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

Sandy Pentland Discusses Wearable Tech and Medicine

credit: World Economic Forum

credit: World Economic Forum

Silicon Valley is clamoring to enter the medical, wearable tech niche.  Every tech company from Apple to Google is trying to solve our health crises with some kind of tracker, some simple, some sophisticated.

Sandy Pentland, PhD., of the MIT Media Lab has been tracking individuals by smart phones and other devices for years. He has gleaned a theory of “Social Physics” that can track and predict behavior and even foresee disease and illness. We had the chance to talk with him about his intriguing research and how physicians can apply it to their patients today.

~ Video Introductions by Ayesha Khalid, MD, MBA, Enterologist

Social Physics and Obesity: In the healthcare world, we have a hard time motivating our patients to follow the plans and pathways we create as doctors. If we can find the right incentives to get people to change their behavior and keep it that way- bingo! Huge win!

Pentland addresses this in a pilot health program. Participants received incentives whenever a person they partnered with worked out.   This buddy system was eight times more effective per dollar than normal financial incentives. More importantly, they kept up the social network and exercise guidelines after the experiment concluded.

 

Social Physics and Genetics: The power of social physics and thinking about the spread of ideas can be very powerful in health care. Disease groups such as depression may be haphazardly grouped based on an accidental clustering of symptoms. Pentland discusses why therapeutics work so differently on individual diseases within a category. One recent project adds a behavioral and phenotypic component to genetics data and starts to tease out the different types of diabetes, or depression.

 

 

Social Physics and mental health: Imagine a world, where soldiers who have PTSD provide their psychiatrist with daily updates via their smart phones. Physicians don’t have to wait weeks for a check-up to see how medication is doing, but can simply check an app to look for tell-tale signs. Changes in behavior, both major and nuanced are tracked relaying a patient’s progression.

 

Social Physics vs Social Media: Recent media discussed the inaccuracy of “Google flu,” an online tracking algorithm that predicts the movement of the flu virus based on people searching for information. Pentland discusses the difference between aggregated data point from individual tracking vs keyword tracking through social media and search.

 

 

Conclusion  

Human beings are highly social and communal in our sharing with one another, a trait signified by the importance of language and sociocultural imprinting. We know that Western healthcare does not pay attention to the power of social dynamics, our external environment, and the role it plays in our own wellbeing. Would it not be interesting if we could measure that in some way and help it to understand the power of the relationship of our genetic makeup with our disease manifestation?

Bios:

Sandy Pentland has been a professor with the MIT Media Lab for nearly 30 years. He is also the co-founder of several companies including ginger.io and Thasos Group. He is the author of two books, Social Physics and Honest Signals.

Ayesha Khalid is a sinus surgeon with an MBA from the MIT Sloan School of Management. Ayesha is interested in the re-design of the health care system with a patient-centered focus, specifically in the area of clinical trials and rare diseases. She is a co-organizer at Hacking Medicine, an interdisciplinary group at MIT that seeks to spark change in healthcare. She also serves as the Young Physician Chair for all ear, nose and throat physicians in the United States.

 

Sermo Announces Eight New Hubs

BiPolar disorder

We are pleased to announce the creation of eight new Hubs, or online information libraries, in several specialty areas.

The new content pages will pull content from around the web and from within the Sermo community to one centralized location.  Each Hub will include topic-specific posts, videos, new research, and polls as well as areas for physicians to discuss the latest updates.

If you are a physician, please join us at our newest Hubs, they are:

  • Infectious Diseases
  • Depression
  • Bipolar Disorder
  • Dermatology
  • Pain Medicine
  • Asthma
  • Rheumatoid Arthritis
  • Pain Medicine

One of the strengths of our community, is the number of doctors who are contributing to the Hubs.  There are over 40 ambassadors who regularly write fresh, thought-provoking posts aimed at improving patient outcomes and sparking debate among fellow physicians.

As an example, the Infectious Diseases Hubs has had recent conversations on Ebola, EV-D68, the upcoming flu season, and HIV/AIDS.  Our Depression Hub currently has an active conversation about the incidence of over-diagnosis for bipolar disorder.

Our newest Hubs join other ongoing information centers for a total of 13:

 

  • Multiple Sclerosis
  • Oncology
  • Diabetes
  • Cardiology
  • Obesity

If you are an M.D. or D.O., please join our community and explore our latest Hubs, polls and posts.  There is a conversation just waiting for your input.

 

Celebrity Medical Treatment: What happened to Joan Rivers?

doctor treating joan rivers

credit: Shutterstock

As Melissa Rivers prepares a lawsuit for damages against the clinic that performed her mother’s fatal surgery, a new report released yesterday details what went wrong with her procedure.

A 22-page report issued yesterday said the clinic where Joan Rivers received care made “major mistakes.” Violations include:

  • failure to recognize deteriorating vital signs
  • improper regulation of the dosage of Propofol
  • failure to obtain consent for each procedure
  • not cared for by authorized physicians
  • and perhaps most telling, a staff member taking a picture while sedated

The report clearly indicates that, at least for Ms. Rivers, she received celebrity treatment that might have cost her life. We asked our physicians about celebrity treatment, and they had a lot to say about it.

Do Celebrities Deserve Different Treatment?

Some physicians found deferential treatment to be against the idea of being a doctor. The goal is to give everyone the best medicine, period.   One anesthesiologist wrote, “I told the CEO of a Fortune 500 company that he’ll get my best effort, just like the homeless guy I took care of right before him.”

An oncologist echoed that sentiment strongly, “When VIPs in need of care enter my realm, I bend over backward not to cut corners. It is a superstition of mine based on a Palmer Slogan, “only the very rich can afford poor healthcare.” Every patient deserves the best efforts I can give them, and there is ALWAYS a cost to cutting corners for anyone.”

Some doctors acknowledged there are reasons to treat celebrities differently, but it’s more about the mechanics of practice management than patient treatment options. An Emergency Medicine doctor wrote, “We get a fair amount of celebrities where I work, some VERY famous. The majority get a room quickly and seen within minutes of arrival. It’s a perk of celebrity, but it also keeps the ER functional. The treatment is the same. I do have to say the vast majority of them have been very decent, patient, and cooperative.”

Some specialties lend themselves to a higher level of celebrity patients. One in particular is Otolaryngology: a doctor wrote, “It really isn’t as cut and dried as ‘treat every patient the same,’ because not every patient has the same needs. Would I treat my next-door neighbor’s voice problems the same as the Bono’s if he was in town for a concert and needed to perform tonight? I don’t think anyone would.”

VIP Syndrome

One cardiologist described what sometimes happens when doctors treat celebrities. “There is a name for this, the VIP syndrome. It is often doing either slightly more or slightly less often at the request of the famous. Alternatively, the physician tries to do more to make sure the procedure will be successful. Unfortunately, things tend to go wrong in these circumstances the most.”

Having famous parents can have an impact on your care as well, one pediatrician wrote, “I covered a practice with lots of household names. The parents brought their kids in and were perfectly normal. The only issue was they were constantly refusing immunizations. They were nice about it, however. It was time consuming to talk about why these immunizations are recommended, the risks of the diseases, etc. They also needed to sign a form they had refused immunizations.”

An otarologist summed up the pitfalls of celebrity and medicine. “By human nature, doctors are just as awe-struck by celebrities as anyone else. Many times celebrities are treated as royalty, and there are many celebrities that expect it—-and demand it. The problem when too many rules are bent to please the celebrity can be fatal. We don’t tell them how to perform and do their business—therefore the celebrity should not command what we do—-especially if you bend rules or push the envelope.”

What do you think about celebrity status and medical treatment? Are there times when treating celebrities differently makes sense such as a singer with a throat problem or a busy urban Emergency Room suddenly dealing with a celebrity? What controls should be in place to protect the famous? If you’re an M.D. or D.O. you can see the full conversation inside Sermo.