Wednesday, August 26, 2009

It's the Calories and Only the Calories. Duh!! How I'm Doing It.

I am 14 1/2 weeks into my diet and exactly halfway done. I am down 46 pounds, as of this morning, with my goal being 90 pounds, so 44 more to go. I posted this on my facebook page and 14 people asked me what I was doing to lose weight so I was stimulated to write this blog on diets and dieting from a skeptical point of view.

Multiple times each day we are bombarded with ads that promise the weight will melt away. When you look at the fine print they almost always say either when combined with an exercise program or even they have the nerve to say when combined with exercise and reducing intake...DUH. Rarely do the diet products work. If they did they would blow the competition out of the market and capture that whole market. The fact that they don't should tell you something.

Science is science and we cannot change the rules of biochemistry, chemistry, thermodynamics or physics. To burn one pound fat you need to burn 3500-4200 calories more then you take in this varies based upon efficiency of converting fat to energy). Now here is where it can get confusion but I will walk you through it. Go to this page and calculate your basal metabolic rate(the back ground rate at which you burn calories before you add your exercise). This can vary based upon lots of factors some individual metabolic rate, age weight. I recommend for this number use light activity ( i will explain in a moment), I was 2555 calories at my starting weight and 2300 at my current weight. You then add your exercise, here is a calculator:|hco|ns|calories|PPCA7FBa|c , When I started I burned 783 calories per day and now am burning 661 calories per day. The reason for the difference is that as you lose weight you are carrying less and therefore both your basal metabolic rate and your calories burned from the same exercise goes down. So at the beginning of my diet I was burning 3338 calories per day and now I am burning 2961 calories per day. This is one of the main reasons as you continue to diet you loss less weight for the same effort and the same calorie intake. So this is one of the reasons but there is evidence also that as you lose weight your abdominal fat cells release a hormone that slows your basal metabolic rate. This number is hard to get a grasp of.

Lets look at the intake side. I cut down to 1200-1500 calories per day lets say 1350. I will talk about how below. So if we subtract this from calories burned you get 1980 calories when I started my diet/exercise and 1610 calories now. That would mean I would lose about .55 pounds at the beginning and about .4 pounds now. Surprise surprise that is exactly what I am losing. If you lose less then you calculate you are either eating more then you think ( patients always say they are eating like a bird and I see in my mind a candor) or exercising less. This is straight math and science. It is so easy to delude yourself. I have not missed a day exercising and have only had 6 days I ate more then my 1200-1500 calories.

O.K. here it is my diet:
  1. Eliminate fried food. I have only had one fried item in 14 weeks.
  2. Eliminate fat containing condiments. No mayonnaise or salad dressing. I have not had any tuna/egg/potato salad and have only had plain balsamic vinegar on my salads. No deviled eggs.
  3. No bread and butter. I have had 3 pieces of bread and butter in 14 weeks
  4. No starch with meals. If you eat out ask for double veggies
  5. When I eat out I ask the waitstaff to only give me half the meal and pack up the rest before they give it to me so it is never on the plate.
  6. Eat as many raw fruits and veggies as you want. Some days I eat 2-3 pounds of melon.
  7. Subway is your friend . A half chicken breast sandwich without dressing (just vinegar) and no cheese is 320 calories for a six inch. Make sure you put on loads of veggies (so 3/4 of the thickness of the sandwich is veggies about 4 times what they normally put on the sandwich)
  • Have lots of low calorie snacks, here are some of mine:
  • Pickles 20 calories for large pickle
  • stick pretzels 5-8 calories each
  • slice of white meat turkey breast 20 calories with spicy mustard - no calories
  • slice of smoked salmon 40 calories
  • assorted nuts 100 calories for one ounce.
I do ask restaurants if they know the calories of the item I want to order. I do keep track in my mind to how many calories I'm eating each day.

Now the exercise. When I started I could only walk briskly for 15 minutes it took me 3 weeks to be able to walk a full hour. At that point I was walking about 2 miles in an hour. by week 5 I was walking 3.0 miles in 50 minutes. A few weeks ago I added stair climbing and now in 60-65 minutes I do 3.0 miles, 17 flights up and 17 flight down. So as you loss weight and sweat less you need to increase what you do. Now about safety. If you are over 40 or get winded when you exercise you need to be concerned. I recommend you get one of those pulse monitors at a pharmacy that you wear on a finger or your wrist. When you start to exercise monitor your pulse rate. Then do the calculation of 220 minus your age. So for me 164. Then take 80% of that so for me 131. If your pulse rate goes over the number for you stop exercising and see you physician before doing anymore exercise. If you have chest pain while exercising stop immediately and call 911.

The final way to be successful and also help others. Tell everyone, and I mean everyone (no exceptions) that you are dieting and exercising to lose weight. The more people you tell the stronger social contract you are making and the more likely you are to stay on your diet. Also this will have a positive effect to get more people to be successful in dieting them self. That is why I blog and post it on my facebook page.

Monday, August 24, 2009

Another One Bites The Dust: Creationist/Inteligent Design Proponents Major Gap Gets Filled.

One of the biggest Gaps that has been pointed to by Creationist/Intelligent Design advocates has been filled.

The evolution of life is one of the most beautiful things I have studied. I am a puzzle fan. I love to put together complex puzzles whether jigsaw, three dimensional, mathematical or geometric. I have had a fascination with puzzles my whole life. When I have trouble putting it together I don't say there has to be a magical step I sit down and try to solve the step or Gap that I'm having trouble with. I have also been a fan of evolution since I first read The Origin of the Species (celebrating it's 150 anniversary this past February) at the age of nine. When you think about the bits of information on life it is not the 2500 pieces of a complex jigsaw puzzle that gets me excited but the billions of facts that we have amassed from almost every field of science by 100's of thousands of scientists from every country in the world. These scientific disciplines include : biology, biochemistry, chemistry, physics, geology, paleontology, archeology, anthropology mathematics, genetics, mathematics and statistics, plus many more. The amazing thing is that these billions of independently arrived at facts all fit together with very few contradictions and these contradictions do not disprove the theory of evolution but just point out holes or as creationist call them gaps. When there are contradictions or gaps this points to areas were research needs to be done.

It is a thing of beauty how nicely this fits together. An example of this is the biologic clock. Scientist have determined the relative rate at which random changes in amino acids lead to substantive genetic changes. Scientist have found that these happen at relatively fixed periods based upon the number of generations. The beauty is that in any two species ( and ten's of thousands of pairs of animals have been looked at) when you look at the number of differences between them and then calculate when they should have a common ancestor it works out to a very high degree of accuracy. This method has been used by scientists to predict what geological layers these common ancestors will be found in and when they look they find the fossils in the right place. This is the most powerful proof of evolution. There are other similar spectacular predictive aspects to evolution and an amazing array of puzzle pieces, literally billions, that fit the puzzle precisely.

Well that Gap was how did Eukariotic(cells with a nucleus) cells develop from prokaryotic(cells without a nucleus) cells. Well in today's Nature researches using two different prokaryotic cells have seen one cell get engulfed by the other forming an endosymbiote or a cell living in harmony within another cell. Over time there is an exchange of genetic material and the engulfed cell becomes the nucleus for the other cell. Also this occurred in an oxygen poor environment. Photosynthesis could not occur until you had eukaryotic cells. This symbiosis led to terraforming of the entire earth to an oxygen rich environment that allowed life as we know it to evolve. In addition this fusion of two cells produced the mitochondria that is present in all eukaryotic cells.

I am sure that the Creationists will find excuses, such as, this happened in a glass dish and there were no glass dishes in the soup that was our early oceans. They may then say that there are now two gaps, one on each side of this finding. The point is that science predicted this result and it fits all of the mountain of data we have and contradicts none. Why would they want a God of the Gaps whose domain keeps getting cut into smaller and smaller pieces. If there is a God isn't it better to envision that that entity created a universe were life can form and not have to do mental gymnastics that try to fit God into gaps we just haven't filled with facts yet.

Tuesday, August 18, 2009

Neutriceutical Supplements Can Kill or Help You or Just Waste Your Money!

When was the last time your doctor asked you if you are taking any supplements? Most of you probably never. I have had patients die or loss a limb from over the counter supplement use.

A recent article from Mayo Clinic Health letter they clarified that over the counter supplements are not always safe. They pointed out that,
"St. John's wort: This supplement can greatly increase or decrease the potency of many medications and cause serious side effects. Patients who take antidepressants, anti-blood-clotting drugs, certain asthma drugs, immune-suppressing medications or steroids should probably avoid St. John's wort.
S-adenosylmethionine (SAM-e): This can cause serious side effects when taken with antidepressant medications that affect serotonin.
Garlic, ginseng, ginger and feverfew: Patients who take anti-clotting medications such as aspirin,
warfarin (Coumadin) and clopidogrel (Plavix) should avoid these supplements. They may increase the risk of bleeding. Supplements chondroitin and glucosamine also may interfere with warfarin.
Ginkgo: Ginkgo may increase the risk of bleeding in patients taking anti-clotting medications. Ginkgo can counteract the blood pressure-lowering benefits of thiazide diuretic drugs. It also can interfere with anti-seizure medications."

This is why every Doctor should ask you if you take any Vitamins, supplements or over the counter meds. Unfortunately very few do. You should tell them if they don't. You should also notify your doctor if you add one.

VITAMINS AND SUPPLEMENTS. There are multiple vitamins and supplements that are available on the market. Actually, there are over 3000 uniquely different vitamins and supplements. During a nine-month period of time, I actually reviewed all 3000 of these in order to determine which ones have actual evidence that is peer reviewed and are blinded studies to confirm that these work. I had a second level that they had studies that were not necessarily blinded. Out of the 3000 supplements, there were actually approximately 120 that had more than one study that showed some form of efficacy whether it was blinded or not blinded. 25 of these substances either had such dangerous side effects that I eliminated from my ultimate list or that were not available in the United States in a dosage that was comparable to the dosage used in the study. Either the dose available in the United States was multiple; one is a magnitude larger or multiple others with magnitude smaller. I have therefore distilled this down to a list of 95 substances that had a hint of some level of efficacy. I have to say that for all but a small few there still is not enough data to say they are efficacious or safe. I do not recommend, unless you are having a specific problem that you are taking the supplement for, that you do take the supplement just to prevent the problem. There is no evidence for any supplement whatsoever that they can prevent you from developing a problem except for the ones which I am going to be listing below. The following lists of supplements are ones which, if you fit into the category mentioned, you should be taking these.

1.MULTIVITAMINS – Many adults should be taking a multivitamin because of the highly processed foods that we eat. However, if you eat a balanced diet you most likely do not need one. Many people who do not eat this balanced diet (40% carbs, 30% calories from fat, 30% of calories from protein with 8-12 portions of fresh fruits and vegies per day) do not get the minimal requirements of the full range of multivitamins. I actually recommend taking the senior types of multivitamins and this is because you want to keep down on the total amount of the vitamin A that you have. Vitamin A at 5000 per day will accelerate osteoporosis and the regular multivitamins, usually at 5000, where the senior has 2500 of vitamin A. So if your multivitamin has more then 2500 of vitamin A take it every other day.

2.B-COMPLEX – B-complex has multiple advantages and multiple studies that show it has advantages. Among women who were of child bearing age, it obviously gives them the folic acid (folate) that they need to prevent birth defects. There have been many studies that have shown that Folate actually does prevent birth defects. I recommend taking a B-complex 100 which has 100 mg of each of the B vitamins and then also has folate appropriately dosed. There are many studies that show B-complex reduces Homocysteine and that leads to a decrease in cardiovascular risk.

3.OMEGA 3 FISH OILS – The recommended dose is 3 g per days which is usually three soft gel capsules. This is very important to prevent atherosclerosis and stroke. It has actually been shown in patients who take this versus controls who do not, that you decrease by between 10% and 25% the incidents of heart attacks and strokes in these patients.

4.LUTEIN 20-40 mg – This has been demonstrated to prevent development of macular degeneration, the most common cause of blindness in the entire population followed closely by diabetes-related blindness. It actually has also been shown to reverse the early blindness caused by macular degeneration (in the higher dose). This should be taken by everyone over the age of 45 and should essentially be taken for the rest of your life to prevent macular degenerative blindness.

5.BABY ASPIRIN – The use of aspirin to prevent heart attack and stroke has clearly been demonstrated. There is still some controversy as to whether everyone should be taking this or whether only people at high risk should be taking it. My read of the research studies and my read of the literature indicate that I feel all adults should be taking a baby aspirin. Now, the actual dose is if you take a chewable form of baby aspirin, you take one everyday. If you take an enteric-coated form of the baby aspirin, you take two every day and you try not to take any aspirin for any other cause. Obviously, if you do have an allergy to aspirin or have intolerance to aspirin, you should not use this and you should check with your physician.

6.CALCIUM – Most people and particularly women, postmenopausal, and patients who are obese with a BMI over 35 need to be taking calcium supplementation. Fat and the change in hormonal balance in old women both seem to be contributory factors to loss of calcium. I recommend between 1500 and 3000 mg of calcium per day. The calcium should definitely have vitamin D in it. Note here about vitamin D, 70% to 80% of all adults not living in the Sun Belt are vitamin D deficient. If you have any problem with calcium metabolism, have osteopenia or your have osteoporosis, I strongly recommend that your doctor obtain a vitamin D level on you because that is probably the biggest cause of osteoporosis (pathologically decreased calcium levels in bone) and osteopenia (mildly depleted calcium levels in the bone). Some people might need mega supplementation with vitamin D to get them back to a therapeutic level.

7.GLUCOSAMINE – There has been a lot of discussion about glucosamine and chondroitin and as individuals or as combinations. I have looked at multiple different studies and the bottom line is that these do work. They do decrease joint complications. Every orthopedic surgeon who does total hip or total knee replacement says that every adult should be on glucosamine on a daily basis, although there is no research evidence that supports this position. However, if you do have any jont problems at all, then this is definitely supported by the medical literature to be one of either medication or the combination. Now, let me talk about which of the three forms you should take. I personally recommend glucosamine for multiple reasons. The typical dosage would be 1500 mg per day. There has not been any study that shows that chondroitin has better or worse response than glucosamine and there is no study that shows that the combination of chondroitin and glucosamine increases the efficacy of either one.
8.VITAMIN D – 70% of all children in the USA are vitamin D deficit and 15% serriously. The rate for adults is even higher especially if you live north of the Mason-Dixon Line. This is a vitamin you cannot take too much of. I recommend 2000 per day in summer months and 3000 per day in winter months.

Monday, August 17, 2009

Breast Rescission: or How you can be Raped by your Health Insurance Company.

I heard the testimony given at a recent senate hearing on a policy called Rescission by Health Insurance Companies. The first testimony was by a woman who had her health insurance for many years having paid her premiums for many years and her Insurance company accepted these premiums. They had the option of not issuing insurance to her in the first place. However, they did issue a policy to her and went along happily taking her money and having very small payout, making lots of money off her. Then one day she comes down with invasive breast cancer involving both her breasts. Her doctor wanted her to have bilateral mastectomies ASAP. They were scheduled for the next week. In the next couple days before she went into the hospital she was told by her insurance company they were canceling her health insurance policy. They broke their explicit contract they had with her. They said she lied on her policy. It turns out she had been diagnosed by a Dermatologist with dermatitis. They claimed this was a precancerous condition and she had lied on her application when she had said she never had cancer or a precancerous lesion. The dermatologist spoke with the insurance company and told them this was acne and completely benign condition and not a pre-cancerous lesion. The insurance company still refused to re-establish her insurance. She could not afford to pay the 10's of thousands of dollars the hospital required to let her have the surgery. Finally after 5 or 6 months she got the decision reversed but she now had a much more advanced cancer that metastasized to her lymph nodes. She is much more likely to die because of this.

Blue Cross Blue Shield of California( not even the largest insurer in Ca.) rescinded 20,000 policy holders over a five year period. This can be extrapolated to hundreds of thousands losing their policy when most vulnerable. Leading to untold pain, suffering and deaths. But hey, they had to protect their profits. When asked if a client did not intentionally lie would they stop rescission all the Insurance CEO's said no they would not. however they would continue to take their clients money.

Half of the people in the United States between Medicare, Medicaid and Veterans services, are insured by the federal government. In 45 years not a single person has had their insurance rescinded by the feds.

This is criminal and should be banned. If there is no allowance for insurance companies to deny people insurance for pre-existing conditions then this will never happen. Rise up and revolt against rescission for you may be the next insured person that finds out on the doorstep of the hospital that you suddenly have no insurance, ending up either bankrupt or dead. RIP.

Tuesday, August 11, 2009

Medical Marijuana, I'm Skeptical About a Ban.

One week from today the State Board of Pharmacy of Iowa will hold a public hearing on medicinal use of marijuana. This is an issue that has vexed me for many years. As a physician who treats patients with severe pain syndromes I have seen many a patient get addicted to legal prescription pain medication while still suffering. This is because the legal pain medication is not the best medication to treat a pain syndrome called neuropathic pain. How I explain it to my patients is that narcotic pain medications will knock you out and as you're drifting off you are still experiencing pain. There are multiple studies which have documented good pain relief with smoking marijuana for neuropathic pain syndromes. There are many other proven uses for medical marijuana. However, our prejudices prevent us from using a proven remedy.

Marijuana has a history that is a mixture of myths and falsehoods that make it problematic for opponents to change their attitude. If you haven't seen the film 'Reefer Madness' you should. It is available free on the web if you look for it. This is the beginning of many of the myths. Regardless of how you feel about those myths, and I'm not going to debunk them in this piece, it is important to put marijuana in perspective to both legal over the counter products (alcohol and tobacco) and prescription products (Morphine, Vicodin, Methadone, and many others).

Marijuana has shown no adverse health effects when compared to either alcohol or tobacco. I think you all know the terrible health effects of both alcohol and tobacco. Alcohol and alcoholism causes 85,000 deaths each year from a combination of direct medical problems or traffic related deaths. Tobacco causes 430,000 deaths each year. In Britain, official government statistics listed five deaths from cannabis in the period 1993-1995. "Tetrahydrocannabinol is a very safe drug. Laboratory animals (rats, mice, dogs, monkeys) can tolerate doses about 5,000 times more than is required to produce a high." (from a British government report). When compared to tobacco there are equal or less effect on the lungs.

Alcohol and tobacco are two of the most addictive products in our society. Millions of people are addicted to both. There are questions about the true physical addiction potential of marijuana but most experts agree it is less then either of the two legal products. So if it is purely the addictive potential alcohol and tobacco should be banned and medical marijuana should be approved. Now the real question is, since we are only talking about medical marijuana, how addictive is it compared to prescription pain and anti-nausea medication. All the evidence points to marijuana is far less addictive then almost all prescription pain medication.

So let us get over our paranoia and allow our patients to have the best treatment available for certain conditions.

Monday, August 10, 2009

Senator Tom Harkin Supporter Rants on his Complementary and Alternative Med (CAM) Proposal

As a strong supporter of Senator Harkin I cannot standby and allow him to put forth an irresponsible,
irrational and dangerous proposal. His proposal is basically the Inclusion of alternative medicine workers in the bill's definition of "health care workforce". This at first seems innocuous, however the consequences will be harmful to our system of evidence based medicine (EBM) and patients health.
The consequences of this is that the government and private insurance companies will be required to pay alternative medicine workers as if they have medical decrees. In other words someone with no education, no certified program, practicing a form of medicine that has no evidence it works and is safe must be reimbursed at the same rate as someone practicing EBM. Currently 34 billion dollars is being spent and not reimbursed for complementary medical care and an additional 34 Billion on over the counter supplements, vitamins, homeopathic (equals water) and naturopathy products. None of them, either the therapies or the products have a single paper showing the work and are safe when compared to placebo.
Senator Harkin claims this will save money. I ask him to explain how......Oh wait..... Maybe the deathers are right Harkins secret plan is that patients who use CAM will not use EBM, that have 150 years and continuing research that shows they work. Instead they will forgo the expensive chemotherapy and go to the Naturopathy for extract of apricot pits (long since proven not to work). This will save money but cost livesI know the Senator is upset. He pushed through and set up the National Center for Complementary and Alternative Medicine, which the taxpayer has spent 100's of millions of dollars to prove that alternative medicine techniques work. However, not a single trial has shown that a CAM technique or product is effective. This has upset the Senator and he feels that the Institute has purposely designed the studies so they would fail. In a statement he said, “One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. It think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving.” Senator you loaded the institute with people that are true believers and even they cannot prove (or approve) the unprovable when the magnifier of science is applied. Science does not and should never be established to 'validate' or 'approve' something but like Justice, should be blindfolded to the results. As you said during 'W's administration, 'we need to bring rationality back to science instead of politics or ideology'. Well hold a mirror up to yourself who is putting ideology before science who is upset if science doesn't meet your pre-conceived expectation. Except the results of the nearly 1one billion dollars 'your' institute spent ( some would say wasted, not me) and realize that when some CAM modality is shown to work it is then mainstream medicine. I can give you many examples.
There are many reasons on separation of powers and states rule that this should not be done. It removes States rights to license and certify practitioners of medicine and to control the practice of medicine within their state.
So Senator please remove this provision from the bill.
n.b. I apologize the program formatted this weirdly and split words inappropriately.

Saturday, August 8, 2009

Dumb, Dumber and Deather

I don't know who is dumb or dumber the Republican/conservative machine(the deathers) or those in the public who believe them. There are few other issues more important for a patient to discuss with their physician then their living will and what their wishes are if and when they get close to death as we all will one day. Now when a physician who usually spends only 12-15 minutes per patient discusses these issues, which require much more time, they have to lie and claim that they are treating the patient for one of their conditions.
The more rational thing is to allow doctors to have open and frank discussions on these issues with their patients. Then allow the doctor to honestly bill for these services. To think that a legislation is going to get doctors to violate our Hippocratic Oath, how ridiculous. Patients need to understand what their choices are in a living will and their doctor needs to understand their end of life wishes. The proposed legislation simply allows physicians to have the appropriate time for this and to get fairly reimbursed for it. So don't be a dead head, a dumber or a dummy and work to get good health reform that covers everyone, has no pre-existing provisions and prevents Insurance Companies from denying care to those they insure.