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.