A recent study released in this weeks JAMA has found an association between being moderately overweight and having longer life. I would like to believe that being mildly overweight conveys a mortality advantage over being skinny because so many Americans (including me until 2 years ago!) fall into that category but consider me in the group of skeptics. From reading the study it seems to me that this study has a major flaw in it's methodology that could explain these results.
This study found a relatively modest (6%) mortality benefit to being moderately overweight. As anyone who has ever worked in medical field knows often times when people are very sick they get very skinny. Many, many diseases cause profound weight loss especially at the end of the road. People who suffer from cancer, AIDS, heart disease, drug and alcohol problems, hematologic disease, renal disease, gastrointestinal disease , dementia, immunological disease and many, many medical problems can lose weight as their disease progresses. In order for this study to be meaningful the authors would have had to have provided sufficient and rigorous statistical corrections to account for this fact. Unfortunately this was not possible based on the study methods.
This study relies on data from numerous other smaller studies pooled together to make it's conclusions. Not all of the studies that the authors included in their data pool were able to correct for the presence of chronic underlying disease. Some of these studies were and some were not. And as readers we have no idea how many were and how many weren't or what if any methods were used. We are left to trust that the authors of all these individual papers sufficiently corrected for the presence of chronic disease when possible, used the right statistical methods to do so and corrected for the diseases most likely to confound the results. Obviously this is a huge area of uncertainty and a huge leap of faith for us to accept this puzzling conclusion of modest effect.
Because many of the papers did not correct at all we can be sure that at least some skinny, very sick people with chronic disease found their way into the study. Was this enough to explain all of the results? The truth is we may never know. To me it seems very plausible that the modest association observed between moderate obesity and mortality could be at least partially explained by what effectively amounts to a confounding variable that impacts both the exposure (body weight) and the outcome (mortality rate) aka the presence of chronic disease.
On the other side of the coin if even if these findings are somewhat skewed it does raise a point I often convey to patients which is the distinction between body weight (which is based on how many calories we eat and burn) vs metabolic/cardiovascular health (which is based more on what we eat and if we exercise). Even if the mortality benefit observed is "white noise" being slightly obese is hardly a death sentence. The truth is the likely effect of being slightly overweight on death risk is somewhere around mildly harmful to none to, as this study argues, slightly beneficial. The overall take home message is that slight obesity does not neccesarily mean completely unhealthy.
While I question these findings, I think it is possible to skinny and unhealthy and that it is possible to be healthy and overweight. The real trick is to exercise, eat right and to keep proven cardiovascular risk factors under control (smoking, hypertension, cholesterol, diabetes). I still maintain that being a normal body weight is probably better than being overweight even after this study, but we can add this skewed study as a reminder that when it comes to mortality the big money is in cardiovascular risk not neccesarily weight.
Friday, January 4, 2013
Wednesday, January 2, 2013
Monday, December 10, 2012
Monday, November 5, 2012
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.
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.
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!
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.
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.
Tuesday, July 3, 2012
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.
Wednesday, June 27, 2012
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.
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