Proposed 2015 Dietary Guidelines for Americans

fruits and vegetables

– by Dr. Irving Loh, MD

The 2015 edition of Dietary Guidelines for Americans has not yet been finalized, but will likely give providers, patients and the food industry fits and confusion.  When the preliminary dietary outline became public and indicated that dietary cholesterol was being de-emphasized, and that eggs were off the no-fly list, a relatively high profile media commentator stated on air that he was going to toss his Lipitor™.  NOT THE SAME!

A bit of history.  Since 1980, the Dietary Guidelines for Americans has been written by the Dietary Guidelines Advisory Committee, which has been appointed by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture and jointly published every five years.  Based on reviews of the literature, best evidence-based science, personal opinions of the appointed experts, and an unknown amount of industry lobbying, these guidelines are tasked to encourage a disparate American population to eat a healthy diet by encouraging the selection of foods and beverages to help us reach and maintain optimal health, weight, and prevent preventable diet impacted diseases.

Data sources include epidemiologic surveys like NHANES (National Health and Nutrition Examination Survey), National Health Interview Survey, CDC, SEARCH for Diabetes in Youth Study and data from the Alzheimer’s Association.

Not surprisingly for those of us watching the eating habits of our patients, the committee found that excess dietary sodium and saturated fat are the greatest dietary risks for all Americans over the age of 50.  In contrast, dietary fiber, vitamin D, calcium and potassium were under-consumed by Americans.  And, somewhat surprisingly, given the negative inculcation surrounding eggs since Framingham, dietary cholesterol is not considered a nutrient of concern for over-consumption.

The committee also reiterated the prior recommendations of eating more fruits, fresh vegetables, legumes, nuts and whole grains, and restricting fats and sugars.  Modest caffeine intake is now acceptable, but only if, I may add, it does not contribute to dysrhythmias or hypertension which I’m sure many of us have observed in our susceptible patients.  The panel did go a bit further than prior panels in that they suggested some policy changes to help effect their recommendations.  One such suggestion was a tax on sugary foods and beverages.  Such a tax was implemented in Berkeley, CA, but was voted down in San Francisco and New York after heavy lobbying by the beverage industry.

More prominent nutrition labeling, perhaps to emphasize added sugar content, was also a possible suggestion.  Regardless of what this committee suggests, this Congress will likely limit any recommendations that have adverse economic impact on the food and beverage industry.  The lobbyists of the American Beverage Association will see to that.

But let’s go back to the dietary cholesterol issue.  Do these proposed guidelines mean that cholesterol as a risk factor for atherothrombotic cardiovascular disease is now not an issue?  How many of our patients will now ask you about whether they need to continue their statins and other lipid lowering regimens?  Moreover, how many will discontinue their lipid therapy and not tell even tell you?

Clearly, and I mean that, CLEARLY, hyperlipidemia remains an extremely important risk factor for both primary and secondary cardiovascular prevention.  The lipids themselves, i.e., the cholesterol in LDL-cholesterol, IDL-cholesterol, VLDL-cholesterol, remnant particle cholesterol, may not be the ultimate culprit, but they are the readily measured surrogates for the protein moieties that may be the atherogenic particles that trigger the immunologic and inflammatory processes that initiate and exacerbate atherothrombosis.

The most critical factor that mitigates one’s lipoprotein values is picking one’s parents carefully.  Genetics dominantly control lipoprotein values, especially LDL-C and, perhaps less so, HDL-C.  Given that genetic “nature”, dietary “nurture” probably impacts LDL-C levels by no more than 15%.  That is not to say that extremely volatile lipid values can be demonstrated when our patients go on extreme diets (however one defines “good or bad” or “extreme”), but the important caveat here is that if the diet is isocaloric, the values may not vary all that much.  The greatest variability in lipid values occur if the patient is gaining or losing weight, not if the weight is stable.  Once the weight stabilizes, the LDL-C tends to creep back to where the genetic rheostat set it originally, correcting for slight upward creep as one ages.  Triglyceride values, and consequently HDL-C to a lesser degree, can be more permanently impacted by weight change.

Remember, all guidelines foisted upon us are really about attempts to modify behavior.  People (including we physicians) don’t really follow guidelines unless they correspond to preconceived ideas.  I’ve evolved my ideas from the perspective of having been involved with research and clinical management of lipids and cardiovascular disease for over four decades.

So, I’m actually OK with the de-emphasis on dietary cholesterol per se, but as clinicians, we need to maker sure our patient’s weight does not fluctuate, which may be associated with significant perturbations in the lipid profile.  But the lipid therapies in at-risk patients need to remain aggressively in place.

We discuss this and a myriad of clinical topics inside SERMO. If you’re an M.D. or D.O., please join us.

Irv Loh MDBio:

Dr. Irving Kent Loh MD, FACC, FAHA (Epidemiology & Prevention), FCCP, FACP is a board certified internist and sub-specialty board certified cardiac specialist with an emphasis on preventive cardiology. He founded and directs the Ventura Heart Institute, which conducts education, research and preventive cardiovascular programs. Dr. Loh is a former Assistant Professor of Medicine at UCLA School of Medicine. He is Chief Medical Officer and Co-founder of Infermedica, an artificial intelligence company for enhancing clinical decision support for patients and healthcare providers.

Mental Illness in the US: Before the happy pills

History of mental illness

Every year, an estimated 42.5 million Americans suffer from some condition linked to mental illness. One could surmise the growth of mental illness reports have risen due to the radical transformation of the relationship between mental illness and its acceptance in society over time.

So how far back can we track mental illness and how was it treated?

Early History

  • Prehistoric times: Mental illness was believed to stem from magical beings and rituals were used to treat these sick people. One of the most primitive ways of dealing with the mentally sick was a procedure called trepanation where a hole in the skull was created using a sharp object, usually a bone. It was believed to release the evil spirits trapped inside curing the afflicted person.
  • Ancient Egypt: The Egyptians believed mental illness was caused by the loss of power or status. They believed the cause of the illness lie within the subconscious and would use opium to stimulate visual dreaming.
  • 400 B.C: There were differing explanations of mental illness during this time from philosophers. Many believed it was a gift or curse from the gods and with no treatment. Hippocrates, however, believed mental illness was caused by physiology. He suggested simple changes to a person’s diet, and physical surroundings would cure them.
  • Middle Ages: Displeasure of the gods and sin were the root causes for mental illness during this time. Causes of illness ranged from witchcraft to demonic possession. For demonic possessions, the patient would be immersed in scalding hot water in an effort to draw the demon out of the body. Women accused of witchery were burned at the stake.
  • Victorian times: Gender bias was experienced fairly often in Victorian times. Menstruation, pregnancy, post-partum depression, disobedience, chronic fatigue, or anxiety could cause women to be seen as unbalanced and labeled as hysteria. These women were then placed in institutions, sometimes for the remainder of their life.

Treatment or Torture?

From the middles ages to the 1800s, the mentally ill were hidden away from society in institutions. Most patients taken to institutions were there to be forgotten and not cured. Behind the walls of the institution, patients were not treated as humans in need of help but prisoners. The rooms that housed patients were jail cells with patients chained to walls, sometimes overcrowded and covered with feces. Bedlam Institute, London’s first asylum for the mentally ill, over the centuries has made a name for itself as a leading example of how the mentally ill were mistreated. For one penny, onlookers could visit the asylum and poke patients through their cells with long wooden sticks.

Gawking at patients as if they were animals was just one form of mistreatment. Their treatment methods are considered inhumane today.

  • Red hot pokers: Patients were branded or poked with a red hot iron to bring them to their senses.
  • Hydro-therapy: Patients stood in a narrow shower while being sprayed by cold water from a hose to stimulate them.
  • Insulin therapy: Used on patients with schizophrenia. The insulin would drop the patient’s blood sugar placing them into a coma and brought on convulsions and brain seizures. Glucose shots either injected or given through nasal passages were used to bring the patients out of their coma.
  • Lobotomy: A brain operation where the cortex of the brain’s frontal lobe was disconnected from the lower centers of the brain. This was normally down by sticking a long needle through the eye of the patient. If the procedure was done incorrectly, the result could be death.

Some of these treatments continued on through the 1970s.

Sermo hub, mental illness resource

If you’re an M.D. or D.O. visit our BiPolar Hub for resources and to collaborate with colleagues

Advancements in mental illness

During a time when mental illness was not prioritized in medicine, two women fought for a change. In the 1840s, Dorothy Dix observed the mentally ill in a Massachusetts institute where she conducted interviews with patients. She documented the treatment of the patients she saw in a piece she wrote to the General Assembly of North Carolina. Her argument was the mentally ill should not be thrown away but committed to institutions devoted to mental health and understanding it’s causes. Over 40 years, she helped to establish 32 state institutes.

Another woman who brought to light the mistreatment of the mentally ill was reporter, Nellie Bly. In an assignment for the local paper in the 1880s, she committed herself to one of the largest institutions in New York as a mentally ill woman where she stayed for ten days. When her story was published, she exposed the mistreatment she experienced and the filthy conditions of the institute. Her story brought attention to the public and politicians bringing in reform for institutions.

It wasn’t until the 1900s that experts began to try and understand the peril of mental illness. During this time, Sigmund Freud proposed the idea of the unconscious. He believed some people had thoughts so upsetting they were buried deep in a person’s subconscious. His practice, known as the “talking cure,” was widely debated then and still to this day.

In the 1940s-50s, the use of medication to solve mental illness emerged. Chemists began experimenting with pills that may “calm imbalances inside the brain and deliver relief.”

Modern Day

While there is still stigma around mental illness, there are many options for help. The mentally ill are not hidden away, but institutions exist to treat and understand their plight. Psychologists offer “talk therapy” while psychiatrists offer talking as well as prescriptive medication if needed. Organizations like the National Alliance on Mental Illness dedicate their cause to bettering lives for those affected by mental illness as well as educating others about illnesses.

As a physician, do you believe there is still a large negative stigma toward mental illness? What do you think are the biggest issues facing mental illness today? If you work in this field, we would love to hear from you.

We will be discussing this and more inside Sermo, our physician community. If you’re an M.D. or D.O., please join us.

Sources:

  1. Treatment of the Mentally Ill
  2. The 10 Worst Mental health Treatments in History
  3. A Short History of Mental Health
  4. History of Mental Health Treatment
  5. Timeline: Treatments for Mental Illness
  6. Early Treatment of Mental Disorders

Doctors Face Tough Challenges in the Workplace

click to enlarge

click to enlarge

Being a doctor isn’t what it used to be; crazy busy schedules, wrangling with computerized records, trying to remember what your children look like after another long week.

We asked our physicians what is the hardest problem they face in their practice.  While no one is surprised about Work/Life balance being number one at 52 percent, the fact that 21 percent of physicians name EHRs as their biggest work headache is telling.

EHR challenges led to a new niche in medicine.  A medical scribe is a person with knowledge of medical terminology who follows a physician throughout their day and enters EHR information for them.  Medical scribes are a small but growing part of medicine.

Another new challenge facing physicians is the increased demands of MOCs (maintenance of certifications).  Doctors now need continuing education credits more frequently and often the MOCs are tied to their ability to work in their specialty.  If MOCs aren’t kept up-to-date physicians can lose hospital privileges or worse.

Work Life Balance for Doctors

We asked doctors earlier this year about physician burnout and what contributed to it.  The top answers included:

  • Lack of control
  • Dysfunctional workplace
  • Extremes in work (boredom/chaos)

As a physician what is the hardest thing for you about your practice?  What would you change?  Do you agree with the poll or do you think there’s something important missing?

If you’re an M.D. or D.O. you can join our free, physician-exclusive community.  Come on in and contribute to cases, vote on polls like this one and more.

Black Friday Humor

black friday cartoon

Black Friday, the rush down the aisles at the mall might mean bargains for some, but for physicians thoughts of injuries also come to mind.  We took this image and ran a caption contest inside the Sermo community.  The doctors voted for their favorite caption.

Enjoy any shopping you might do today and maybe even some leftover turkey!

Two Physicians Give Thanks

giving thanks turkey

Editors Note: Our columnists, Linda M. Girgis and Doctor Curmudgeon, have teamed up to give thanks for their professions.  Grab a hankie and enjoy. 


The hardest task…
To stop…
Put our mental brakes on…
Let them screech…
And think…
About being thankful.
A much easier task is whining, complaining, and grumbling.
It is so easy to grouse

About people whom we feel are rude, and treat us with ill will,
About our aches and pains,
About the lack of appreciation we have,
About our finances,
About those who appear to have more than we.

But do these things really matter?

Isn’t it healthier and happier to focus…

On the family members who are loving,
On the friends who are always there,
On those who gave us compassion when we needed it the most,
On helping hands that were there when we reached for their firm grip,
On teachers who patiently gave us their wisdom and sense of integrity,
On those who showed us loyalty?

In this season of giving thanks, it is so easy to get lost as a doctor in all the changes going on in the healthcare landscape. It is easy to feel frustration with demanding patients and  with patients we can’t cure. However, being a doctor is still one of the noblest careers around, and we are deeply thankful for this opportunity. We came to know so many people, treated the homeless and the rich alike, stayed up all night with the sick and dying. We have witnessed the very first breaths a baby has taken in this world — and witnessed the last words another will ever utter as he/she passes into the next. We are so thankful for this glimpse into humanity and the chance to help alleviate suffering.

We are thankful for all those patients who endure pain, novel treatments, fear — some knowing that they are never going to get better.

We are thankful for all the innovation happening in medicine — and hope one day we can cure everyone.

We are so thankful for our colleagues who know what we are going through — and help us carry our load.

And we, the doctors of the Sermo community, are most thankful for this place that is a second home to so many. We are thankful for all the great doctors in the community who help us solve cases and just listen when we need to vent. We are thankful for all the friends we have made inside.  There is no other on-line community that fosters such deep friendships.

We are thankful for the leadership of the community and the vision they have for the future. We are thankful for their assistance and care — and sometimes just stepping back when we need room to soar. Without Sermo, we would be lost in the sea of medical chaos, islands all alone. Sermo truly transformed our lives like nothing else in medicine.
Thank you to all who are reading this and follow the Sermo blog. We would like to wish everyone a truly blessed holiday.

With love and wishes for lots of chocolate,

Doctor Curmudgeon and Dr. Linda

Bios

Diane Batshaw EismanDoctor Curmudgeon is Diane Batshaw Eisman MD, FAAFP, a Family Physician, writer, voiceover artist, and medical educator. It was in the Neolithic Era that the doctor became renowned for expertise in Trephination. After so much time in practice, Doctor Curmudgeon is now cranky and has rightfully earned the honorific of “Curmudgeon.”

Doctor Curmudgeon has no idea of what will appear in this space. It depends on the Good Doctor’s mood and whatever shamans and doctors are channeled at the moment.

As a curmudgeon, I may stray from what I observe happening in medicine and slink into other areas. But that is the prerogative of a Curmudgeon.  Please check out my first book, “No Such Agency.”

Linda Girgis, MD

credit: Linda Girgis, MD

Dr. Linda Girgis MD, FAAFP is a family physician in South River, New Jersey. She has been in private practice since 2001. She holds board certification from the American Board of Family Medicine and is affiliated with St. Peter’s University Hospital and Raritan Bay Hospital. She teaches medical students and residents from Drexel University, UMDNJ, and other institutions.  Dr. Girgis earned her medical degree from St. George’s University School of Medicine. She completed her internship and residency at Sacred Heart Hospital, through Temple University.  She has appeared in US News and on NBC Nightly News.