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March 2004

Diets Revisited
Prescription Mismanagement
Drug Abuse
Non-Drug Therapies
Ask Dr. J: Metabolic Typing -- No Science
References
In the Health News
Diet and Disease
Recipe of the Month: Pan Fried Buckwheat Noodles

Diets Revisited

Dear Friends,

A reader commented on my last editorial on the value of high-complex-carbohydrate diets as opposed to the popular high-protein diets recently being promoted, saying “carbs are unnecessary and that meat is good.” I do not write to promote a vegetarian philosophy, nor from a need to control how people eat. I simply report the science behind various diet selections so that my readers (and patients) can make informed choices.

The issue of whether eating a mostly-vegetarian diet is healthiest is no longer a scientific question: the science is quite clear on this. It is now a personal, emotional, and even a political question. In spite of the evidence, many people and some doctors still promote high-protein, non-vegetarian diets, but the science consistently says a mostly vegetarian, high-fiber diet is best.

My reader’s comment included a bit about two explorers who lived in the north pole for a year, and “thrived on an all meat diet.” What happened to just two people for such a short time on a radical diet is irrelevant. Of more concern is what happens to large numbers of people who consume various diets over the long term. From this perspective, mostly vegetarian diets are clearly healthiest. Paleolithic diets are irrelevant to modern humans, who live decades longer than our remote ancestors.

Prescription Mismanagement

It is increasingly clear that many medications are overused in both hospitals and in private medical visits (see below). It is also being reported that doctors can safely prescribe effective doses of medications that are much lower than the levels commonly used. This would reduce both costs and side effects.

Pharmaceutical companies usually set the recommended doses, and if lower doses were just as effective, they would see a reduction in sales and profits. Often, the drug company representatives visit doctors offices and make suggestions for drug use. Medical journals frequently have more ads for drugs than they do research articles, so the physicians reading these journals may have unscientific influences on their prescribing habits.

You should be aware of this and not be afraid to ask questions of your doctor to make sure that you are receiving proper medications based on good scientific information. From a public health perspective, antibiotic overuse is a particular problem, contributing to the increasing appearance of antibiotic-resistant organisms. This problem is only made worse by the extensive use of antibiotics in feedlot animals meant for human consumption. If you do use animal products in your diet, you can avoid these problems by choosing organic sources. In any case, it is important to be cautious about dietary choices or accepting any prescription without an adequate medical reason.

Drug Abuse

Recent evidence shows that about eight percent of all seniors’ doctor visits resulted in inappropriate prescriptions, leading to side effects that could be avoided. Pain relievers, anxiety medications, anti-depressants, and sedatives were particularly overused.

The problem was greatest among women. High risks from multiple medications were also a significant problem as reported by a researcher for the Centers for Disease Control. Eight percent amounts to about 20 million incorrect prescriptions.

About one third of the time, visits by seniors to physicians resulted in multiple drug prescriptions, compounding the risk of side effects. It is always important to let your doctor know what drugs you are taking, and to be sure to ask questions about why you need a particular medication; often, you do not.

This problem is not confined to the elderly, particularly when it comes to antibiotics. The use of antibiotics in children and adults for viral infections, unaffected by such drugs, leads to side effects, allergic reactions, and the risk of developing infections with resistant organisms.

The real drug problem in the US is not from illegal drugs, but the overuse and inappropriate use of prescription medications. Even correct prescriptions lead to side effects that are responsible for over 100,000 deaths per year, and we are continuing to learn of negative effects from drugs.

An analysis of the anti-psychotic drug Zyprexa shows that in elderly patients with dementia, this commonly prescribed medication causes increases in strokes and overall mortality. Another anti-psychotic drug, Risperdal, was also shown to cause the same harm. These two drugs are often used in elderly demented patients to control behavior.

Although commonly prescribed for this, Zyprexa is not approved for use in dementia-related psychosis. A warning letter from the Zyprexa manufacturer (Lilly) notes that overall mortality risk is 133 percent higher in the elderly taking Zypreza compared with placebo.

While these specific effects are not seen in younger patients on the medications, this new evidence follows an all-too-familiar pattern, in which a drug is approved, hailed as an advance in medical therapy, and later found to have unexpected long-term side effects. By the time this happens, many people have been harmed, and the drug companies have had time to switch their financial dependence to a newer drug, of which the side effects have not yet been discovered.

Another such drug treatment is hormone replacement therapy (HRT). Regarded for many years as not only a symptom reliever in menopause, but also a way to reduce risks of heart disease and brain dysfunction, the combination of Premarin and Provera (Prem-Pro—estrogens and a progesterone-like drug) has now been shown to increase the risks of heart disease and strokes, leading to a sharp drop in its use.

This is in addition to the known risk of breast cancer, and a newly reported side effect from HRT—an increase in adult asthma. Although development of asthma in later life is uncommon, that risk is more than doubled in women who take estrogen alone or in combination with Provera. (No such risks have yet been described in women who take bio-identical hormones.)

Another potential problem with HRT is hearing loss. In a small study (only 64 subjects), women between 60 and 86 years old who were taking HRT had a 10 to 30 percent greater hearing deficit than those not taking the treatment. While not a lethal problem, hearing loss significantly affects quality of life.

I am not saying that prescription medications are not an important part of medical care, or that they should never be used. I recommend them when necessary, including heart medications, antibiotics, and others. They can be lifesaving, and they can improve the quality of life, and modern medical care would be almost impossible without the use of many drugs.

Non-Drug Therapies

However, in many cases drugs are prescribed when they are unnecessary, sometimes at too high a dose when less would be effective, or when safer natural products will do the same job or better, without the side effects. Using coenzyme Q10 for heart disease and hypertension, vitamin B3 for mental illness, black cohosh for menopausal symptoms, and glucosamine sulfate for arthritis are all examples of safer approaches to health care at lower expense.

St. John’s wort is often helpful in mild to moderate depression, and safer than prescriptions. Saw palmetto is equal to or better than the prescription drug, Proscar, for prostate symptoms, and policosanol is superior to statin drugs for vascular disease and cholesterol elevations.

It is apparent that many people are already looking for alternatives to their medications, and not always by taking supplements or making other lifestyle changes. In a recent poll by the Associated Press, many people reported that they either stopped taking their medications because they were too expensive, or they reduced their dose (in some cases, perhaps unwittingly, giving themselves both better medical care and fewer side effects at the same time, as many drugs are prescribed in too high a dose).

My advice is to manage health problems with lifestyle changes and dietary supplements before medications, unless the situation is urgent or clearly responsive to specific medications. Also, try to avoid long-term use of prescription or over-the-counter drugs, at least without frequent review of their necessity. If the more benign methods are not adequate, it is always easy to add medication later. Often you won’t have to.

Ask Dr. J: Metabolic Typing -- No Science

Q. Do you think a person needs to find out their metabolic type to know what foods are healthy, or is this just another fad?
—SR, New Mexico, via Internet

I have been unable to find scientific support for a way to assess dietary needs through metabolic typing, variants of which have been around since before I started practice almost 30 years ago. Many physicians would like to find out precisely what you need to eat (how much protein, carbohydrate, and fat) by analyzing your metabolism, but evidence is scarce.

One practitioner mentioned as a researcher in the field has no listings in the database of medical publications. The idea is that you can divide people into protein types, carbohydrate types, and mixed types. Even the so-called “carbohydrate types” are supposed to eat “only” 25 percent of calories as protein, which is quite high, at about 80 to 100 grams. This makes typing seem more like a promotion of protein diets, even for the “carb” types, while a healthy carbohydrate intake is 65 to 70 percent of caloric intake.

People clearly differ in size, shape, personality, digestion, hormones, and biochemistry, but their similarities are far greater than their differences. Individual differences have not yet been typed. Your protein, carbohydrate, and fat needs are more dependent on your activity level than your metabolism.

The need for micronutrients to achieve optimal health (vitamins, minerals, essential fatty acids) is much more varied. However, the amount that will prevent serious deficiency is probably similar for most people with minor variations.

While we have differences, no one has published reasonable studies that show how to determine what an individual needs. Most species have a fairly consistent dietary pattern between individuals, and humans are probably much the same. Avoiding food allergens is a different and very important issue.

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References

Diets Revisited:

McKeown NM, et al., Carbohydrate nutrition, insulin resistance, and ... metabolic syndrome... Diabetes Care. 2004 Feb;27(2):538-46.

Hays NP, Effects of an ad libitum low-fat, high-carbohydrate diet on body weight, body composition, and fat distribution in older men and women: a randomized controlled trial. Arch Intern Med. 2004 Jan 26;164(2):210-7.

Prescription Mismanagement and Drug Abuse:

Goulding MR, Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med. 2004 Feb 9;164(3):305-12.

Lilly Warns of Zyprexa Risks for Elderly Patients, Reuters, Feb 20, 2004.

Wooltorton E, Risperidone (Risperdal): increased rate of cerebrovascular events in dementia trials. CMAJ. 2002 Nov 26;167(11):1269-70.

Scott JG, et al., Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription. J Fam Pract 2001 Oct;50(10):853-8.

Zdziarski P, et al., Overuse of high stability antibiotics and its consequences... Acta Microbiol Pol. 2003;52(1):5-13.

Garbutt J, et al., Diagnosis and treatment of acute otitis media: an assessment. Pediatrics. 2003 Jul;112(1 Pt 1):143-9.

Barr RG, et al., Prospective Study of Postmenopausal Hormone Use and...Asthma...Arch Intern Med. 2004 Feb 23;164(4):379-386.

Hormone Therapy May Affect Hearing, Study Shows, Reuters, Report on the meeting of the Association for Research in Otolaryngology, February 24, 2004.

AP Poll: Drugs Costly for U.S. Families, Associated Press, Feb 23, 2004.

Cohen JS, Do standard doses of frequently prescribed drugs cause preventable adverse effects in women? J Am Med Womens Assoc. 2002 Spring;57(2):105-10, 114.

McPherson K, Hemminki E, Synthesising licensing data to assess drug safety. BMJ  2004 Feb 28;328(7438):518-520.

Metabolic Typing:

No references are available, as none appear in the medical literature

In The Health News

The National Center for Health Statistics reviews the disturbing but familiar lifestyle habits in the U.S. (www.cdc.gov/nchs/releases/04facts/healthbehaviors.htm). Only one in ten adults engaged in vigorous physical activity, and only 25 percent in any physical activity. While 60 percent of the population was overweight, only two percent were underweight (concerns that weight obsession has led to anorexia are overstated). One fifth of adults smoke a pack of cigarettes a day, making it important for everyone to protect themselves from second-hand smoke by taking appropriate antioxidant supplements and flavonoids.

Light alcohol intake (1 to 8 drinks a week) reduces inflammatory markers (CRP and IL-6) associated with higher heart disease risk (Volpato S, et al., Relationship of alcohol intake with inflammatory markers...Circulation. 2004 Feb 10;109(5):607-12). It would be interesting to know if within the 1-to-8 group risk varied from the lowest to the highest intake (that is, is it better to be in the lower or higher category?). It is likely that flavonoids and antioxidants from non-alcoholic sources could provide similar benefits, as could supplements of curcumin, ginger, coenzyme Q10, niacin, policosanol, and omega-3 fatty acids.

Diet and Disease

Diabetes risk is reduced if you consume more antioxidants. A study of 4300 subjects showed 30 to 40 percent lower risk in the group with the highest compared to those with the lowest intake of vitamin E or carotenoids (Montonen J, et al., Dietary antioxidant intake and risk of type 2 diabetes. Diabetes Care. 2004 Feb;27(2):362-6.) Avoid diabetes by watching your diet and weight, exercising, and taking chromium and other supplements.

Recipe of the Month: Pan Fried Buckwheat Noodles

I’ve mentioned buckwheat noodles (called soba in Japan) made from a combination of whole wheat, kamut, or spelt plus the buckwheat (an organic brand is Sobaya from health food stores) as a base for pesto, but I also like other recipes with them. Boil the noodles in adequate water and drain them in a collander. Meanwhile, stir fry some onions and garlic in olive oil, add tofu cubes until they sizzle, and then add half of some very dilute soy sauce with cider vinegar. When that is stirred in, add broccoli florets and any green vegetable that you like (be aware of the different cooking times, for example, the broccoli should be added before any chard or spinach as they cook so fast). When all of this is stirred together, add the noodles and sauté the mixture, add in the remaining soy sauce-vinegar mix, and turn off the flame before folding in some chopped cilantro. Delicious.

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CONSULTATIONS:

From September to June, I see patients in New Smyrna Beach, Florida.
Call 386-409-7747, or send an email to to make arrangements.

In summer, I have a variable schedule, and I see patients in offices at the
Rothfeld Center for Integrative Medicine in Waltham, Massachusetts. For appointments, send an email to make arrangements, or call: 386-409-7747.

I primarily do phone consultations, as well as email and instant messaging consults.


Information herein is not medical advice or direction. All material in this newsletter is provided for information only. Its contents should not be used to provide medical advice on individual problems. Consult a health care professional for medical or health advice.

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