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.

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.

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.

 

The Despicable Patient and Name Calling

click to enlarge

click to enlarge

~ by Maxwell M. Krem, MD, PhD

How does a physician deal with a despicable patient—not just a difficult patient, but an individual whose maladaptive behavior reaches the extremes of physical and verbal abuse, persistent sexual harassment, and even danger to medical staff or the patient’s family members? The answers lie on two levels, professional and personal.

Professionally, techniques such as boundary- and limit-setting, an empathetic demeanor, obtaining additional staff for security and chaperoning purposes, careful monitoring and documentation of clinical encounters, and reasonable attempts to develop a therapeutic alliance are likely to help the physician navigate encounters with even the most behaviorally challenging patients.

However, on a personal level, the answers are less clear. How does one face regular exposure to some of the ugliest facets of human behavior and maintain sanity? Many, if not most, physicians employ defense mechanisms, and humor is high on the list. In the humor category some unofficial acronyms have emerged, some of which are not intended to be derogatory but are clearly inappropriate for professional settings or patient encounters. Examples include FLK (funny-looking kid) and LOL (little old lady).

A recent Slate article by Columbia University psychiatrist Anne Skomorowsky looks at one of those acronyms, exploring the author’s experiences with it and exposing it to the general public. The abbreviation: SHPOS, standing for “subhuman piece of shit.” The author discusses the acronym as one commonly used by physicians for patients they despise or who behave disgracefully. She describes encounters with patients who displayed severely dysfunctional behavior, such as harassing medical staff or endangering themselves, staff, and family members; she discussed her own intense reactions to those patients, as well as the misogynistic components to the behavior. Dr. Skomorowsky additionally explains that the term has been in use since at least the early 1980s and is “known to physicians everywhere.” She concludes that “[n]o one is proud to call another person subhuman.”

Dr. Skomorowsky is certainly correct that the despicable patient does exist. A recent discussion of her article on Sermo confirms that physicians from nearly all specialties have had similar encounters. Maladaptive, misogynistic, abusive, infuriating, assaultive, and dangerous behavior is not confined to the psychiatry ward, and it cannot be tolerated in a therapeutic setting. SHPOS may reflect “the clash of various narcissistic needs between the resident and his difficult patient,” in the words of Strauss (South Med J 1983; 76: 981-984). SHPOS also goes too far, is not in common usage and carries overtones of arrogance and lack of sympathy by the medical profession.

Why is SHPOS an unjustifiable acronym? Despicable behavior is an element of the human condition. The behavioral range of our species is vast and ranges from the most noble to the most base. The “SHPOS” is as human, and as “subhuman,” as are we in the white coats. Though physicians, professionally and often personally, aim for the noble end of the human behavioral spectrum, members of our profession have committed terrible acts against mankind, their patients, or their families. We are not above reproach and must not rejoice in a false sense of superiority. Superiority is at the heart of the abbreviation SHPOS, which labels the wrongdoer as something less than human; his behavior is explained by his inferiority. When confronted with what seems to be a SHPOS, we are looking at one of our own kind.

The Slate article brought back a memory from the very beginning of my medical education. Stephen Lefrak, MD, Professor of Medicine at Washington University School of Medicine, delivered the address at the White Coat Ceremony on my first day as a medical student. He recounted a story from early in his own training, during which he assisted a Jewish surgeon and Holocaust survivor in a procedure to save the life of a patient. As the procedure was getting underway, Lefrak noticed that the patient was tattooed with swastikas and other neo-Nazi insignias. He asked his colleague whether that patient deserved their efforts. The Holocaust survivor’s response was that to give any less than their best effort would be sinking to the patient’s level.

That ethos is what makes medicine special—a calling—and provides the glue of the doctor-patient relationship. Medical care is nonjudgmental. To be repulsed by despicable behavior is only natural, but to denigrate patients behind their backs erodes the central compassionate culture of the medical profession. The vast majority of doctors do not engage in the denigration of patients. A poll on Sermo (with more than 2500 responses at the time of writing) revealed that 90% of physicians had never heard the acronym SHPOS. We may occasionally have (justified) unspeakable thoughts in response to despicable behavior, but perhaps that is how those thoughts should remain. As one physician on Sermo said, “but when you let it out your lips, others hear you. It makes you look bad.” To call the offender subhuman is a facile defense mechanism, but for our good fortune we do not walk in his shoes. To call him a SHPOS is to be judgmental and be drawn into despicable behavior ourselves.

credit: Seattle Cancer Care Alliance

credit: Seattle Cancer Care Alliance

Bio:

Dr. Maxwell M. Krem, MD, PhD, is a medical oncologist who sees patients with hematologic malignancies at the VA Puget Sound Health Care System. His primary specialty is bone marrow transplantation.

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How Long Does Your Doctor Really Spend With You?

how a doctor spends his time

click to enlarge

by Linda M. Girgis, MD, Family Practitioner

I often hear patients complain their doctor barely spends time with them at their appointments. Many feel rushed in and out, dumped on the curb, their wallets lighter by a co-pay. But, the truth is far from assembly line medicine. Patients rarely stop to consider the time we spend outside the exam room on their behalf, and it is hours a day.

Prescriptions eat up hours

Pharmacies often call us when a patient’s insurance rejects a prescribed medication. Instead of letting our patients battle it out with their insurance companies, we do the task ourselves. We spend time trying to find equally effective alternatives that may be on their insurers formularies. If not, then we are condemned to do the dreaded prior-authorization. The whole process can take up to half an hour of just being on hold waiting to speak to a living person. Or it can mean filling out prior authorization paperwork required by a particular insurance company. The patient just sees the prescription waiting for them at the pharmacy and not the work that went into getting it into their hands.

Diagnostic testing causes headaches

Authorizations for diagnostic testing can take hours, sometimes days, occasionally months. It includes a phone call to the insurance company, or a case management company as many now use.  These calls can take 30-45 minutes of hold time to reach the responsible party.  Office notes need to be faxed over for review. Often, the decision is made for a one-on-one peer consultation before approvals are granted. This means the doctor has to have a phone discussion with the medical director of the insurance company. Usually, this is a 15-minute call but can be longer.

When I’m fighting insurance companies, I can’t be in the exam room. These days the majority of my time is stolen by people with checklists following up on the work I do.  They never see a patient or understand the nuances of a case. Doctors simply cannot examine patients and do these tasks at the same time. Every day, there are more and more regulations requiring us to do more paperwork and record more metrics.

EMRs and my former personal time

Doctors do not have the leisure to go home at the end of the day and just put our feet up and relax. Many days, I take my laptop home to work on patient charts after hours. To ensure we’re using our chart software in a meaningful way, the government dictates what information is important (even if we don’t agree).  We are often filling in data points that are useful to the government for tracking purposes, but not to our individual patients. While we may spend 15 minutes with a patient in the exam room, recording that visit often takes longer. So, while most people go home and put their jobs down for the day, many of us are spending more time with patient charts.

On Call Is Still A Way Of Life

Doctors must be available 24/7 for patient care. Many of us take call hours and are available all night for calls and emergencies. We often sleep with phones next to us in case we’re needed, regularly jolted  by a 4 am call.  While this is not time in the exam room, this is time available to our patients to provide them better care. Yes, I’ve even taken a call at 3 am on Christmas morning, my children dreaming of Santa and presents.

Patients might feel they are at war with us as they try to get more face-to-face time.  We feel we are in a war of paperwork and insurance bureaucracy to make sure our patients get the care they need.  All we ask is for patients to take a little time and think about what happens outside of the exam room.  That’s medicine too.  Maybe if we work together we can reform the system, tame the paper tigers and put us back where we belong, with our patients.

Bio

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.