diabetesdoctor

Twitter

2010-09-25T13:50:00.000-07:00

Just started twitting. Not convinced yet that it works, but I guess it reflects who we are. No time for any serious conversation, please - "just twit me". On the other hand, it's convenient, on the go sort of thing which can give alerts about things to come, or in the making. So I think that the purpose for me will be to alert about longer pieces which will be written in facebook. That should be enough about twitter...

Facebook Site

2010-03-16T20:25:00.000-07:00

I recently started a new venue for distributing information about diabetes on Facebook. The idea came from a patient who remarked that Facebook can give me a platform which is easy for me to access and utilize. It has multiple features and can be viewed by "fans" or "friends". Well, I took the advice and started the Facebook site called: Litvin Centers for Diabetes. You can put it at the search area and reach it with ease. I can't say that I'm totally happy - mainly for technical reasons. I cannot separate the business site from the personal as much as I tried. Short of that, it's great. So please look us up, and sign up as a fan as well. Your feedback is always wanted and appreciated, so please utilize the tools at your disposal.

Hope to see you on Facebook!

Sincerely,

Dr. Litvin

Homeostasis

2009-09-09T20:21:00.000-07:00

Homeostasis is the art and science of keeping the internal environment stable, unaffected by external forces or influences, and at peak performance. That is exactly what the body and its multitude of systems are doing 24/7. All biological systems, in fact, are doing the same. Biological systems are all about survival and perpetuating the species. There is tolerance, of course, but it is delved very sparingly. Mother nature is very demanding in that way, and in order to survive, organisms must be at their peak performance. Such is the case for humans, as well. If it slacks off, such as it has over the past several decades, the consequences are devastating. The reasons for this slacking off have to do with our industrial, technological, and digital revolutions, which have allowed for conditions which shelter humans from their environment, and thus preclude the necessity for such a mechanism as homeostasis to play out. The price that we humans have to pay, can be seen in our clinics and hospitals. We have become a species of obese, unfit, and burdened by chronic disease, who quite often have erectile dysfunction, and thus jeopardize the continuation of the species. Obesity is easy to spot, and blatantly parading outside the bounds of homeostasis. Most interestingly, it has been socially accepted almost as a norm, and we as a species are much the worst for it. Obesity cannot and must not become an acceptable norm, by no stretch of the imagination. People with obesity are not at their peak performance, but in fact, are probably at their worst. Storing calories may have insured survival on the African desert plains during times of famine, in the West, it translates to danger. Social pressures should impact obese individuals into surrendering their adiposits and into shedding their weight in exchange for a more fit and homeostatic existence. Until such pressure is brought to bear, however, no shedding will unfortunately take place. As a society, we should emphasize the homeostatic beauty of nature, and the need for us as individuals to maintain our bodies in equilibrium where calories ingested are quickly burned.

The "Cup" Diet

2009-09-07T11:23:00.000-07:00

I recently saw a patient in the office after he underwent a gastric bypass procedure. By the time he saw me, several months had elapsed since the procedure, and he managed to lose about 50 lbs! He felt good, and his blood glucose was much improved. While talking about his eating habits, he remarked that he can't tolerate meat, and that his meals are very small in volume. "In fact", he said, "if I go beyond a certain measure, it comes right out". I asked him about that measure, and he said that it's one cup. His stomach, I thought, has been made the size of a cup, and that is all it can tolerate in volume. It's not your normal stomach that can extend and stretch in order to accommodate the nutritional whims of the typical citizen. It's stitched up into a miniaturized version of a normal stomach. So from that little anecdote, I began thinking about the volume of our meals, and came to the obvious conclusion that we must do better regarding this measure. None of us really think about the volume of our meals. We think calories, carbs, fat, etc., but we never think volume. I have a hunch that if we started restricting our meal volume, and demanded from ourselves that the meal should fit in a cup, a lot of food would end up staying on the plate. The typical cup is about 8 oz, how about if we double that to 16 oz, and demanded from ourselves to restrict our meal to that weight/volume. We could get a little scale and weigh our meal prior to consuming it, verifying that it's under 16oz. Doing so would liberate us from calculating the number of calories, or ever from paying too much attention to carbs/fat, etc. Think of it, when you survey the frozen food isle, all you need to do is look for the ozs on the labels. Easy and simple, and I propose we call it : The cup diet.

FIT

2009-05-10T17:26:00.000-07:00

While everyone is talking about obesity (including me), what seems to be forgotten is the issue of fitness. Being fit is actually more important than just having a reasonable BMI (body mass index). It's only with proper aerobic capacity that insulin receptors are sensitive enough and therefore properly respond to insulin. When they do, glucose smoothly enters muscle cells in order to refuel them and thus allow for more muscle activity. Without fitness, on the other hand, insulin receptors are sluggish to respond, and glucose cannot enter muscle cells. Remaining in the capillaries, blood glucose soon rises to abnormal levels. We typically assume that all thin people are fit, and that all overweight/obese individuals, are not. This, is not true. There are plenty of thin people who are not fit, and lots who are obese and fit. Fitness is not easily defined, but in general, it's a certain capacity to perform physical activity for a certain length of time, without the need to stop or rest. Most of us are capable of doing some physical activity, but few are able to run the marathon. Those who do, are "super athletes", while the rest of us should aspire to just be fit. I say aspire, because the majority of adults, are not fit. We work long hours, drive to work and back, sit at home opposite the TV set, eat at least 3 meals a day, and sleep the rest of the time. Repeating that pattern at least 5 times a week, thus accruing many "immobile" hours. How can we change that, and become fit? What are the components of fitness? These are mainly two. One has to do with cardiovascular(CV) fitness, and the other with good muscle tone. CV fitness is the function of the heart-lung unit. When we're able to either run, walk briskly, swim fast, bicycle distances, hike, skate, or dance for a period of time without stopping, that's good aerobic conditioning. It's when both the lungs and the heart work in concert to bring oxygen in and to move the oxygenated red blood cells fast enough to all the distant organs that need it, in a smooth and prolonged fashion. That's aerobic capacity, and to achieve it one must do it at least 30 minutes daily. What is meant by "good muscle tone"? By that we mean that the main muscle groups in our bodies are viable, healthy, and at their near-peak performance. To achieve that state, they need to be constantly challenged and made to flex against resistance. Simply stated, we need to do squats for the legs, sit-ups for the stomach, push-ups for the chest and shoulders, and pull-ups for the arms. But who has either the time or the energy for that, very few. So the best advice is to pick a few exercises from each group, and create a routine that can be repeated daily, while trying to touch on all muscle groups at least once a month. Those of you who will be able maintain such a pattern, will achieve a level of fitness that will help overcome many medical calamities, including diabetes. Good Luck!

Paris Trip

2009-05-04T18:52:00.000-07:00

Not too long ago I visited Paris. Everything you were ever told about Paris is right. Mainly, it's a great place to visit. Beauty and aesthetics are everywhere. The architecture, the cleanliness, the museums, the Eiffel Tower, The Louver, the Chance Elise, the Mona Lisa, the Arch De Triumph, and , of course, the food - are all simply great! And we went around to all of these places and actually saw them and took pictures like all of the tourists. We also ate in several French restaurants which served authentic French food and even offered good French wine! In short, we had a blast! But soon enough something caught my attention. There were no fat French people to be seen anywhere. I started looking for them, but to no avail. And I don't mean obese, but simply overweight. Where were they? Certainly not in Paris! So I started observing the locals. The way they talk to each other, the way they dress, the way they move, the way they eat, and that led me to the following conclusions. The French culture does not and cannot tolerate obesity. It's so measured, defined, and highly aesthetic, that it always stays withing it's well-defined borders, and so do people. They don't dare expand beyond their youthful waistlines. They gage each other, and utilize great will-power to maintain the BMI where it should be. This expanding beyond one's borders is so American. Here no one is looking ,and no one cares about their or your waistline. Here, there are no social boundaries or restraints on waists. It's a free country, after all.. Well, maybe we should have some social restraints in place. Maybe we should put some social pressure on those individuals who's waistlines are expanding, without regards to aesthetics or to health. The French are certainly more disciplined, and it showes. So lately I've started advising my obese patients that if they wish to lose weight, they should move to Paris..

Physical Activity-Time and Weight Loss

2009-01-11T12:23:00.000-08:00

Most of us have gained weight with aging. We tend to attribute it to life-style, which mainly means over-eating and lack of physical activity. There is also, of course, the component of age itself, which we think has to do with the effect of aging on our genes. Those genes which were so efficient in burning our ingested calories, are now less efficient. So the calories get stored much easier. But this phenomenon of gaining weight with age, may not be as complex as we think. I started thinking about this while walking the treadmill this morning. As you know, it's snowing outside. I also decided not to turn on CNN while on the treadmill (better for your mind). So there I was doing 4 miles/hour, heading towards 400 calories after 1 hour. Weight-gain, as we all know, has to do with being fat, which means gaining fat tissue. Let's focus on fat, then. One gram of fat equals 9 calories. So dividing my 400 calories by 9 gives me 44 grams of fat, which means that in one hour of walking I may be burning approximately 40 grams of fat. Multiply by 25 translates to 1 kilogram (2.2 lbs) in 25 hours, or about 1 pound of fat in 10 hours. So, my friends, if you have gained 10 lbs, my simple math states that you have to get on that treadmill at a 4 miles/hour clip for a total of 100 hours! That's about 4 full days! Obviously, not doable, so here comes the element of time. We all gain weight over a certain time period. How does that factor in? Difficult to answer, but the longer you've been overweight, the more difficult it is to lose weight. To keep things simple, I would suggest that you do the math : 1 lb gained=10 hours on the treadmill at 4 miles/hour, and start by returning that "debt" ASAP. This may take a while, but should be completed as a first step. After that's done and you have burned off that fat, you have to know how many calories you consume daily, and be ready to "treadmill" off any extra calories that you may have consumed that day. Start a log which elaborates both calories consumed and calories burned, and try to stay ahead of the game. Don't forget to deduct for those calories that you actually utilize for daily activities. Good luck!
In normal physiology, carbohydrates are the main energy source for active muscles. As we jog or walk, they're released from the liver and delivered to muscle. Only when carbohydrate sources are depleted or cannot enter muscle cells, does the system resort to tapping fat tissue. Things change in the type 2 diabetic, where fat is released along with carbs, from liver sources. For the purpose of using the above recommendation and thereby achieving the stated goals, let's assume we have a diabetic physiology.

Treadmill vs. Walking Outdoors

2008-12-28T19:47:00.000-08:00

As long as you do either, you're in good shape, which one, however, is better? There is no single answer, obviously, otherwise we would not discuss this. But one may have an opinion. Since we started having this very bad weather over the past week, I had no choice but to go to the treadmill. I found myself walking at a 4 miles/hr clip for almost one hour, burning 400 calories. That's pretty good if you can maintain it on a regular basis. The problem, I found, is with the TV set, that's part of the treadmill. It's built-in and we all turn it on. So in addition to getting a workout, we end up being also updated on the latest news, as well. The problem with that, however, is that our minds are not getting the work out. You see, when you work out, your brain is getting a larger than usual blood supply, which serves as a booster-like effect for the brain's function. While working out, in fact, your brain is or can be most productive. But you have to let it be. Focusing on the TV screen is equivalent to hand-cuffing the brain and forcing it to follow the information being projected. Letting it be, allows the brain to function freely and sometimes most productively. Some people attribute this phenomenon to increase of endorphin levels in the brain, others to sheer blood flow. Regardless, that is one of the advantages of walking outdoors. Unless, of course, your ears are plugged into some electronic music/talk source such as an mp3. Being plugged is also equivalent to those handcuffs. If, however, your ears are not plugged, your brain is free to roam, and that's when the best ideas appear. So doing the treadmill is a good aerobic exercise, but only fair for the mind, while walking the outdoors is good for both.

Weight-Loss Surgery

2008-10-22T20:09:00.000-07:00

Yesterday's New York Times Science section had an article by Denise Grady about a new procedure for obesity. What's novel about this approach is that there is no cutting. The surgeon goes through the mouth, and by using various methods and equipment (mainly a stapler) is able to create an artificial pocket in the stomach, thus rendering it smaller. A smaller stomach gives a quicker sense of fullness, and the patient stops eating. Patients with these procedures have been known to lose up to 100 pounds! Remarkably, obese individuals with diabetes, have shed their diabetes within several days of surgery, many weeks prior to losing weight. This has intrigued many doctors, and the current explanation for this phenomenon has to do with the physiology of the gastrointestinal(GI) tract. The GI tract makes multiple signaling proteins which are responsible for orchestrating the complex processes of digestion. Among others, are GLP-1 and GPT, which are secreted by intestinal lining cells in response to passing nutrients. These proteins then travel to multiple areas where they exert their effect. One of the effects, is to stimulate the pancreatic beta cells to make insulin. So by shifting the intestines around, food is detoured for an earlier exposure to cells that make GLP-1. Consequently, insulin is secreted early in the digestive cycle. lately, surgeons have been advocating these procedures to diabetic non-obese patients. The proponents of these surgical procedures go so far as to say that the future of diabetes care (type 2) is surgical. Well, my friends, (as John McCain says repeatedly), not so fast. Diabetes is a complicated medical syndrome with multiple pathophysiological defects, that need to be addressed. By cutting food supply, we only address part of the story. What we need is a more comprehensive understanding of the pathophysiology of this condition. In the interim, however, anything beneficial will do.

Update, 2008

2008-10-16T20:45:00.000-07:00

It's been more than a year since I've written anything. Just been too busy and tired. Well, I have a new desktop, and while exploring it, I came across this blog.. So what's been happening, you're asking. The real action has taken place in the two offices. We now have two nutritionists - one for each location! We have our own Podiatrist who comes to both locations on a weekly basis - Dr. Rosenblum. We still have our Nurse Practitioner - Caroline - now only in the Fort Lee location. We have a new camera which takes photos of the retinas, without needing to dilate the pupils, and I'm moving the camera between locations. We're planning to restart our nuclear stress testing in both locations, and ,of course, we have Ultrasound and Nerve Conduction testing in both locations, as well. Most importantly, we were recently recognized by the American Diabetes Association as a center of excellence for care of the diabetic patient.
I'm still trying to write my newsletters, although not always as punctually as necessary, but I try. In the not too distant future, I'm planning to involve a Chef/MD in teaching classes for our patients. In these sessions patients will be instructed in proper cooking for the diabetic. Please let us know if you are interested. There will be a fee, which will include the meal following the demonstration. We also plan to start a monthly meeting in the evenings for patients who are interested in reviews by a Diabetes Nurse Educator. This will take place in the offices, and will be free of charge. As always, we are eager to hear from you and receive your suggestions.
I promise to try and write again soon.
Dr. Litvin

Fresh Air and Leg-Power Day

2008-03-30T12:25:00.000-07:00

It's Sunday, and it's spring outside. The sun is out and the air is crispy cool, with a slight breeze. Perfect for a walk. I started late, but better late than never.. My usual weekend walk takes me about an hour and a half, but more importantly, it takes me up some steep hills. As I set my breathing to the pace of my walk, I realize how important healthy and correct breathing is. We take it for granted. The fact that the air-containing oxygen molecules rush into our nostrils and into our lungs in order to join the hemoglobin proteins in our red blood cells, is tantamount to a wonder. I recently noticed that my nasal air passages have been clogged ever since coming back from a long flight several weeks ago. On the flight, I must have been exposed to some air-born viruses which were trying to get access into my respiratory system but were likely blocked by my "local" immune system. The consequence of that episode is probably why I have been "clogged". It's been a few weeks, I was thinking, and this fresh air walk aught to do it much good. How often do we really have a "fresh air" walk? One that clears out our nasal passages and exposes us to pure air? Certainly not on an airplane! Walking up hill, in fact, does that with a vengeance. As fresh air gushes into our lungs, it must expose local viruses to a higher oxygen concentrations, which can't be good for them. Just then, I was reaching one of the peeks, and couldn't help but feel my thigh and calf muscles tightening. That had a great feel to it! Leg power! We always talk about horse power, but hardly about human leg power. It was then that I was eyeing this new Porche sitting in the driveway of a nice house with the driver revving up the engine, transmitting to all within earshot his horse power prowess. I have leg power, I thought to myself, and that's what counts. We need to get back to basics. The industrial and the electronic revolutions have allowed for much progress on a social/global level, but possibly for some regression on the personal level. As humans, we need to be active and outdoors. We need basic things such as oxygen rushing into our airways, and to use our leg power. So please everyone, just go back to basics and don't underestimate the importance of the "simple" things in life.

Fear of Failure vs. Seeking Success

2008-02-24T14:09:00.000-08:00

My sister was on the line, telling me that someone wanted to speak to me. I had no clue who she was referring to, and didn't recognize the voice on the other end asking me "where is that God... Zippo lighter that I gave you? What?, I responded, bewildered. I vaguely felt some familiarity with the topic of the question, but had no idea where from, nor who was the person asking. He then asked me if I knew who he was, and I told him that it's almost within my grasp, but that I just can't put my finger on it. It's Phil, he said, your old-time buddy. We haven't spoken nor seen each other for over 40 years! No wonder I couldn't remember. Well, we went on reminiscing for a few minutes, pledging to get back in touch, and soon the call came to an end. Later, thinking back, I realized that Phil was part of a period in my life when I made decisions which were mainly driven by fear of failure. He had given me that lighter when I decided to leave college, and the country. I was unhappy with my situation, and ran away. Since then, "much water has flowed under the bridge". Am I still in that fear-of -failure mode, I wondered? Am I still running away? The answer to that question is resolutely, "no". I've since made a switch. I don't know how it came about, but today I feel a distinct sense of "seeking success". It's the kind of feeling that makes one want not to give up trying to get somewhere or achieve something that one decides to do. It pushes/pulls one forward! It makes one "driven". I remember once many years ago seating with friends talking about what each of us was doing, and with my turn I went on about wanting to build a mini "diabetes center". Their response was very doubtful, with one of them saying that it will not succeed, since many people before me tried and failed. I, of course, persisted, and I think one can safely say that today I do have a "mini center". How does one make the switch from fear of failure to seeking success? Difficult question with many potential answers. I think that what's most important is to have a passion. To feel strongly about something. When you do have that feeling, almost anything can be achieved. If, on the other hand you are "limp" and lacking in energy, don't expect success to pay you a visit. It's the passionate doers who make it to their success. So find your passion, and go for it..

My Treadmill

2008-02-23T11:38:00.000-08:00

My wife bought one a few weeks ago. I never would have, because I like walking outdoors and interacting with the environment. I like to feel the fresh air on my face, I like to breath it deeply, I like to feast my eyes on everything, and I like to listen to the birds also. So for me walking becomes a little adventure. The treadmill, of course, could not offer any of that. But, there it was in our den, waiting to be tested. I resisted for several weeks, braving the cold temperatures with the aid of several layers, but finally even I succumbed. Hell, I said to myself, it's snowing - I have no choice! So, there I was on that treadmill for my third time already, finding some subtle advantages. First of all, I'm jogging at 5 miles/hour! It takes me 5 minutes to warm up - walking, and then I start with the jogging. I go for 20 minutes, burning 200!! calories, and then I walk again for 5 minutes - coming in for a safe landing.. I've done it only twice, but I can see that this may develop into a long relationship. You really learn to appreciate the value of calories this way, and consequently think about them when you eat. We simply don't realize just how many calories we ingest daily, and just how difficult it is to burn them off. But besides the burning of the calories, there are many other advantages, as well. I presume that my aerobic capacity/conditioning will improve with this routine (if kept up). I already feel the muscles in my legs, and a slight suggestion of pain in the knees. If my knees hold, I can see only advantages. I would like it to become like a daily ritual. Many researchers view it as an activity which promote longevity. They claim that the time that you spend on the treadmill, is basically time added to your life-span. Could they be right? Regardless, it seems to me that such an activity on a daily basis is very good for one's mental and physical health. Please indulge yourselves and start your daily half hour of promoting your longevity.

Twins As a Lab for Type 1

2007-11-20T18:50:00.000-08:00

Today's NYT science section has a long article about the plight of a family discovering that one member of their set of twins has type 1 diabetes. Until it is discovered, the teen is in diabetic ketoacidosis, and just shy of losing her life if not for her healthy twin sister urging their plastic surgeon father to urgently call for an ambulance at 3 AM. The markedly underweight girl is saved with intravenous fluids and insulin, and since the episode has apparently done well. The article then takes us to the treasure trove of information that the twins represent, and to the logic of using this human lab for further enhancing our knowledge about this disease. The rational has to do with the assumption that the twins face an identical genetic risk to get diabetes, and with the reality that only one of them actually does. Furthermore, with the assumption that the unfortunate newly diagnosed diabetic has succumbed to some environmental assault which has not compromised her healthy sister. That assault may be a virus, which causes the immune system of the individual to produce antibodies which are now damaging the insulin-producing cells(beta cells). Researchers are reasoning that if it were possible to avert or delay the immune response of the individual, damage to beta cells could be put "on hold". In order to "trick" the immune system, researching are using oral insulin in tablet form, taken daily by the healthy twin. A clinical trial is set up to which multiple twins are recruited, and treated with either oral insulin or a placebo (dummy pill). These twins are followed every 6 months with a glucose tolerance test in order to assess their tendency to develop diabetes. Results are far from being available, so at this point one can only speculate. Suffice it to say that if this indeed works and the immune system is tricked, that's great news. It means that all those individuals at risk of developing type 1 diabetes may look forward to a healthy and normal life. However, it may be that we are too optimistic and simplistic in our approach to this problem. Simply stated, the insulin protein as such, may not be the antigen in question at all. Other proteins may be playing a central role. How to identify these proteins is the real challenge. Let's all hope that their identity is soon to be realized, but until that time we all have to be vigilant in educating the public about diabetes in general, and about type 1 in children/teens, in particular. There's always hope that the right discovery is around the corner.

IBM to the rescue

2007-10-24T20:47:00.000-07:00

Today's Wall Street Journal has a short article about IBM's new and innovative approach concerning childhood obesity. IBM plans to pay its parents-employees for enlisting their obese kids to participate and complete a 12-week online program of diet and exercise training. IBM is reasoning that its employees will be more productive when their kids are occupied in such activities, and in the long run will thus help the company. Moreover, IBM estimates that its employee-wellness programs have saved it between $100 to $130 million a year in avoided health-care costs. Wow! This is significant. We're seeing here how big business is coming up with novel ideas regarding this epidemic. The realization that profits may be compromised by this epidemic has caused corporate America to pay attention. This may work, but I have a hunch that only to a marginal extent. What I think is missing are role models. We need some leadership and some real impact on the food industry. We also need to change the preception of what is healthy, and lump obesity together with diabetes and with smoking. If I were IBM, I would create "boot camps" for obese kids. I would take them out of their food-toxic environment and into a healthy one with good nutrition and lots of physical activity. Kids in the big city are trapped in an environment which almost always leads to obesity. We need to either change the environment, or take the kids out of it. The latter is easier. I would also enlist the professional athletes for this cause. They are basking in riches and in public attention, but are short on the contributing-end. This should be an oppurtunity for them to contribute back to society, and who better to do it for then for the kids. They should make this into their mission, and help our kids regain their self esteem. If big business was to team up with the professional athletes, we may have a winning team on our hands, and may be able to turn this obesity tide around. Is anyone out there listening??

Gift from a Patient

2007-09-10T11:23:00.000-07:00

Coming into the office several days ago, I saw three containers filled to the brim with beautifully colorful fresh vegetables, with a single rose on top. Large red tomatoes and small cherry ones were there, along with huge green cucumbers, several halopinio peppers, and many green peppers, as well. One of my patients had brought the bounty from her own garden. I was taken a back with surprise and joy. I didn't remember receiving such a nice gift, and so personal, from anyone before, let a lone a patient. So that evening I went home with one of the basket, itching to make a salad for dinner. Calling my wife to join me, I sliced the vegetables, added olive oil, balsamic vinegar, salt, and some black pepper, and mixed it all. I put some pita bread in the toaster, took out the jar of Greek black Kalamata olives from the frig, and feasted on the site. My wife arranged the table, and we sat down with some hot mango-orange tea to wash it all down. Eating the salad was a real treat, but even more so, because it came as a gift from a patient. Seeing patients in the past, I thought to myself, was based on similar circumstances. It was bartering health care for items which were important for self sustaining in a difficult environment. Doctors were part of society then. They did not stand out particularly, but rather melted with the rest of society. Not so today! Doctors today have a sense of entitlement. They consider themselves above the fray. They demand a better financial present for themselves and for their families, and they expect a better future as well. But that is currently not available. Consequently, doctors are leaving their profession to seek better opportunities elsewhere. Those of us who are left behind are the ones that possibly could appreciate a gift of vegetables. We, despite our ambitious wives, are ready to settle for a bushel of vegetables. We appreciate the interchange. We never intended to become rich from medicine in the first place! We just wanted an interesting profession, with some gratification to go along. And that, we got! So as long as the vegetables are coming, count me in!

Some New Tricks

2007-09-02T09:27:00.000-07:00

Life-style changes and diets are two terms that I often use when talking to patients with diabetes who are in most cases in need of both. But how to drive these points home, and even more importantly, how to achieve results. There are myriads of ways and suggestions out there that only seldom work, so one has to be careful when introducing any new ideas. Well, I'd like to take a chance, and do just that. I'm going to talk about one idea for each of the above areas, so as not to "overburden" you, and would like to know if this has proven beneficial in any way shape or form. If you think that these ideas are "hog-wash", you may let me know as well.
First regarding your diet. I would like to recognize the fact that one of the more difficult areas of dieting is our ability to achieve enough self-control, so that we can at will either stop or start eating. When hungry, typically, we lose control, and it's somebody else doing the eating. Only when that somebody else has achieved full satiety, do we really push the plate away. Well, that's called loss of control. How can we regain that control? How can we be again the drivers of our "vehicle". Just like with any other machine that needs a driver, it takes practice. We need practice "driving" our bodies. The problem with many of us is that we have relinquished control to that part of the "panel" where the automatic pilot is located. What I suggest is that we resume the controls. How do we do that? It takes training and discipline, and, of course, time. Give yourselves a few weeks. During that time, start manipulating your eating habits according to whim. Make decisions about every little detail. Decide when you're going to eat, which meals you'll eat, how much you'll eat, what portions will suffice, and most importantly - how much you will not eat. Make sure that you don't finish everything that's on the plate. Remember, you are in control! In fact, make it a rule to always leave something uneaten on the plate. Remember, you are controlling the plate, and not the other way around. After a few weeks of this, you should be in a much better position to control your caloric intake. Good luck!
And now regarding this ever-important life-style entity. Into this entity can be thrown everything of value which makes our lives worth living. Think QUALITY and start itemizing. What adds quality to your life? Not just your physical life, but also your mental, spiritual, and psychological life, as well. There are many items to be added, for sure. Start by listing them in those different categories as I've outlined above. Some of you will end up with very long lists, I'm sure. What should be missing from these lists is "money", which in and of itself cannot add quality, unless when used as currency. The lists can stay open, and items may be added with time. Now start using the lists. Try to incorporate items from the lists into your every day life. Try to incorporate at least 2 to 3 items daily, and increase if possible. The more items included in your every day life, the more quality you are adding. We all know what REAL quality means.. It's health, physical activity, healthy food, good sleep, good friends, family, good sex, interests, relaxation, vacation, reading, giving, helping, and many more items which can and should be personalized. The more you focus on these items, the more involved you are with life-style issues which add quality to your life, and makes it worth living. Stay well.

God's Warriors

2007-08-26T19:35:00.000-07:00

Christiana Amanpur just had a 3-part series on CNN about religious fanatics from the three main religions, and it was VERY IMPRESSIVE. She is a gifted journalist with wonderful diction who gives an even-handed report of the current state of affairs. She focused on fanatics who use God's word or message as a justification for their actions. People who radiate a sense of entitlement and virtuosity that is indisputable and will not be influenced by other opinions, and that are willing to go to all extremes in order to enhance their beliefs. People who are not deterred by the injury or death that they commit in the name of their God. The common denominator is, of course, religion and what it can do to us, and what we can do to others, using it's name. It makes you wonder about us, and about our needs as humans. We must have a very basic need for spirituality, but some of us get carried away. Those that do, are not satisfied with the benefits of spirituality that they incur for themselves, they have a need to shove it down our throats, as well. In all three major Western religions, there are extremists that will not take no for an answer. They view themselves as the messengers of God, and will not abate until his "message" is delivered. Others, on the other hand, can distance themselves from this involvement, and continue with their rational every day life. What makes a fanatic become one, or has he/she always been like that? Or maybe some people under certain circumstances, "slide over the top". I don't think we know. Human beings are very complex, to say the least, so it is most likely some combination of the above possibilities. I presume there is some research in this fascinating area of human behavior. Can we tell who will become a fanatic? Can we diagnose it early and possibly avert it? Imagine if we had a test that could predict or warn that a certain personality is likely to develop fanatic features. And imagine that we could possibly develop some antidote that would avert such behavior. The world would certainly be a better place for it. The world has no need for fanatics! They are responsible for pain and suffering throughout history, and should be excommunicated. Human progress has been achieved by dedicated talented and modest individuals. By those who see themselves as being an integral part of the human web. Individuals who work towards unity and not towards divisiveness. Fanatics usually hold extreme views which demand extreme actions. They are not concerned about the means, but rather regard the ends as most important. I'd like to propose that the opposite should actually be regarded as important. In medicine we learn that first and foremost we should :"do no harm". That same rule, I think, should apply to all human action. It's OK to have ideals and ambitions, but we should all abide by that important dictum. It seems though, that the social pendulum is swinging towards fanaticism, and it's taking all of us for a ride. Hold on to your seats.

The Ailments of American Medicine

2007-08-12T19:36:00.000-07:00

This Sunday's New York Times had the leading editorial about the state of American Medicine, and it wasn't a pleasant read. The World Health Organization (WHO) apparently ranked the US in the 37th spot from 191 states, seven years ago. More recently, the highly regarded Commonwealth Fund placed the US in the next to last spot compared with 5 other nations - Australia, Canada, Germany, New Zealand and the United Kingdom, in quality of care and access to it. All major industrialized nations have universal health coverage, whereas the US has 45 million people without, and many more millions with very poor coverage. True, there is more access to health care in the US, but not if you need it at night or on a weekend. On those occasions, you better head to the nearest emergency room. If you're poor, you have less of a chance to get care than if you're well of. The US ranks last among 23 nations as far as infant mortality, and near the bottom in healthy life expectancy at age 60. We're bad at reducing the obesity epidemic, but we're good at reducing smoking. To our credit is that we provide the "right care" for the condition, but poorly in coordinating the care to the chronically ill. We rank first in best survival from cancer conditions, but last when it comes to controlling for chronic conditions such as diabetes. We lag behind our European colleagues in conducting electronic medical records, and in brief, there is allot of work yet to be done. Why is the situation so bleak? I'm sure the answer to that question is very complex, and multi-factorial, but the right question to ask is: "can it be fixed?". The answer to that question should be a resounding: "yes".

Part of the reason for the current state of affairs may be explained in an article I just read in Business Week. It's about the wasted effort Congressman Henry Waxman (D-Calif) has gone to, to try and limit the pharmaceutical industry's promotional advertisement during the first 3 years a new drug is on the market. The drug lobby, of course, won, and the effort was defeated. The only other country where direct to consumer advertising is allowed is New Zealand. The rest of the world thinks its too dangerous. But in the US, contending freedom of speech, TV drug advertising surged to $5.3 billion in 2006, and is steadily rising. Critics of drug companies are alarmed by the combining powers of the drug industry and the media giants, and would like to disengage them at least for the first 3 years that the drug is out.

What is really wrong with the American medical system? Mainly, the fact that it is not about healing, but about profit. These two concepts don't always coincide, and in fact typically, collied. Profit is a great way to move a society from poverty to a self sustaining condition. Case-in-point is China which has made such a move and is today a rich nation. But pure profit should have no role when it comes to healing the sick. The motivation there should be different. Typically, healing should help embolden a person's reputation and stature within the society that he/she is part of, and not necessarily make him richer. But since everything in this society is equated with money, success mandates having it. So healing becomes a business that everyone is devising ways to penetrate. What we see is that some doctors are in it for the money, and some will not get near it for the same reason. Instead of being recruited for the job of healing for altruistic reasons, or volunteering out of a calling, what beckons are the dollars. What should we do??? I believe that (a)the profit motive should be removed from medicine, and (b)that the USA should move towards a single payer system. Lobbying at the congressional level by the pharmaceutical industry, should of course be banned, thus allowing the doctor to give his opinion prior to the patients exposure to biased opinion.

Weekend Biking

2007-08-04T12:14:00.000-07:00

I must confess, I'm a weekend biker. I've been doing it for quite a number of years. Mainly with friends, but also by myself. Typically, on a Saturday morning and obviously weather-permitting. Of course, it's nice to be outdoors, feeling the wind and experiencing the camaraderie, but there is more to it than that. There you are on your bike, solely responsible for its propulsion and maneuverability on the road, and, there are those hills where you really have to pump. In short, it's a challenge. Every extra pound you carry, becomes a burden. In addition, you have to be aerobically fit. On that "hot seat" of the bike, you are in control. You can't rely on anyone but yourself. So given that everything is alright, and your joints don't ache, and your muscles don't send you any unfavorable messages, and your breathing is good, and you are managing those hills, the prize is extraordinary. It's akin to any experience where you are moving fast under your own power. It's almost a primal feeling. It's what nature meant for us to do. It feels "right". I guess it goes back to one of our primary drives as living things. It must be similar to what birds are feeling when they take off, or what any animal in the wild is feeling when it's moving fast. All of that, of course, is unavailable or unattainable to our "man-made obese" members of society. They cannot just get on a bike and attain that feeling that I was talking about. They are "grounded" by their sheer weight. The reason that I call them "man-made obese", is because it dawned on me that obesity is non-existent in nature. Nature has no tolerance for obesity. In the animal kingdom, you better be at your top form, or you perish. The purpose of calories is to procure energy for survival. Survival in the narrow sense of your own organism, and survival in the broad sense as pertaining to your species. Obesity is a luxury that does not exist in nature. It's purely "man-made". We, as homo-sapience, have made a leap away from nature. We are not really a vital organic part of nature. In fact, we have managed to recruit nature to our ends. We exploit nature, and we reap its bounty. Not being in a position of concern for our survival, we have become complacent and even shortsighted about our position and relative significance. And consequently, man-made obesity is reaching epidemic proportions. There is allot of blame to go around, but that will not help us. What we need is a strategy that will help us get back to where nature intended us to be. Nature would have us run like a deer, fly like a sparrow, or swim like a seal, if we were not human. As humans, we have our limitations, but nature certainly had not intended us to become obese and immobile. So let's all try to move the pendulum back towards an existence which is more at harmony with what nature had intended for us. Let's view man-made obesity as a consequence of moving away from nature with all of its related implications.

Food Ads

2007-07-11T04:09:00.000-07:00

Yesterday's Wall Street Journal had a report in it's Health Journal corner about the effect of watching food ads on TV on kids and their subsequent tendency to overeat. In two groups of kids, researchers in Liverpool found a significant effect. In kids 5-7 year old calories consumption increased by 14% to 17% after watching food ads as compared to the control group that watched cartoons. In the 9-11 year old, consumption went up even further, to 84% to 134%! This later group were heavier, and were more likely to eat sugary and high fat foods. This has finally gotten the attention of government agencies, and of the food industry. Both say they are committed to reduce kid's exposure to food ads. The food industry, the article goes on, has been claiming that it is only trying to build "brand loyalty", so that the child will ask mother for the item while shopping with her. Now we finally have data that proves that this is a naive approach. Kids will eat more of any type of food after seeing food ads on TV. Large food companies are planning to remove some ads and to reduce exposure of kids to them. How effective that will be, only time will tell. What's important is the recognition that young minds are very easy to impress and to manipulate, and that it is the responsibility of all adults not to abuse this, but rather to protect it and to channel it into constructive and healthy directions.

The Joy of Jogging

2007-06-13T08:08:00.000-07:00

I've returned to jogging. I started several weeks ago after a hiatus of many years, but already I feel different. Of course, I lost a few pounds. But the feeling that I'm experiencing is not due only to that. It's a general feeling of well being. My leg muscles are tight, and my hunger is down. I also have this new ambition to stay as thin as I can. Jogging, I find, puts one in a "positive" vicious cycle which promotes normal body weight and a sense of good physical, mental, and even psychological health. I initially started jogging about thirty years ago after reading a paperback book by an American (forgot his name)who started doing so after his father dropped dead from a heart attack at a very young age. Right afterwards, it became a fad all over the western world. At the time, I was a young father and a budding medical student in Jerusalem. I used to run all around the suburbs where I lived. Several years later I bought a bicycle, which I used to ride to work. Once, I even rode it from Jerusalem all the way to Tel Aviv. With the years though, I slowed down. I stopped running and started walking instead. I still ride the bike on weekends, but that special feeling that one gets from jogging has since eluded me. I know that a lot of people are saying that jogging is bad for you. They say you get arthritis of the knees, and back problems. I disagree with that. It's like any other physical activity. If you do it right, it's great. If you don't, you risk getting injured. If you're overweight, you have to do it very gradually in order to develop enough aerobic capacity so as not to become too short of breath. Don't give up, because the benefits are great!

Sugar Cane

2007-05-26T05:47:00.001-07:00

The NYT had an article about a small shop in Cairo where juice is being extracted from sugar cane, and where people from all walks of life, all religions, all ages, and all financial status hover for their "fix". The juice is apparently white-green in color, served in small glasses, and is chugged down in one gulp. The shop is located in the old part of Cairo, and has been there for many decades. All around everything has changed, but it has endured and maintained its crowd of followers. The cane are grown in the fields along the Nile in Upper Egypt. In the shop, they are run between two steel rollers, and the juice is served with ice after the pulp is removed. The shop is called The Sons of Saad Afifi. I remember from my childhood buying a piece of sugar cane in the local produce store, and gnawing at it - spitting out the pulp and savoring the sweet juice. I can still feel that raw sweetness going down my throat. I haven't done it since, but lots of people in that part of the world apparently still do. That craving, for sweetness, is not restricted to humans alone. Many species, the bear being best known, have that craving as well. What is that craving, and why do we have it? I don't know if a specific answer to that question is available, but certainly evolution makes no mistakes. The simple explanation has to do with the fact that sugar is a source of energy, and linking it with a craving ensures the demand side of the equation. If the supply is ample however, why does the demand continue? That probably has to do with nature's way of protecting itself. Modern man, with his strive for self control, should try to curb such cravings. I know that it is easier said than done, so I can only sympathize with any of you out there, who fail.

ONCE - A Gem

2007-05-20T08:50:00.000-07:00

A new Irish movie is in town. It's very unpretentious, seems low budget, with a very simple plot, but yet, it's a must-see. Boy meets girl, they come from different worlds, they're obviously from different age groups, but they're drawn together because of their love of music. That's what the story is really about. It's how almost magically music can pull people together, and how it can make them scale to even higher peaks. And the by-product of their energy and musical talents is something which is as wondrous as a newly born baby. The movie does all of this without resorting to sexuality, but with an impact that leaves you with a fixed smile on your face and with a thumping foot to the rhythm it projects. This is definitely not Hollywood, and it's also not Rap music. There is no "over the top" here for purposes of grabbing the audience's attention. There is no swearing or use of foul language. It's simply amazing to behold that there are actually people like that, somewhere. Our senses have become so raw from the constant bombardment of the entertainment industry, that it takes a while to adjust to the subdued volume that this movie projects. "Brilliant", to quote the leading actor, the message comes across just fine. The extra "volume" which is constantly used by Hollywood, is really not necessary.
For years, I've held the view that real damage does occur when our minds are exposed to offensive stimuli. We can't yet measure this damage, but it's only a matter of time until we will be able to do so. Such damage could have, for example, played a role in the fatal and grotesque violent outburst that we saw done this year by a student at Virginia Tech. It was reported that prior to the murders, he watched a violent Korean movie multiple times. As an aside, that same Korean movie was nominated by the famous director Tarantino (from Pulp Fiction) for the top prize at the Cannes film festival last year. Worst than living in a violent culture, we live in a culture where violence is glamorized, fully financed and supported by corporate America. Just like we got wise to the damage caused by smoking, it's time we become wise to the damage caused by the violent-projecting entertainment industry. Furthermore, as the tobacco industry is being sued for damages, so does the entertainment industry deserves to be sued. They should be held accountable, and not hide behind the argument of freedom of speech. But their most grievous offence is focusing on the young. Like other industries, they know that if they "hook" younger people, they have a devoted life-time consumer.
It is our duty as responsible adults to prevent our young people from being exposed to damaging stimuli, physical as well as mental. The early Greeks had it right when they strived for the balance of a healthy mind in a healthy body. Can we today claim that our young generation has achieved that goal? Probably not. That only means that there is allot more work to be done!

Blaming Moms..

2007-05-20T06:14:00.000-07:00

In his Sunday morning health show, Dr. Gupta from CNN gave a snippet which is bound to be controversial, and even down-right upsetting. A certified epidemiologist was brought in and claimed that the increase in childhood obesity in this country - 16% of kids are obese - parallels closely the increase in the number of working moms. The phenomenon of working mothers is apparently something that started in the 80's, when family income was insufficient and/or when being a single mom needing to support her family, became not too uncommon. What followed, the epidemiologist continued, was a marked increase in eating out at fast food restaurants. Mothers no longer stayed at home to prepare dinner and to monitor the kids and encourage them to go outdoors and exercise, but lacking in time, settled for a fast-meal.
What's unfortunate about this argument is that it focuses on mothers who made the change from being a stay-at-home mom to a working mom, instead of focusing on the larger social issues that initiated this move and have since not abated. Society has changed! It is no longer composed of the traditional family units that are made up of a working father and of a stay-a-home mother. In fact, the traditional family unit is today a rare phenomenon. Maybe having lost the traditional family unit has something to do with childhood obesity, but blaming working mothers for that unfortunate outcome, is bordering on plain cowardice. Working mothers are trying to do their best under the current circumstances, and we, as a society, have to come up with better explanations and better solutions for this epidemic, than blaming what could be defined as the pillar of our social structure.

It Takes a Village...

2007-05-12T19:11:00.000-07:00

Thursday's WSJ had a front page article that really caught my attention. It was titled : As Child Obesity Surges, One Town Finds Way to Slim. It went on to tell how in one small town in Massachusetts, the whole community is involved in combating childhood obesity, with some measure of success. The town is Somerville, and the program was launched by Dr. Economos, who is a specialist in pediatric nutrition. Dr. Economos has recruited the mayor of the town, and the whole community. Roads leading to school were made safer, leading to a 5% increase in children walking to school. Bike paths were marked, and pedometers were given. Dozens of new bike racks were put in place, and city workers were reimbursed if they joined a gym. Restaurants committed to this project (named Shape Up), received designation as participants if they changed their menu to include smaller portions and for using low-fat substitutes. Food in schools was changed with the emphasis on improving its taste and nutritious content. Children are allowed to eat as much vegetables and fruits as they want. With all these changes, when researchers compared Somerville's children to neighboring towns' children, they found a significant decline in Body Mass Index (BMI). Dr. Economos was able to show that by changing the environment in the town, and by involving everybody, conditions were such that children no longer become overweight, but rather even lost weight. This is a very important lesson for the whole country! We have to create an environment which is conducive for maintaining a healthy weight, and not an environment where children gradually become obese. Unfortunately, the current environment in a typical American town is calorically "toxic". By being expose to this environment, our children will inevitably and irreversibly, become obese. It is our (the adults among us) responsibility and duty to change the environment!

Longevity and Red Wine

2006-11-02T21:22:00.000-08:00

Both the New York Times and The Wall Street Journal today had a major article on the effect of a substance derived from red wine, on longevity in mice. The substance in point is called resveratrol, and is able to also protect mice from the expected ravages of a high fat diet. Mice on massive doses of this drug were significantly healthier while on the same fat diet as their twins who were not on the substance and eating the same diet. Clearly, science has stumble into something profound. Here at last is the "mother" of all substances. Not only does it protect from disease, it also prolongs life. For the first time in human history, science has a substance that prolongs life. The elixir of youth, no less. Even if humans will not respond similarly, much mileage of information will be derived, eventually.
If indeed that proves to be the case, larger problems may loom. Who gets the drug? The privileged? The rich? The powerful? Or maybe just the clergy? The problems may be larger than expected. A whole Pandora's box may open. Therefore very timid and careful steps must be taken. Lets keep our sense of civility and wait patiently until solid data in humans is made available, while sipping some red wine...

Medicine in America

2006-10-15T09:31:00.000-07:00

After some thought, I've decided to write about a topic which may seem to some of you a bit "unconventional". It's a complaint. A complaint about the state of affairs in American Medicine. Obviously it's biased, and obviously it is presented from my vantage point. I see patients in two different offices which are located in New Jersey. The type of medicine that I do is always non-emergency, ambulatory, and typically consultative. People who see me always have to put their trust in me and listen to my advice. Mostly, people do, and quite often they ask me about other medical issues that they encountered. They often tell me about their experiences with other doctors, and sometimes about their experiences even with their dentists. This has been going on for many years, and it's probably the same with other doctors, as well. I would like to speak out about some of my impressions from these conversations.
Without going into specifics, many patients convey a feeling of insecurity and lack of complete trust in the actions and decisions made by their doctors. Some of these decisions, I must admit, seem strange even to me. Doctors are no longer perceived as being the patient's advocate or even partner/friend, but rather very often as the adversary. Their underlying motives are sometimes perceived as being non-professional, or even down-right greedy. In some cases they cross the line into frank malpractice. What is the patient to do? It may be only a few rotten apples, but that's enough to create a bad impression. The system, of course, is to blame, as well. The emphases is not on excellence, but rather on money. "If you bill, they will come", rather then "if you cure they will come". The incentives to bill eclipse the incentive for excellence. But that's the system that we have, and for now we must live with it. Ideally, the system should change to a system that rewards excellence only. Meanwhile, what are the patients to do? I've thought about it and have come up with my conclusion that what is missing is an alternative way for the patient to get trustworthy and professional advice from a third party. The patient needs a friend in the medical community. Those of us with "connections" know what that can mean. But most patients don't have connections. So, I'd like to create a service that offers friendly professional advice for all. To be that advocate, and to facilitate that "connection". It may sound too ambitious, but it sure is needed. Before embarking on such a journey, it would be nice to have some reassurance from the general public. Please tell me and ask your friends to tell me if you think that this is a reasonable idea. My wife was very much against it. She claimed it would never work, and that only the government should step in for such a challenge. I beg to differ. What do you think?

Transplanting Pancreatic Beta Cells

2006-09-28T20:52:00.000-07:00

Several years ago, scientists from the University of Alberta in Edmonton, Canada, published data about their success at transplanting cadavar pancreatic beta cells in type 1 diabetics. The proceedure they described was not too invasive, and involved infusing these cells into the abdominal cavity of volunteering diabetics, where they setteled in the liver. While viable, these cells where able to function like normal healthy beta cells, either secreting insulin when necessary, or shutting off, to prevent iminent hypogycemia. The major issue, of course, was how to prevent rejection by the host's immune system which typically will "seek and destroy" all invader cells. The Edmonton team was able to overcome rejection by coming up with an anti-rejection coctail which did not damage the transplanted beta cells, and thus allowed for their function. Today's NYT reports a study from the recent NEJM where a group of 36 such patients were followed for two years. By that time, only 5 of the initial group were able to avoid the use of injected insulin. This is disappointing, to say the least, and it obligates scientists in this field to come up with more solutions. Most progress is currently being made in the area of insulin pumps, which soon will function along with a glucose sensor and provid for a "closed loop" system imitating the normal pancreas.

Poor Sleep and Diabetes

2006-09-19T20:41:00.000-07:00

Today's WSJ had a short article about a recent finding that there is more diabetes in individuals who sleep less. The study was conducted in African Americans, and looked at diabetes type 2. The mechanisms are, of course, yet unknown, but nontheless, intriguing. The only connection I can come up with is stress. Less sleep could mean more stress, and more stress translates to more cortisol. Cortisol is the stress hormone secreted by the adrenal glands which are situated on top of the kidneys. Cortisol is great for preparing the body for stress, and one of its effects is to oppose the hormone insulin. This, of course, results in less glucose molecules entering the cells, and consequently, more glucose in the blood stream. More glucose in the blood stream means that more is available for consumption by the brain. The brain needs to function well during stress!
An alternative explanation could be a direct effect of the brain on glucose levels. Sleep deprivation may cause the brain to directly increase glucose levels. If this is a chronic condition, then we're looking at diabetes.
Irespective of the mechanism, sleep seems to play an important part in general normal physiology. So don't deprive yourselves of sleep!
What about dreams? That's probably next on the agenda of researchers...
"Sweet" dreams...

Childhood Obesity

2006-09-14T19:16:00.000-07:00

A small article in today's Wall Street Journal coaght my eye. It's title ran: Measures to Stem Childhood Obesity Are Found Lacking. Written by Betsy Mckay, it summerises a recent report by the Institute of Medicine. The author states that while awareness of the obesity epidemic has grown, not much in practical terms has been done by the various federal bodies, to address these isssues. The article doesn't give solutions, but it does give some insight into the politics behind the scenes. What is lacking, the author states, is cooperation between the different governmental agencies. Once a good program is identified, money should be earmarked for that program. But despite these recomandations, obesity is still on the rise. The last sentence of the article calls for more physical activity programs in the schools. This sentence started me thinking about my own childhood. Obesity then, was a rarity. Especially among kids, it was practically unheard-of. What did we do then, that was so different? Apperently, it's probably related to our need to go outdoors. I remember that after school meant outdoors. There were no TV-dinners then, in fact, there were no TV's! We ran all the time. It was all about friends and the neigborhood. I don't even remember formal "playgrounds". We had a field with improvised goals in which to play soccer, but that was it. I don't remember a single obese child! If there was one, he would be sent to a doctor for possible medical problems. Today it's almost the norm. Large percentage of kids are obese or on their way to obesity, and as a society we look the other way. Hello! Is anyone home? We need to have solutions which are up and running, because once a child is obese, it's too late!
What comes to my mind are the Spartans. They were those Greeks with the war ethics that ended up defiting the Helenists (I hope I'm right). My association is with the training camps that they built for their kids. Obviously, they carried it too far, but they were in the process of producing soldiers. We could, however, use their basic idea and create these camps where the country's youth would receive basic physical training and proper nutrition for a set period of time on an annual basis. We could set goals for proper physical fitness for all ages, and encourage all to attend a fully-funded program lasting several weeks every year. There would also be built-in incentives, which could possibly count towards college credentials.
Just a thought. Is it doable? Possibly! But surely something must be done very soon, otherwise we're all doomed to drown in our own blubber!

A Little Fat with Your Veggies

2006-08-08T21:29:00.000-07:00

Today's Wall Street Journal had an interesting and important article in the "Health Journal" part of the Personal section written by Tara Parker-Pope. The author reviewed an article written by Steven Clinton who is the program leader for the molecular carcinogenesis and chemoprevention and the Ohio State University Comprehensive Cancer Center in Columbus. Dr. Clinton's work involves looking at the effect of a low fat diet on the absorption of the various vitamines and cancer-fighting compounds. It is well known that fruits and vegetables contain lots of these compounds. It is also well known that the absorption of these compouns in the gastro-intestinal tract requires the presence of some fat. What is not known, is that people on a low fat diet absorbe these compounds extremely poorly. By adding some fat in the form of avocado or canola oil to the salad, the absorption of vitamines is increased by as much as x4 times as without the added fat. Adding about two tablespoons of canola oil means an additional 250 calories. For cereals with fruit, adding 2% milk or full-fat yogurt instead of skim milk, will translate to better absorption of vitamines and cancer-preventing compounds.
Bottom line, don't be a fanatic about anything. Act in moderation, and eat in moderation as well.

Curing Diabetes Type 1

2006-03-26T08:05:00.000-08:00

Both the New York Times and The Wall Street Journal ran articles this weekend about recently published data claiming a cure for diabetes type 1 in mice. The articles describe data published by three important groups from three major universities in the US. In these studies, scientists tried to repeat data which was previously published by Dr. Faustman from Harvard University in 2001. Dr. Faustman should be considered a pioneer and given credit for first publishing data which demonstrated how diabetes type 1 can be reversed/cured - in mice. She reasoned very simply that curbing or halting the autoimmune attack (the immune system of the organism attacking certain organs of the self) would slow down the progression of type 1 diabetes. The most potent cells of the immune system are the so-called T cells, and they can be damaged chemically. Dr. Faustman went beyond this initial step. She also transplanted spleen cells from healthy mice into the diabetic ones, reasoning that these may have stem cell-like characteristics which may lend them the ability to transform into beta (insulin secreting) cells. This is indeed what happened, and subsequently a significant number of mice were cured. Their pancreases, which for years were nonfunctional, began secreting normal levels of insulin, thus controlling their blood sugar. Dr. Faustman's data was criticised initially, but current research has found her data to be of significance, and she has been fully exonerated by the scientific community. The three groups which recently published their data and tried to duplicat previous data coming out of Dr. Faustman's lab have mainly supported her findings, and thus opened the way to human studies with the same principle in mind. If this feat can be repeated in humans, we may indeed be at the cusp of a cure. One of the fascinating aspects of these experiments is the ability of the "sick" pancreas to bounce back into action despite years of onslaute by an aggressive immune system. Pursuing these avenues, in addition to possible stem cell research directions, will likely yeild results in the not too distant future.

Byetta in the NYT

2006-03-02T19:45:00.000-08:00

Todays business section of the New York Times has a long article about Byetta. There's even a picture of the pen device, and a graph showing the sharp increase in sales since Byetta's introduction in June '05. For those of you who have no clue about this novel drug, it's a protein derived from the saliva of the Gila Monster (a desert lizzard which is found in the southern part of the USA). This protein is present in the normal human intestinal tract. It is produced by special cells aligning the intestinal wall when glucose/carbohydrates are ingested. Once present in the blood stream, it travels to the pancreas, where it stimulates the beta-insulin producing cells to make more insulin. But in addition to increasing insulin, Byetta has other intestinal effects which culminate in significant weight loss. For the first time, diabetologists have a drug that improves diabetic control without the typical weight gain involved. At the time this column is being written, I have approximately 120 patients on this drug, and the list is growing literally by the day. I am definitely impressed by the combination of weight loss and improvment in the diabetic control in my patients. The article in the Times eludes also to the "off lable" (lack of approved indication) use of this drug in the fight against obesity without diabetes. This is just emerging, but given the extent of the problem(obesity), and the ease of the solution(Byetta), I expect that in the very near future, Byetta will be recruited towards alleviating some of the suffering caused by obesity. Please stay tuned.

Diabetes in the New York Times

2006-01-09T19:54:00.000-08:00

Today's NYT has a FRONT page article about diabetes in NYC. Someone has finally paid attention to this illness and has become alarmed! Portrayed in the most stark of terms, diabetes is defined as a dangerous epidemic with dire consequences. For some unknown reason, NYC seems to have a higher prevalence of this condition than the rest of the nation. Here is the true melting pot, where people from third-world, rural countries arrive and quickly undergo a "fast-forward" transformation into the 21st century in a country where the abundance of calories is simply too great. Their exposure to these calories, coupled with the notion that eating fast food is the all American way, inevitably culminates very often with their obesity. Being obese, inactive, and from a rural country, automatically puts them at risk of developing diabetes, and they very often do develop this condition. Most concerning is the attention this report gives to the appearance of diabetes in young children and in young adults. The same type of diabetes that we were accustomed to see in adults (the so-called adult-onset), is now seen in much younger individuals. The article criticizes our health-care system's inability to address prevention issues. It goes on to state that we're good at opening bodies and at dispensing pills, but not at prevention. This is a true argument.
What strikes me most about this article is the fact that it seemed to point out that we're no longer looking at just a medical problem, but also at a social one. Diabetes is a social problem of the highest concern. It involves all layers of society, and should therefore enlist all or any portion of society in order to ring the alarm bell and come up with solutions. Are there solutions? Certainly not fast or simple ones. Most important is education. Education about diabetes should be mandatory in all school levels and neighborhoods. Kids should know about it, and particularly about the food industry's mission to sell more calories per capita than in any other country in the world. But even more important than education, government at all levels should start focusing on protecting the individual, and not industry. What I would like to see created in the city are centers of excellence for treating only diabetes and its complications. In addition, centers for prevention and education. Such centers may stem the tide of diabetes - maybe.

The Anti-Atkins Diet

2006-01-05T20:30:00.000-08:00

Yesterday's WSJ had an article about the results of the Women's Health Initiative which involved 48,835 post-menopausal women who were followed for 7.5 years from 1993 to 2004. The study's objective is prevention of heart disease, osteoporosis and breast and colon cancer in women. One aspect of the study is looking at the effect of low fat diet on prevention of cancer and heart disease. The researchers are presenting preliminary data involving the effect of low-fat diet on weight. About 40% of the women in the study were assigned to a low-fat diet, while about 60% were the so-called control group which ate a normal diet. Women in the low fat-diet were told to eat no more than about 20% of their total daily calories in fat. Researchers found that overall, after the first year of the study, women in the low-fat group lost an average of 4.8 pounds, compare with the control group who were on a normal diet. This loss was maintained throughout the study period. The authors concluded that women on a low-fat diet may resist the tendency to gain weight during the early post-menopausal years. Another conclusion was that, contrary to previous perception,replacing fat with complex carbohydrates such as vegetables, fruits and grains, is likely NOT the cause of the past several decades' increase in the rate of obesity. Atkins would be gravely opposed to this conclusion, but ,alas, one cannot deny the power of a really large and careful study. As always, I go and believe in the "middle ground". I think that the best approach is to have a balanced diet, and try to restrict the calories. Good luck!

Music Therapy

2005-12-29T20:57:00.000-08:00

On the last page of today's Wall Street Journal there is an article about the healing power of jazz. It talks about Louis Armstrong's involvement with the idea, culminating with the Louis Armstrong Educational Fund which was responsible for establishing many related projects. Armstrong was apparently quite impressed with the medical staff of Beth Israel Medical Center in Manhattan, where he was a patient, and therefore provided funds for music therapy for children. This center has been functional all along, and now it is being expanded and will evolve into the new Louis Armstrong Center for Music and Medicine. Its main mission will be the medical treatment of children and adults with asthma and chronic pulmonary disease. The Center will also attend to the multiple problems that afflict musicians as a result of their occupation. This is certainly interesting and thought-provoking.
I wonder though, what effect music might have on the level of control of diabetes. Would it be different with the two types of diabetes, and would a specific type of music be effective, versus different types of sounds. One may aptly surmise that music will at least effect the level of anxiety or lack thereof. But to expect music to actually have a positive therapeutic impact, I think is quite naive. Listening to Beethoven instead of taking the insulin shot will probably not work. Exercising, however, does. In fact, we recently learned that weight lifting may be just as efficacious as aerobic activities, in lowering blood glucose. In that vein, maybe where Beethoven doesn't work, Motzart will... I find that the idea of this center and the association between music and medicine is wonderful. Will it bring results? Only time will tell. Meanwhile, lets be open minded and allow music into our examination rooms and into our operating suites. Even if double-blind studies don't show a significant difference - who cares! Meanwhile we've enjoyed the music. In my humble opinion the notion that music is helpful is similar to the one attributing a significant effect of herbal or homeopathic approaches. The motto of these is that if it doesn't hurt it's worth a try. I'll go along with that, as long as we realize that these methods reduce anxiety, which is a very good thing. But let's not get carried away into thinking that music therapy actually offers a cure.

Ushpizin

2005-12-18T12:43:00.000-08:00

Another Israeli movie. I hope you don't mind. I only write about it when I feel that it has a universal message, and , of course, when I can't resist the urge. Well, this one is very different. It takes place in an ultra-orthodox community in Jerusalem. Everyone is in full religious-regalia, which I won't describe. The plot deals with what happens when two unexpected guests arrive at the Succah (festive hut commemorating the huts that the ancient Israelites built when escaping Egypt) of a barren married couple who have recently converted from being secular to being orthodox. The main character is the burly husband formerly from Eilat (a southern Israeli town), who apparently was quite wild and prone to violent outbursts. His relationship with God is personal, and when in need, he addresses him directly by looking upward to the sky and by conducting a conversation. The wife does the same. Right at the beginning of the movie, we witness how the husband works his magic by demanding a miracle. In dire need of money for the holiday, he would like to have a "loan". Promptly, an envelope full of cash is neatly delivered under his door by an unanimous donor. This allows for a plentiful holiday which seems ideal, only to be disrupted by two unexpected guests. These are two prison inmates on short leave, that have just decided to take their chances and not return to prison. One of them knows the husband from Eilat when they were "brothers in crime". Their arrival in the Succah is interpreted by the husband as a spiritual challenge and an opportunity to perform a virtuous deed. While the couple tries their best, things inevitably go awry. Eventually the police arrive, and the wife leaves, suspecting the husband had lied to her about the guests. What the couple really wishes and hopes for is a son, but what they get is a botched-up holiday. Succumbing to his fate, the husband lets his two friends treat him to a consoling meal, only to discover that they mistakenly used the "Etrog" instead of a lemon, for the salad. The Etrog was previously purchased by the husband for a 1,000 Shekel especially for the succah, and as a "good luck charm" for having a baby boy. Its use for the salad infuriates him to the point of a temper tantrum, which he only barely manages to control. Running to the forest, again he addresses God directly, questioning him for his purpose. No answer is given, but upon arriving back home and while dismantling the succah, his wife returns and announces her pregnancy. All is festive when a baby boy is born, and at the ritual circumcision even the inmates show up with a present and a meaningful smile. God has again worked his magic. We don't know how, but it seems as if the guests ( ushpizin), and the tasting of the Etrog, may have had something to do with it. Regardless, the celebration,(with God's help), is complete. The lesson, I think, is to have faith. Faith is synonymous with optimism, and optimism is a positive force that tends to direct events onto the right and healthy path. We could all use a little faith, so lets try and have some, and then maybe miracles might just happen...

Health Crisis

2005-12-05T20:36:00.000-08:00

Today's Wall Street Journal has a front page article about how Chinese doctors refuse to treat patients unless payment is made up front. The author describes several situations where severely ill individuals are deprived of their life saving medications in mid-course, predictably culminating in deterioration of the patient and inevitably leading to their demise. Patient's families are expected to come up with cash owed, or patient will be left to their uncontrolled hemorrhaging. Doctors in hospitals are expected to collect funds owed by patients to the hospital, or face having themselves become responsible for that money. An intolerable situation develops, where doctors are both the care-givers and the money-collectors. This, obviously, is very bad for the medical profession in particular, and for the economy, in general. China has come to the realization that this situation is having a bad impact on the social fabric of its society. Interestingly, the other super-power(the USA), is having its own problems. Here too, medicine is big business. Doctors in general are not the main beneficiaries, but the pharmaceutical industry, on the other hand, is "laughing all the way to the bank". Understandably, in a capitalistic society, the approach in any given area must adhere to business principles. Anything should be translatable into currency, and consequently not just merchandise, but even time is money. Therefore, even doctors adopt that approach and in their minds eye instinctively translate every patient into dollar signs. What we have is a system that is driven by profit, and sometimes by greed. According to Adam Smith (the philosopher), greed is what lubricates the wheels of capitalism, and therefore it is good. But is it good when considering the medical profession? I think not - to answer my own question. The medical profession should be free of greed and full of altruism. Doctors, of course, are people too, and they should be allowed their ambitions and their material comforts, but not at the expense of their patients. Society should create a system where doctors have enough incentive to do what they know how to do, without resorting to the whip of financial gain. Ideally, this should be a world-wide system where doctors from all countries and hospitals from all nations are joining in a partnership for the benefit of mankind. In fact, medicine should serve as a beacon of light onto nations, for giving an example of how cooperation leads to benefits. The global budget for medicine, should be allocated by the global community. All human beings should have equal opportunity to share in the benefits of good medicine. Medicine for all is really about equality and about the sacredness of all human beings wherever they may be. Of all nations, China should be the last to exhibit such callus behavior as is described in the WSJ article. But it is the country where we can see how capitalism cannot work to promote health, on a national scale. What is needed and what may work is a capitalistic country with socialized medicine. This may be difficult to accept, but it might just work.

The Syrian Bride

2005-11-27T20:24:00.000-08:00

I just saw this low budget, but vintage Israeli movie. The story deals with the difficulties that a Druz family residing in the Israeli-occupied Golan Heights encounters, wishing to Marry off their daughter to a Syrian national from Damascus. Between the two would-be lovers(they've only exchanged photographs), runs the Israeli-Syrian border with its fences - both metal and human. Bureaucracy and its inability to become personal, is king. Both countries hide behind it, refusing to see the unfolding human tragedy. But the human spirit wins. Out of frustration, and unwillingness to succumb to the whims of the churning wheels of bureaucracy, the heroin/bride, takes matters into her own hands and simply walks across the border to meet her betrothal. Her act contrasts all the beehive-like activity that preceded it, in both its simplicity and in its directness. She becomes a symbol. One can envision her as being the white dove of peace which transcends human quibbling about mundane matters of earthy existence. But even more importantly, she could be regarded as an example for how conflicts can be resolved. People are basically very much alike, the world over. We all want some basic things, and we all have our dreams and aspirations. Governments typically get in the way. Let people deal directly with each other without borders or bureaucracies, and conflicts may be resolved.

How The Obese World Can Save The Starving One.

2005-11-21T20:39:00.000-08:00

Despite the "Flattening of the World", and the intense globalization that is underway, it seems that the world is still divided along "caloric" lines. While part of the world is undergoing an epidemic of obesity, the rest seems to go deeper into malnutrition and even sheer starvation. Not surprising, the obese citizen is likely to live in the western part of the globe, while the starving one, in the third world. The reasons for this sharp divide, have to do with the technological prowess and agricultural know-how of the West, versus the third world's lack of same. The West is able to produce in such abundance, that the respective governments need to either subsidize their farmers so as to prevent them from being too productive, or destroy some of the finished product. Third World countries, on the other hand, have fairly low reserves, and are quite often at the mercy of mother nature, which may deplete quickly even those meager reserves that are available. Consequently, it has become a common every-day-event to see on our TV screens starving babies and sick adults dying or at risk of death. What can be done to stop these disgraceful images and bring an end to this unnecessary and premature starvation-genocide? There are no easy solutions, but it seems to me that the world can no longer sit in passivity, thus perpetuating this situation.
I would like to suggest a possible solution. Calories produced world-wide, should be viewed as a global resource which should be made available for consumption by all citizens of the world. At approximately 2,000 calories per person per day, it is fairly easy to calculate exactly how many calories are necessary in order to feed adequately the world's population. Calories produced by, and in abundance of the needs of a certain nation, should be transferred to a neutral entity which would serve as a clearing house. Countries which find themselves in a predicament where inadequate calories are available, should be able to approach this clearinghouse, and receive what they need. The difficulty is with the incentive that countries with plenty might have, in order to "unload" their extra calories. One such "incentive" could be a mechanism whereby respective governments might be "taxed" for every "obese" citizen. These tax dollars would be made available as a fund towards purchasing calories from the clearinghouse. Rich countries would thus encourage their citizens to keep trim, so as not to be taxed, whereas poor countries would have funds available in order to purchase calories at a time of need. The incentive for rich countries would be both self-serving(keeping trim), and humanitarian. The incentive of poor countries should be to "graduate" to the leading group, and not be on the receiving-end. Certainly, there should be other methods for handling this complex scenario. Please feel free to emulate them, but always keep in mind that the focus has to be on eradicating hunger, and curtailing obesity. If these two global epidemics can be linked, and thus neutralized, we may be able to aptly "kill two birds with one stone".

My Morning Walk

2005-11-06T07:56:00.000-08:00

I must admit to a ritual that I have become dependent on over the past six months or so. It's a morning walk. So simple, yet so life-altering, that I decided to share it with whoever is reading this blog. I get up a half an hour earlier, drink my coffee and eat some cereal, and go out for a half an hour-45 minutes walk. I thought it would be difficult to stay disciplined and maintain the habit, but to my surprise, it's become very central and almost critical to the rest of my day. I perceive it as the foundation on which the rest of my day rests. It has not only an obvious physical dimension, but also a therapeutic-spiritual one. I find that as my breathing settles down to a regular pace, my thoughts almost assume some new energy and are liberated from their usual constraints. That's when I get new ideas, and that's when I can "see" more clearly and interpret more lucidly the unfolding of events in my life. I also notice while walking the beauty of nature. Vegetation is somehow not taken for granted, and even the bird's chirping is allowed a more significant audience. The physical exertion of this activity coupled with its therapeutic/emotional dimension, give me energy for the rest of the day. It's become so critical, in fact, that now I look forward to it and have incorporated it in my daily routine. I highly recommend it to all of you out there, friends and patients alike.

The Tragedy of Dialysis

2005-11-03T20:41:00.000-08:00

Today's Wall Street Journal ran a front page article devoted to a patient with diabetes with multiple complications, culminating in chronic dialysis and eventually ending in death. The patient's struggle with the disease and the impact on the patient's family and friends, were very thoroughly described and detailed. The national problem of dialysis, and its heavy financial toll on the economy were also addressed. But the focus was mainly on the human and personal tragedy of this condition, which in some patients races forward with unrelenting speed, causing an inevitable death. Some patients on dialysis make a conscious decision to discontinue this procedure, thereby quickly terminating their life. This is a very bleak reality, which seems to have not received the magnitude of attention that it deserves. Why do some diabetics deteriorate so much faster than others, and why do some end up on dialysis while others have heart attacks? The short answer is that we don't know. We do know that diabetes translates to vascular disease, but it's impossible to predict which patient will develop which complication and at what severity. We lack those particular markers which could make for early detection of the specific complication, with possible consequent improved outcomes. But even before that, reading this article again brings home the message of how poorly we are handling this complex condition. Today's diabetic patient faces not only multiple complications, but also multiple primary care physicians, multiple specialists, facilities, laboratories, hospitals and insurances. The amount of duplicity of service and sheer waste, is staggering. Patients typically get a full-panel blood test from several physicians who are unaware of each other and who typically do not share the data generated. Because of the multiple potential complications, a single diabetic patient may be "supplying" much work for multiple specialists. On any given day, a specific patient might be scheduled to be seen by several specialists, who generate multiple procedures. All this activity obviously generates multiple bills, contributing to the "buckling" of the health care system. Many wise and capable men/physicians have most certainly suggested this before me, but I would be remiss if I neglected to specify now my humble suggestions. What we should do is create a national network of clinics catering only to the diabetic patient. These should be manned by highly motivated physicians capable of diagnosing and treating the multiple complications of this condition. Needless to say, this network should have its own intranet where all clinical data is saved and is made available to other qualified health-care workers, upon request. As a prelude to this network,however, I suggest that we create a national data-bank where laboratory data is maintained and is available to all patients with diabetes, and to their physicians. Subsequently, other features of a network can be introduced, but creating the data-bank seems to me very basic and critical. The famous Chinese proverb that every long journey must start with the first step seems very appropriate here. Lets take that first step now.

Monkeys and Honey

2005-10-10T19:24:00.000-07:00

I was watching a TV nature show, where the focus was on the behavior of a certain group of monkeys. Parallels were drawn to human behavior, and I couldn't help but feel that monkeys were indeed very likely our biological ancestors. Then, an interesting activity started. The monkeys discovered a bee hive, and all the abled-bodies crowded in on the hive. Fully grown males and females were pushing to get their chance to stick their arms into the bee-hive, despite being repeatedly stung by adult bees - all for a little taste of that sweet honey. That settled it for me. Here I was deceiving myself all these years that our "sweet tooth" is a product of the "corrupt western capitalistic system", where a conspiracy of sugar-cane growers was pushing their product onto our diner tables, only to discover that our biological ancestors have the "sweet tooth", without the conspiracy. So, I've decided to modify my views to accommodate both the "sweet tooth" and the "conspiracy theory", as two main reasons for the diabetic epidemic. Joking aside, some people have a sweet tooth, whereas others simply do not care for that condiment. Why is that? Possibly for the same reason that cats, cannot taste sweetness for lack of a certain gene that codes for the receptor which recognizes the sugar molecule. Some people may have a small dose of that gene, whereas others may have an abundance of it. Monkeys, for that matter, may be similar. Only those with an abundance of that gene may be the ones mindlessly risking the many bee stings in order to get their "sugar fix". The lesson for us - learn how to control that gene, and half of the battle is won.

Veggies and Obesity

2005-10-10T19:02:00.000-07:00

Critically important, a small study by a California-based think tank claims that there is an inverse relationship between the price of produce, and the rate of obesity in children. If indeed true, it's a big wake-up call. The authors examined the weight gain of 6,918 children from 59 metropolitan areas around the U.S., and compared the children's weight gain between kindergarten and third grade, with the relative prices of produce in their communities. In areas with the highest relative produce prices, the children gained about 50% more excess weight than the national average, and in areas with the lowest prices, the weight gained was half the national average. More information is necessary, but these results clearly point towards the need for more produce being made available to children and to young adults in their neighborhoods. Fresh fruits and vegetables are the best antidote to junk food!

Dizzy Gillespie

2005-09-18T20:55:00.000-07:00

The Sunday Times Arts & Entertainment section had an article about auctioning remaining items taken from the Gillespie's Englewood home, where they lived from 1965 until their deaths. Mr. Gillespie died in 1993, and the Mrs., last year. More than 3000 objects, among them Dizzy's record collection, were sold for about $500,000. A few old photographs were shown in the article, among them his bent trumpet, which has become his trademark. I became acquainted with Dizzy Gillespie and his special brand of Jazz, possibly 30-40 years ago, when by chance I bought his long-playing album called "Dizzy Guillepsie on the French Riviera". I remember that it had a picture of a beach with bathers, and him playing his trumpet. I really loved that album, and I used to play it at every opportunity. Years later I must have loaned it to someone, or simply misplaced it, because it just disappeared. I started looking for it in record shops, only to be repeatedly disappointed. No one seemed to have it. One day I spotted it on the stall of a vendor in a music fair. I managed to convince the owner of the stall to copy it for me onto a tape, and paid him then and there $13 for it. Several weeks later the tape arrived, but to my great astonishment had only a few traks on it. However, listening to those few traks always manages to transport me to different periods, when life for me was much more idealistic and more dramatic then the present. As I write these words, the music is again playing in my ears.
It's amazing how important a role music has in our lives. We may not realize it, or be willing to admit, but it is major.
If anyone out there has this record or access to its music, please give me a call, or simply copy it for me, and I shall gladly come to any require location in order to pick it up.

The Ten Commandments for the Diabetic

2005-09-11T19:56:00.000-07:00

1. Know your A1c.
2. Know your blood pressure.
3. Know your medications.
4. Know your BMI(body mass index).
5. Do not smoke.
6 Do not over-drink alcohol.
7. Spend at least 30 minutes daily doing aerobic physical activity.
8. Avoid sugar-containing foods and plain sugar.
9. Utilize discipline to restrict portion size for all your meals.
10. Be tolerant, and allow for humor to enter your life.

The above are intended as general guidelines, however if you choose to adopt my advice and try to adhere to the letter of the commandments, you should expect some improvement in your general well being and definite improvement in your diabetes.
Please write the above commandments in your personal notebook, make sure you have all the required information, and try to follow their instruction. Please bring your commandments when you come in for an office visit.

Olive Oil

2005-09-10T13:37:00.000-07:00

As an owner of a Mediterranean palate, olive oil is high on my preference list. I can envision myself retiring on some lonely Aegean island, surviving very well on the local cuisine which will obviously contain a generous portion of olive oil. But beside it's wonderful taste, the olive also has health benefits. These benefits translate mainly into extending longevity. A recent article, in fact, documented this benefit by comparing the Mediterranean diet to multiple other diets, and concluded that followers of the former have a greater chance for an extended healthy life. These results are achieved by reducing the likelihood of a vascular "accident", which would be either a heart attack or a stroke. How does the olive achieve that feat? Well, apparently it contains a substance which is called oleocanthal, which has a similar anti-inflammatory effect as drugs like aspirin and ibuprofen. This effect is critical in reducing the tendency that certain individuals have to spontaneously form clots. Clots can enhance the tendency towards a vascular accident. Consequently, all diabetics are told to take a daily baby aspirin. In addition to its vascular effects, chronic anti-inflammatory activity has other health benefits. These range from reducing the rate of certain cancers - breast, lung, colon - to reducing the risk of such conditions as Alzheimer's. So bottom line, this seems to be a case of a win-win situation. No need to sacrifice for longevity, just have some olive oil and enjoy!

Darwinism vs. Intelligent Design

2005-08-22T19:34:00.000-07:00

A main article it today's NYT (front page!) deals with the age-old contentious issue between the school that accepts evolution as the mechanism that explains modern biology as we know it, and an opposing school that sees creation as the likely explanation. The article focuses on this latter school, where things have been "evolving" and where currently the term "creation by design" is preferred. Among the followers of this view are many distinguished scientists who point out that several phenomena in biology can only be explained by an intervention of a designing hand. The example that is given is the clotting mechanism which is comprised of no less that 20 different proteins working in unison in order to manufacture a stable clot. Missing only a single protein, renders the whole cascade useless, and puts the organism in mortal danger. The "anti"-evolutionists conclude that this cascade must have been designed in order to explain such complexity. The "evolutionists", on the other hand, claim that one of the main premises of science is that miracles are not allowed. Science attempts to explain the physical world by using reason and without resorting to the "supernatural", they say. Perceiving this criticism, the creation by design school has perfected its approach and has forwarded the suggestion that the designing hand may be inherently embedded within the universe since its inseption and does not require a specific act, but rather is constantly propagating events. In support of their hypothesis, some of these individuals have tried to use mathematical models in order to lend further credibility to their arguments. An intriguing example is the calculation by Dr. Axe of the likelihood that a bacteria sensitive to penicillin will acquire an enzyme (penicillinase) that can metabolize penicillin and subsequently allow for survival. The odds calculated are 1 in the number one followed by 77 zeroes. This probability, they argue, is essentially zero, and therefore would have to be explained by "design". The designer is, of course, no other than God, although, they concede, he works in mysterious ways. This brings to mind the book by Hawkin about the universe and its black holes, where he claims that the universe is self sustaining to the extent that God is not necessary. The universe, Hawkin says, self-propagates itself. It undergoes a cycle of expanding and contracting, with endless repeats.
I think it's beneficial to live with the notion that the "designer" is within or part of the universe, as long as one does not proselytizes for the presence of miracles. I can agree with the notion that the "whole thing" is one big miracle, but to wait for a miracle to happen, I think is ludicrous. Such miracles happened only in the Bible. The sea opened, the sun stood, the walls fell, etc. etc.. Man has since evolved and has become a much more sophisticated and insightful being, with far-reaching capabilities which may harbor a "designer"-like faculty enabling him to reach far beyond his physical limitations. It may be sacrilege, but it seems to me that we may be harboring a "designer gene" which is responsible for our biological advancement from a single cell creature to the multiple-organ phenomenon that we are today. Regardless of the school you follow, one must concede that man has achieved today what was attributed to gods in the past.

Gaza Tragedy

2005-08-17T19:16:00.000-07:00

Watching the news from Gaza this evening was very heartwrenching. Scenes of Israeli soldiers in a standoff with local Israeli residents could not have been more painful. Much has been said, but the pictures were more dramatic and more painful than anyone could have imagined. When the Israeli female officer sat down in a secluded corner and allowed herself to release a heaving cry of exhaustion followed by an outburst of tears, I found myself almost crying with her. When kids were orchestrated into Nazi-type of demonstration by wearing a yellow star and raising their hands in a sign of surrender, I felt appalled and sad that it had to come to that. When religious leaders tore their clothes in a sign of mourning, I could identify. When whole families could not bring themselves to release their grasp of their homes and their neighborhoods, I understood. I saw a group of people who were told to uproot themselves from their homes and from their communities. People who, it was obvious, are very much devoted to that area, and who would do almost anything to stay there. I also saw the Israeli army and the humane way it handled itself in this very sensitive of projects. Soldiers were yelled at, spat at, and verbally abused, took it all in stride. The world watching this drama should take note of the sacrifice and the pain, and the nobleness of spirit, which has characterized this unilateral move that has been taken by the Israeli government. The true enemies of the peace process are the extremists on both sides. True peace shall never prosper in a place where extremists are allowed to foster. The sane world should unite against these extremists, and expel them. The Gaza tragedy will be etched in the common memory of nations as an example of true national sacrifice toward the noble cause of neighborly peace. Lets all hope that peace indeed shall follow.

On Being A Patient

2005-08-14T07:27:00.000-07:00

This Sunday's New York Times has a major article on the plight of the typical patient of this day and age. The picture that emerges is that of a person who is burdened by both their medical condition, and the responsibility of the decision making process regarding which "medical course to chart". The modern patient is indeed in a very difficult position. As the article eludes, it is a combination of multiple forces which have placed the patient in this predicament. Medical knowledge has certainly exploded, making even the informed doctor sometimes at a loss for the right decision. Other issues, however, are at play as well. The pharmaceutical industry is constantly preying on patient's fear and ignorance, by prodding them with vast amounts of information regarding various drugs, urging them to request their doctors to prescribe. But even more impressive, is the patient's sense of self empowering. Patients today demand to have full access to all the decision-making process, and to pack the veto power authority for each decision. Patients vehemently demand to have control. Where does this leave the fragile patient-doctor relationship? Opinions about this contentious issue, differ. Some would argue that more control for the patient means less anxiety and therefore more survival. Others, however, would say that the patient is the loser. I tend to agree with the later. I don't disagree with the opinion that having access to the latest medical information is critical. I do think, however, that the patient-doctor relationship is just as important. For some patients, in fact, this relationship is even more important. With all of the empowering that has been recommended by some very astute social advocates, patients are still patients. They are still in a very compromised position, needing a supportive and guiding medical environment. True, some doctors are incapable of providing this environment, but in an ideal world, this is what I believe is most important for the average patient. Even those doctors who are capable of providing this support, quite often find themselves unable to do so. As the article quotes a local NJ doctor who treats 5000 patients annually, it is simply impossible to provide this support under the current environment. Unfortunately, there are no easy answers. I feel that patients have been manipulated into a corner with few options. In the current scheme of things, they don't get what they deserve. What they deserve is an approach which combines both compassionate support and cutting-edge medical knowledge. But the current medical-market place is denying that. Patients are squeezed today between two giant forces which are represented by the pharmaceutical industry on the one hand, and the HMO-conglomerate, on the other. It is these two forces which are shaping the medical landscape of today. Neither, of course, has the patient's interest at heart. Both, obviously, are vying for his pocket. The typical doctor, unfortunately, has been taken out of this equation, leaving the patient-doctor relationship on life-support, in the interim.
What can be done? Nothing short of a major change in the landscape. Provocative as it may sound, I think that doctors should be on equal footing vis-a-vis patients, as are either the pharmaceutical industry or the HMO-conglomerate. The current asymmetry has to be corrected. Doctors should wield as much clout and power as do either of these two industries. Only then can the patient-doctor relationship renew it's former days. A constructive partnership between these three entities may yield the proper balance which would be conducive with both effective and supportive patient care. Some may call this a fantasy, I would like to think that it is the only prescription for this ailment. Time will tell.

Beautiful Country

2005-07-31T10:51:00.000-07:00

I've written before about a movie, and I'm compelled to write about this one, as well. I saw it last night, and am moved to the point of writing. It's called Beautiful Country, and it's about the voyage that a young Vietnamese "outcast" makes from his native village to the "beautiful country" that is USA. Born of a mixed marriage to an American father and a Vietnamese mother, he is treated as an outcast by the Vietnamese society. He grows up in a foster family, doing household work and being treated as a servant. After being given the boot, he makes his way to the big city - Saigon, looking for his real mother. After finding her, and joining her at her work place, he is on the move again. Fleeing with his small brother, he makes his way to the USA aboard a cargo ship, after committing himself to hard labor for several years upon arrival in the "promised land". The voyage is filled with hardship and tragedy, culminating with the death of his little brother. Arriving in NYC, he starts working for his captors, only to discover later that as a son of an American father, he has full citizenship rights. Emboldened, he starts his pilgrimage to find his biological father. The final chapter deals with this discovery and its flowering, with a final very touching scene of great intimacy and respect between a Vietnamese son and an American father who is unaware of their biological relationship. This movie is about the voyage and the sacrifice that a child is capable of undergoing in quest of the lost/absent love that was due from an absentee parent. A must-see for all parents.

Sweet Cat

2005-07-28T19:51:00.000-07:00

Cats, both your common house-pet type, and your wild tiger variety, apparently are unable to enjoy sweetness. Not that they couldn't have the opportunity, they just don't have the tools to identify it. Tuesday's Science section of the NYT devoted a short story to this very interesting fact. A researcher at the Monell Chemical Senses Center in Philadelphia has pinpointed this problem to a defect in the gene for the receptor that identifies sweetness. Why cats? Apparently, when cats separated from dogs during evolutionary history, they developed this defect, and hence-forth were deficient of sweet-tasting receptors. Dogs, on the other hand, maintained the capacity to identify sweetness. Humans, of course, get the prize in this contest. The striking thing for someone like myself about this piece of information, is the huge potential it offers for future scientists to manipulate this "defect" and create a molecule that could modulate our (humans) tendency to develop a sweet tooth. Especially for diabetics, wouldn't it be nice to be able to cancel or modulate their craving for sweets? It's probably a long way off, and I doubt that I'm the first that this idea came to, but I think that at this state of the epidemic of obesity and diabetes, much potential use may be made from a medication that can block our sense of sweetness. Chocolaholics - beware!

Stress and Our Waist

2005-07-19T19:49:00.000-07:00

Today's Wall Street Journal has an article about the possible connection between our girth and our stress. The author, Tara Parker-Pope, argues in favor of the hypothesis that stress begets a bigger girth, and that the role of that bigger girth is to allow for relief of the stress. In rats exposed to chronic stress, along with increase in belly-fat, scientists also noted a decrease in the level of stress-hormones. Thus, supporting a possible dampening effect of the fat on stress hormones. Similar findings were found in monkeys. Those living under stressful conditions and eating a Western diet tended to develop more visceral fat than those monkeys who were not exposed to stress. In humans, the situation is more complex. Visceral(stomach) fat is generally part of the insulin resistance syndrome. This is also called "the metabolic syndrome", or "syndrome x", which typically leads to type 2 diabetes. The syndrome includes 3 out of the following 5 criteria: 1) hypertension, 2)dislipidemia - high triglycerides with low HDL-cholesterol, 3)increased waist to hip ratio, 4)insulin resistance, and 5)impaired clotting.
Fat accumulating within the visceral area or in the liver as well as in the muscles, appears to be a more sinister fat than that which accumulates in the subcutaneous (under the skin) depot. The former is composed of fat cells which release substances that appear to interfere with the action of insulin, causing insulin resistance. We don't know why in some people there is the predilection for fat to accumulate in certain locations. What we do know is that if it accumulates in the viscera, the likelihood of insulin resistance is much greater. Other conditions which result in visceral adiposity, such as Cushing's Syndrome or Polycystic Ovarian Syndrome, tend to have elevated levels of stress hormones at the "get-go". Consequently, in humans, it is more likely that excess levels of stress hormones are a cause of visceral adiposity, and not as is found in other species, where the adiposity may serve to alleviate the stress hormones. Regardless, the relationship between stress and the endocrine/energy systems is far from being resolved. The use of Yoga, or any other modality which relieves stress, is always highly recommended.

Famine in Africa

2005-07-18T20:39:00.000-07:00

The BBC ran a short report on this evening's news broadcast which really shocked me. A healthy, well-nourished western reporter with a nice British accent was reporting from Niger, in Western Africa. Apparently, she was saying, Niger has experienced one of its worst droughts, and simply put, has no food to feed its people. Consequently, everybody is at risk of dying from malnutrition. Most targeted, are the children. Pictures of them were projected for all to see, starving, and inevitably dying, while she was reporting. Some so weak, they could not even eat the food they are given in the hospital. Skin and bones, with protruding abdomens, sunken eyes, and crying without tears, these kids presented heartbreaking images reminiscent of holocaust victims. A local interviewed physician was complaining that help is simply not arriving, and that children could not be prevented from dying.
While in the West people are dying from complications of diabetes caused partly by exposure to a "toxic-caloric" environment causing obesity, people in Africa are dying from famine. The contrast is mind-boggling! We all know that there is enough wealth in this world to prevent famine, yet we lack the tools to bring this about. We tolerate it. We watch the images, and move on, hoping that someone else will have the stamina to take this awful reality on. To do something about it. Well, I have a suggestion. How about if we ask the fast-food and beverage industries, who are most responsible for the obesity epidemic in the West, to step up to the challenge and deliver some of their "goods" to this famine-stricken part of the world. It would give them an opportunity to occupy the moral high-ground by showing that they "care", and it could literally save million of lives. This may, at first, sound "crazy", but I think it's doable, and it's right! In fact, maybe the government should pay them to divert some of their expertise and energy to the developing world. There are many "creative" solutions, and they need to be thought of in order to stop famine in a world where obesity is an epidemic causing diabetes.

If you have any practical suggestions, please do not hesitate to give me a call, and do please forward this blog to people who you think may be in a position to help.

Rumania - Personal

2005-07-17T12:24:00.000-07:00

During the 4th of July weekend, my wife and I went with friends to Rumania. We would have never dreamt of going there, but three of our friends decided to celebrate their 60th birthday there, so we had no choice. I don't know how exactly the decision was made regarding the location, but the fact that one of them comes from Rumanian heritage probably had something to do with it. It is important to mention that with one of the three I actually went to elementary school, and that with the best friend of the second, I went to medical school. The third is the Rumanian one. About one hundred and twenty people attended the birthday, which was a success by any standard. People came from Israel and from the USA, which meant traveling time of up to 12 hours. The birthday "boys" organized everything. We had a one night hotel in Bucharest, and a next day tourist bus which took us to a mountain resort where we stayed for several days. We were treated to sightseeing during the day, and parties at night, where Rumanian food wine and music were enjoyed, and nostalgia was indulged. After several days in the mountains, we returned to Bucharest and visited Chauchesko's palace, before returning to the USA. Rumania is definitely still in the sixties, but it's making efforts to close the gap with the West. Rumania's women have most noticeably closed that gap. They're mostly very well dressed, slim, pretty, and well ahead of the men. We had the opportunity to take a cab on two occasions. The first driver seemed like a responsible family man who was complaining that he just does not make enough money to feed his family, let alone send his kids to a good school. The second driver was an obese malodorous male who only spoke a few words of English, and who's cab we wanted to evacuate very quickly. Except for that obese cab driver, I did not see any obesity in Rumania. Their ethnic food is wholesome, their music is gypsy-like in its rhythm, and if they stick to a hard work ethics and a non-western culture, they may very well avoid the perils that are currently pervasive in our "carolie-toxic" environment. I don't think we'll visit Rumania again, but I certainly hope that I'll be able to revisit a similar birthday celebration some time in the future.

Sugary -Drinks

2005-07-14T20:28:00.000-07:00

The Center for Science in the Public Interest is a nutrition watchdog group that has recently asked the Food and Drug Administration (FDA) to put labels on sugary sodas and fruit drinks, warning drinkers about the potential dangers of obesity and diabetes if these drinks are consumed in excess. The beverage industry is obviously resisting such a labeling, fearing that their market may shrink. The data linking these drinks to obesity, however, is quite convincing. One has to just know that each 12-ounce can of regular Coca-Cola contains 39! Grams of pure sugar, to realize that consumption of 3 to 4 cans a day is equivalent to about 500 calories. This behavior/habit most certainly contributes to the epidemic of obesity seen currently particularly among teens in this country. In addition to sugar, these drinks are also dosed/spiked with more than 10 milligrams of caffeine, creating an addictive following almost a certainty. This is very reminiscent of the tobacco industry's resistance to this type of labeling, despite the obvious damage that smoking creates. Just as labeling of cigarettes was forced down the throat of the tobacco industry, I believe that it's only a matter of time before such labeling is forced down the throat of the beverage industry. It's high time that we as a nation take care of our young citizens who are exposed to marketing forces that create an environment where drinking sodas is "in". It's all about greed - in both industries - and it should be stopped!

Sleep Apnea in Diabetics.

2005-06-15T19:25:00.000-07:00

Not only have we known that coronary artery disease can be "silent" in the diabetic patient, we now learn that sleep apnea may be silent in the diabetic, as well. Yesterday's Wall Street Journal had an article about this new finding as detailed by Dr. Einhorn from the Scripps Institute in San Diego. His findings suggests that approximately one third (!) of diabetics suffer from this ailment. In brief, this condition is one where the individual stops breathing for short intervals during sleep. This will cause sleep to be disrupted, and consequently the next day this individual may be tired. More serious consequences are cardiac arrythmias (irregular heart rate), and even a heart attack. Dr. Einhorn suggests screening all diabetics for this problem. He also goes on and treats his patients - with continuous positive airway pressure(a mask device that drives air into the mouth/nose throughout the night) - and claims that after treatment, their sugar levels improve. This suggests that sleep apnea probably activates the stress hormones which are know to cause insulin resistance and consequently hyperglycemia. Very interesting and plausible, however not clear yet how practical. More information is needed, and will probably come. Stay tuned.

Sex in the Eighties

2005-06-07T19:56:00.000-07:00

One of my soon-to-be nonagenarian patients (currently 89 years old ) was sitting across my desk stating that she is feeling very well and that her only problem is the fact that she has two boyfriends and a third in the making. This ignited my curiosity and I pursued asking her in some detail what that actually meant. Well, she went on, there is definitely a sexual attraction component with these men. They are after her alright, and when they get her alone in the room, they certainly give it a try. But they rarely succeed in having a bonafide erection and therefore are hardly able to penetrate. That has happened, however, on occasion. They usually end up just kissing and hugging, she went on, and they have a serious need to talk. Some have lost wives, and are therefore in need of companionship, whereas others are bachelor survivors. What was interesting to me was that even at that advanced age, the attraction of the sexes does not cease.
And on to an interesting story from today's NYT which reports that the length of the DNA molecule which codes for a certain hormone receptor in male prairie voles (mouse-like rodent), determines how these male rodents behave within their family unit. Certain length will result in more time spent with the pups, whereas a different length will result in a neglecting parent. Interestingly, and at this stage very poorly understood, the hormone is Vasopressin. This hormone is responsible for controlling the amount of water which is conserved by the kidneys. Finally, we see that genes too are involved with control of behavior, and not just one's cultural/ethnic/social environment. Some of us may have genes which facilitate active sexual behavior well into the nineties, whereas others may not, thus explaining the differences in libido and/or level of sexual activity. This may be a frightening thought, but some of these genes may be identifiable in the not too distant future, giving us explosive information about our offspring well before they would be expected to exhibit behavior which is a function of the presence of these genes.

The Icy Hypothesis of Diabetes Type 1

2005-05-21T16:21:00.000-07:00

In the science section of Tuesday's NYT, a new hypothesis of Diabetes Type 1 was presented. This is touted by a Dr. Sharon Moalem from the Mount Sinai School of Medicine in NYC. Dr. Moalem is an expert on evolutionary medicine, and according to his hypothesis, the icy weather of the north has predisposed the Nordic peoples to develop diabetes type 1. He claims that one method of survival under those conditions, is to dramatically elevate one's blood glucose. This elevation in glucose depresses the freezing point of fluids, and places a protective barrier around proteins. Nordic peoples with this capability have a better chance of surviving the cold, but may, in the long run, succumb to diabetes. What's obviously missing from this hypothesis is, of course, the whole autoimmune pathogenic body of evidence that is accepted by all scientists as the explicit cause of this type of diabetes. This hypothesis will need to show that under cold conditions, genes which encourage the immune system to attack the islet cells, evolve or are preferred.
I find the symmetry of the two hypotheses very interesting. Type 1 coming out of the white icy environment and prevalent in the Caucasian races, and type 2 coming out of Africa and prevalent in the dark races. Both have mechanisms which are intended by evolution to protect the organism, and both end up with the "complication" of diabetes. In the first, blocking insulin to achieve the high protective glucose ends up in diabetes type 1, and in the second, evolving the "thrifty genes" culminates in diabetes type 2. Mother nature starts out with "good" intentions, but ends up with dire consequences. For those of you who are not familiar with the thrifty gene theory, it simply states that under conditions of famine, the organisms that survive are those with genes that are better equipped for storage of nutrients. Once these organisms (or humans) are exposed to conditions of plenty, they tend to develop obesity. Therefore, the current obesity epidemic in the West. Despite the symmetry, however, much research is needed in order to prove any causality between diabetes type 1 and icy conditions. Dr. Moalem may need his whole carrier to do it.

The Sugar Addiction

2005-05-15T08:37:00.000-07:00

Front page article in the NYT today tells us how the food industry is scrambling to replace the low-carb trend with the low-sugar trend. Sugar is the new demon, they claim. But the ominous thing that they are doing is substituting sugar with the various sugar-alternatives. The most popular currently is , as you know, splenda. This, however, presents a new problem. Apparently, as do other sugar-alternatives, splenda may also be mildly mutagenic. So, are we getting into a bigger problem now? Within the context of "normal" consumption of these alternatives - as in adding to your coffee, mutagenesis (cancerous) is likely a non-issue. Major consumption, however, may present a danger. Regardless, I find this discussion a bit off-mark. The issue here should not be how to preserve our consumption of sweetened food, but rather how to successfully undergo detoxification from it. Why have we become addicted to sweetness, and why can't we "shake it off?". Since some people need a sugar "fix", I truly think that excess consumption of sweetened food may evolve into an addictive-like situation, where a "fix" is necessary in order to prevent withdrawal symptoms. How did we get there? Probably the same way we got to smoking, excessive alcohol drinking, and even excessive water drinking. There are at work here a combination of forces, both sharing in responsibility: 1) human weakness, and 2) marketing pressures. In a free market society, where profits are all-important, marketing becomes indispensable. All an industry needs to do in order to increase profits, is push marketing. People are pliable, and will be convinced by mass media to behave according to suggested norms. So if the billboards show that it's "in" to smoke, drink, or eat sweets, etc., the average human will follow suit. And that's what the billboards have been showing. Luckily, responsible social and medical entities are in place, and over the past decade we've seen trends to correct some of the above behaviors. Smoking has definitely decreased, and now eating is slowly becoming more responsible, as the obesity epidemic is becoming alarming. Therefore, I think we should re-focus our discussion about sugar and sweetness. The crux of the matter is the simple fact that we don't need so much sweetness. Our bodies function very well without it, thank you very much. We should address our sweetness-seeking behavior, and ask ourselves how can we alter or substitute for that just nutrition-seeking behavior. My personal detox suggestion is to go "cold turkey". No sweetness, period! Don't even use the substitutes in your coffee or tea. Once you're beyond the detox phase, you'll find that having a little real sugar every once in a while and not substituting, is the way to go. Of course, you need discipline. And remember, evolution hasn't provided us with sugar, it's only recent industrialization that has pushed it onto our tables. So push it away!

Cialis On Board

2005-05-11T21:00:00.000-07:00

The patient in my waiting room seemed to doze-of, because he didn't immediately respond when I called his name. Only after raising my voice and calling him again did he move, and quickly recognizing where he was, walked towards the examination room. He was in his fifties, and apparently in significant denial of his diabetes. He was aware of the condition over the past five years, but has neglected to take any steps in order to regain control of his blood glucose. He doesn't even check his sugar, he admitted. He was very busy with professional responsibilities, and only now has found the time to come to the doctor. He is not on any medications. Examining him, I noticed that his weight defined him as "obese". Although his blood pressure was normal, his pulse was distinctly elevated. His blood glucose on finger stick at that time showed :446 mg/dL! And then he confided with me that he had just taken Cialis. I was flabbergasted. This is what we've come to, I thought to myself. This is what happens when these medications become recreational. They end up in the wrong hands, and it's a set up for disaster. "No wonder you have problems with your erections", I told him, "you're drowning in honey!". "You can't expect to have normal erections with blood sugar in the 400's", I said to him. And I continued to tell him that with such lack of control he may be at risk for coronary disease, and that taking the Cialis could potentially precipitate a heart attack. He comprehended and even became alarmed, but how many patients actually do? Erectile dysfunction medications should be used in diabetics only after reasonable control of blood glucose has been achieved, and not prior to that. Without good control they can expose the patient to danger, and , in fact, will usually not help the erections. The wide availability of these medications without prescription, is harmful, and potentially dangerous. Please seek advise from your doctor before using these drugs.

"The Litvin Diet"

2005-05-08T17:38:00.000-07:00

"What, you must be saying, another diet?" Well, it's not really a diet yet. I'd like to think of it as some guidelines for improving ones life-style. I'm certainly no authority on nutrition, but as an endocrinologist over the past 25 years, I've developed some ideas which may be helpful. In general, as you may have noticed from my previous blogs by now, I think that we're exposed to too many calories on a daily basis. So one of your initial efforts should be directed towards reducing this exposure. That translates to NO buffets, NO cruises, NO barbecues with the "boys" where meat and beer are devoured without regard to quantities, No parties, NO restaurants, or any other occasion where you feel insecure with the "caloric-exposure-quotient". To be practical, I know that what I'm requesting is nearly impossible to abide with. But that is the kind of discipline and commitment that is needed, initially. Later, with the loss of some weight, and regaining of some self confidence, the guidelines may be more flexible. But for the first several months, I would say - try to abide. Once exposure is reduced, half the job is done. Now to the actual diet. In general, I'd like to suggest that you should not look to food for your source of entertainment. Another words, try to eat boring food. Try to think of it only in terms of energy. Truly, that's all it is. Another generality, our bodies like to function in cycles. Just like there is a cycle of night and day, so there should be a cycle of meals. Our bodies don't like surprises, so try to have your meals at approximately the same time each day, and not less important, don't try to over-impress your body with the variety of food items that you consume. With those generalizations, I can now move to the specifics. Breakfast. Open with half a glass of orange juice with lots of pulp. The pulp is an important source of bran so don't compromise with that. Then throw into the microwave a packet of instant plain oatmeal with half a glass of 2% milk on top. It takes 90 seconds and you have a nice warm cereal on which you should slice a whole banana, and add a handful of dried cranberries. Don't forget your unsweetened coffee, and you're now ready to face your day with enough calories and a feeling of satiety, until lunch. I should say that the oatmeal is excellent for lowering your cholesterol and moving your bowels, the banana is a good source of potassium and some vitamins, and the cranberries are good antioxidants. And without noticing, it's time for lunch. Since most of us have a busy day, lunch falls squarely in the middle. It's a time to replenish our energy, and take a short break. You need to stay light so that the meal doesn't stop you in your tracks or prevents you from peak performance till the end of the day. Therefore, the meal should not be one of those prolonged affairs where several courses are served "diner style", along with wine, etc(so-called power lunch). And remember, keep it boring! So what I would recommend is that you stay away from the carbs - they tend to give us a "fix", which may be followed with a low blood sugar (hypoglycemia), dragging us into sleepy "never-never land". A fresh mixed salad should be the foundation, and on top of it a piece of grilled chicken, or grilled salmon. Of course, it doesn't have to be grilled, but it's nice that way. No heavy dressing either. Salt, pepper, lemon, and a little olive oil is all it takes to make it tasty. An unsweetened drink should go along with that, and you're set for another several hours. Notice that I didn't limit the quantity of the salad, so go ahead and have as much as you like. So far, so good. Now comes mid afternoon, and it's usually crisis-time. We're either too tired or too sleepy, or both. You must have unsweetened coffee, and a snack. I like to have a granola bar and coffee, but you may choose to have fruit and coffee, or anything else for quick energy-boost. Just don't get carried away. Don't go to the carbs again - you'll have a hypo. The snack should carry you to diner. That's all I have to say for now. Recommendations for dinner, and beyond, will come at some other time in future blogs. If you try to stick to the guidelines which I have detailed above, I'm sure that you'll see some progress.
Good luck, and Bon Appetite.

Korean-Americans

2005-05-08T16:47:00.000-07:00

Since moving to Fort Lee, I've been seeing many more Korean patients than ever before. They were absent from my practice in Englewood. As I have become more familiar with their particular ways and ethnicity, so has my appreciation and respect for them grown. One of their strongest characteristic is their family structure. There is amazing loyalty and support within their families to all of its members. I can't forget the young lady who was brought to see me by her brother and his wife. She had sustained brain damage when during her surgery she was not administered sufficient oxygen. She was brought in on a wheel chair with total paralysis. Her brother and his wife showed such devotion and care, that even I have never seen before. They were taking care of her every need at their home. Or that elderly gentleman who came in with his daughter-in law. In addition to interpreting for him, she also helped him with his clothes, shoes, and probably his food, as well. I couldn't help but tell her that I would wish it to myself to end up with such a daughter-in law, to which we both laughed. And that young man that seems to be upward-mobile, coming in with his uncle who in addition to not knowing a word of English, seemed to have difficulty comprehending instructions in Korean. He treated his uncle with such dignity and respect that it was inspiring. I can continue with many more examples, but can also generalize, that from all the Korean patients, I have not yet seen one who did not have a warm and supporting family with them. I'm sure that just like other ethnic groups, so is the Korean community not above criticism, but as far as creating and maintaining the family structure, they must be considered in a different league. They can serve an example to other ethnic groups who experience problems with these issues.

On Becoming a Herbivore

2005-05-05T20:31:00.000-07:00

Yesterday's NYT had an article about the discovery of a dinosaur which scientists believe was on its way to changing from a carnivore (meat eating) to a herbivore (vegeterian). They reached their conclusion mainly based on the shape of its teeth, which would have been more adapt to handle vegetation, than meat. In addition to the teeth, the creature's stomach was found to be larger than expected - in order to allow for better digestion, and its neck elongated - better to reach the tall vegetation. This animal evolved from the carnivores some 230 million years ago, and disappeared from the face of the earth along with its relatives many million years later. What are the forces that can cause such a change? Well, the assumption is that global warming caused vegetation to flourish, causing dinosaurs to gravitate towards this source of calories. And what caused the demise of these creatures? We don't know! Many hypotheses are raised, but the one that seems to be in favor suggests that a large meteorite hit the earth and caused much destruction, which led to the demise of these creatures.
Many millions of years from now, scientists may also say that based on the evidence, we could be considered in transition, as well. They would say that we were likely obese, with very large stomachs, and very poor skeletons caused by a very sedentary life-style. And they would wonder about what led to this outcome. Their conclusion would likely be that there must have been an epidemic of diabetes, which indeed, as we now know, there "was". So lets all do something about this obesity business, and not get confused by those recent articles that claim that being a little fat is healthy. What's healthy is to be young, thin, and in good physical condition. If you can't be young, at least settle for the other two.
For the very curious, the name of this dinosaur is : Falcarius Utahensis (its fossil was discovered in Utah).

Thomas Friedman's Flattening of the World

2005-05-01T18:27:00.000-07:00

This weekend Thomas Friedman appeared both in the New York Times book review section, and for three hours on C-SPAN'S book review program. At hand is his new book : The World Is Flat, a Brief History of the Twenty-First Century. I haven't read it yet, but given Mr. Friedman's record, it's sure to make a big splash. In it, he presents his hypothesis that due to globalization, the world has become "tiny", and has for the first time an equale-level playing field. This allows for countries that invested in education, have ambition, and high regard for achievement, similar opportunities as were always available to the West. Given the nature of this new playing field, the West will likely lose ground to such great powers as China and India. Mr. Friedman recommends that we invest in our abilities to always be able to "retool" ourselves for future challenges. We should all "learn how to learn". He contends that new job skills will be require from all of us in order to be able to compete for those American jobs that we took for granted were available to us only. Apparently, the competition for them will be world-wide. What Mr. Friedman didn't dwell on is the health-related down-side of globalization. By that I mean, the appearance of Western-like maladies in third world countries. A classic example of one is Diabetes. By 2025 the world-wide toll of Diabetes is estimated to be at 300 million cases, most of which will come from countries such as India and China. These third-world countries will have arrived at the globalization goal with an added burden of health-related issues. Mainly due to excess calories and a sedentary life-style, the world's population is gradually becoming obese and saturated with sugar. How are these issues addressed? Very poorly, at best. I would like to humbly suggest the creation of an international "task force" which will try to describe and come up with potential solutions to these problems.
One of my diabetic patients has arrived from India one year ago. In her homeland, she was followed by a special diabetes center which addresses all aspects of diabetes under one roof. According to her, the clinic may see up to 1,000 diabetics in one day!! She also said that patients come there from all over the world to receive treatment. I think that we should take heed in this country of such examples, and create similar centers which cater to diabetics world-wide. We certainly have the technology and the know-how to do it. We need some vision, and of course, some seed money as well.
How does all this relate to The Litvin Centers for Diabetes? Well, we in the LCD identify with this vision, and will strive to advance ourselves in that direction, in the future.

The Matzah Diet

2005-04-26T17:46:00.000-07:00

As you probably know, when the Hebrews were ordered by God to leave Egypt, they had no time to waste. They were instructed to do so with haste, and among other neglected items, bread was not allowed time to leaven. Since then, tradition has dictated unleavened bread only, during Passover. Consequently, for about one week all observers of the Jewish faith consume Matzahs, and stay away from anything made from flour. For all practical purposes, they are on the Atkin diet. As someone who appreciates tradition, I too follow the above directive. Today, during lunch break, I walked up to the local bagel place looking for something to pacify my hunger. I finally picked up a plate with some salad and pieces of chicken placed on top, and as I was eating, I couldn't help but think that I was actually on a diet. Since I don't particularly like matzah, I wasn't consuming any carbohydrates. Maybe after Passover I'll be able to maintain the low carb consumption by virtue of restricting my carbs to matzahs only. This may be the ingredients of a new diet, I reasoned. "You may have carbs, but only in the form of matzahs". For those who dislike mazah, this maybe a reasonable solution.
Give it a try. I certainly will.

Calories Galore

2005-04-18T20:38:00.000-07:00

Yesterday I returned from a meeting in Dallas. I was invited by one of the pharmaceutical companies to a conference regarding a new product. It was just for one day, arriving on Friday night and departing on Sunday at noon. But during that short time interval, I must have been exposed to millions of calories. I realize that it's Texas, but the amounts of food put before us were just unfathomable, let alone "consumable". Of course I joined in with the rest of the crowd, and unsurprisingly, upon returning home found myself weighing five pounds more than when I left. Looking at the scale, I couldn't believe my eyes, but obviously had to accept. During the meeting, I had the opportunity of watching my colleagues and also some of the locals eat, and came away with the conclusion that we're becoming a nation of gluttons. Food is evolving into our major aphrodisiac. No wonder that successful chefs are becoming sexual icons. The activity of cooking and eating can be very enjoyable, but when it becomes a major activity, usurping other every day activities, something is a miss. After such a party, some of us can "bounce" back to their previous weight, not thinking much of the recent new weight-gain. Others, however, are not so lucky. They will retain those extra pounds, only to move on to an even higher weight-plane in the near future. As a society, we owe these individuals some "protection" from these weight increases. We have to be able to identify these individuals "at risk", and then "protect" them from such a caloric "onslaught". Maybe just like alcohol is restricted to certain bars, so should excess calories be restricted to certain restaurants. I know it sounds very undemocratic, but maybe we have no choice if we want to keep this country "thin". Better yet, maybe culinary events should have a grading system similar to the one that the movies have developed in order to forewarn their viewers what they are about to be exposed to. Potential diners should be warned ahead of the meal, what they can expect as far as caloric exposure. Some of us who may be at greater risk for chronically retaining calories, may then be able to make the decision if they would like to attend or forgo such a "risky" culinary funcion. Don't misunderstand me, I appreciate good food, but I also appreciate discipline, which I think is currently missing from our culinary life style.

Salmon for Dinner

2005-04-10T19:45:00.000-07:00

Before leaving for the weekend to a friend's wedding, my wife gave me a quick recipe for cooking salmon. It's very easy, she said, just salt and pepper it, put on it a few slabs of butter, and throw it into the oven at 350 degrees for 15 minutes. So the first evening that I was alone, I did just that. Of course I also fried some anions, garlic, potatoes, and zucchini in the skillet to have on the side, and even opened a new bottle of wine. I must say very humbly, that I thoroughly enjoyed that dinner. But the next morning the NYT had a front page article about salmons that had me wondering.. The Times sent some investigative reporters to buy wild salmons in several major food stores in the city. These were then sent for an analysis to see if indeed they are wild, or possibly farmed. The results of that little study revealed that only a shameful one out of eight stores carried the true wild salmon. The other seven stores were actually selling the farmed salmon instead of the true wild one. When confronted with the results of the study, none of the managers of the stores came up with a satisfactory answer. It made me wonder about the salmon that I ate, which was bought at Cosco. The reason to worry is the finding that farmed salmon contain more toxic contaminants than the wild one. How does one differentiate between the two? Apparently, the wild salmon is pink-colored, whereas the farmed one is gray. Wild salmon becomes pink by eating sea creatures like krill, which contain a carotenoid (same as in carrots) called astaxanthin. In order to fool the consumer into thinking that the farmed salmon is in fact wild, it is fed a synthetic astaxanthin along with some yeast and microalgae, which render it pink. Pretty sad, but true. So don't be fooled by these astute business people and demand to know where the salmon is from. I realize that we are at their mercy, but at least we can show some knowledge and hope that maybe some pressure from the consumer will influence the retailer to be more honest. And don't forget the butter...

Big Breakthrough for the Food Industry

2005-04-06T19:41:00.000-07:00

Today's business section of the New York Times opens with a major article about new and novel chemicals produced by a small biotechnology company called Senomyx, which are able to replace salt, sugar or MSG. Apparently, this company has been able to develop chemicals which identify and activate the different receptors to these flavors within the oral cavity. The chemicals themselves are devoid of taste, but by activating these receptors, they are able to dramatically curtail the amount of condiment necessary for the particular dish. Although chemicals, their activity is high enough so that only minute quantities are needed (less than one part per million), and therefore they do not need to be reported to the FDA and may be classified as artificial flavors. This is going to be huge for the food industry, which will now be able to reduce dramatically the quantities of sugar and /or salt it uses on a regular basis in its many products. Although particularly beneficial to the diabetic, I cannot help but wonder what if any side effect these new "drugs" will present. And in a "futuristic" vein, I can envision people sitting down to a multi-course meal in a fancy restaurant, being served several pills which imitate the experience. Personally, I would rather go for the "real" thing, and just cut it down in size, as opposed to taking a chemical which "imitates" the experience. But to each his/her own... taste...

Cancer of the Pancreas

2005-04-04T21:05:00.000-07:00

One of my long-standing diabetic patients just came to the office. In addition to her diabetic care, which includes insulin and some oral medications, I have also taken care of her severe neuropathy over the past several years. This manifested with pain of a burning nature of both lower extremities. In her case, it spread up to her ankles, but it can also spread up to the thighs. In fact, we call the distribution of diabetic neuropathy a "glove and stocking" distribution. What's typical about it is that it's symmetrical. It effects both extremities. Not to say that diabetic neuropathy cannot effect a single neuron - that can happen too. That phenomenon can manifest as neuropathy of a single superficial femoral nerve, with pain along the lateral aspect of the thigh, or, for example, of one of the nerves inervating a muscle of the eye-ball, causing one-sided double vision. But typically, it's symmetrical. This visit, the patient was brought in by her concerned daughter for different reasons. The daughter stated that her mother had recently lost alot of weight, and that her sugars were difficult to control. I took one look at her, and immediately knew that something very serious was going on. The mother seemed much thinner, but what was even more alarming, she had a jaundiced look. The physical examination confirmed my alarm, and I took some blood tests and sent her then and there for an abdominal CT scan. The blood tests showed an elevated bilirubin with disturbed liver function tests, and the CT scan showed an obstructed biliary tract caused by a large( 1 inch) tumor in the pancreas. The likely diagnosis is cancer of the pancreas causing obstruction of normal bilirubin flow. This patient will likely end up on the operating table, but first a "tissue" diagnosis has to be made. In order to make that diagnosis, a tissue biopsy is necessary. This is done by a procedure called ERCP, or endoscopic retrograde cholangio-pancreoscopy. An endoscope(viewing device) is inserted through the mouth into the stomach and further into the small intestine. In the small intestine the gastroenterologist (doctor) looks for the opening of the biliary duct which he enters with the scope. Once in the biliary duct, a stent can be introduced (just like in the coronary arteries of the heart) in order to relieve the obstruction, and allow for normal biliary flow (which stops the jaundice); and puncturing the duct, a biopsy from the surrounding tumor can be taken. If cancer is diagnosed, major surgery is in order. If the tumor is benign, the stenting with some local minor surgery may be sufficient.
My patient has not had the procedure yet, but along with her family, I too am anxious for the results.
Cancer of the pancreas is not common, but it can happen in diabetics also, and its outcome in them is just as devastating as in non-diabetics. Sudden weight loss coupled with the appearance of jaundice should always make your alarm bells go off very loudly. I just hope that for my patient, it didn't go off too late!

Obesity Article

2005-04-03T07:17:00.000-07:00

This Sunday's New York Times has a major article about the state of obesity research in the US. It reports of a clinical research center somewhere in the mid-west, that recruits obese individuals to its multiple clinical trials. Apparently, many volunteers have to be turned away once the slots are filled. Those lucky ones that do participate, don't know if they are receiving the real pill or the placebo, but there are enough successful stories from satisfied customers to perpetuate the center. Most obese individuals, however, cannot maintain their reduced weight. That's where the battle is "lost". The body, throughout evolution, has devised multiple redundant biological systems in order to insure survival. The role of these systems is to retain calories once they have entered the gastrointestinal tract. The "depot" for that job is , of course, the adipose (fat) tissue. Multiple hormones are involved, and current research is trying to decipher the biological "code" which is responsible for the different phases of obesity. There is the phase that results in acceleration in body weight gain, there is the phase where weight is maintained at "steady-state", and there is the phase where after weight loss, the body will refuse to stay at that lower weight achieved and return to the previous weight. It is reasonable to assume that each phase has its own mechanism with a different set of hormones.
The kind of medications that are currently in clinical trials seem to be agents that are like "a shot in the dark". Since the body's energy system is not well understood, any presumed perturbation of it is given a trial. One company is even looking for an agent that will "attack" fat cells directly.
My personal conclusion from this article is that we're only in the "dawn" stage of understanding obesity, and that until we truly understand the system in its complicated totality, no effective agent will emerge. So brace yourselves for a long haul if you're waiting for the magic pill, or assume a different attitude. What's the right attitude? Well, first of all, one has to recognize the simple truth that we're all living in a "toxic-caloric environment". It's an environment with exposure to too many "wrong" calories which is coupled with a heavy dose of sedentary life-style. It takes that kind of combination to make some of us ( more than %50) obese. After that recognition, one is faced with the question, "what can I do about it?" I view it as if it is a battle. The commitment that it takes is similar to the one taken by freedom fighters. Obese individuals are the byproduct of an "obese society". We are an obese society, and unless we make some drastic changes in our society's wellbeing, we'll continue seeing an increase in the number of obese individuals. Obesity is the symptom of the illness. The illness is the toxic environment that I mentioned. The only way to win is to become freedom fighters for the cause of changing our society. Blame has to be redirected from the obese individual, to the government and to its institutions. This is a state of national crisis, and unless it is addressed as such, obesity will prevail. On a personal level, one has to be poactive in reducing "exposure" to those wrong calories, and increasing exposure to physical activity. I know it's easier said than done, but recognizing that a "quick fix" is not imminent, should make us all embrace the more mature approach of hard work. The pharmaceutical industry would have us believe in an imminent "quick fix". That's how they hope to make their greedy-billions. But, there's no magic in pills. In fact, there is little magic in life, in general. As biological creatures that thrive on homeostasis, we should strive for a society that glorifies moderation and not excess. But , unfortunately, our freedoms have led us down some wrong paths, and we need to retrace our steps. Obese individuals should join the party of the disenchanted. That party should have on its flag the words : "Thin Nation", and should engage government in pushing legislature for stopping all those marketing forces responsible for our obese nation. As it has taken about two decades to become an obese nation, so it may take just as long to reverse the process. This is not encouraging to the obese individual, but it is an inevitable truth. The pharmaceutical industry would have you think otherwise. Don't be duped!

Suit Against the Food Industry

2005-03-28T21:04:00.000-08:00

Today's Wall street Journal had a small article in one of the back pages about a suit which is seeking "class action status" that was filed on behalf of a single citizen against several of the giant cereal manufacturers. The suit claims that these giants are selling their "low sugar" cereal based on false information to the consumer, since filer's research has shown that these cereals contain equal number of calories then do the regular sweetened ones. Sugar, they claim, has simply been exchange with starches, which are handled by the body in a similar fashion. The suit is in its very early stages, but it signifies the public's heightened awareness to sugar content, and various types of carbohydrates.
I am of the opinion that we are all eating too many refined carbohydrates as it is, and should probably stay away from any commercial cereals, unless they're made from natural carbohydrates. Personally, I go for an oat-bran with some fruit breakfast every morning. Currently, I would also support the notion that we have become addicted to sweet-tasting foods, and that we should invest some thought to see if solid approaches could be introduced in order to rid us of that addiction. Sugar has been aggressively promoted by the food industry, and unbeknownst to us, has found its way into most foods. This is certainly at least part of the reason for the current obesity epidemic, that as per a recent publication in The New England Journal of Medicine, may accually cause the continued up-slopping of the longevity curve, to take a "nose dive". So leave the cereals on the shelf, and go for a more natural breakfast.

Stem Cells

2005-03-15T18:39:00.000-08:00

Yesterday's New York Times had a front page article about the state of affairs with research regarding stem cell's ability to become heart cells. Apparently in 2001, researchers injected stem cells from bone marrow into damaged mice hearts, and observed how the stem cells developed into special cardiac muscle cells. Since, researchers are trying to repeat these results in humans. Several human trials are on-going or recruiting patients. Clinicians conducting these trials report of anecdotal cases where dramatic improvement of cardiac function was demonstrated. Researchers, however, are still very skeptical. They claim that you can't expect positive consistent results when an unknown extract of stem cells is injected. Much research involving the individual stem cells still needs to be done in order to understand how and under what conditions these very special cells evolve, they say. Everyone seems to agree that much potential is trapped in these cells, but it will likely take several more years to unlock their secret.
The same can be said of stem cells and the beta cells of the pancreas. The ideal scenario where stem cells are injected into an organ like the liver, where they evolve into mature beta cells, has not occurred as of yet. The hope is that one day enough scientific knowledge will be available in order to steer these cells from their undifferentiated state into a functional state. That will represent a definite cure for diabetes, but much work still needs to be done.

Different Hearts

2005-03-14T19:07:00.000-08:00

I've always been drawn to public libraries. When I'm strolling among the many books, it gives me a certain pleasure that is very different. So I often visit and take out different items. The last time I visited, I took out several magazines which looked interesting, one of which is called The American Scholar. It looks "high brow", but it's actually very nice. I enjoyed several stories, but one in particular left an impact which I thought might have some relevance here. The story's title is Joyas Volardores, and it's written by Brian Doyle. Joyas Volardores means flying jewels, and it's the name the first white explorers in the Americas gave to hummingbirds, the like of which they had never seen before. Indeed, the hummingbird is typical to the Americas and is not found elsewhere. There are more than three hundred species, and each one visits a thousand flowers a day. They can dive at sixty miles an hour, they can fly backwards, and they can fly more than five hundred mile without pausing to rest. Their hearts beat ten times a second, and it's the size of a pencil eraser. Their heart muscle is built from leaner fibers than ours, containing many more mitochondria, and their coronary arteries are stiffer. Interestingly, they suffer more heart attacks, aneurysms(dilatation of a vessel) and ruptures than any other living creature. By contrast, the largest heart in the world belongs to the blue whale. It weighs more than seven tons, and it's as big as a room. It's valves are as big as the swinging doors of a saloon. We know very little about the blue whales, or about whales in general.
The author claims that every creature on earth has approximately two billion heartbeats to spend in a lifetime. A tortoise will take its time and spend them in two hundred years, whereas a hummingbird will spend them in two. I guess humans, are somewhere in the middle. But that's under optimal conditions. Most of us don't live under such conditions, and, therefore, our lives are shorter. As a rule, diabetics live shorter lives, and most often die of a cardiovascular event. Such an event is typically caused by a heart attack which is brought on by a ruptured plaque within the coronary arteries. Plaques are created as a byproduct of the atherosclerotic process, which is a natural process that is enhanced by the diabetic state. The challenge for the medical community is to understand the multiple interactions between the different factors which are responsible for plaque formation and eventual rupture. Much progress is being made, and ,hopefully, within the next decade a real cure will be available.

Quality Care

2005-03-13T14:39:00.000-08:00

A major article in The New York Times Magazine this weekend entitled "The Quality Cure?", resonates very much with my modest vision of how to conduct and improve the health care system. The author, Roger Lowenstein, quotes heavily a rising star in this field - David Cutler. Cutler focuses mainly on chronic conditions that require ongoing care, and are a source of many health care dollars. Diabetes, obviously, is way up there among the chronic conditions that need much attention. Cutler's approach is to reward doctors for patients' improvement in health out-comes, and to computerize the health care industry so that doctors have on-line data about their patients' progress. Having access to such data, will enable doctors to take note of their performance, and plan improvement strategies. Apparently, several large companies have begun doing just that, and marked improvement in out-comes have already been documented.
My drive to create a diabetes center has evolved mainly after much frustration at the lack of quality-care combined with the massive waste that I have personally observed throughout the years while taking care of patients with diabetes. Since patients with diabetes have multiple health-related problems, many health care professionals are involved with their care and consequently the lack of coordination and communication between these professionals leads to near chaos. A center where all professionals are available and all data is collected, makes perfect sense, and should be reimbursed by the various secondary payers with monetary incentives in addition to the customary fee schedule. Since it may take a while for all those secondary payers to take notice of my little center, I can only hope that some major contributor will come along and donate some funds so that we can continue with our mission, despite their lack and our growing financial crisis. Money aside, our mission is on the right track, and the diabetes center is alive and well.
See you in the office.
Dr. Litvin

The Appalachia Tribe

2005-03-10T12:13:00.000-08:00

Wednesdays I'm in the West Orange office, so I don't get to read the Wall Street Journal which is delivered to the Fort Lee office, until Thursday. So today, at lunch, I'm reading one of the front page stories about this rediscovered Indian tribe that has resurfaced in Florida, and thinking to myself that this is really interesting and that I wish there was an angle there for my weblog, when - boom, there it is! Apparently, the Apalachee tribe was an Indian nation sprawled across the Appalachian mountains (named after them) when back in the seventeen hundreds the Spanish started converting them to Christianity. Since then, they have gone into hiding to avoid discrimination and gradual but persistent "ethnic cleansing". Only recently in the 1980's, did their leader - Mr.Bennett - decided it was safe enough to resurface, and since has been reclaiming their heritage. What caught my attention is the fact that Mr. Bennett's wife has diabetes, and that he recently had a quintuple(x5) bypass surgery. This reminded me of the Pima Indians who have not gone into hiding, and in fact have been participating in research at the NIH (National Institute of Health) facility in Arizona since the days of Dr.Joslin. Doctor Joslin was one of the founders of modern diabetology and has a major diabetes institute named after him in Boston. The story goes that as a young researcher he visited the Pima Indians in Arizona and was amazed at their low rate of diabetes. At the time, they were all thin and still hunters and gatherers. Over the past 60 years, however, they have changed dramatically and are now mostly obese and diabetic. Interestingly, their Mexican brethren have maintained their lifestyle, and have managed to stay thin and nondiabetic. Given the fact that the Bennett couple have diabetes and coronary disease, it is safe to assume that throughout their life they were exposed to the sedentary calorie-toxic environment of these united states, and would probably have been much healthier had they stayed on the Appalachian range. Since Native Americans seem to have the highest rate of obesity and diabetes in this country, they should probably serve as an example to everyone of what not to do, and how not to live. Ironically, they must have been the symbol of health back in the days when they led their traditional life in the open space of the wild west.

Doctor DeBakey and Longevity

2005-03-08T11:41:00.000-08:00

The Wall Street Journal had an article about Dr. Michael DeBakey in today's Personal section. Dr. DeBakey is 96 years old and is seen in a current photographed in his surgical scrubs. I remember his name from my medical school days and later from my internship, when I was vacillating between a residency in Cardiac Surgery or Internal Medicine. I used to stand up holding a retractor before an open chest next to the cardiac surgeon, while various repairs of valves and coronary arteries were performed. Sometimes surgeries took as long as six to eight hours. Those were the heroic days of open heart surgery, and Dr. DeBakey was certainly one of the main heros. His name is interwoven into the matrix of current cardiac surgery procedures and general heart disease. But all that was in the mid seventies. What is he doing today at his age, in surgical scrubs?? Well, although not actually operating, he is still very active and reports to work daily! His routine includes five hours of sleep at night, ten hours in the hospital, and five hours of writing/reading in his private library. His diet is based on one meal a day, he does not take any medications or vitamins, nor does he smoke or drink any alcohol. So what's his secret? In his opinion, it's work. Staying productive and busy, in his opinion, has kept him healthy. Dr. DeBakey, may be on to something. Work is something we often overlook as a factor which may sway the equation of longevity. Especially in our retirement-cherishing society. "Retire early" is often a much sought-after and envied situation. According to Dr. DeBakey's philosophy, never retire should be more coveted if we desire longevity.
That approach has had an impact on my game-plan already, and I suggest that you do the same.
Good luck!

New Drug for HDL

2005-03-07T18:25:00.000-08:00

HDL, as we all know, is that wonderfully "good" cholesterol that is constantly busy cleaning our arteries. It is considered today as playing a very prominent role in the progression of coronary artery disease(CAD). Needless to say, low levels of this cholesterol will quickly get you into trouble. Unfortunately, though, we have very little at our pharmaceutical disposal which will effectively elevate HDL levels and reverse the risk. Traditionally, what doctors have been saying to their patients with low HDL levels is to dramatically increase their level of physical activity, and drink a daily glass of wine. The vitamin Niacin is also helpful, if tolerated(it sometimes causes sever flush). Regarding the physical activity, it would probably take a daily marathon run to make a difference, and regarding wine consumption - one would probably have to be almost an alcoholic. Anecdotally, whenever I see in my practice a patient with very elevated HDL levels, I assume first that he/she is drinking too much alcohol, and it's usually so. LDL - the "bad" cholesterol, on the other hand, also shown to be associated with increase in CAD, does not pose a therapeutic problem since several Statins(drugs that lower LDL) are available and effective. Researchers at Pfizer have recently found a very promising drug that selectively elevates HDL levels and consequently will probably dramatically lower CAD. The drug is called Torcetrapid, and is currently the focus of several clinical trials. Pfizer insists on marketing the new drug only as a combination with its very profitable LDL-lowering statin - Lipitor. This should be a bonanza-drug to all patients at risk for CAD - diabetics, obviously, included. The expected date for its arrival is sometimes before 2007. Lets all hope that the trials will be so dramatically in favor of its usage, that the FDA or Pfizer itself will terminate the trials early, and make the drug available sooner.

Homo Floresiensis

2005-03-06T12:00:00.000-08:00

The New York Times had a second article this Friday on a newly-discovered little Homo-species. The first article was several months ago when the little creature's bones were first discovered on the Indonesian island of Flores. What was found there, in a cave, were several bones, and a female skull which were dated approximately 18,000 years old. The sensation, though, is the size of these skeletal remnants. Apparently, this human creature stood all but three feet tall, with a skull about a third the size of our human contemporary. Further findings on the island eluded to the creature's ability to hunt, and even use fire. The current article elaborated on the findings described in the scientific journal Science, in which the authors were able to come up with a true-size model of the creature's brain. Based on the size and the anatomy of this brain, the authors concluded that although very short, this creature had the capacity for higher thinking processes, a significant memory bank, and an ability to plan. Of particular interest, they wrote, were the enlarged temporal lobes, which are associated with speech and hearing. Irrespective of where this creature is situated in our evolutionary tree, my associations are with this creature's pancreas, and his/her potential to develop diabetes. What brought on the association was my medical school physiology course, where I remember studying about some of the achievements of the father of modern physiology - Claude Bernard. We were taught then about his famous experiment (I think in dogs) where he inflicted an injury to the animal's lower brain, with the animal subsequently developing classical symptoms and signs of diabetes. At the time, this seemed absurd. Modern science (in the sixties) was not aware of a specific connection between the brain and the pancreas, and consequently there were no simple explanations. Today, however, we know of many connections, and accept Claude Bernard's experiments as truly scientific. Energy balance, hunger, satiety, eating behavior, and glucose homeostasis, are all controlled via brain circuitry. So could our little ancestor on the island of Flores have diabetes? Probably not! This species was a hunter that had to survive under harsh conditions, with little access to calories. Given the fact that his small brain was proportional to his body, there is no reason to assume that it malfunctioned in any way. Why then did it become extinct? That mystery is unlikely to get solved in the near future, but diabetes has probably not played any significant role in the Homo Floresiensis's demise.

Million Dollar Baby

2005-03-05T11:41:00.000-08:00

I saw the movie last night. Nothing to do with diabetes, but I have an urge to write about it. It exceeded my expectations for a movie that took the oscars. There's real drama in it. I typically go to foreign films for drama, and don't expect the oscars to nominate a very dramatic movie, but this home-grown American film certainly gave much food for thought. It's a modest story, but it carries a "punch". It's about a journey that's made by the two heros that come from different worlds and belong to different generations. A journey of self-discovery, and then discovery of each other. A young women seeking to define herself in a world of loneliness, where the only warmth she remembers is her late father. Realizing that boxing makes her come alive and gives her a sense of self-worth, she clings to it unforgivingly. Part of the package includes the father-like figure of the trainer she recruits. She is persistent and determined only to be trained by him, and eventually achieves his submission and her goal. The trainer, is a lonely father, who is constantly being rejected by his biological daughter, to whom he obsessively writes letters which are promptly returned unopened. His journey is that of discovering the spirit of his new daughter in his trainee, which he nick-names "Cushma" - Gaelic for "darling, my blood". When their journey is almost over, their father-daughter relationship is sealed with true affection, and it's time for the inevitable tragic separation.
The movie highlights many questions about all of us; about our journey through life, about our goals - personal and professional, about our loneliness, and most importantly about our relationships. The movie particularly points out the disparity between family relations, and relationships that are created by us with people that are not our blood relatives. The true magic of searching souls that discover each other, is portrayed beautifully.
Highly recommended.

Dieting According to Your DNA

2005-03-01T17:31:00.000-08:00

Today was a snow day. I leisurely drove south to my West Orange office, not expecting too many patients to show up. Indeed, mine was the first car in the parking lot. So I had some time on my hands which I thoughrouly enjoyed with a cup of coffee and The Wall Street Journal. The health section had a detailed article about a new and budding industry that promises to make some health care professionals millionaires. Apparently, some companies are selling home kits that can analyze an individual's DNA. This information is then used in making a nutritional recommendation which is supposedly tailored to the individual's specific DNA. Of course, there is a "nominal" fee of about $1,000, but when it comes to our figure, money is never an issue... The company involved boasts of selling about 10,000 kits in the US and Europe over the past several years. As I'm reading this story, I can't help but think of those Shamans throughout history who have sold us on an idea/cure that we craved ever so much. They always appeared at the right time, and just happened to know the perfect vehicle that would secure our deliverance. And, of course, a price had to be extracted as well, to make the transaction complete. Such is the case, I think, with these fancy DNA kits that would like to emulate "high" science, but will end up on a "low" flatulence note... The reason for my criticism is the great disparity between our very basic knowledge of gene behavior vis a vis nutrition, and the huge pent-up frustration of the average obese individual. Whenever such a gap exists, there's always someone or some company who will step up and try to fill the void with a "cure", by all means possible. Quite often, though, not in a scientifically honest way. So my advice is that whenever you sense such a gap, stay away. Healthy waiting is always a prudent approach when dealing with novel medical developments.
Why not just try the good old fashion low calorie diet? It works every time - guaranteed!

Supercentenarians

2005-02-26T06:28:00.000-08:00

Right next to the "Salt" article, there is one about supercentenarians. These are people who can validate that they are more than 110 years old. According to a certain group of scientists that are researching this topic, the longevity barrier is at 115. No one has ever been validated as being older, although many have tried. World-wide, there are validated 55 women and six men over the age of 110. The mystery of longevity has yet to be solved, and certainly by interviewing these individuals not much information or clues are revealed. They all seemed to live a normal life, without any particular habits or indulgences so as to point towards some "method". Recent research has shown - in mice - a clear and direct relationship between withholding caloric intake and longevity. Mice eating significantly less calories, live significantly longer. Several humans have taken this up as a personal mission, and have embarked on a similar experiment. Obviously, no results are available yet. The rational for the above relationship is that when the organism is exposed to a lower caloric intake, the "metabolism" overall slows down and consequently there is less "burnout". My personal observation is different. I've noticed over the years that all my very elderly patients - eighty and ninety year olds - have one thing in common. They all have an elevated HDL. Whereas normal is around 50, theirs is typically at around 80! As you probably know, HDL is the "good" cholesterol. It is responsible for shuttling excess cholesterol from arterial walls back to the liver thereby "cleaning" the arteries. So what bearing does all this have on diabetes? Very much! Diabetics typically have shorter lives - they die from complications of the disease. But even more interestingly, they all have a low HDL! This is part of the metabolic syndrome where one finds an elevated triglyceride level and a low HDL. Reversing this trend is clinically very difficult, but that's the challenge. The other point to be made is that related to the reversed relationship between weight and longevity. As we all know, most diabetics are obese. Therefore they face double jeopardy vis a vis their longevity - they are both obese and have a low HDL. It's a lose-lose situation. What to do? Lose that extra weight, and raise your HDL! Unfortunately, easier said than done...

Salt

2005-02-25T18:18:00.000-08:00

I'm reading the Wall Street Journal front page story about salt, and am constantly having a dejavu feeling. You guessed it, I'm thinking of ...sugar! Just as we're all hooked on sugar, so all of us are also addicted to salt. Our consumption of salt has steadily increased from about 2.3 grams daily in the early seventies, to about 3.3 grams currently. We all know the consequences - hypertension and heart disease. Doesn't that sound familiar? Interestingly, just as most affected by excess carbs/sugar causing obesity and diabetes are ethnic minorities, so most affected by excess salt causing hypertension are noncaucasians. There is no doubt that salt is important. It plays a major role in our normal physiology by maintaining adequate tonicity within our vascular system. Our bodies have sensitive mechanisms at their disposal in order to correct any deviation from the closely guarded normal range of salt ions concentration. But like any good thing, too much is harmful. Too much will cause a rise in blood pressure, which will lead inevitably to complications such as stroke, heart disease, kidney failure, and eye disease. So why are we consuming too much?! It's partly history, partly human nature, and partly, of course, the food industry. The history of salt is fascinating. It was once considered precious, and used, in fact, by the Romans as currency. Hence, the term salary. In the 20th century, however, drilling techniques made salt very inexpensive, making it available to the masses. Salt appeared on every table, and humans discovered its qualities and gradually demanded more. Here enters the food industry with its multiple methodologies of preservation of food, and causing taste enhancement, and the path is set for a vicious cycle of ever growing demand. What to do? Apparently there are no good salt substitutes, so we are all consuming the real thing. We need, therefore, to change our behavior pattern. This reminds me of the time when I met my wife and was very impressed by the fact that she did not add sugar to her tea or coffee. I was so impressed, in fact, that I decided to try it myself. To make a long story short, if you give me today tea or coffee with sugar, I simply cannot drink it. My taste buds have undergone a transformation or maybe rehabilitation so that they cannot tolerate sugar. This is what we have to do for salt. We have to train our taste buds to less salt. This may take a little time, but it's doable! But, you say, it's not as tasty as with salt. True, but still unhealthy! Until a salt substitute is discovered, we all must reduce our salt consumption. The food industry must rise to the challenge and look at the benefit to mankind, and not at the benefit to their own pockets.
If we stay away from sugar, food may be too salty. If we stay away from salt, food may be too sweet. If we stay away from both, food may be just right! Try it out.

Ferry Street

2005-02-25T17:26:00.000-08:00

So, I finally went to Ferry Street in Newark's Ironbound district, where I was scheduled to attend a medical talk in one of the Portuguese restaurants. Mistakenly, I arrived about an hour early and unexpectedly found some extra time on my hands. I don't know how, but through a process which I poorly understand, the thought of my Portuguese patient/friend with his recent wine suggestion flashed through my mind. Great, I said to myself, I'll look for that special wine which he recommended. I went into the first wine store on Ferry street, asking for the Portuguese section. After some searching and help from the owner, we found the rare bottle. A slender tall brown bottle with a lovely sticker showing a colorful photograph of a vineyard with a mansion in its midst nestled at the footsteps of some rolling hills, added to it even more mystique. The sticker was titled Alvarinho above the photograph, and Reguengo de Melgaco, below. The vineyard is , of course, Vinho Verde, and the year - 2003. It also read Produto de Portugal, and 12.5%vol. I paid for it a reasonable but not inexpensive price, and exited the wine store contemplating what to do next. Well, I must admit that I didn't go to that talk, but rather drove home. Debating with myself what to do next, I opened the bottle that same evening. Bottom line, I'm hooked! I wish I could describe the flavor and smell of this wine, but even if I could, it needs to be tasted in order to be appreciated. Now I really appreciate my patient/friend, and I feel we're bonded by his gesture.
Salute!

Apples from McDonald?

2005-02-21T18:04:00.000-08:00

I read it, but it took me awhile to appreciate how big a news-item this was. In the business section of this Sunday's New York Times, an article about McDonald bringing apples to their menus dominated the front page. They are planning to slice "real" apples (it's so unreal, isn't it?) and package them as fresh slices in small bags. This will replace the French fries in some child's happy meal. In addition, they plan to introduce some "premium" salads, "in Caesar, California Cobb and Bacon Ranch varieties, a lineup that will soon be joined by a salad of grapes, walnuts-and, of course, apples." They still sell 1.5 billion cheeseburgers annually, but salads have certainly made their mark at 300 million since their introduction in March of 2003. McDonald's claim that they have to be very careful before introducing a new food item, since they have 26 million customers to please. They conduct multiple focus groups, and the apples cleared the hurtle only when a 9 gram sugary dipping sauce was added. After reading this article, I now envision McDonald as a food giant caught between its profit interests and a changing public perception of what is tasteful vs what is healthy. Obviously, what drives sales is demand, but demand is influenced by public perception of what's "in". It is the responsibility of government, the health industry, and the media to educate the public so that demand is tempered by reason and sound information about what is healthy and nutritious. Since salads are being already sold, and fruits have made an entrance, it seems that norms are slowly changing and the above-mentioned bodies should get the credit they deserve. Bon Appetit!

The Trans Fat Story

2005-02-20T19:33:00.000-08:00

A seasoned endocrinologist reminisced to me over dinner not too long ago that as a teenager he used to work in the kitchen of one of the fast-food chains and that to make the hamburgers more tasty, according to the protocol, they used to add to the pan a significant portion of lard. This practice is of course long gone, but apparently these food chains have been adding instead trans fat which appears to be just as dangerous to our arteries. Recent studies have shown, in fact, that not only can these trans fat molecules cause an elevation in our so-called "bad" cholesterol - LDL, but even more concerning, they can also cause a lowering of our "good" cholesterol - HDL. The food industry loves using trans fats for their multiple benefits, such as creating the right taste, for achieving a certain crispness, and for keeping packaged foods fresh for months. Trans fats came into favor about fifty years ago when a trend away from saturated fats was considered important in the fight against heart disease. The process of producing the trans fats involves adding hydrogen molecules to liquid vegetable oil(which is unsaturated) at high temperatures. According to a study from the Harvard school of Public Health from 1999, as many as 100,000 cardiac deaths a year in the US could be prevented if people replaced trans fats with healthier nonhydrogenated oils. Because of such data, the Food and Drug Administration has ordered food companies to come up with food labels which explicitly state the amount of trans fat on each food item, by January 2006. This of course has put the food industry into a state of "high alert", and much effort is being invested to come up with a suitable alternative which will both maintain the qualities, and not alter the lipids deleteriously. The important message to the consumer is to pay attention to the labels, and to include the trans fat category with the rest of the fats/cholesterol when calculating the total fat in a particular food item. Although far from the "lard" days, caution is always warranted when dealing with the fast-food giants.

Homo Sapiens

2005-02-19T10:57:00.000-08:00

A short article in the International section of the New York Times from Feb 17, 2005 ran a story on another article that just appeared in the recent journal Nature. The authors there were describing their assessment of sediments from Ethiopia in which fossils of two human skeletons were found. These fossils were found 38 years ago, and at that time the sediments in which they were found were dated at 130,000 years. The Nature authors, using more modern techniques, claim that the true age of the sediments places the human fossils at 195,000 years ago. This information fits very nicely with some biomolecular research on the genetic diversity among human populations, which points to a common maternal ancestor in Africa(African Eve) dated at 150,000 to 200,000 years ago. From all of the above, it may be assumed that Homo Sapiens appeared on the "evolutionary stage" approximately 200,000 years ago. Understanding sediments is of course key to being able to date accurately any fossil material. This brings me to the association that I had with this article - a biography about William Smith that I recently read. "The father of English Geology" is how he was described. Armed with only a village grammar school education, he was able to ascend to intellectual achievements in par with the greatest within the scientific community. He put together the then scattered information about the different layers of the earth and their respective fossil materials. From his elaborate and colorful data sprang forth the obvious concept of evolution as a process taking place along a timeline which can be traced throughout earth's layers. His legacy also includes a huge colorful geological map of England, Wales, and part of Scotland, which can be downloaded from the internet or seen in its original in the offices of the Geological Society in London.
The diabetologist in me is fascinated with the environment that our homo sapien ancestors have survived versus the life style that our current humans lead. Assuming a truly hostile environment where nutrition is scarce, it is clear that genes responsible for storage of any "extra" calories, would be strongly favored. Slipping with these genes into an environment of plenty, would certainly favor these individuals towards obesity, which is our current predicament. We therefore face the daunting challenge of either altering our environment, or our genes. Neither seems feasible. We just may need to wait another 200,000 years for a different set of genes to develop... These would work towards turning off any storage of calories, rendering us thin again. But an alternative to such a long wait may yet come out of the scientific community. Targeting the adipocyte(fat cell), scientists are looking for ways to manipulate it genetically. In our lifetime, I think a method will be discovered in order to custom-tailor the fat cell to function as we see fit. Effective weight control medications are likely on the horizon, and should be able to slow down the rampant obesity-diabetic epidemic that we are currently facing. My sound advice, though, is that you should not hold your breath, and start weight reduction on your own.

A New Diet

2005-02-13T10:06:00.000-08:00

I just finished reading the wonderful book of Daniel Defoe: The Life and Strange Adventures of Robinson Crusoe. As all of us have, I also have been exposed to the story since childhood, but have never read the unabridged version. I thoroughly enjoyed it. Although fiction, the introduction to the book claimed that Defoe sat for several months with a survivor of a similar episode, absorbing all the information that he could garnish. Defoe lets his hero express and behave as would be excepted from an individual caught in these circumstances and according to norms of the then Christian eighteenth century Europe. As a physician, and particularly as a "diabetologist", what impressed me was Mr. Crusoe's excellent health throughout the ordeal. Baring a single episode of some infection which is described very vividly, Robinson was quite healthy. So, naturally, I assume that it had to do with his healthy life style. Indeed, Defoe makes it very clear that our hero is constantly active. He is very optimistic about life, and is always discovering ways and methods to improve his lot. Beyond his mere physical survival, Defoe is also concerned with our hero's spiritual well being, and to that end he has him reading the scriptures and actually evolving full circle from the heretic that he once was into a religious personality. Much attention is also devoted to Mr. Crusoe's diet. Gradually, his kitchen is producing a several course meal, and one can easily observe that Robinson certainly had a balanced diet. This included goat meat, fish, turtle eggs and flesh, fowl, barley, rice, corn, grapes, raisins, goat milk and cheese, and some alcohol that he managed to save from the wrecked ship. Very conspicuously missing is, of course, sugar. Interestingly, once saved by a British ship, he is offered plenty of sugar and other sweet foods as part of his prize of the approaching freedom. Sugar has been known since antiquity, but in the Europe of the seventeenth-eighteenth century, it managed to reach the masses who were not previously exposed to it as much. So as a diabetologist, I cannot help but cringe at the prospect of the healthy Mr. Crusoe once off his island consuming much larger quantities of sugar, gaining weight, and developing type 2 diabetes. Daniel Defoe doesn't carry the story that far, but I can see the "writing on the wall".
So my "Robinson Crusoe Diet" would be all of the above ingredients, plus a life of constant physical activity, and a quest for spiritual contentment.
Hard to achieve, but well worth the effort.

C-Reactive Protein

2005-02-06T13:07:00.000-08:00

This protein - CRP, has been in the news for the past several years. It was found serendipitously to be elevated in patients with an active coronary heart condition, and the scientist who made that discovery (Dr.Ridker), went ahead to establish a fairly solid relationship between the severity of the coronary condition and the level of inflammation. Of course, we're not dealing with a full-blown systemic inflammation such as one can find in autoimmune conditions (Lupus,Rheumatoid Arthritis, etc.), but rather with a "subclinical" inflammation which does not have any clinical manifestations(such as fever). It seems that the body can enlist the immune system to mount an inflammatory response at multiple levels of intensity. On a scale of one to ten, where Rheumatoid Arthritis is ten, in the coronary heart situation we're talking about a level from one to two at most. Whereas previously we had thought about coronary heart disease(CHD)as a condition of plumbing only, now our level of understanding is much more sophisticated. The actual blockage of a coronary artery is truly the end of the story. Obviously, when that happens, a portion of the heart muscle usually dies, with the patient facing a possible similar fate, as well. However, prior to the actual blockage, an active inflammatory process is taking place, with a clear objective of the immune system to "pacify" the ominous plaque. CRP levels apparently reflect the activity of the immune system, with lower levels signifying a better prognosis(outcome) and higher levels a much poorer one.
Dr. Ridker's most recent article in The new England Journal of Medicine has also hit the national news media with as much splash as it has the medical community. Here he sets out to show that it may not be enough just to lower levels of "bad" cholesterol(LDL), but one has also to consider lowering levels of CRP, in order to achieve lowering the risk of a recurrent coronary event(heart attack) in a patient who has just undergone one. This opens up a whole Pandora's box. However, it probably signals a turning point in the care of patients at risk of CHD. We are going to be much more vigilant in the future in preventing both a rise in LDL and a rise in CRP. So get ready for more testing and more surveillance. Science moves on!

International Study about Heart Attacks

2005-02-05T18:32:00.000-08:00

I'm a little behind on my reading - as hard as I try, I can never catch up. I often wondered how people who are at higher positions than I am in (US president, for example, ha,ha,ha), ever manage. Well, anyway, I just finished reading a very important article in The Lancet summerizing the data from the INTERHEART study. The study is important because it was conducted in 52! countries. Included were people who had just had a heart attack. 15,152 such cases were recruited, and 14,820 people who did not have such an attack were enrolled as controls. Since worldwide cardiovascular disease is estimated to be the leading cause of death, and since the majority of cases are now from low-income and middle-income countries, the authors reasoned that knowledge of the important risk factors in different geographic regions and among different ethnic groups is critical in order to better address this "epidemic". The risk factors investigated were: smoking, Diabetes, Hypertension, abdominal obesity, psychosocial stress, daily consumption of vegetables and fruits, exercise, alcohol intake, and lipid status. Worldwide, the two most important risk factors are smoking and abnormal lipids(cholesterol). Interestingly, the highest proportion of cases with first acute heart attack at age 40 or younger, was in men from the Middle East(?stress caused by the Intefada). Consumption of vegetables and fruits, exercise, and alcohol intake had a protective effect. The authors quoted some investigators that suggested that taking a pill that combines a statin(cholesterol lowering), an antihypertensive drug, and an aspirin, together with avoidence of smoking, could potentially reduce the risk of a heart attack by more that 80%-90%. Meanwhile, we should all stop smoking, increase our fruit and vegetable intake, and exercise, and that should put us at an 80% lower risk for a heart attack. Please follow through!

Second Opinion

2005-02-01T19:19:00.000-08:00

Today's Wall Street Journal ran an article about how difficult and how important it is to get a second opinion. I couldn't agree more. What's coincidental and funny to me is that it was only last night that I had spoken to a friend and stressed to him just that. This friend experienced sudden abdominal pain while abroad, which reminded him of a similar pain he had had several years ago, and for which he was operated with a diagnosis of a ventral hernia. To make a long story short, he went to another physician who sent him for a CT scan and from there to a surgeon. The surgeon looked at him briefly and set up a date for surgery. My friend went for that surgery, but is now unhappy. He did not have a good experience, and from his story, I'm not convinced that much was accomplished with this procedure. Time will tell if the problem has been resolved, but the nagging thought that he should have gone for a second opinion, will not go away. That's what the article is concerned with, as well. The author claims that when reviewed by a second consultant, as many as 30% of cases who were operated on, were found to have gone through an unnecessary procedure. That's a very high number! Not that the second opinion is immuned from being flawed, it's the seeking of a consensus that makes the process so advantageous. Opinions usually vary, and that's why a consensus carries wisdom.

A new patient

2005-01-31T20:11:00.000-08:00

A new patient referred himself today. I am the third physician that he's seen during the past week. He has already seen a neurologist and a cardiologist. Both have given him tests to do, but no treatment was prescribed. He's in his 70's and has had diet-controlled diabetes for several years. He watches his diet and manages to keep a stable weight, and exercises daily. He doesn't take any medication except for a baby Aspirin. Two weeks ago, he reports, he experienced an episode of dizziness lasting about two minutes. There was some nausea, but no vomiting, chest discomfort, shortness of breath, or any other symptoms. Since his son is a doctor, he went immediately to see the neurologist. That doctor examined him, tolded him to change the Aspirin to Plavix, and sent him for an MRI, and an MRA of the carotid arteries. From the neurologist our patient went to the cardiologist, who scheduled him promptly for a stress test and an echo of the heart, after finding that his blood pressure was 140/90. And that's when he came to see me. When I examined him, his blood pressure was 160/100. His only other findings were mildly decreased blood flow in the lower extremities, reduced hearing, and Dupytrance contractions in both hands.
This case illustrates how sometimes several doctors see a patient in consultation, and despite clinical findings, neglect to start therapy. This patient's dizziness is likely unrelated to his underlying cardiovascular condition, however he does obviously have that condition. In addition to conducting tests, therapy has to be initiated! This patient's hypertension was not addressed despite seeing several doctors. I see this kind of hesitancy quite often and wonder about it. Especially in a diabetic - even if only diet controlled - blood pressure has to be optimal, and that means 120/80! Obviously, tests were sent, and therapy started, and patient will be followed until he is optimally controlled.

Making a Fortune

2005-01-30T10:08:00.000-08:00

In a recent NY Times front page article we were told about a certain individual who just purchased the most expensive estate in New York State - a $45 million mansion in East Hampton. Although a neighbor of Steven Spielberg, this guy just seems to have been lucky and was at the right place at the right time. What's disturbing is that his fortune comes from being a middle man between the pharmaceutical industry and the retail pharmacies. Apparently, over the past two decades, between the manufacturing of the drugs and the distribution thereof, was almost like "no man's land". A system called speculative buying allowed our middle man to buy from the manufacturer and sell to the retailer at a differential that created a 60% profit! In 2001, when the practice was at its peak, this created profits of $980 million(nationwide). The industry has since changed and restructured, and the profit margins have decreased, but our mister middle-man is sitting pretty in his mansion laughing all the way to the bank.
The disturbing part about this story is the sad fact that so many elderly fixed-income individuals, cannot afford to pay for their medications, while a middle-age guy sits in a mansion reaping profits from the same industry. One cannot help but think that some of his profits could potentially be diverted towards reducing the cost of medications. But, of course, capitalism works in mysterious ways...

On a personal note

2005-01-25T19:03:00.000-08:00

One of my patients is Portuguese. As a boy he grew up on the family vineyard, mainly pruning the grape vines, but also, of course, drinking the wine. He claims to know if a wine is good just by looking at its color. On his last visit to the office he was telling me about a wine that I must try. It can be found in a liquor store on Ferry street in Newark, he claimed. In fact, he said, I'll bring you a bottle the next time I come to see you. Meanwhile, he scribbled for me the name of the wine on the back of a torn piece of paper from my prescription pad. It read: Alvarinho do Adega cooperativa de Melgaco (as best as I could tell). Since he didn't bring me the promised bottled, I went into a local liquor store in Fort Lee and inquired about the wine. They didn't have it, but they had an Alvarinho from Spain, and they also showed me the Portuguese section. I took the Spanish Alvarinho, and a few Portuguese bottles, as well. One of the white Portuguese bottles read : Vino Verde (the vineyard, I think) and Famega(the name of the wine). It looked nice. It had a nice sticker, a greenish hue to it, and a very reasonable price. I opened the bottle for dinner, and had a wonderful surprise. First of all, I found out that it's carbonated, secondly, that it contains only 9% alcohol, and thirdly, that it has a light sweet taste that beautifully blends with any food. As I was sipping the wine, I couldn't help but remember my Portuguese patient/friend with a twinkle in his eyes, and an ever present smile.
Le'Hayim!

Global burden of hypertension

2005-01-22T19:00:00.000-08:00

A recent article in the medical journal The Lancet, coming out of the department of epidemiology at Tulane University, New Orleans, has addressed hypertension in its true global impact. The data very dryly describes a 26.4% of the adult population in the year 2000 having the diagnosis of hypertension, and a projected 29.2% of adults by the year 2025. Translated to patient numbers, this means 972 million and 1.56 billion, respectively. Interestingly, very similarly to the situation in global diabetes, here too the majority of patients are in the "developing" countries, and not in the "developed" countries. The main impact of hypertension is on cardiovascular, kidney failure, and cerebrovascular diseases (heart attacks, possible dialysis, and strokes), and the methods of prevention are very similar to those that are recommended in the prevention of diabetes. Specifically, the recommendations include: weight loss, reduced intake of dietary sodium, moderate alcohol consumption, potassium supplementation, modification of eating habits, and increase physical activity.
The "developing" world seems to be in a rush to consume more calories, more salt, and more sugar, while steadily decreasing physical activity. No doubt, these developing countries will achieve some day the "developed" status, and will have the data and the experience that is currently at "our" disposal.
Putting on the hat of the philosopher, I cannot help but disclose the insight that while the world is moving "forward", it certainly is paying by a constant retreat.
Inevitably, we may find out some day that the right way is the balanced way. Humans are fragile creatures, and everything should be done in moderation(only my humble opinion).

Meridia to the rescue

2005-01-22T16:46:00.000-08:00

Sibutramine, or Meridia, in its brand name, is one of only two very "impotent" drugs approved by the FDA and available to patients suffering from obesity. Obesity, as we all know is a spreading epidemic in countries which are part of the global economy, and is defined as a body mass index greater than 30. Most alarming to all concerned, is the sad fact that obesity is rising in teens as well as in adults. Teens are subjected to the same lifestyle that all of us are subjected to, but quite often are given allowances which adults are not. We typically consider teen behavior as part of growing up, and are not quick to take disciplinary action. Recent data of a significant rise in teen obesity has prompted a study of the effect of Meridia in this age group. The results of the study were reported in the recent meeting of the North America Association for the study of Obesity. The study lasted 12 months, and was a randomized, double-blind, placebo-controlled trial - meaning that the results should be objective! It should be stated that Meridia is not approved for patients younger than 16. The proportion of teens who lost at least 5% of their BMI was 3x greater in the Meridia group compared with the control group! For a BMI loss of 10%, the Meridia group showed a 39% advantage over the 6% of the control one. Along with weight reduction, as expected, all the parameters of the metabolic syndrome which are often the prelude to frank diabetes, improved.
This seems to be very good news for obese teens. However, long term concerns are still looming - increased rate of teen suicide while on certain antidepressants not being least.
I know it's important to find a drug that can help obese teens, and they deserve all the help they can get, I don't hear, though, cries coming from any sector, for reversing this morbid trend. Prevention is key, but parents don't seem to get that message. Teens are great, and we were all once there, but there is definitely a lack of vision and discipline if they are allowed to continue with their current life-style. Educators and government officials everywhere should be rallying to that cause, and not allowing the pharmaceutical industry to usurp their important role!

US guide on diets

2005-01-16T15:55:00.000-08:00

Thursday's New York Times had a front page article about the department of agriculture's new diet guidelines. These have been drastically revamped from the previous guidelines, and seem to represent a much more sane approach to how we should all deal with the excess calories that we are constantly being bombarded with. A table representing the food groups with their respective quantities showed the heavier leaning on fruits, vegetables, and whole grain sources, rather than on meat, dairy, and fat. Regarding sugar, the new guidelines say that people "should consume foods and beverages with little added sugars."
Regarding exercise, the new guidelines increased the number of minutes of aerobic activity to sixty daily - in order to prevent weight gain. Sixty to 90 minutes daily are needed in order to lose weight! The activities recommended were walking, bicycling and hiking; although, I would add many more including, such as dancing,skiing,roller-bladeing, skating, and all court games involving a ball (not golfing).
These are good guidelines, the issue is how to effectively implement them, and achieve meaningful results. And how are results measured? Unfortunately, the way they can be measured is by reduction of national obesity rates. Unfortunately, because it's incredible where these rate are. From what I remember we're talking 40-50%!!! Unbelievable! Almost every second person(including teens) is obese.
The impact on the nation's health, is, of course, enormous, and my instinct tells me that unless we approach this problem with the seriousness that it deserves, expectations for a solution will not be met. We are in the midst of a "tsunami" of obesity, and unless we view it as such, and enlist all of our resources to address it, this giant wave will take its human toll.
My approach would focus of education of our children, first. Education towards a more healthy lifestyle should be part of every child's curriculum from pre-k. Of course, I would not allow any representation from the food/candy/sweets/cakes/etc/etc industry even a fraction of a foot in the door. Zero exposure to kids would be the correct policy. Along with that, aerobic activity for one hour daily, should be mandatory, as well. As these kids grow, with that kind of education, the rates of obesity will decline. Unless we do that, in my opinion, we are doom to become an obese nation!

Wall Street Journal article

2005-01-16T13:51:00.000-08:00

In this Friday's WSJ a front page article told us about Dr. Rutledge's success with his version of gastric bypass surgery for obese individuals. His procedure takes less time to perform, and he considers it to be a more simplified version of the original. In this "minigastric bypass" procedure the stomach is divided with staples, and the smaller portion which is the continuation of the esophagus, is then connected to a loop of small intestine. The main complaint from patients who have undergone this procedure, is the regurgitation of bile into the stomach, with subsequent vomiting causing a severe burning sensation. Long term data about this surgery are still unavailable, but it may be fair to assume that constant washing of the lower esophagus with bile is probably not "a good thing". The article then goes into elaboration of Dr. Rutledge financial exploitation of the current obesity epidemic, by telling the reader how the doctor has set up centers where this procedure can be performed by other surgeons who have trained to do the procedure with the doctor, and who,of course, will pay the doctor a certain fee for each procedure. We're also told how the doctor accepts cash only, and that the fee is $17,000. Obviously, this doctor is on his way to riches. That's why this article is in the WSJ! It's the nexus of money and medicine (reminding me of another "nexus" that was recently in the news)!
My association with the above story is with another surgical procedure that is familiar to all of us - CABG - or: coronary artery bypass graft. This procedure has a history of approximately three decades, and has been thoroughly and systematically made use of throughout the world. Again, this is a bypass procedure, allowing blood to overcome an occlusion in a coronary vessel. Presumably, the occlusion is mechanical, and the solution is as expected, mechanical in nature. However, research over the last several years has shown that the problem within the coronary artery is much more complex than a simple plumbing malfunction. Rather, a whole host of factors and hormones are involved in producing the blockage and thereafter causing it to rupture. As this science has unraveled the complexity of coronary blockages, so have more refined solutions become a reality, and, subsequently, surgical (or plumbing) solutions have and will slowly recede into the select few that are really indicated.
In the gastric bypass procedure, we are again witnessing a plumbing solution to a very complex problem. In this case there is an attempt to divert calories by creating a small stomach pouch. Understanding the complete story of how the body handles its energy, is only moderately understood. The level of complexity here seems even greater than the one found in the coronary artery. There are many more hormones and lots more factors influencing this "commodity". Therefore, such an oversimplified solution as diverting calories, is doomed for the same "junk pile" that the CABG procedure is doomed for.
More "silver bullets" are likely on their way in the not-too-distant future! However, in the mean time, our energy concerning this issue should be focused on the real causes. These are the American lifestyle, which allows for ingestion of abundant calories, and does not require expenditure of any.