Nutrition and other Thoughts on Medicine

     From time to time I have had certain thoughts about the practice of medicine as well as what patients have been told by their doctor, or by advertisements, or by TV "talking heads". Some of the thoughts are summarized below. Please remember that due to my training in and work in physics, I cannot accept any statement about medical treatment unless it has been substantiated by at least one clinical trial. Often medical treatments or suggestions are inferred and never tested. As a writer once remarked: "Just because roses smell sweeter than cabbages do, it does not follow that rose soup tastes better than cabbage soup, or that rose soup is healthier".

     Let me first re-iterate an important point about all studies of human diets and their conclusions: A laboratory white rat reproduces every 30 days, so in six months I can study six generations of rats, and develop a pretty good idea of foods that are beneficial for or harmful to them. Humans reproduce every 25 years, and the longest forward interventional study was a five year study of approximately 5,000 American women, or a study that just looked at 20% of the human reproductive time. We have absolutely no good interventional studies in humans, i.e. where  we have a study group and a control group and the diet of the first group is artificially controlled.

     What we do have is a lot of epidemiological, retrospective studies, comparing groups of humans on one diet with those on a different diet. Coincidence and correlation are not the same as CAUSATION, and the results suggested by a statistical analysis of human diets should be treated as hypothetical, to then be verified by a proper single or double blind study that goes forward in time. In an earlier blog I have mentioned some of the statistical problems that arise when we do such comparisons.

     I am constantly astounded at the number of different vitamins and "health" foods my patients ingest. They all assume that if a little is good, then a lot is better, and that no "health food" could possibly be dangerous. I will tell you here and now that almost no health food has been tested on humans with a view for looking for dangerous side effects, probably because it is not in the manufacturer's best interests to do so. For instance it is widely assumed that milk thistle is protective of the liver,  but I know of no study that looked to  see if milk thistle can damage the liver or elevate liver blood tests.

     Except for the fat-soluble vitamins A,D,E, and K, if you ingest more of a vitamin that the body needs, then it is excreted (usually unchanged) in your urine. The B-complex vitamins cause the urine to look deep yellow or gold, so now we know why the book was titled "The Golden Stream". (For those of you who lever learned this joke in elementary school, the author of the book is I. P. Daly.) A curious fact is that penicillin is excreted almost 100% unchanged  in the urine. When it was first introduced, supplies were scarce, so the urine of any patient given penicillin was collected, and the penicillin re-crystalliazed from the urine to give to the next patient. So the members of the richest country in the world have the richest urine in the world.

     I think that it is healthy to be at ideal body weight (whatever that is) and to take a vitamin a day to prevent any deficiencies  that may develop as well as 1 mg/day of Vitamin B12 and400 Units /day of Vitamin D.
One should also remember that it is easier to achieve a balanced (i.e. contains the eight amino acids and three fatty acids as well as all the vitamins  that the body cannot manufacture for itself) diet with a meat diet that a vegetarian diet.There is no evidence to show if it is healthier to eat one, two, three or many meals a day, and whether or not all meals should have an equal calorie content. Or if the Spaniards are healthier or not because they start their largest meal at 10PM. When we look at long-lived octogenarian (age 80 +) people around the world, they have widely varying diets, because your diet is largely a function of where you live: north Africans eat more orzo than we do, the Far Easterners eat more rice, and people more than 500 miles from a lake or ocean eat very little fish. BTW, there is no evidence that a daily children;'s aspirin (81mg) is beneficial for the average patient with no chronic diseases.

     Every study shows that moderate drinkers live longer and have fewer heart attacks than non-drinkers. I have seen studies with scotch, wine, beer, brandy, etc. Our government has accepted this fact half-heartedly: They say that if you are a moderate drinker, please continue, but if you do not drink, don't start. Huh? If doing something is beneficial for your health don't start doing it? Also I have seen at least two studies showing that the consumption of a glass of wine or its equivqalent on a daily basis for a pregnant woman does not cause any damage to the fetus.

     Your parents may have told you that swallowing watermelon seeds or chewing gum is dangerous to your health, or not to swim right after eating, or to drink eight glasses of fluid a day----all bushwah.

     Do you recall the food pyramid you learned about in school up to about the year 2000? The pyramid has now been inverted by nutritionists, and the foods at the top, of which you were supposed to eat only once a day, you now should eat frequently (!?) And there is no mention of two key food groups: caffeinated coffee, especially in the morning, and (dark?) chocolate. Who among us could eat just one Mallomar after opening the double box? I have been reliably informed that in Ohio a giant Mallomar is sold without the cookie crust on the bottom, and is called a "Chocolate Whip".

     If you leave the table before you are completely full, avoid white potatoes (including French fries) because they are the most glycemic food of all, and remember that ALL white bread is useless calories (exception made for dipping French bread into bouillabaise), you should be able to lose weight easily.

     "I can resist anything except temptation"----Oscar Wilde

     "I wish I had drunk more champagne----Jackie Kennedy on her deathbed.

   

   

 

Weight Loss, Nutrition, Low Salt, Low Sugar

This blog was stimulated by the recent surge to have government endorse/require lower salt in the diet. There is, of course, no direct evidence that a low salt diet prolongs life. In the recommendations, lowering salt in the diet is taken as a surrogate for lowering blood pressure. It is assumed that lowering the amount of salt in the diet by 3 grams/day will lower systolic blood pressure between 3.5 and 5.5 mm; no estimate is given for the effect on diastolic blood pressure (is there any?). It is claimed that this will reduce death by heart attacks and other problems.

High blood pressure is a demonstrated risk (i.e. there a correlation, but an 0.80 correlation is a 0.8x0.8 or 64% estimate) for strokes, hypertensive heart disease, and abdominal aortic aneurysms (the latter in male smokers). However, every study of lowering blood pressure (usually by diuretics) only shows a reduction in the risk of strokes; there is NO demonstrated reduction in mortality or hypertensive heart disease. I should also mention that reduction of blood pressure by beta-blockers alone has shown no reduction in any risk of stroke or heart attack. In addition, there has been no prospective study to see if lowering the amount of salt in the diet has any injurious effect, and a lot of medicine is counter-intuitive. I recall a study that lowering the salt in the diet INcreases the risk for heart failure, but who really knows?

A related dietary question deals with lowering the amount of sugar in the diet (?by taxing sodas). I pause here to remind my lay readers that just because diabetes is evidenced by elevated blood sugar, this does NOT mean that increasing the amount of sugar in your diet causes diabetes, assuming you gain no weight. And we will also ignore the white lab rat study that shows that if we keep lab rats 30% below their IBW (and who determines the Ideal Body Weight for a lab rat?) they live longer. The flip side is the recent studies that demonstrate that overweight adult humans (BMI 26-29) have an increased chance of surviving a heart attack.

Now let us assume that we wish to lose weight. What is the most efficient and surest way to do this? (Remember that when you lose weight as an adult, your fat cells shrink, and get smaller and have a smaller net surface area for metabolism.) Of course, the obvious method is to eat less. No one was overweight in a concentration camp. The lap-band surgery shrinks the functioning volume of your stomach, so you can't ingest many calories, and again you lose weight, and usually cure your diabetes as well. Anorectics have absolutely no problem in losing weight. In another vein,liposuction sucks the fat cells away from your body,and these cells can never increase in size again.

But the brain demands homeostasis, and strives to keep your body parameters as constant as possible. Most people's weight varies very little from year to year. All nutritionists agree that 3500 calories = 1 pound. If you divide 3500 by 350 days, you find that you have to micromanage your food intake to plus or minus 10 calories a day to keep your weight constant for the year. Not even the most dedicated fanatic can do this. Obviously, the brain has a mechanism to raise or lower your metabolism to keep your weight constant, sort of a feedback mechanism, which has nothing to do with leptin. This metabolic/mass inertia is what makes it equally difficult to gain or lose a lot of weight. In fact studies have shown that when you gain weight, your metabolism increases, and when you lose weight, your metabolism decreases, in a true negative feedback manner, which is why most dieters hit intermittent weight plateaus.

In order to lose weight, you must feel good about yourself, and be relatively happy and free from anger. Food was the first pleasure, given to you by your mother. It is very difficult to deny yourself this pleasure if you are not "in a good place". If you are mentally at peace, then you can walk around hungry without feeling (emotionally) deprived. You can be satisfied by the flavor of half a chocolate chip cookie rather than a whole box of Mallomars. So losing weight is not a matter of pure will-power, but rather a matter of not being too out of rhythm with the world and ego-dystonic. This is not to say that all overweight people are neurotic. Many are very happy with themselves, and see no need to change their body habitus. Your self-image is everything to you, and this is what we all rely on and judge ourselves by. This is why I don't think special diets are the answer. We all eat the way we like, and no one does Weight Watchers forever. The answer is always portion control. Why torture yourself by eating foods you don't like , instead of simply eating less of the foods you do like?

Let me close by saying eating "healthy" food is less important than eating less and losing weight. We know very little about nutrition. When I went to school as a child, the food pyramid was the exact inversion of what it is now. We don't even know (i.e. have good evidence) if the biggest meal of the day should be breakfast, lunch, or dinner. Should we have one large meal a day or six small ones. For every study, there is a counter-study. Do lefties live longer than righties? Do short people live longer than tall people? Why does overall health correlate so strongly with economic position in life? Maybe we all would be healthier if everyone were a millionaire? Any time any person or authority tries to tell you that something is "good" for you, or "good for your health" always ask the same question we asked reflexively in physics and on hospital rounds: "Do you have a published article to support that opinion?".

The Obesity "Epidemic" and Nutrition

There has been a lot of talk and newsprint about the obesity "epidemic" that is occurring, but I feel that certain facts have been ignored, as well as certain principles of human behavior. Whenever patients tell me that doctors don't know much about human nutrition, I generally comment that neither does anybody else. There have been very few double-blinded studies about the effect of nutrition on human health and well-being, but that doesn't seem to stop people from being more certain about human nutrition than the facts will allow:

1) No one knows how many meals a human should eat each day: one, six, or whatever.

2) No one knows at what time of the day the largest meal should be eaten, (but if you eat within 2 hours of bedtime you increase your risk of reflux esophagitis).

3) If you eat only vegetables, you will die from pernicious anemia, aka vitamin B-12 deficiency, since vegetable cells contain NO vitamin B-12; vitamin B-12 is is needed for animal cell DNA synthesis, and not for vegetable DNA.

4) Nobody smiles in a vegetarian restaurant, but everyone looks ecstatic at a steak restaurant such as Peter Luger's.

5) The only vegetables that seem to benefit human health when added to the diet are alcohol (beer, wine or whiskey), dark chocolate, olive oil (the Mediterranean diet), and the bark of the willow (salicylic acid, which Bayer transformed into aspirin).

6) No one knows how much water/fluids a human should drink each day, but the general consensus is a minimum of 0.5 liters, since that is the urine volume required to excrete the products of oxidation in maximally concentrated urine.

7) In a hospital, the minimum IV should be D5/0.5NaCl with 20 meq of KCl at 125 cc/hr, and then adjust to the patient's condition.

8) Fat cells require cholesterol and preferentially absorb insulin, so if you are a diabetic or have a cholesterol problem, you should lose weight.

9) Cholesterol does not increase cholesterol, so egg yolks are OK, and, in fact, eggs have about the highest protein per gram of any food.

10) If you do not have high blood pressure and are not diabetic, then salt and sugar should cause you no problem.

11) Almost all my patients who on oral medicine for diabetes cannot/will not lose weight, even after I tell them that a 20m pound weight loss will probably (temporarily) cure their diabetes.

12) As you get older, your metabolism slows up, and your blood pressure, cholesterol and fasting blood sugar generally increase.

13) Most women find it impossible to lose the last 5 pounds necessary to get down to their pre-pregnancy weight.

14) Most men gain at least 10-15 pounds the first year they work or get married, in the first case from lack of exercise (8-10 hrs/day behind a desk), and in the second case from an increase in calories consumed at dinner.

15) Cigarette smoking increases your metabolism and decreases your appetite, so most men gain 10 pounds the first year they quit smoking and most women gain 15.

16) And this is key: The first pleasure all humans got was from being fed, either at their mother's breast or from a bottle. The first desire to be fulfilled was that created by hunger. Therefore, it feels good to eat, and it is difficult to deny yourself this fundamental pleasure and to feel hungry, which you must do in order to lose weight. The first time a woman's dress goes from size 6 to size 8, or a man's belt from 32" to 34", they rarely say "I must lose some weight". It has nothing to do with not knowing how many calories they are eating, or doctor-patient information, or lack of electronic medical records. Most patients don't care enough about how they look after gaining 10 pounds, or believe that there is enough increased health risk from added weight to lose the additional pounds. Men actually are less stressed by their appearance when overweight than are women: When a woman looks full face into a mirror, she sees the added weight that went to her hips, but when a man looks in a mirror the same way, he barely sees the added weight that went to his belly.Losing weight means being willing to suffer present pain for future gain, and the human brain is not geared to worry about the future, but rather to fasten the seatbelt 10 seconds before the car hits a brick wall. The same comment about future gain also holds true for exercise, but the average patient finds it much easier to exercise than to lose weight.

17) I also think the reason that almost all humans love ice cream is that it is rich in sugar and fat, just like mother's milk.

18) Don't you think that by the time he/she is 7 days old, a baby is addicted to sugar by Pavlovian conditioning: whenever he/she is hungry (or whatever is felt), this discomfort is assuaged by a warm sweet fluid, so that the baby associates warmth (chicken soup?) and sweets with a sense of comfort and well-being. It's difficult to see how an external message can easily overcome this dependence.

19) Final observation: based on my informal questioning of my patients, the majority of adults who loved chocolate ice cream as a child can curl their tongue (I can!), while the majority of patients who did not like chocolate ice cream cannot. I wonder what the genetic linkage is. I personally thought that my friends who preferred vanilla ice cream to chocolate could not have possibly tasted the same chocolate flavor that I did.

Nutrition

I expect I will receive more e-mails from this blog than from all the others together. Nutrition is fundamental, not only to life, but, as per Freud, the first stage of mental development. Our first sensation of love, warmth, and security was at our mother's breast. Because it has such a fundamental connection with our psyche, this is probably why we have more and different personal habits and religious taboos over food than any other aspect of our lives. We also have magical thinking about "good" foods and "bad" foods.

Mother's milk is heavy in sugar and fat, which is probably why we all love ice cream. (Separate thought:I prefer chocolate to vanilla, and I often wonder if people who prefer vanilla taste the chocolate in the same way that I do.) Fat is appreciated because it adds flavor and substance to food It also markedly slows stomach emptying, so we feel fuller for a longer period of time if the meal contains fat. Some of my patients equate "low fat" to "low taste" especially low-fat mayonnaise.

There are eight essential amino acids, which are called "essential" because every animal cell needs all eight to make proteins,and cannot synthesize them. Vegetables have at most seven of these amino acids, which is why a complete vegetable dish contains rice + beans, or corn + peas (aka the American Indians' succotash); that is, at least two vegetables.

There are also two or three essential fatty acids (depending on your definition), and again any animal cell contains all of them, which again is why you need at least two vegetables if no meat is eaten. This is probably why no one looks truly happy in a vegetarian restaurant, because they sense they are missing something (or subconsciously are aware of the fact that tofu lowers men's sperm count because soy is a phytoestrogen). On the other hand, everyone is all smiles in a steak restaurant.

Everyone should be aware that Vitamin B-12 is necessary for an animal cell to synthesize animal DNA, but not vegetable DNA. Vegetables contain no vitamin B-12 whatsoever. Therefore, if you eat neither meat nor fish nor eggs, you will eventually die from pernicious anemia. It as also a curious fact that no one is literally addicted to eating meat, or can achieve an altered mental state by eating meat (licking Colorado toads being a notable exception). All the addicting or mind-bending foods are vegetables, with their totally different chemistry: nicotine, alcohol, caffeine, opium, marijuana ,peyote, "magic" mushrooms, etc. In fact, if you kill an animal or fish at random and eat it, the odds are that it will agree with you. But if you eat a random vegetable or berry, there are good odds that it will make you ill or kill you (mushrooms, choke cherries, oleander, foxglove, mistletoe, rhubarb, yew, manicheel), not to mention the severe contact allergies from poison ivy, oak and sumac.

As for cholesterol, it is an essential component of the membrane of every animal cell, through which all nutrients pass. (Plant cells have a cell wall outside the cell membrane, which contains no cholesterol whatsoever.) So when we chemically lower cholesterol, we lower a constituent of the membrane of every cell of the body. This in turn alters trans-membrane potentials, ion fluxes, molecular transport, and sensitivity to neural stimulation. This may explain why some patients develop leg cramps (muscle cell irritability and sensitivity), or altered liver tests (? inflammation of the cell membrane and enzyme leakage), and sometimes just don't "feel right"(altered electric potentials in brain cells). If cholesterol is lowered by weight loss, the body responds as a whole, and therefore there are no such side effects. When Wise's Potato Chips tried to advertise their chips as "having absolutely no cholesterol", which is a literal scientific fact, the FTC pulled their add, claiming that patients would confuse "no cholesterol" with "no fat".

We don't even know how many meals we should eat daily: one, two, three,or six. We don't know the proper time of day to eat the largest meal, even though we know that all our minerals and hormones have a diurnal cycle (cortisol is highest in the AM, serum iron in the PM, etc.). We don't know if the fact semi-starved rats exceed their natural life span applies also to humans. We don't understand why, if a normal BMI is optimal for health, how is it that people with an elevated BMI survive heart attacks better.

As for vitamins, a vitamin is a chemical which, if you do not ingest, you get ill and may die (scurvy, beri-beri, pernicious anemia, etc.), because your body needs it as a co-factor for essential enzymes, and cannot synthesize it.A,D,E, and K are fat-soluble vitamins, but C and all the B's will be excreted in your urine, if ingested in excess. Oddly enough, an excess of daily vitamin B-6 causes neurological symptoms, just as a deficiency of the same vitamin does. (cf article in NEJM, more than 10 years ago; research done at Albert Einstein Hospital)Since it is a pure chemical, your body cannot tell the difference between "natural" and synthesized vitamins. Since the FDA does not regulate or supervise vitamin manufacture, there is also absolutely no guarantee as to if a capsule labeled "400 U of Vitamin E" contains 0, 400, or 1200. And the idea that too much of a vitamin cannot hurt you never applies to fat-soluble vitamins, which are stored in your body. We have already seen studies of the coronary artery dangers of too much daily Vitamin E.

Finally, all the suggestions about "healthy" diets are based on retrospective and/or epidemiological studies, which all fail to remember that correlation does not mean causation. The only food intervention shown to lengthen life, mostly by preventing heart attacks, is alcohol. I have read studies with beer, scotch slivovitz, red wine, etc. It is the C2H5OH molecule that saves you. There was an article as far back in 1974 in JAMA, in which comparative autopsies showed that moderate male drinkers had larger diameter (i.e. wider and less clogged) coronary arteries than age and weight matched controls (non-smokers only). Every time a forward study (low fat, beta-carotene, selenium) has been done, the results have been nil, or even negative (especially with vitamin E).

The overall problem is that no prospective food study has ever been done with adult humans, so all are beliefs are just that; beliefs without a sound foundation in experimental fact.