Thursday, January 19, 2012

Thank you, Paula Dean

Rule #1 in healthcare: don't try to fool Mother Nature.

The telegenic and endearing celebrity chef Paula Dean is herself a victim of the American diet. Too many calories? Check. Too much saturated fat? Check. A disproportionate amount of refined sugars without accompanying exercise? Check. Cook for 5-10 years (the time diabetes remains "silent" yet causes 60% of its eventual cardiovascular damage). Serves one.

Paula Dean's recipes may be unique but her biochemistry is similar to everyone else's. Unknown to her and apparently her physicians, she passed through the relative calm of insulin resistance. Then three years ago, her blood sugar rose above 126mg and diabetes "suddenly" appeared. The HIPAA laws prevented this information from leaking out to her fans, but now that she has appeared on national television in a selfless act of contrition, all is forgiven.

Except of course by the small arteries in her heart, brain, and kidneys. On the other hand, a profitable relationship with a new sponsor seems a good fit--it's as all-American as any of her recipes. I have been pleased to endorsed diet plans, nutritionists, personal trainers, and vitamin supplements that are health-promoting. If a physician told an obese patient to eat pecan pie, fried chicken--let's not go there.

But in a crazy way, Paula Dean may have contributed an important service. And it's therefore up to the American public, 67% of whom are struggling with weight issues, not merely to marvel at the complexity of these media/medical/ethical issues but to look inwardly for healthcare. Paula Dean is a lovely, talented, and inspiring chef--but you can't fool Mother Nature.

Monday, April 4, 2011

"Let Them Eat Celebration Cake"

When told that the peasants were starving and had no bread, the cruel French artistocrat Marie Antoinette responded "Let them eat cake." Or so the legend goes. Soon thereafter, the Parisian citizens exacted their revenge in a barbaric form of weight-loss surgery not covered by current medical insurances. Of course times have changed, and today, the New York City Health Department issued new rules for their own staff. According to the Daily News, employees received a brightly-colored pamphlet which spells out a set of regulations guaranteed to cure obesity at the workplace: 1) Tap water must be served as a healthy (?) alternative to other fluids. All beverages must be less than 25 calories per 8 ounces. 2) "Cut muffins and bagels into halves or quarters or order mini-sizes. " 3) No deep-fried foods can be served. 4) For celebrations, cake and air-popped popcorn "popped at the party and served in brown paper lunchbags" are permitted. 5) If a "celebration cake" is served, cookies are not permitted. Here is an excellent example of your tax dollars at work. You might not have known about the health benefits of zero-calorie water or smaller-sized muffins if the medical researchers and exercise physiologists at the NYC Health Department had not done their homework. Yesterday, cookies were a choice--now their illicit use is regulated by the same individuals who have turned second-hand smoking into a frightening toxin...and have ignored epidemic pediatric diabetes for decades. Perhaps with added civic revenues and governmental controls, a child's "celebration cake" will be available only from the Department of Health. Parents may need to have their child weighed by designated civil servants, and once his or her BMI is calculated, an appropriately sized/calorized pastry can be purchased. But no cookies ! And small-sized balloons at the party. How far we have come since the days of the Ancien Regime of Marie Antoinette and Louis XIV. Or, as these beheaded artistocrats might have put it before their demise, plus ca change, plus la meme chose.

Monday, March 28, 2011

Notes on "The Park Avenue Diet Show: Controversies in Weight Loss"; March 27, 2011

From its very earliest days the world of weight loss has been filled with controversy. The very first diet doctor was Banting, and he wasn't even a physician. Banting was an undertaker in the mid-1800's who invented a primitive form of the low carbohydrate diet. In fact the term "banting" was synonymous with dieting for many decades. Just as Dr. Robert Atkins did in the late 1960's, Banting advocated eating a disproportionate amount of protein. Most modern nutritionists would find this alarming, for among other things this program increases the risk of gout and kidney stones. When he was the on-site physician for Bell Telephone, Dr. Atkins adapted Banting's philosophy into a more concise set of recommendations. Controversy followed Dr. Atkins throughout his professional career. And the arguments still rage eight years after his death. You can buy Atkins Bars virtually everywhere, but are they correctly utilized by purchasers in the context of a low carbohydrate diet or assumed to have magical weight loss properties despite the high fat content? The Kempner Rice Diet, the bill of fare at the same-named institute at Duke University, seems like a sensible therapy. You check in prepared to eat nothing but steamed rice for several weeks and hope that the pounds melt off as quickly as possible. Sounds like a winner, no? But as Dr. Atkins himself told me, the "patients" must leave a urine sample in a jug outside their door at the end of every day. Lab technicians will test the urine for protein, something that is totally absent in steamed rice. But where would such protein be coming from? A tech-savvy patient could use his or her smart phone to find any one of dozens of gourmet restaurants surrounding the Kempner Institute. Dr. Atkins told me that the overweight comedian Buddy Hackett used to switch his urine sample with that of his neighbors after a delicious forbidden meal. Fast forward to 2011 when obese individuals who have had lap band surgery have devised a multitude of ways to have their liquified cake and eat it. Who is being cheated by this type of irrational behavior? The manufacturer of the lap band? The surgeon? The insurance company that paid for the procedure in the first place? The other policy holders in that insurance plan who must contribute additional moneys in their premiums to support such behavior? The scientific community encourages healthy debate in order to find the objective truths in the areas of health care of most benefit to society. You'll find very little objectivity in the world of weight loss. From banting to bariatrics, controversy have raged for almost two hundred years. Plus ca change, plus la meme chose.

Monday, March 21, 2011

Notes on "The Park Avenue Diet Show: The Capacity for Close Relating"; March 20, 2011

What are the most important defining characteristics of someone who has lost weight, changed his or her image, and maintained their new-found health consistently? Surprisingly, this subject has rarely been addressed at the annual convention of the American College of Physicians, a convocation I have attended almost continuously since 1983. But this year at the upcoming meeting in San Diego in a few weeks, an answer might be forthcoming.

In a seminar entitled "Treatment of Obesity", Dr. Robert Kushner will present data that provide a fascinating but not surprising set of answers. He asks: "What behavioral issues need to be appreciated for successful weight loss?" And he provides a partial list, one that dovetails remarkably with the philosophical and psychological infrastructure of The Park Avenue Diet.

First we should mention what is not important or predictive of success, namely the macronutrient food constituents of a weight-loss program. Endless ink has been spilled over the supposed benefits of the American Heart Association/ Atkins/ South Beach/ Weight Watchers/ Pritikin/ etc program--take your pick because their results are almost uniformly identical and depressing: a 5-10% "success" rate, with "success" being defined as approximately 10-15 pounds in one year, hardly a remarkable achievement. The American College of Physicians and the AMA have stated that they will not be accepting papers for presentation on the supposed benefits of any of these programs anymore. There is no point comparing one "therapy" to another when none of them isn't even remotely beneficial to a majority of people.

On the other hand Dr. Kushner provides a list of seven defining characteristics of the successful weight-loss patient, and here they are exactly as enumerated:

1) Coping capacity
2) Self-efficacy
3) Autonomy
4) Healthy narcissism
5) Motivation for weight loss: more confidence
6) Stability in life
7) Capacity for close relating

Virtually all of these are covered in one way or another in The Park Avenue Diet by either the famed humanistic psychologist Dr. Stanley Krippner or the glamorous, wise socialite Tinsley Mortimer. And the publication of the book predates this ACP academic presentation by two years.

Several of the behavioral issues might be defined by Dr. Krippner as offshoots of personal myths, the rulebook, narrative, or code we have formulated based on our life experiences and upbringing. Autonomous, efficacious people are self-reliant and self-motivated. Those of us who are better at coping with stress may avoid relying on "comfort foods" or high-calorie snacks for temporary pleasure during life crises. And more self-confidence means more pride in appearance, behavior, and physicality.

But it is the inclusion of "the capacity for close relating" that most interested me. One's need for intimacy, close relationships, bonds based on trust and affection--this is also crucial for maintenance of weight, a matter I can attest to professionally and personally. The converse situation, wherein an individual eats, relaxes and sleeps alone, is sometimes a scenario for introversion, loneliness, carelessness, self-neglect, depression, and an unhappy existence.

Except for The Park Avenue Diet I have never seen "the capacity for close relating" applied to any medical condition. But it certainly is important for one's health, especially as defined by the World Health Organization. "Physical, mental and social well-being, and not merely the absence of disease." Social health depends in part on self-confidence and good interpersonal skills, two of the seven most important components of image. And social health is a dynamic construct--you cannot measure it by weight, height, or a blood test value. You must actually do something, namely interact well with others on a professional, familial, and personal/intimate level.

We'll return to this topic after I return from my ACP conference in about three weeks. But you can certainly learn a lot from my guest expert Bernadette Penotti--in our book, on the radio, on her website, or in person !

Wednesday, March 16, 2011

The Last Word on Stress (for now)

The topic of stress can not be covered in too great detail. There are so many aspects to the subject, neurochemical, behavioral, hormonal, pathological, social--such that any brief discussion might seem overly simplistic. Moreover an academic presentation might leave out what readers or listeners need the most, namely practical advice.

Coping with stress is a learned skill. One needs multiple attempts, failures, and successes before having a confident approach to life's trials and tribulations. This is a learning curve that never ends because the stresses of adolescence, challenging as they may appear, have little relationship to the stresses one encounters late in life. But the self-confidence we gain by learning "not to sweat the small stuff" is a way to become better equipped for dealing with more momentous issues.

As a physician I have always felt that the stress of illness is the most important stess to learn to cope with. A young child overreacts instinctively to a slight accident or infinitesimal bodily harm. A fall in the playground will result in minutes of loud crying for no apparent purpose. A mother knows her duties well: not just soothing the area but giving psychological support. "Awww, it's okay." or "This is not something to cry over." I'm sure you've heard these before even if you don't remember. And your mother's advice on how to cope with stress is probably not too far from the truth right now as well.

The pre-eminent psychologist Jean Houston teaches people to view stressful situations in an unusually objective way. She instructed one of her colleagues (currently the Secretary of State) to put her problems in an imaginary box when dealing with other matters. The problems have not been solved, but they are seemingly isolated, to be dealt with at another time. She also teaches people to bolster their own self-confidence by dealing with complex issues as if they were famously self-assured celebrities.

We naturally gravitate to movie heroes who never reflect stress in their physical demeanor or conversation. Think of Gary Cooper in High Noon, Sigourney Weaver in Alien, Daniel Craig in Casino Royale or any other of your favorites. They do not ponder or complain about problems. They solve them. And part of coping with stress is not repeatedly enumerating all of one's current stressful issues, especially at 1 a.m., the worst time possible.

Psychotherapists, physicians, and in fact all health care providers must be able to offer constructive and user-friendly techniques of coping with stress to their patients. A personal favorite of mine was Albert Ellis, who certainly understood the ways that negative thinking can actually inhibit people from finding an appropriate solution to a troubling issue.

But you don't need a professional license to be able to offer good advice to a stressed-out friend. The most serious challenges of life must be handled in a calm and rational way. As an emergency room physician, I learned that speech patterns and body language can be equally as calming as the actual message. Even in dealing with your own problems, slow, calm, and methodical thinking is the first order of business no matter what the stress is. And the stronger and healthier you are physically, the more this will be reflected in mental acuity and a rational approach to stress.

Let's leave this subject for now. Stress will not go away, as you can see right now on the front page of any newspaper in the world. But coping with stress is an ongoing learning process, so pick some examples of "easy" problems and think of how you can frame them, analyze them, and solve them in a rational and healthy way. Your physical well-being depends on it.

Wednesday, March 9, 2011

How to Cope With Stress (Part Three)

Stress is such an important topic that two lengthy discussions of the subject are a mere introduction. I have lectured on this topic frequently, and Dr. Krippner and my DOROT Institute co-presentation from 2004 can be heard on my website. Our recent follow-up discussion is the March 13th WOR broadcast of "The Park Avenue Diet Show".

What is the biochemistry of stress? Although incompletely understood, it can be simplified by focusing on three discrete body parts: the hypothalamus, the pituitary, and the adrenal gland. Let's start at the top, namely the cerebral cortex, the outermost part of the brain where we do most of our thinking. As we view challenging situations or think stressful thoughts, impulses are sent to the hypothalamus, a tiny organ at the base of the human brain.

In addition to dozens of other known and unknown functions, the hypothalamus will secrete a chemical called corticotropin releasing hormone. This will travel a very short distance to the pituitary gland nearby, which will in turn secrete ACTH, adrenocorticotropin hormone. And this chemical in turn will stimulate the adrenal glands adjoining the kidneys to release cortisol.

You may not have heard of any of these chemicals before, and you are probably not aware of this cascade of hormones that rapidly follows exposure to a stressful situation. But you certainly know the feelings that they engender: nervousness, palpitation, dizziness, forgetfulness, and unremitting worrying.

Human neurochemistry is an extremely complex topic, as is physiological psychology, although both are extraordinarily interesting. Why we think what we think is an amalgam of neurotransmitters, hormones, behavioral patterns, social relationships, and personal mythology. Yet no one needs to be told what stress feels like. Everyone experiences it from cradle to grave.

Sometimes we can get used to stress and become less worried under a given set of circumstances. This is called desensitization. New Yorkers for example are accustomed to hearing car horns, police sirens, and other noises that might be startling to someone from a quiet rural area. Emergency room physicians are unaffected by beeps, buzzers, flashing lights, and other noises that might startle or frighten an already tense patient.

The stress response that is "pre-installed" in our bodies was a protective mechanism in our pre-historic past. "Fight or flight" might have been a daily activity in the dangerous world of cavemen and cavewomen. The adrenal gland was thus a lifesaver: this organ which sits on top of both kidneys is the control center for dealing with pre-historic environmental crises. Not only would it allow humans to flee dangerous animals by increasing cardiac and respiratory rates, it would allow the glucose supply to be rapidly increased, fueling the leg muscles so they could work in overdrive.

But these days, although we may have severe stress throughout the day, we certainly do not need excessive blood sugar, a racing heart, or hyperventilation. A simplistic definition of anxiety might be excessive secretion of cortisol and adrenaline when none is necessary.

Anxiety is also a complex topic, one usually discussed by prominent psychologists like Dr. Stanley Krippner rather than physicians. Needless to say anxiety like many other mood disorders depends in part on altered or dysfunctional neurochemistry.

People who suffer from unremitting anxiety may also have certain generalized fears, sometimes worsened by stress. Acrophobia (a fear of heights) is actually quite normal: extremely few people feel comfortable standing on a cliff overlooking Grand Canyon. But agoraphobia (a fear of public places) can be extremely debilitating and frightening. Acute and/or chronic stress can make certain individuals extremely reclusive, prohibiting them from virtually all social interactions.

Stress can affect one's perception of one's own health. Unremitting anxiety can lead to a somatization disorder, when an individual seeks medical attention repeatedly for an illness that doesn't exist. Another possible scenario is called a conversion disorder where neurological symptoms such as paralysis, numbness, or apparent blindness are a direct result of extreme personal stress.

These are considered psychiatric conditions, but stress unfortunately can be a co-factor in dozens of medical ailments. Excessive cortisol can decrease the production of mucus that lines the stomach and protects it from highly caustic hydrochloric acid. In this way, stress causes ulcers, a subject which I unfortunately am an expert in (having suffered an attack in 1991).

Stress is translated into hair loss for many people. How do you know if this is affecting you? When you run your hands gently through your hair, if 5 out of 12 hairs become loosened and fall out, stress may be the reason. And how does stress cause hair loss? "Growing" hairs are converted into "resting" hairs (which are not implanted as well) and fall out.

One of the most fascinating medical expressions of stress can be seen in a hyperventilating patient. Due to carbon dioxide and calcium imbalances, an extremely stressed out person may develop main d'accouchment [delivery hand, namely the hand shape that an obstetrician uses].

But enough talk about the neurochemistry, physiology, and pathology of stress. I'm sure that you are familiar with a great deal of this already. Did you know that the human body also has embedded anti-stress hormones and "software"? We have focused primarily on the sympathetic nervous system, which is responsible for "fight or flight". It has a mirror-image in the parasympathetic nervous system, a parallel set of nerves, neurotransmitters, hormones, and physiologic responses.

By gently rubbing one side of the neck near the carotid artery, a cardiologist or emergency room physician is able to stimulate an "anti-adrenaline" mechanism when faced with a patient with an extremely rapid heart rhythm. Don't try this, but gentle pressure on the eyes elicits a similar response, namely stimulation of the vagus nerve, the superhighway of the parasympathetic nervous system.

Another outstanding example is the "diving reflex". When certain birds and animals plunge into ice water, their heart rate, breathing rate, and metabolic rate all rapidly decrease. One of the extremely rarely used emergency room treatments for palpitations due to life-threatening arrhythmias is to plunge the patient's face into a basin of ice water, eliciting a type of "diving reflex" in a human being. Do not try this at home.

These examples although quite dramatic will show you that there exists in the human body a neurochemical balance to the stress mechanisms we have already discussed. Of course these emergency room heroic techniques are inappropriate for solving personal problems or coping with daily stresses. I'm sure you probably have not been aware of this unusually complex interrelationship.

Depersonalization, however, is a common and rather unconscious technique of coping with stress. This can be broadly defined as a technique of forgetting about one's self and directing one's thoughts totally externally. And I'm sure you have done this rather frequently in the last few months. Going to an exciting sports event, watching a thrilling James Bond movie, even reading a gossip magazine--all of these are activities that allow us to escape from our problems and briefly enter a "parallel universe" nearby. The stressful problems we are temporarily escaping will still be there later on, but our bodies are refreshed by the relief from unremitting bombardment by stress.

Alpha waves in the brain appear on EEG's when people are in a relaxed state, and quite often people can be taught how to achieve this level of psychological comfort. One classic way is through meditation, which can be somewhat duplicated by repeating a particular word or phrase over and over. Recent research has focused on endorphins, neurochemicals that are associated with positive and pleasurable feelings. You have no doubt heard that aerobic exercise, particularly jogging, is associated with the release of endorphins. Moreover, aerobic exercise "tones down" the sympathetic nervous system. This partially explains why "cardio" is a useful ancillary therapy for high blood pressure and heart disease.

Many people feel that coping with stress is best achieved through the use of minor tranquilizers such as Valium or Xanax. But I think it's more important to understand the neurochemical, physiological, and psychopharmalogical aspects of the topic rather than simply resorting to the simplistic therapy of prescription medication. Let's leave our discussion of this extraordinarily important issue at this point. We will continue at another time. Now go have a totally stress-free day!

Tuesday, March 8, 2011

Notes on "The Park Avenue Diet Show: How to Cope With Stress (Part Two)"; March 13, 2011

Stress. You can't live with it, you can't live without it. But what is it?

Stress may be an acute reaction to a traumatic event or the breaking point when multiple challenging issues overwhelm a given individual. Stress varies from person to person, age group to age group, country to country, and continent to continent. It is classically thought of as a psychological disorder yet there is strong evidence for biochemical mediation. Everyone experiences stress at some time in his or her life, with only about 5-10% of the population experiencing severe recurrent symptoms.

What may provoke stress in one person may not necessarily affect others the same way. Yet no one would deny that these are especially stressful times. In addition to the unavoidable personal issues we may struggle with, there are plenty of problems locally and internationally to complicate the picture: terrorism, financial instability, chronic diseases, international conflicts.

While you may not know the names of the areas of the brain associated with feelings of stress (the hippocampus, amygdala, and cerebral cortex) you certainly know the feelings: restlessness, exhaustion, inability to concentrate, labile emotions, insomnia, incessant worrying. Some people may react to stress with emotional detachment, carelessness, and depersonalization. The latter describes a type of flight from reality, where the person temporarily escapes anxiety-provoking situations by retreating into an imaginary world.

Stress, however, is definitely a more serious problem when it creates or worsens medical conditions. Virtually every known illness can be affected negatively by stress. Blood pressure may rise, glucose levels may double, coronary arteries may narrow, and breathing may become difficult. Stress may also create or worsen lifestyle patterns such as overeating (or paradoxically anorexia nervosa) and may unfortunately lead to substance abuse as the individual self-medicates his or her anxiety with alcohol, cigarettes, or illegal drugs.

As you are well aware the primary treatment of stress in the United States is with prescription medication under the supervision of a psychopharmacologist. Supportive psychotherapy is not part of a typical visit to an internal medicine specialist. Moreover, since the average length of such a medical visit is only eight minutes long in 2011, the physician has absolutely no time to discuss his or her patient's life stressors. Not surprisingly, physicians too have stressful lives. If you don't believe me, read Uncle Vanya by Anton Chekhov.

Just like watching your weight and doing structured physical exercises, learning how to cope with stress is a skill that is necessary for optimal health. It is not merely a useful tool, it is a necessary technique for survival. Debilitating stress can derail any of our long-term personal or career goals quite rapidly. And simplistically relying on tranquilizers, sedatives, or antidepressants does not change the nature of the stress or give us guidance in how to resolve challenging issues.

I have been lucky to know Dr. Stanley Krippner since 1967 when I was his file clerk at Maimonides Medical Center during my high school years. As one of the most esteemed humanistic psychologists of the recent past, he has written dozens of books and hundreds of articles about mood disorders and how they affect an individual's thinking, interpersonal relationships, creative work, and community activities. We have discussed this enormous topic in various venues, and although we are seemingly experts in the field, we still experience enormous stress for which we must continually reinvent our own coping mechanisms and positive strategies.

Some of these are explored in our WOR radio interview and our lengthy lecture at the DOROT Institute, both of which you can hear on this website. You will never be able to totally eradicate stress from your life. You will certainly have something stressful happen to you within the next twenty four hours, hopefully minor. But you must not avoid learning and relearning how to cope with stress. And if you are suffering from palpitations, hair loss, insomnia, feelings of worthlessness, extreme sadness, or similar symptoms, the time to learn how to cope with stress is right now.