women at muscle beach in Venice or in the weight rooms at the gyms around the country "healthier" or fighting the aging process? In terms of preventing osteoarthritis (from wear and tear on joints/bones) and improving balance these people are likely doing their bodies a great service.
Much like many of you, I am sure, I was bored with running on a treadmill and lifting weights in the traditional manner. If you have been reading this blog since its creation you have learned about my new found love for spinning (a great cardiac workout). Now, I have been on a search for the anaerobic equivalent to spinning to build my overall muscle tone. Hopefully, with this information regarding skeletal muscle loss, sarcopenia, we will all be determined to prevent this condition's complications. Here are some tips that I have, and will, be using for anti-aging (as cliche as it sounds).
Resistance training appears crucial to prevent osteoporosis and osteoarthritis, probably in large part to building skeletal muscle. Balance exercises (standing from a seated position, walking on tip toes, etc.), floor exercises for building lower-body and abdominal strength (sit ups), and free weights are all beneficial to longevity. Personally, I have been doing half my cardiac work out then some strength training followed by completion of the cardiac exercise. This has kept the gym more "entertaining" since it includes much more variety.
Nutrition is another key component to maintaining a good balance of skeletal muscle to fat (it basically is always about diet and exercise). As we get older, our protein requirements will increase due to a reduction in the absorption. It is important to continue to maintain a well rounded diet high in fruits, vegetables and good sources of protein. Whey protein and the supplement glutamine are excellent sources of nutrition that are relatively easy to incorporate into everyday nutrition. I continue to have a protein shake (whey protein base) with a scoop of L-Glutamine every morning (I add a banana or other fruit for extra flavor).
Since it is baseball season I figured I should include some final comments on hormones, specifically steroids. As we age, our testosterone and growth hormones decline. With below baseline testosterone/growth hormone (matched against the same age group) it is difficult to build and maintain skeletal muscle. Blood tests are available, most routinely testosterone, which can be supplemented if deficiency exists. Testosterone may also play a role in cardiac health among other things (including the obvious).
Two links for you to check out:
1. www.cdc.gov/features/musclestrengthening (guide to various exercises, also can google resistance training and likely get some good exercise routines).
2. http://www.masssuit.com/ (some good friends of mine have developed and are selling this body suit specifically for resistance training). They have shown some incredible results.
My wish is that this knowledge is power. Now, time for us all to pump some iron. Your comments/questions on the entries is always encouraged. Please continue to share with your friends and families.
Monday, April 12, 2010
To Carbs, I Love You!
Americans are blessed (or maybe cursed) with an exorbitant amount of food choices on a daily basis. These options are multiplying on a daily basis. The sensory overload of perusing the aisles of a Whole foods, Trader Joes, or any major supermarket is likely commonplace for most Americans. Even the task of trying to make a decision about a drink in a take out deli can be a 5 minute process since there are at least 5different tea options and even multiple different brands of bottled water (some prefer their water from the island of Fiji others from the glaciers). For this entry, I will focus on the ever growing land of carbohydrates.
We all have a love hate relationship with carbohydrates. The nutritionists (including scientists, dietitians, physicians, etc.) are in large part to blame since we haven't been able to make up our mind. The recent theory is that it doesn't have to be all or nothing when it comes to carbs, sorry Atkins (although we now have the modified Atkins). Our bodies favorite source of energy is sugar in the form of glucose, therefore, we should not deprive our physical beings but rather ensure it has the right fuel to run.
Carbs got a bad name when they became refined/processed. Refined carbohydrates, much like most processed foods (as we have discussed) provide minimal nutritious value. In an effort to right the wrong of completely abandoning carbohydrate love the food industry (with the help of the scientific community) has made whole grain/wheat options that can help us balance our diet while still enjoying great taste.
However, not all whole grain/wheat options are created equal. The majority of us have stared at the multiple shelves of breads in the supermarket only to pick the one that has the most visually appealing wrapping (that's why there is money in advertising). While good looks can be persuasive they will likely not help your health (at least in terms of bread).
What does whole grain mean exactly? Well, "whole" essentially means not refined/processed. Whole grains contain all the original components (bran, germ and endosperm) and thus all the B vitamins, magnesium, selenium, iron and fiber that they were meant to deliver. The act of processing these grains results in the loss of the bran and germ components which contain the majority of the nutrients. So it seems clear that in terms of overall nutrition that we should choose whole grain over white floured (refined) carbohydrates but which whole grain is the best since there are so many options?
Choose the whole grain option (pasta, bread, cereal) with the most fiber. Fiber is something that we all know is supposed to be healthy but for many the reasons are not clear. Basically, fiber is a carbohydrate that cannot be digested. There are two forms, insoluble and soluble (meaning it can be dissolved in water). The more fiber a whole grain has the slower it will be digested. A slower rate of digestion is beneficial since it controls our bodies blood sugar spikes (along with insulin) that can be detrimental for weight and moods. As we have discussed previously, we generally want to avoid rapid changes in blood sugar (that is why we should eat something every 3-4 hours). Soluble fiber also binds to fatty substances in the intestines and carries them out as waste which results in lowering our bad cholesterol (LDL). Insoluble fiber helps move food through the intestines, thus maintaining regularity and preventing constipation.
For those of us that want to strive for maximum health (and at least have regular bowel movements) the current guidelines for fiber intake are 20-30 grams/day for women and 30-40 grams/day for men (varies by age). Some sources of soluble fiber include oatmeal, nuts and seeds, blueberries, strawberries and pears. Sources of insoluble fiber include whole wheat bread, brown rice, barley and tomatoes.
In my initial stages of this new lifestyle I attempted to avoid carbs. I have learned that they can't be avoided, nor should they be, if eaten correctly. Some refined carbs every once and awhile is also recommended, no reason to make ourselves crazy. If you haven't tried brown rice, a whole wheat bagel or whole wheat pasta give it a shot since you may be pleasantly surprised.
Please continue to pass the blog onto friends and family. Always love the comments and when I see new people have signed up to follow the blog and receive email updates. Thanks for reading!
We all have a love hate relationship with carbohydrates. The nutritionists (including scientists, dietitians, physicians, etc.) are in large part to blame since we haven't been able to make up our mind. The recent theory is that it doesn't have to be all or nothing when it comes to carbs, sorry Atkins (although we now have the modified Atkins). Our bodies favorite source of energy is sugar in the form of glucose, therefore, we should not deprive our physical beings but rather ensure it has the right fuel to run.
Carbs got a bad name when they became refined/processed. Refined carbohydrates, much like most processed foods (as we have discussed) provide minimal nutritious value. In an effort to right the wrong of completely abandoning carbohydrate love the food industry (with the help of the scientific community) has made whole grain/wheat options that can help us balance our diet while still enjoying great taste.
However, not all whole grain/wheat options are created equal. The majority of us have stared at the multiple shelves of breads in the supermarket only to pick the one that has the most visually appealing wrapping (that's why there is money in advertising). While good looks can be persuasive they will likely not help your health (at least in terms of bread).
What does whole grain mean exactly? Well, "whole" essentially means not refined/processed. Whole grains contain all the original components (bran, germ and endosperm) and thus all the B vitamins, magnesium, selenium, iron and fiber that they were meant to deliver. The act of processing these grains results in the loss of the bran and germ components which contain the majority of the nutrients. So it seems clear that in terms of overall nutrition that we should choose whole grain over white floured (refined) carbohydrates but which whole grain is the best since there are so many options?
Choose the whole grain option (pasta, bread, cereal) with the most fiber. Fiber is something that we all know is supposed to be healthy but for many the reasons are not clear. Basically, fiber is a carbohydrate that cannot be digested. There are two forms, insoluble and soluble (meaning it can be dissolved in water). The more fiber a whole grain has the slower it will be digested. A slower rate of digestion is beneficial since it controls our bodies blood sugar spikes (along with insulin) that can be detrimental for weight and moods. As we have discussed previously, we generally want to avoid rapid changes in blood sugar (that is why we should eat something every 3-4 hours). Soluble fiber also binds to fatty substances in the intestines and carries them out as waste which results in lowering our bad cholesterol (LDL). Insoluble fiber helps move food through the intestines, thus maintaining regularity and preventing constipation.
For those of us that want to strive for maximum health (and at least have regular bowel movements) the current guidelines for fiber intake are 20-30 grams/day for women and 30-40 grams/day for men (varies by age). Some sources of soluble fiber include oatmeal, nuts and seeds, blueberries, strawberries and pears. Sources of insoluble fiber include whole wheat bread, brown rice, barley and tomatoes.
In my initial stages of this new lifestyle I attempted to avoid carbs. I have learned that they can't be avoided, nor should they be, if eaten correctly. Some refined carbs every once and awhile is also recommended, no reason to make ourselves crazy. If you haven't tried brown rice, a whole wheat bagel or whole wheat pasta give it a shot since you may be pleasantly surprised.
Please continue to pass the blog onto friends and family. Always love the comments and when I see new people have signed up to follow the blog and receive email updates. Thanks for reading!
Wednesday, March 31, 2010
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.
Please share your comments/questions below. You and your friends can still sign up as a follower of this blog and also subscribe by email for updates at the top right corner. Thanks for reading!
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.
Please share your comments/questions below. You and your friends can still sign up as a follower of this blog and also subscribe by email for updates at the top right corner. Thanks for reading!
Wednesday, March 24, 2010
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.
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.
Thursday, March 18, 2010
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.
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.
Monday, March 8, 2010
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.
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.
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