The Problem With The Gun Control Debate: Assessing The Evidence Is Key.

A Responsible Vote on Question 3: Medical Marijuana Will be A Major Mess.

It seems to me that the debate over the legalization of medical marijuana (question 3 on tomorrows’ ballot) can be broken down pretty simply.  Individuals who want to smoke marijuana are for it and those that don’t are against it.  While personal preferences are a part of life, when it comes to good medicine and sensible health policy it is important to consider things on a broader level.   When we examine the science and the implications there can be no doubt: We should not legalize medical marijuana. 

 Putting medical decision making into the hands of the general public is dangerous practice.   Science and not the whims of people should govern health policy and medicine.  I am not neccesarily opposed to medical marijuana, just this particular question.  As  a physician if science could convince me that medical marijuana (a) had clear medical benefits that outweighed harms (b) improved people’s overall functioning and productivity for specific well defined medical problems with known mechanisms of disease and, most importantly of all (c) would not lead to gross abuse of the distribution system and become a vehicle for contributing to individuals substance abuse than I would be for this bill.  The facts are that the medical science is not there to support this bill and none of that above mentioned criteria exists.  This way this question is written is dangerous. We don't know if it would make people worse or better and until we do we should avoid using it as medicine. 

I have no personal vendetta against people who want to smoke marijuana recreationally.  As a physician I think substance abuse of any kind is bad for the soul and I empathize with people who suffer from addictions that alter brain chemistry of any kind be it alcohol, drugs, tobacco, prescription drugs or food.   Marijuana is no different.  

As I see it the problem with medical marijuana use is three fold.  First and foremost the health effects of marijuana are unknown.  There are some concerning signs but nobody really knows what repeated marijuana use does to brains, lungs, and reproductive systems of human beings over the long haul. Many studies have shown adverse effects on these organ systems and others in animals and humans but more science needs to be done.  Dose for dose, marijuana has much more tar and carcinogens than tobacco does but people tend to use less marijuana than tobacco.  How does this effect the development of disease?  No one knows.

There are hundreds of chemicals in a marijuana plant and I would bet that some of these have some beneficial physiologic effects.  I am in favor of researching these chemicals, harvesting their benefits in a safe and controlled way and making medicines from them (after all how could they be worse than many treatments we currently use, especially opiates??????).  But many of the hundreds of poorly studied chemicals in marijuana are harmful as well.  At the present time based on the scarcely available science to me it seems that smoking marijuana to get a small physiologic or symptomatic benefit in light of these potential harms is similar to eating a McDonald’s cheeseburger to getting the health benefits from the lettuce and tomatoes.  

The second problem (and the major problem for me) is that the medical system has proven that it is woefully incapable of responsibly managing the dispersal of potentially addictive substances.  Based on the available medical evidence physicians should rarely if ever be writing for medicines like Ativan, Percocet, Dilaudid or Ambien.  These medicines have very narrow therapeutic windows and are dangerous, addictive and not beneficial in the long term.  Yet doctors continue to irresponsibly dispense them every day in mass.    The opiate epidemic alone is evidence enough that physicians struggle to dispense potentially dangerous substances judiciously.  Forget addictive substances: physicians can’t even get antibiotic prescriptions right!

If Medical marijuana passes be ready for rampant abuse of the system.  If this question was written to give marijuana to people with terminal diseases and prognosis of less than 6 months to live than I also probably would be for it, but thats not what will happen.  Medical Marijuana will end up being given mostly to people with chronic diseases.  An entire legion of people with nebulous and poorly defined medical conditions like fibromyalgia, bipolar disease, ADHD, chronic pain, depression, cyclic vomiting syndrome and many, many more “photo shop” diseases will be waiting in line for medical marijuana because sufferers have co-morbid substance abuse problems and want to get stoned.  Some will convince well meaning but poorly informed physicians they have one of these poorly defined conditions and get prescriptions. And irresponsible or weak minded doctors who don’t care that much about patients  will simply oblige them.   People with certain chronic diseases will even be allowed to grow pot in their back yards.
  
A third problem pertains to the larger social implication of marijuana use.    Consider the example of tobacco.  Tobacco use was widespread for hundreds of years before we discovered not only the adverse personal health consequences but also the larger social cost.  If we legalize marijuana we will normalize it.     When we normalize it much like tobacco we will then see the individual and social unintended consequences of a substance with hundreds of chemicals of unknown physiologic effect. 

I took an oath to do no harm and I take that serious. To me that means that everything I do for a patient should come only after rigorously controlled studies of the harms and the benefits of a medicine are conducted under scientific conditions.  Clearly no such process has happened for marijuana.

The fact is that there is scarce medical evidence showing any long term clinical efficacy of medical marijuana to improve outcomes, enhance quality of life or improve functioning for distinct medical problems.  We can’t say for sure these individuals will be better off 5, 10 or 20 years down the road if we give them marijuana because we don’t know.  Many people like getting stoned, but dealing drugs is not good medicine.  And just like the millions of opiate addicts medicine has created, guess who will be paying to support these people, their addiction and their basic needs?   Our already strained system that we all contribute too.  

I think the current system works fine.  Marijuana is illegal but no one I know who smokes marijuana seems to have a hard time getting it or gets in much trouble for it.  It remains somewhat on the fringe of society and people can smoke it recreationally as they wish with relative ease.  If it's not broke don't fix it.

Opiates, which admittedly are more addictive than marijuana, have become a scourge on our civilization propagated by modern medicine.  Legalizing medical marijuana will result in manifold abuse of the system and create a similar mess.  It will ultimately serve to further worsen our ever burgeoning problem with addiction.  It will be proven to be a clinically ineffective treatment that may have some palliative effect at the expense of worsening substance abuse problems and hindering functioning and productivity in our most physically and psychologically vulnerable populations.  It will lead to health consequences.  

In closing I offer a hypothetical question:  If a drug company came out with a drug that had hundreds of chemicals in it (at least 400 at last count) with unknown short or long term physiologic effects, had not been studied in any clinical trails or under any real scientific conditions, had in some studies been linked to cancer but in other studies not been, could offer little information on the benefits or harms, was known to be physically and psychologically addictive and might offer some short term slight palliative effects at the expense of making users less productive and functional would any voter in their right mind vote yes on a question asking doctors to use it medically?  This is exactly the question we are faced with tomorrow.    
I get that some people like to smoke marijuana recreationally and I don’t judge them for it, but a responsible vote is a No vote on Question 3.   

The Difference Between Good Carbs and Bad Carbs Is Key To Health

The most important public health issue in American health is in your kitchen cabinet and not your medicine cabinet. Pills and surgery may be the back bone of modern medicine in most Americans minds but for the majority of the population health and wellness will be intimately tied with lifestyle. Among the most critical components of lifestyle medicine is how the body metabolizes a class of food known as carbohydrate.

A study released today in the Journal of American Medicine touts the importance of not only how much we eat but the composition of what we eat. The study suggested that when it comes to maintaining weight loss among diets with the same amount of calories, calories higher in healthy carbohydrates may offer an advantage over diets filled with unhealthy carbohydrate

“From a metabolic perspective, all calories are not alike,” said study senior author Dr. David Ludwig,“The quality of the calories going in affects the quantity of the calories going out.”

In order to understand not only this study but arguably the most important public health issue in the history of mankind ( namely the American epidemic of obesity and cardiovascular disease) Americans need to understand how the body breaks down carbohydrate and the closely related concept of the glycemic index.

For the vast majority of Americans, the biological mechanisms that provide the foundation for the glycemic index will be far more important to the quality and quantity of their life than anything else. And it turns out the choices we make on our dinner plate are a major factor in this process.

Carbohydrates are a type of nutrient found heavily in the human diet. They are basically rings of carbon, hydrogen and oxygen and human beings can break down the chemical bonds in the rings and harvest energy from them to be used. Carbohydrates or “carbs” are found in breads, grains, pasta, rice and “starches.”

The bottom line is that there are some kinds of carbohydrate that are very healthy for human beings to consume and others that are literally poisonous to consume. What distinguishes a healthy carb from an unhealthy carb comes down to not so much the chemical structure of the carbohydrate itself but how the carbohydrate is packaged.

When carbs are packaged in a way that makes them easy to digest they are harmful to human physiology, whereas carbs that are physically harder to digest are beneficial. The reason for this is that when the body absorbs carbohydrate the pancreas makes a hormone called “Insulin.” Insulin helps deliver carbs to your cells so the carbs can be used as energy. But insulin is a hormone and it has many, many other functions on other organ systems besides delivering carbohydrates to cells. For example, Insulin is made during times when food is available and therefore a second task of the hormone besides delivering carbohydrate to cells for energy is to promote cell growth and replication. Insulin also exerts direct effects on the kidneys, the liver, the brain, the endocrine system and most importantly of all the inside walls of your blood vessels.

Your body will secrete insulin based on how quickly you are able to absorb the carbohydrate you eat. Some carbs like simple sugars found in soda or candy are easy to digest and they cause a spike or surge in insulin. Other carbs that are wrapped in bulky fiber molecules are more difficult to digest and they cause a slower, more moderate release in insulin. High insulin spikes brought on by easy to digest carbs for energy are quite harmful to multiple organ systems because of the many other effects of insulin.

Further complicating this is that if a person repeatedly eats carbohydrate that makes their insulin spike high eventually the muscle and tissue cells that use carbohydrate for energy will grow less sensitive to insulin and become “insulin resistant”. This means your pancreas will have to make more and more insulin every time to break down the same amount of bad carbohydrate.

But here is the real catch: just because in terms of energy metabolism a person becomes insulin resistant does not mean that insulin’s other effects in the body will also become desensitized. Remember we said before that helping your body breakdown sugar was only one of insulin’s many effects in the body. So your kidneys, liver, brain and blood vessels will still be quite sensitive to the effects of insulin as you make more and more of it to facilitate energy metabolism in insulin resistant cells . Furthermore, insulin will still have the same effects of promoting cell growth and differentiation throughout the body.

This is what I mean when I say some kinds of carbohydrates are poisonous. These easy to digest carbohydrates cause a natural and necessary hormone made by your body (insulin) to spike and reach toxic and damaging levels to critical organ systems, especially the inside walls of blood vessels. Your body is not meant to eat food like this day in, day out and in excess and this process is causing more disease than anything else in the western world.

The distinction between “good carbs” and “bad carbs” can be made by a scale known as the glycemic index. The glycemic index is a measure of your bodies insulin response to certain foods. Foods that are processed, loaded with refined sugar and “white” foods tend to be easy to digest, causing dangerously high insulin spikes and therefore high on the glycemic index. Foods that are natural, high in soluble fiber and “brown” (brown breads, sweet potatoes, brown rice) tend to keep insulin levels more moderate, be low glycemic and therefore extremely healthy.

The danger is that American diet is based on foods that are high glycemic. The typical western diet is based on foods that cause Americans insulin levels to spike up and down like a yo-yo all day, with deleterious effects on the body and the mind (insulin spikes lead to counter regulatory surges in several important stress hormones like adrenaline). Even many foods that are considered healthier options are in fact high glycemic and therefore unhealthy.

The top two causes of death in America now are cardiovascular disease and cancer. Insulin is a hormone that promotes cell growth and differentiation and is likely oncogenic in levels seen in repeated insulin spikes in unhealthy eaters. Insulin also damages to inside of blood vessel walls and is likely pro-inflammatory and contributing to the process of plaque build up in arteries that is the basis of all vascular disease (strokes, heart attacks, erectile dysfunction).

When it comes to nutrition it is important for Americans to make the distinction between obesity and insulin dys-regulation. The two are closely related, but regardless of body weight the way the body breaks down carbohydrate via insulin is a critical factor in the development of many diseases and especially cardiovascular disease. As cardiovascular disease continues to rise to epic levels in the United States (we crack open about 400,000 chests per year) one of the best and most profound solutions is the type of carbohydrate we serve on our dinner plates.

Understanding The Most Important Concept In Medicine Today

The most important public health issue in American health is in your kitchen cabinet and not your medicine cabinet.  Pills and surgery may be the back bone of modern medicine in most Americans minds but for the majority of the population health and wellness will be intimately tied with lifestyle.  Among the most critical components of lifestyle medicine is how the body metabolizes a class of food known as carbohydrate.

A study released today in the Journal of American Medicine touts the importance of not only how much we eat but the composition of what we eat. The study suggested that when it comes to maintaining weight loss among diets with the same amount of calories, calories higher in healthy carbohydrates may offer an advantage over  diets filled with unhealthy carbohydrate

        

“From a metabolic perspective, all calories are not alike,” said study senior author Dr. David Ludwig,“The quality of the calories going in affects the quantity of the calories going out.”

In order to understand not only this study but arguably the most important public health issue in the history of mankind ( namely the American epidemic of obesity and cardiovascular disease) Americans need to understand how the body breaks down carbohydrate and the closely related concept of the glycemic index.  

 For the vast majority of Americans, the biological mechanisms that provide the foundation for the glycemic index will be far more important to the quality and quantity of their life than anything else.     And it turns out the choices we make on our dinner plate are a major factor in this process.

Carbohydrates are a type of nutrient found heavily in the human diet.  They are basically rings of carbon, hydrogen and oxygen and human beings can break down the chemical bonds in the rings and harvest energy from them to be used.  Carbohydrates or “carbs” are found in breads, grains, pasta, rice and “starches.”

The bottom line is that there are some kinds of carbohydrate that are very healthy for human beings to consume and others that are literally poisonous to consume.   What distinguishes a healthy carb from an unhealthy carb comes down to not so much the chemical structure of the carbohydrate itself but how the carbohydrate is packaged.

When carbs are packaged in a way that makes them easy to digest they are harmful to human physiology, whereas carbs that are physically harder to digest are beneficial.  The reason for this is that when the body absorbs carbohydrate the pancreas makes a hormone called “Insulin.”  Insulin helps deliver carbs to your cells so the carbs can be used as energy.   But insulin is a hormone and it has many, many other functions on other organ systems besides delivering carbohydrates to cells.  For example, Insulin is made during times when food is available and therefore a second task of the hormone besides delivering carbohydrate to cells for energy is to promote cell growth and replication.  Insulin also  exerts direct effects on the kidneys, the liver, the brain, the endocrine system and most importantly of all the inside walls of your blood vessels.

Your body will secrete insulin based on how quickly you are able to absorb the carbohydrate you eat.  Some carbs like simple sugars found in soda or candy are easy to digest and they cause a spike or surge in insulin.   Other carbs that are wrapped in bulky fiber molecules are more difficult to digest and they cause a slower, more moderate release in insulin.   High insulin spikes brought on by easy to digest carbs for energy are quite harmful to multiple organ systems because of the many other effects of insulin.  

Further complicating this is that if a person repeatedly eats carbohydrate that makes their insulin spike high eventually the muscle and tissue cells that use carbohydrate for energy will grow less sensitive to insulin and become “insulin resistant”.  This means your pancreas will have to make more and more insulin every time to break down the same amount of bad carbohydrate.

But here is the real catch:  just because in terms of energy metabolism a person becomes insulin resistant does not mean that insulin’s other effects in the body will also become desensitized.   Remember we said before that helping your body breakdown sugar was only one of insulin’s many effects in the body.  So your kidneys, liver, brain and blood vessels will still be quite sensitive to the effects of insulin as you make more and more of it to facilitate energy metabolism in insulin resistant cells .  Furthermore, insulin will still have the same effects of promoting cell growth and differentiation throughout the body.

This is what I mean when I say some kinds of carbohydrates are poisonous.   These easy to digest carbohydrates cause a natural and necessary hormone made by your body (insulin) to spike and reach toxic and damaging levels to critical organ systems, especially the inside walls of blood vessels.  Your body is not meant to eat food like this day in, day out and in excess and this process is causing more disease than anything else in the western world.

The distinction between “good carbs” and “bad carbs” can be made by a scale known as the glycemic index.  The glycemic index is a measure of your bodies insulin response to certain foods.  Foods that are processed, loaded with refined sugar and “white” foods tend to be easy to digest, causing dangerously high insulin spikes and therefore high on the glycemic index.   Foods that are natural, high in soluble fiber and “brown” (brown breads, sweet potatoes, brown rice) tend to keep insulin levels more moderate, be low glycemic and therefore extremely healthy.

The danger is that American diet is based on foods that are high glycemic.  The typical western diet is based on foods that cause Americans insulin levels to spike up and down like a yo-yo all day, with deleterious effects on the body and the mind (insulin spikes lead to counter regulatory surges in several important stress hormones like adrenaline).  Even many foods that are considered healthier options are in fact high glycemic and therefore unhealthy.

The top two causes of death in America now are cardiovascular disease and cancer.  Insulin is a hormone that promotes cell growth and differentiation and is likely oncogenic in levels seen in repeated insulin spikes in unhealthy eaters.  Insulin also damages to inside of blood vessel walls and is likely pro-inflammatory and contributing to the process of plaque build up in arteries that is the basis of all vascular disease (strokes, heart attacks, erectile dysfunction).

When it comes to nutrition it is important for Americans to make the distinction between obesity and insulin dys-regulation.   The two are closely related, but regardless of body weight the way the body breaks down carbohydrate via insulin is a critical factor in the development of many diseases and especially cardiovascular disease.  As cardiovascular disease continues to rise to epic levels in  the United States (we crack open about 400,000 chests per year) one of the best and most profound solutions is the type of carbohydrate we serve on our dinner plates.

Understanding The Most Important Concept In Medicine Today

The most important public health issue in American health is in your kitchen cabinet and not your medicine cabinet.  Pills and surgery may be the back bone of modern medicine in most Americans minds but for the majority of the population health and wellness will be intimately tied with lifestyle.  Among the most critical components of lifestyle medicine is how the body metabolizes a class of food known as carbohydrate.

A study released today in the Journal of American Medicine touts the importance of not only how much we eat but the composition of what we eat. The study suggested that when it comes to maintaining weight loss among diets with the same amount of calories, calories higher in healthy carbohydrates may offer an advantage over  diets filled with unhealthy carbohydrate

“From a metabolic perspective, all calories are not alike,” said study senior author Dr. David Ludwig,“The quality of the calories going in affects the quantity of the calories going out.”

In order to understand not only this study but arguably the most important public health issue in the history of mankind ( namely the American epidemic of obesity and cardiovascular disease) Americans need to understand how the body breaks down carbohydrate and the closely related concept of the glycemic index.  

 For the vast majority of Americans, the biological mechanisms that provide the foundation for the glycemic index will be far more important to the quality and quantity of their life than anything else.     And it turns out the choices we make on our dinner plate are a major factor in this process.

Carbohydrates are a type of nutrient found heavily in the human diet.  They are basically rings of carbon, hydrogen and oxygen and human beings can break down the chemical bonds in the rings and harvest energy from them to be used.  Carbohydrates or “carbs” are found in breads, grains, pasta, rice and “starches.”

The bottom line is that there are some kinds of carbohydrate that are very healthy for human beings to consume and others that are literally poisonous to consume.   What distinguishes a healthy carb from an unhealthy carb comes down to not so much the chemical structure of the carbohydrate itself but how the carbohydrate is packaged.

When carbs are packaged in a way that makes them easy to digest they are harmful to human physiology, whereas carbs that are physically harder to digest are beneficial.  The reason for this is that when the body absorbs carbohydrate the pancreas makes a hormone called “Insulin.”  Insulin helps deliver carbs to your cells so the carbs can be used as energy.   But insulin is a hormone and it has many, many other functions on other organ systems besides delivering carbohydrates to cells.  For example, Insulin is made during times when food is available and therefore a second task of the hormone besides delivering carbohydrate to cells for energy is to promote cell growth and replication.  Insulin also  exerts direct effects on the kidneys, the liver, the brain, the endocrine system and most importantly of all the inside walls of your blood vessels.

Your body will secrete insulin based on how quickly you are able to absorb the carbohydrate you eat.  Some carbs like simple sugars found in soda or candy are easy to digest and they cause a spike or surge in insulin.   Other carbs that are wrapped in bulky fiber molecules are more difficult to digest and they cause a slower, more moderate release in insulin.   High insulin spikes brought on by easy to digest carbs for energy are quite harmful to multiple organ systems because of the many other effects of insulin.  


Further complicating this is that if a person repeatedly eats carbohydrate that makes their insulin spike high eventually the muscle and tissue cells that use carbohydrate for energy will grow less sensitive to insulin and become “insulin resistant”.  This means your pancreas will have to make more and more insulin every time to break down the same amount of bad carbohydrate.

But here is the real catch:  just because in terms of energy metabolism a person becomes insulin resistant does not mean that insulin’s other effects in the body will also become desensitized.   Remember we said before that helping your body breakdown sugar was only one of insulin’s many effects in the body.  So your kidneys, liver, brain and blood vessels will still be quite sensitive to the effects of insulin as you make more and more of it to facilitate energy metabolism in insulin resistant cells .  Furthermore, insulin will still have the same effects of promoting cell growth and differentiation throughout the body.

This is what I mean when I say some kinds of carbohydrates are poisonous.   These easy to digest carbohydrates cause a natural and necessary hormone made by your body (insulin) to spike and reach toxic and damaging levels to critical organ systems, especially the inside walls of blood vessels.  Your body is not meant to eat food like this day in, day out and in excess and this process is causing more disease than anything else in the western world.

The distinction between “good carbs” and “bad carbs” can be made by a scale known as the glycemic index.  The glycemic index is a measure of your bodies insulin response to certain foods.  Foods that are processed, loaded with refined sugar and “white” foods tend to be easy to digest, causing dangerously high insulin spikes and therefore high on the glycemic index.   Foods that are natural, high in soluble fiber and “brown” (brown breads, sweet potatoes, brown rice) tend to keep insulin levels more moderate, be low glycemic and therefore extremely healthy.

The danger is that American diet is based on foods that are high glycemic.  The typical western diet is based on foods that cause Americans insulin levels to spike up and down like a yo-yo all day, with deleterious effects on the body and the mind (insulin spikes lead to counter regulatory surges in several important stress hormones like adrenaline).  Even many foods that are considered healthier options are in fact high glycemic and therefore unhealthy.

The top two causes of death in America now are cardiovascular disease and cancer.  Insulin is a hormone that promotes cell growth and differentiation and is likely oncogenic in levels seen in repeated insulin spikes in unhealthy eaters.  Insulin also damages to inside of blood vessel walls and is likely pro-inflammatory and contributing to the process of plaque build up in arteries that is the basis of all vascular disease (strokes, heart attacks, erectile dysfunction).


When it comes to nutrition it is important for Americans to make the distinction between obesity and insulin dys-regulation.   The two are closely related, but regardless of body weight the way the body breaks down carbohydrate via insulin is a critical factor in the development of many diseases and especially cardiovascular disease.  As cardiovascular disease continues to rise to epic levels in  the United States (we crack open about 400,000 chests per year) one of the best and most profound solutions is the type of carbohydrate we serve on our dinner plates.

Spending More Time Explaining and Less Time Examining.......

Somewhere, somehow my physical diagnosis instructor from my second year of medical school is cringing.

Today I saw a patient for a history and physical who was in good health.  He had no complaints and reported no medical problems, but when I asked what medicines he took and he answered me with 3 commonly used anti-hypertensive medicines I knew there was more to his story. 

Turns out this gentleman’s blood pressure was almost 170 as he sat and rested in my clinic.  Further questioning revealed him to be a pack-per-day smoker who while not obese rarely gets meaningful aerobic exercise.  Combine his poorly managed high blood pressure, his extensive smoking history, his male gender, his sedentary lifestyle and his age over 45 and he has 5 major risk factors for cardiovascular disease and is at relatively high risk for a cardiovascular event over the next ten years.

Faced with the constraints of time and a roster of waiting patients I had to make a tough choice.  My training told me to do an extensive physical exam in this situation but my common sense dictated a different approach.  Instead of spending a large chunk of our time together looking in his ears, percussing his abdomen and making him grab my fingers to test his strength I spent our time together talking about cardiovascular risk factors, nutrition, smoking cessation and exercise.

Turns out this smart gentleman hadn’t the first clue about cardiovascular health.  He had no understanding that our body metabolizes different carbohydrates different ways (the critical concept for all American’s to understand known as the “glycemic index”), knew little about the difference between saturated and unsaturated fats or the protective benefits of omega-3’s and had only a rudimentary understanding of the importance of smoking cessation and just why those nasty little fumes are so bad for his blood vessels. I explained all that and more to him today and I told him the truth that he was shaping up to be a high risk cardiovascular case as he aged and why I think he probably already had an element of sub clinical vascular disease right now. 

While perhaps I did not get a look at the cerumen building up in this guy’s ears I do think I did the right thing for my patient. That physical diagnosis instructor may not have approved but by spending my limited time talking to this patient instead of doing a bunch of pointless poking and prodding I laid the groundwork for this patient to have a greater understanding of his health and empower himself if he so chooses.  I did do some essentials like listen to his heart and lungs on exam and a few other basic things. 

He had been to dozens of doctors in his life but according to him no one had ever explained these critical concepts to him.  These are the people who five-ten years from now will be showing up in our clinics and emergency rooms with strokes, diabetes and heart attacks.   This particular gentleman was so appreciative that I took the time to tell him all this today and even paid me a great compliment at the end of our visit. 

Seau Tragedy Brings Light To Root Causes of America's Struggle With Mental Health

The recent tragedy of Junior Seau has the issues of suicide and depression at the forefront of American minds this week.  When someone who was as athletic, vibrant and famous as Seau takes his own life it garners attention.

While attention shifts to these issues this week in light of this tragedy,  America’s problem with mental health issues and especially depression and anxiety are severe and chronic and go beyond this one unfortunate incident.   America is a nation ravaged by mental health problems and there are some logical contributing factors.

Last week when a medical journal published an article on biochemical markers found more commonly in patients with a diagnosis of depression it received wide spread coverage in the mainstream media.   The idea that we could biochemically quantify depression appeals to the reductionist and materialist cultural paradigm about depression that mainstream psychiatry and drug companies propagate and make billions off of.

However this research was not as impressive as it seemed on the surface.  The research was done on an extremely small number of patients and none of the markers were really strongly predictive of depression but rather were just associated with it. The directionality of this association and many biasing factors that may have polluted it are unknown.

Furthermore, to proponents of mind body medicine, the concept that there are physiological elements of chronic stress associated with various psychological states is not news at all.

Research like this is useful to help quantify the psycho-physiology of various mood states.  However 40 years of research into depression has yielded little concrete information into the genetic or biochemical basis of mental health problems.

The real yield for fixing America’s mental health crisis lies in our social and physical environments.
There are 6 environmental reasons that America is struggling with mental health problems more than it needs to:

 Nutrition- Insulin dysregulation appears to have strong neurobehavioral effects.  Recently I learned something about insulin resistance that I had never learned before in 6 plus years of clinical training as a physician.  When your body eats a sugar load and your insulin spikes in response there is a subsequent cascade of stress hormones, including Adrenaline, released.  Indeed Insulin appears to have a profound effect on neuro-behavior in both human and animal studies.  The American diet remains loaded with processed foods, high glycemic carbohydrate and high fructose corn syrup that make surges in blood sugar and therefore insulin a regular part of most American’s physiology.  This is a big part of our nation’s struggles with mental health problems and mood in both adults in children.


Sedentary Lifestyle-  Nothing, not a pill, surgery, treatment or anything else, has as profound an affect on mood, stress relief, concentration, sleep and peace of mind as exercise does.  For hundreds of thousands of years human beings evolved living physically active lifestyles.  We are made to move and be active.   The evolution of post modern industrial life style of the past few generations is a relatively new experiment.   It creates a set of conditions that dictate a biological unnatural level of docility and this has created a whole host of physical and psychological manifestations.  America’s mental health crisis ties closely into it’s sedentary ways.

Social Environments-  Man evolved in social environments in which intimate relationships and community were critical.  We are social beings, and some research even validates the impact of empathetic and social relationships on our physiology.  One of the great tragedies is that in the last 50 years America has suffered an erosion of community and family.  Cultural conditions have favored the breakdown of extended family and community as a significant role in most people’s lives.  This is in stark contrast to the conditions that man lived in naturally for thousands of years, and one of the reasons why America struggles with mental health.  People need support.

Environmental Toxins-  The Neurobehavioral effect of many toxins and pollutants has been well established in animal and human studies.  As a physician studying environmental health at Harvard School of Public Health I can say definitively that we know dangerously little about the physiologic and neurobehavioral effects of many common pollutants.  What we do know is frightening and we currently release billions of pounds of heavy metals and pollution to the environment each year and this undoubtedly is contributing to mental health problems.

 Cultural Values-  Americans have no problem smoking,drinking or drugging themselves into a stupor, but there is a cultural value in place that discourages or stigmatizes emotional honesty.  The result is that many are raised in conditions where they don’t learn how to deal with or express natural feeling states and this ultimately affects mood and health profoundly.

Sleep-  Americans don’t sleep long enough or well enough and studies show this can profoundly affect mood.


On a population wide level our nation is struggling with mental health and behavior because of the food we eat and the way we live.   Pfizer or Merck will never make a billion dollars extolling the virtues of a natural lifestyle. I don’t believe many people are meant to be depressed (there may be a few), but some unfortunate people are just more vulnerable to how the abnormalities of the American lifestyle in addition to their life experiences (especially in childhood) interact with the genome.

The Seau tragedy is a horrible reminder of our nation’s ongoing struggles with mental health issues.  Like many with depression  Seau appears to have been a good and well loved person who was stricken  by a horrible illness.  Hopefully one good that will come from it is increased awareness of the root causes to prevent similar things from happening in the future.

Key Deficiency in Medical Education System Costs Us All

A friend of mine recently finally got from their doctor something they had been seeking for almost 8 years with little results: an actual diagnosis.

This person began having symptoms of tingling in their fingers and pain in their shoulder almost a decade ago.  During this time they worked as a nurse which is a labor intensive job that requires frequent use of arms and hands and regular heavy lifting.  As time passed her symptoms got worse and worse and she experienced little relief.

Over those 8 years this person visited their primary care physician for this problem about a dozen times, got 3 MRI studies, 2 Electromyograms (a test where doctors test nerve functioning by running electrical currents down nerves), saw 2 neurologists, 3 occupational medicine doctors and 3 orthopedic doctors.  She had several work related shoulder injuries and missed several weeks of work for shoulder related problems during the decade.  The cost of all this, which we all contribute to paying, is exorbitant.

This process continued with little relief until recently she saw a shoulder specialist who at long last diagnosed her with a disease of her shoulder called “Thoracic Outlet Syndrome.”  Thoracic outlet syndrome occurs when nerves and blood vessels exiting the shoulder are compressed causing symptoms of pain, tingling and occasionally vascular insufficiency in the shoulder, neck and arm.

The good news is that almost all patients respond to the specific kind of physical therapy appropriate for this problem and experience an improvement in functioning and symptoms.  For those that don’t respond effective surgical and non surgical treatments (like botox or steroid shots) exist that can lead to improvement.

The bad news for my friend and all of us is that it took the health care system 8 years, dozens of office visits, a half dozen expensive tests (MRI tests cost approximately $2000 a scan and EMG’s $1000-$1500), numerous specialist referrals and several weeks of work disability to reach the diagnosis.  The cost of the system’s failure to diagnosis this injury could easily be estimated to be several tens of thousands of dollars.  The cost for mistakes like this are absorbed by us all.

When one individual fails we can look to that responsible person and chalk the mistake up to deficiency or chance, but when several extremely competent and well trained individuals all fail I believe we need to look at the system that they function in to explain the shortcomings.

In this the failure to me is simple: None of of the half dozen or so physicians she saw before this final one had the necessary expertise to diagnose her problem in spite of a collective decades of training.   No test or study should have been needed to make this diagnosis. To me this is reflective of a larger problem in medical education.  Medical education biases towards training doctors at treating really, really sick people which is a good thing, but there is little emphasis on taking care of the problems that commonly occur in healthy adults.

Shoulder injuries are among the most common complaints that people visit doctors for.  Studies estimate that 1 in 20 visits to primary care providers are for shoulder problems.  As someone who is going through medical education I can state definitively how little I have been educated in shoulder injuries now in my 7th year of medical education.  I know about rare enzyme deficiencies and strange infectious diseases I will never likely encounter, but for something that composes 5% of all doctors visits I know little about.

The same could be said for many of the other problems that healthy adults commonly experience.  Doctors know shockingly little about how to properly manage many things that are relevant to healthy adults like back pain, musculoskeletal problems, pain syndromes, anxiety/depression, nutrition, vitamins and minerals, physical fitness, common skin and eye problems and psychosomatic problems (which one study by Kaiser Permanente estimated to be responsible for 70% of visits to primary care clinics!).  Taken together these problems routinely come up but medical education simply does not emphasize them.

I think Doctors generally feel more comfortable taking care of really, really sick people than they do taking care of people who are mostly healthy.   The kicker is that by the time people are really sick our expertise in stabilizing them is often times not going to make much a difference in the quality and quantity of their lives and will cost a lot a money.  Clinically effective care of the problems that arise in healthy adults, on the other hand, can make lives better, prevent disease, minimize suffering and, as evidenced by the case of my friend, reduce unneeded or harmful treatments, prevent prolonged suffering and save tons of money.

 

Taking care of healthy adults is an important part of medicine that is underemphasized.   Doctors lack expertise to do this even though it has the ability to reduce cost and improve lives.  Integrating expertise in this is an important part of medical care with major public health implications that should be emphasized.

The Dangers of A Widely Used Drug

Imagine that I invented a medicine for a common, widespread chronic medical problem.  I could mass produce and spread this imaginary pill to the entire American population as needed and the medicine was reasonably inexpensive and effective in the short term but it came with some major caveats.

The first caveat is that the medicine was only helpful and effective for short amounts of time.  In fact if this medicine is used for longer than a few weeks based on the body’s adaption to the medicine it loses its effectiveness outright.  This would lead to increased dosage requirements.

The Second caveat is that the medicine comes with a side effect of severely altering level of consciousness in users and also causes depression.  The medicine leads to powerful sedation and has been shown to ultimately hinder people’s ability to function normally or do things like work jobs, care for children, drive vehicles or operate machinery. 

The third caveat is that because the medicine causes a short lived sense of euphoria the medicine is highly addictive.   In fact this medicine is actually one of the most addictive substances known to exist and has been known to ruin millions of lives. 

A shocking fourth caveat is that in a substantial amount of patients who take this medicine continued use will actually make the underlying condition worse.  Many users from taking this pill will become “super” sensitized to the medical condition by this medicine and will experience horrible symptoms which require even more potent and massive doses of the medicine and it’s side effects.

A fifth caveat is that the medicine can powerfully alter human respiratory physiology and routinely cause death in cases of overdose.  In fact this imaginary medicine ends up being one of the leading causes of medically caused death worldwide. 

A sixth caveat is that if patients take the medicine for a few weeks and then stop abruptly they will go through a several week period of physically and psychologically painful withdrawal.  

Clearly I have invented a medicine that has a long and dangerous list of cons to accompany it’s usefulness in the short term. Further imagine that you are a patient being asked to take my medicine.  Would you do it?   What about if you were a policy maker for our government.  Would you allow this medicine to be widely used?  If you were a physician, would you routinely prescribe it?

The frightening reality is that my medicine and all these caveats is not at all an imaginary pill.  It is indeed terrifying that the above scenario actually describes the single most widely used classes of drugs in our country at present time.   The above “imaginary” medicine is opiate drugs.   And the millions of Americans who suffer from chronic non cancer pain and take high doses of these medicines are living with the above caveats whether they realize it or not.   

Opiate drugs are powerful pain medicines that have a well established role in the management of acute pain and trauma and in chronic cancer pain.  However studies show that the outcomes of using opiates for chronic non cancer pain are not as good. 

Despite their widespread use in this area many investigations have shown that these drugs do not have great long term efficacy.   For example one large meta-analysis ( a type of study that pools that results of several smaller studies together) showed that the use of opiods in patients with chronic back pain, compared to placebo or non-opiod analgesia, did not result in significant long term improvement in pain scores or functioning.  

The side effects and consequences are well established however.  People who take high dose opiates for long periods of time have lower functioning and more disability than others.  Because the body quickly adapts to opiates they gradually lose their therapeutic effect and require higher and higher doses to produce the same amount of pain control.   This phenomenon is known as tolerance.   With higher doses of opiates come more and more side effects, sedation and risks of addiction.

Another issue is that for reasons not entirely understood chronic high dose opiate use often makes the body much more sensitive to pain thereby ultimately worsening the underlying problem for which the drug was started. This leads to horrible discomfort and even sometimes can make normal sensations horribly painful a phenomenon known as allodynia.  Imagine taking a treatment for a medical condition that may help in the short term but ultimately could make the underlying problem much worse is the long term.   Who would make such a trade off?

Addiction remains a major problem for prescription opiods.  Recent epidemiologic studies have shown that overdose with prescription opiods is now more common than overdose with street heroin.   It is estimated that almost 5 million Americans engage in non medical use of prescription pain relievers each year.      Opiate dependence can happen rather quickly and Withdrawal symptoms occurs after only 1-2 weeks of daily use and can take several weeks to stop.  

Besides it’s negative impact on functioning and disability, another danger is that opiates are a powerful respiratory depressant and overdose of cause thousands and thousands of deaths every year.  

Opiates are an important and needed component of managing acute pain and cancer pain.    However on a population level opiates have grown from a way of alleviating pain and suffering in acute situations to a widely used panacea for all types of chronic discomfort, aches and pains.  Prescriptions of opiates have increased exponentially over the past few decades.   This happens in spite of medical evidence that these medicines may not be very effective for long term use and come with debilitating side effects, impairments to overall functioning, risks of overdose and addiction and the potential to actually make the underlying pain syndrome worse.

The imaginary drug I described painted a complicated scenario that happens in the real world routinely.  When we use opiates to manage chronic non cancer pain we are making a dangerous trade.   The benefit is short term comfort but the price is the above mentioned caveats and it is a large price to pay.  

To me the bottom line is that the cons of using opiates for widespread management of chronic non cancer pain out weight the pros.  Opiates may have a role in select cases of  severe chronic, refractory non cancer pain (especially in people who have little hope of functioning normally anyways) but the pervasive way that they are currently being used is a dangerous and ineffective way to treat a challenging medical problem. 

 Who could feel comfortable knowing that such a medicine is the most widely used drug in America right now?   

Widespread use of opiates has created nothing less than a public health emergency for our country.   Millions are dying or being harmed every year because of the short sighted way that opiates are presently being used in the management of chronic non cancer pain.   If a virus or bacteria came along that  killed as many people every year as misuse of opiates did it would be in every newspaper and television show and would be considered one of the sentinel events in the history of the human race. 

Misrepresentation of Mental Illness Is Major Problem for Mainstream Media

The headline on the Associated Press Business story published today in media outlets across the globe and undoubtedly read by millions reads "Schizophrenic Markets Shrug off Greek Deal."

The headline attempts to convey the volatile nature of the markets as described in the story.  Financial matters aside, this headline provides yet another example of the gross miscategorization of the mentally ill in popular media.  I cringe when I see words like "schizophrenia" or "bipolar" used in news stories about politics, finance or sports teams.  They do nothing but contribute to misunderstanding of mental disease and stigmatization of the mentally ill.

In clinical terms Schizophrenia is a poorly defined disease without any clearly identified causal pathophysiology or basis. The truth is that mental illness takes it roots in some murky combination of physical, mental, environmental and existential/ psycho-spiritual factors.    The disease schizophrenia in actuality can be given to any number of clinical syndromes and different clinicians will label different individuals with wide disparity of labels.

The nebulous nature of mental illness adds to the confusion in the mainstream about it.  The debate about what if anything exactly  is schizophrenia will rage on for decades, but as a matter of communication and convenience for medical billing the disease is  definined in the DSM-IV as a disease of disordered thought with both positive and negative symptoms.

Positive symptoms include hallucinations (almost always auditory), delusions, paranoia and negative symptoms are things like poor communication, blunted emotional affect, inabiltity to express pleasure and poor interpersonal relationships.  Not all schizophrenics have all these symptoms.  In fact every one is unique in how their disease manifests itself.

In the article Carol Pepper, CEO and founder of Pepper International, a money management firm in New York is quoted saying "The market is going to continue to feel very schizophrenic. Some days it’s depressed, some days it’s excited, some days it’s terrified"

Headlines and quotes like this miscategorize and oversimplify schizophrenia.   They make schizophrenia sound like a disease of raging lunacy, when in fact the diagnosis encompasses a broad range of functionality and symptomology.  Emotional lability can be seen in some schizophrenics, but it is hardly the hallmark of the disease.  In fact emotional apathy or bluntedness is a much more accurate depiction of its effects.

The sufferers of mental illness face tremendous adversity throughout life.  They live shorter, sicker, less happy and less functional lives.   They are stigmatized and misunderstood in a way that few others can understand early in life and this contributes to their suffering and illness.  The last thing they need is to be further ostracized from the rest of society.  The mainstream media should be more responsible about how they categorize mental illness in the headlines and quotations they publish.




Authors Challenge:  please feel free to post further examples of the misrepresentation of mental illness in the mainstream media of you come across them.  Here is the original link:   


http://bostonherald.com/business/general/view/20120312us_edge_higher_as_europe_nears_final_greece_deal/srvc=business&position=also

Medicine's Silent Threat

A silent, hidden threat continues to gain power in our nations medical apparatus. It is

threat which makes no sound, is completely invisible to the eye and stimulates no

senses. Yet it’s power to impact human health in a profound and powerful way is clear

and undisputed. The name of this threat is Ionizing Radiation.

There are several types of radiation found in nature, but ionizing radiation remains

notable for it’s ability to damage human genetic material and exert physiologic effects in

the body. In an era when medical imaging is routine and as accessible to this

generation of physicians as stethoscopes and reflex hammers were to previous ones,

the problem of medical radiation remains an unseen but deadly manifestation of modern

medicine.

The story is one which plays out thousands of times a day in every hospital, clinic and

emergency room in the developed world. A patient presents with a nebulous medical

complaint and the physician taking care for them must answer a critical question:

Should this person undergo medical imaging or not. This decision might not be so

vexing were it not for the long list of harms and benefits that accompany it. It is

estimated that ionizing radiation from medical imagining now accounts for half the

overall radiation exposure in the US each year.

While some medical imaging studies offer harmless non ionizing radiation (like MRI) or

small doses of harmful ionizing radiation (X-ray) among the most widely used imaging

studies is the CT scan which gives a massive dose of ionizing radiation. A single CT

scan provides more ionizing radiation than 200 Chest X-Rays. Despite the radiation exposure, CT scanning remains increasingly among popular among physicians with use of the CT scanner growing exponentially over the past several decades. It is estimated that use of CT scanning in the United States has tripled since 1993.

The effects of all this radiation on the population is far from miniscule. Studies

estimate that the lifetime radiation dose of a few CT scans (how many depends on

which part of the body is being scanned) is comparable amount of ionizing radiation to

being in Hiroshima on the day the atomic bomb went off. One particularly controversial

study estimated that 1.5-2% of all future cancers in the United States will be because of

medical radiation. Another study estimated that CT scanning increase any one

individuals risk of cancer by .35% and while this may not sound like much on a

population level that would translate into tens of thousands of cases of cancer per year.

In fact another study estimated 29000 cases of cancer caused by CT scans done in

2007 alone.

And yet The CAT scan has changed the way medicine is practiced. It was not long ago

when physicians had to rely on history and physical exam to make the diagnosis. CAT

scans gave physicians an accurate, objective way of seeing exactly what was

happening inside our patients that exceeded the power of our own senses.

.

Anyone who has ever practiced medicine understands that the idea behind any medical

intervention is that the therapeutic benefits of doing something that could cause harm

outweigh the risks. The same rules should apply to CT scanning. There are many

indications where the relatively small individual increased risk of cancer from giving a

CT scan is outweighed by the benefit of making a diagnosis, confirming suspicions and

governing treatment.

The problem is that the CT scanner is being used too much and it is contributing to a public

health crisis. Studies estimate that 30% percent of CT scans are not needed and I

believe that is an underestimate. All those unneeded scans are creating exposure to a harmful, but invisible, toxin. If a newly discovered environmental toxin in our food or water was noted to cause almost enough cases of cancer to fill a baseball stadium every year it would be all over our televisions, newspapers and webpages. Should we not hold modern medicine to the same standard?

A few months ago my 6 year old nephew George fell about 12 feet and landed on the ground head first at a family party on rock hard pavement. He was rushed to the emergency room and

even though he was conscious and appeared well he was given a CT scan. The reason

for this was that George’s mechanism of injury was deemed “high risk” and therefore

the CT scan was indicated. His scan was normal and all the adults left the Emergency

Room feeling better that day, reassured that Georgie did not have bleeding inside his

brain. Georgie and his family will have to live with the increased risk of cancer but

overwhelming odds are he will not get cancer from his CT scan.

But George’s situation was black and white. George needed the scan because his fall

was high risk and the good outweighed the bad. When the situations are black and

white decisions are easy to make. When situations are grey things gets tricky. What

if instead of falling from 12 feet he fell from only 4 feet? And what if instead of

absorbing the blow only in his head Georgie had a second injury on his arm indicating

that it had absorbed some of the force of the fall? Georgie would have been in a grey

area under those circumstances. Physicians today who find themselves in those “grey

areas” are relying on CAT scanning to help them figure things out. It

reassures physicians and patients but the costs are tremendous: we are creating tens of

thousands of cancer patients per year. This is the definition of a public health

emergency.

Studies have been done and there are clear evidence based rules that tell doctors when

to use CAT scans to image heads, necks, abdomen and chests. Physicians should be

conscious of the harms of CT scan and the price of getting definite answers and try to

stick to these rules in the context of their own judgement.

The risk is one physicians must take at times, but unnecessary CAT scans are causing disease and we all took an oath to do no harm. When physicians minimize patient harm and rely on evidence based rules to form the backbone of their decision making and help them decide when to use the CT scan then they will  be making decisions that benefit patients and truly doing no harm.

The Chest Cracker Diet and Why the Heart Disease and High Cholesterol Epidemic Makes Perfect Sense to Me

Heart disease is one of the leading killers of Americans and I can see why.

  

Much attention has been placed on prevention of cardiovascular disease in this country and on identifying and controlling risk factors for it. Among the many known cardiovascular risk factors cholesterol is important both for it’s powerful impact on the development of heart disease and in it’s capacity to be modified by medical and lifestyle interventions.   Based on the American diet the cholesterol and heart disease epidemic we are experiencing makes perfect sense.

 

 

About one million Americans die each year from heart disease.  A persons cholesterol level is important to the development of heart disease because of cholesterol's ability to strongly contribute to the process of developing plaques in blood vessels. The presence of these plaques increases the chance that someone will experience heart disease.  A major culprit in this process lies in something that is probably in the kitchen and on the plate every day of almost every person who is reading this: Meat.  

Scientists search for the solution to heart disease and high cholesterol in laboratories with pills and physicians crack open about 250,000 chests each year to try to fix the hearts of Americans who have developed severe heart disease. All the while the cholesterol epidemic rages on as currently it is estimated that over 50 million Americans have high cholesterol.

But the cholesterol epidemic we are experiencing now is no mystery and the most powerful solution is not pills or surgery. A close look at what and how most Americans eat reveals that the cholesterol epidemic is a logical consequence of our cultural beliefs around nutrition and especially eating meat.

 

 

The bottom line is that Americans eat far too much meat per year and it is literally killing us. Every year the typical American eats an artery clogging 260 lbs. of meat per year (that breaks down to about 12 ounces of meat per day) which is the world's highest rate. According to the United Nations that is about 1.5 times the industrial world average, three times the East Asian average, and 40 times the average in Bangladesh .

 

Meat is a problem because ALL meat is high in cholesterol, including white meats like chicken and turkey. I want to repeat that because it is a MAJOR misconception among most Americans: White meats like Chicken, turkey, pork and even fish are all loaded with artery clogging cholesterol and have a comparable amount of cholesterol to red meat. White meats usually (but not always) have less dietary fat and that is why they are considered healthier than red meats but it has nothing to do with cholesterol.

 

How meat contributes to our cholesterol problem is two fold. It is part of our culture to eat meat with every meal. Most Americans don’t feel like they are having a “real” meal if it doesn’t involve meat. Therefore most Americans eat meat several times a day with every meal. Secondly the typical American portion of meat is insanely large. Even a pro-meat nutritionist would advise only a 3.5 ounce portion of meat with a meal (about the size of a deck of cards), but the typical American portion of meat at home or in a restaurant in usually around 12 ounces per meal or 3-4 times what is recomended in a serving.

 

It is important to note that some cholesterol is an essential part of a healthy diet. The ADA advises most Americans to have between 200-300 mg of cholesterol per day to maintain normal bodily function. But the typical American diet dwarfs that amount.

 

Just do the math. A 3 ounce serving of any meat has around 70mg of cholesterol depending on the cut. If, as the U.N reported, the average American person eats 12 ounces of meat per day than that person will have nearly met their daily requirement for cholesterol just from meat alone in a typical day. Now add on all the other cholesterol from other non meat foods comprising a full diet of 3 or 4 meals and 3 snacks each and every day over the course of decades of life and it is quite logical why over 50 million Americans have high cholesterol and our nation is suffering a cholesterol epidemic.

 

Doctors have good medicines that can help combat high cholesterol, but this is like using a band aid to cover a major wound. The real problem is in the dietary traditions of Americans. Americans choose to eat too much too often and that is why we struggle to control cholesterol levels.   American need to change the way they think about food.    

The typical American meat heavy diet should be called “The Chest Cracker’s Diet” because it leads to hundreds of thousands of chests getting cracked open every year among unfortunate, genetically predisposed individuals who develop severe heart disease. Meat eating is often categorized as being manly in the popular media but trust me there is nothing strong or masculine about heart disease or Coronary Artery Bypass Grafting.  Occasionally eating meat is probably alright (I would say one small 4 ounce portion every2-3 days) but as long as Americans insist on following the myth that massive slabs of any kind of meat must be a part of every meal than we will continue to suffer from a cholesterol epidemic and experience alarming death rates from premature heart disease.