Archive for December, 2010

More on salt; is it addictive?

Friday, December 31st, 2010

Salt for your addiction

Finished with shoveling snow for the second time in twenty-four hours, I sat down to eat hot oatmeal with pumpkin, a treat Lynnette dreamed up recently. In her mail stack I noted a copy of Prevention, a magazine I seldom read, but this particular issue had a story with an intriguing title "The Food Addiction That's Making you Fat,"

After reading the article, which I regraded as strong on suggestions, but light on references, I went back to the medical literature trying to discover if the basic premise, that salt can cause a spike in the level of dopamine, a chemical that stimulates our brain's "pleasure center" made medical sense. It took a while, but I found a 2008 article on PubMed Central (part of the National Library of Medicine's website that offer access to abstracts and full-text articles), and discovered the background data for the statement.

In 2008, in the journal Physiology and Behavior, a University of Iowa group published an article titled "Salt Craving: The Psychobiology of pathogenic sodium intake." I won't bore you with the details, but the 46-page article was well=written and the data seemed sound.

The abstract mentioned that salt is essential to our physiological functions and generally is regarded as "highly palatable." Other sources say it brings out flavor in many foods and a humorous Time Magazine article on that subject that I found  (Josh Ozersky May 17, 2010) said a New York legislator had recently proposed banning all salt use in restaurant kitchens, making the author think of fleeing to Canada. He called salt "cocaine for the palate."

That made me delve into the body of the much longer article. The data and studies quoted did point to the dopaminergic mechanism being involved in salt depletion experiments. But that's salt depletion and our typical diet is a long ways from leading to that state.

I think the bottom line is salt enhances taste and we get conditioned to expect it as a learned behavior. Newborns either dislike salt or don't care; we're two or three before the baby-food industry or our parents get us hooked on salt.

But hooked most of us are; that's the bad news. The good news is that addiction can be broken, starting with removing salt shakers form your dining area and coking without salt. We now use many other spices, not spice mixes which may have salt as a major ingredient...and get by just fine.

The bottom line is that many things can be regarded as addictive: drugs of course, but also fats, chocolate, carbs, sex and voluntary exercise. And with that note, I think it's time to go to the gym. Now there's an addiction I enjoy.

Maybe not all trans fats are bad for you

Monday, December 27th, 2010

We're back at the trans fat farm

I got my copy of the Annals of Internal Medicine today and, for once, read at least the summary of almost all the articles. One in particular caught my eye. It's a report of a prospective study that was multi-institutional (Harvard, the NIH, University of New Mexico and University of Washington with associated branches for two of the schools), fairly large (3,736 adults), multi-racial and lengthy (1992-2006). The study group was limited to adults over 65 who were living in the community, not in institutions. It was termed a "cohort study" and one definition of that is "A study in which a particular outcome, such as death from a heart attack, is compared in groups of people who are alike in most ways but differ by a certain characteristic, such as smoking."

In other words it's not a prospective controlled study, which I view as a higher level of medical research; in those you decide in advance what the object of the study is and select groups again in advance who will differ in some important aspect (e.g., they will or will not receive a particular medicine that's being studied or they'll be put on differing diets with one group getting whole milk and the other low-fat or non-fat milk). That may seem a subtle distinction, but it's an important one to me.

In any case the outcome was fascinating, though I'd term it preliminary.

Remember I mentioned trans fats (or more precisely trans fatty acids) as being bad guys. Well here's a case where one particular trans fat may be a good guy.

Most trans fats in the diet of Americans are/were artificially produced (I say were because a number of places (NYC and California) have almost totally banned them (less then 0.5% is allowed in the CA law). The FDA required strict labeling of these in 2006.

But small amounts are found in milk and  red meat. This study appears to demonstrate that a  particular trans fat called trans-palmitoleate, found in whole milk is associated with a lower risk for developing diabetes in adults. The effect wasn't found with red meat consumption or low-fat milk consumption.

Now that's very interesting, but it doesn't prove this particular fatty acid itself is healthful, only that, in this admittedly large and well-conducted study, that it's "associated with" several good metabolic effects, i.e., less diabetes and less obesity. The fatty acid could be a marker for consumption of something else that causes the effect.

More studies need to follow this one, of course, but the authors suggest that if those were to show the same effect, a case might be made for enriching/supplementing milk with this fatty acid. They also mention that, until this issue is resolved, the current push toward drinking only low-fat or even no-fat dairy products may be viewed differently.

No pun intended, but I need to digest this information a little before making a choice for myself.

Fats and fatty acids and our health: chemistry and politics

Thursday, December 23rd, 2010

Butter on a dish

I wrote about omega-3 fatty acids the last time, but, until I read Professor Robert L. Wolke's wonderful book, What Einstein Told His Cook, I didn't understand the name or remember much of the chemistry behind the fatty acids or fats themselves for that matter.

So let's start with a little chemistry, thanks to Wolke who is an emeritus  professor of that discipline and wrote a Food 101 column for the Washington Post for a number of years.

Fats, also called triglycerides, are chemical substances whose molecules are made up of three fatty acid, long chains of carbon atoms hooked onto a connector called glycerol. The carbon atoms themselves usually have two hydrogen atoms and if every carbon in the fatty acid chain has both its soul-mate hydrogens then we call it a saturated fatty acid.

When one carbon hydrogen is lacking its pair of hydrogens, the fatty acid is termed monounsaturated; if two (or three or more) carbons find themselves without their hydrogens, the fatty acid is polyunsaturated.

And then there's olive oil

The last carbon on a fatty acid's chain is termed the omega carbon from the final letter in the Greek alphabet. Omega-3 fatty acids, the good kind I've mentioned before, are missing hydrogens three carbons from the end of their chain.

So Omega-6 fatty acids, the much less healthful kind, lack hydrogens six places away from the omega end of the carbon line. And so on for Omega-9 fatty acids.

And while we're at it, if we're talking about a mostly saturated fat, it's likely to be a solid and from  an animal source (or a chemistry lab). Those that are mostly unsaturated are usually from vegetable sources and are much more commonly liquids.

Two more chemistry concepts for today, then I'll quit. If you look at the composition of a particular vegetable oil, part may be saturated, part monounsaturated and part polyunsaturated. The proportions count in deciding if the veggie oil is good for you or not, as saturated fats aren't healthy.

When food manufacturers want to stack the deck and sell you solids, not liquids (think margarine versus canola oil), they can add hydrogens in a technical process. On the other hand, partially unsaturated fats are easier to spread than totally solid ones.

That process, hydrogenation, can produce molecules rarely found in nature and one of the consequences of doing so led to trans fats, where the hydrogens added end up on opposite sides of a carbon. Those trans fats turned out to be nasty beasts (this was suggested in the medical literature as early as 1988), causing heart disease, with one estimate of 20,000 additional deaths per year in the United States. That number was published in  The American Journal of Public Health in 1995.

Thirteen years later, in January 2008, the state of California passed a law to minimize restaurants use of trans fats to less than half a gram per serving and in 2010 started to enforce that law. Apparently the state didn't think the restaurants would be able to comply with the new rules immediately and gave them two years to make changes. During all that time they could serve more than the limit of trans fats. Bakeries will have to comply with a similar law beginning on January 1, 2011.

I'll come back to the various kinds of fatty acids next time as there's more to add.

In the meantime, especially over the holidays, be aware of what you choose to eat.

Have a Merry (and healthy) Christmas.

Omega-3s to the rescue or not?

Monday, December 20th, 2010

A while back (actually in March 2010) I accompanied my wife on a trip to Phoenix where she was going to attend an Integrative Mental Health Conference with Dr Andrew Weil as the co-director. One of the sessions she attended was on new methods for treating depression.

Among the alternative medicine approaches to this major issue, said to be the world's fourth leading cause of morbidity and death, is the use of Omega-3 supplements. The notes from the conference intrigued me, especially since we were already taking fish oil.

fish in the raw

So we've both dug into the literature and talked to others about fish oil and omega 3s. I just watched a video on the National Library of Medicine's MedlinePlus site and printed off articles from that website, Science Daily and the University of Maryland Medical Center and read portions of a book, The Omega-3 Connection published in 2001 by a Harvard researcher.

So here's my take on Omega 3s.

They are helpful in lowering triglyceride levels, likely effective for preventing heart attacks and possibly are effective for a host of other conditions, including depression.

You can get them from oily fish, but eating large amounts of fish may expose you to mercury, dioxin and PCBs; the NIH feels it's well worth the risk to eat fish, at least moderately. If you do eat fish several times a week, bake or broil them, don't fry them or eat so-called fish sandwiches.

Fish oil supplements appear to help a number of conditions, although the evidence seems mixed. I think the real benefit likely comes from taking a moderate dose of fish oil, using a good brand and keeping the bottle in the dark and probably in the freezer.

fish-oil capsules

The use of high-dose fish oil should be restricted to people who are under the care of an experienced physician. We take two capsules a day and some of the research results I read about would require 12 or more capsules.

High doses of fish oil can reduce your ability for blood clotting and therefore increase the risk of strokes and other bleeding problems. I'd avoid it if I were on blood-thinners (e.g., Coumadin) or high-dose aspirin.

When it comes to depression (and I'm talking about so-called unipolar depression, not bipolar (severe mood swings, what used to be called manic-depressive disorder), a number of studies seem to show the EPA fatty acid in fish oil works, not the DHA.

If you're on an anti-depressive medication, taking a small amount of fish oil may help potentiate the drug's effect. Again, using large amounts of fish oil without any medication could be effective, but must be restricted to Rxs from an experienced physician.

And, fish oil may also potentiate the efects of anti-hypertensive meds. So if you're on one and start taking fish oil capsules, have your blood pressure checked several times.

But, having read as much as I have on fish oil, I'm certainly going to keep taking it. When taken in low doses, the MedlinePlus website says "it's likely safe for most people." And my bet is it can help a lot of us.

I'm over 100

Friday, December 17th, 2010

Well I don't mean I'm that old (actually I'm 69), but I looked at my old posts in the process of extracting tidbits to go into the book I'm working on, Eat like the Doc Does, and realized this would be my 103rd post. On the over hand, if my brain and body hold out, especially the former, living past 100 might be okay.

This man is over 100

There's a Chicken Soup book coming out on December 28th with one of my stories included. The book has the subtitle "Shaping the New You," and is centered on diet and exercise and lifestyle topics. My story is titled "Life Changes." I got ten pre-print copies, kept two for myself and sent eight out to friends, writing mentors, relatives and former graduate students.

When I reflect on the changes I've made in my lifestyle and diet over the past year and a half, I come up with a few simple concepts. I eat less overall and lots more veggies and fruit. I exercise more, usually iding a recumbent bike for an hour and five minutes a day and sometimes hiking or snowshoeing. I fall off the diet wagon from time to time, but always get back on (I weigh twenty-five pounds less today than I did in May of 2009). And finally, I usually think before I eat...not always, but usually.

I came up with an acronym for my weak spots; I've mentioned it before, but will reiterate. it's TABLE, meaning my triggers for overeating and mindless eating come when I'm "ticked off," on "autopilot," "bored," at a "low energy/late night state" or at an "event," loosely defined.

I'm by no means perfect, but my progress keeps evolving. This week my wife identified an area where  I could short-circuit one problem area. I got a new Clancy book and instead of reading until eleven, which is my usual pattern, I stayed up until 12:30 devouring not only the book but also five different snacks.

The next day, after our discussing the issue, I read while I was on the bike and again from ten until eleven PM, then quit. My weight, which had ballooned up two plus pounds, was down three pounds today, back in my acceptable range.

I don't expct this to ever be easy, but I don't intend to be one of the 90% who regain their weight after losing it.

Find your own path and join me. It's time and past time.

Guidelines for diagnosing food allergies in flux

Wednesday, December 15th, 2010

I've been tracking down some changes in the diagnosis of food allergies, especially in kids. I started with a Wall Street Journal article, dated Tuesday, December 7, 2010 and titled "New Rules for Food Allergies." That mentioned the National Institute of Allergy and Infectious Diseases, a segment of the NIH under the US Department of Health and Human Services, had recently convened an expert panel on the subject.

The resultant guidelines were published in the "Journal of Allergy and Clinical Immunology." I found a review in WebMD ( and then the lengthy report itself online at the NIAID website. I realized it was so voluminous there was a separate 29-page summary for clinicians and a much shorter set of guidelines for patients with a more thorough patient guideline to be published in 2011.

An Epi-Pen for severe allergic reactions

So what's the short version? Well to start with about 5% of kids and 4% of adults have food allergies. If they eat specific foods they may have reactions varying from mild to life-threatening.

The most freguent food allergies are to eggs, milk, peanuts and tree nuts, soy (that surprised me), wheat and some shellfish. Kids often outgrown an allergy to milk, eggs, soy and wheat, but not those to peanuts and tree nuts.

There are no cures to these allergies and having a mild reaction to a food once doesn't mean you won't have a severe reaction on another exposure.

Allergies often are seen in people who have some other diseases, asthma for one example and eczema (a skin disease) for another. Those plus a family history of food allergy may alert you and should alert your physician to your having a greater risk of food allergies.

Neither of the usual office tests used to diagnose food allergies, is definitive. Those include a blood test looking for antibodies to specific food and skin-prick test where a tiny amount of a suspected allergen is paced on a forearm then pricked to see if a wheal result.

The only test that proves you have a food allergy is a food challenge. That must be done, for safety reasons, under the careful direction of an experienced healthcare professional.

Yet all is not as dire as the above sounds. One study published in the Journal of Pediatrics this fall looked carefully at the medical records and testing of 125 children who had been sent to the National Jewish Hospital in Denver for evaluation of eczema and food allergies.

After careful food challenge tests were evaluated, over 90% could go back to eating foods they had been avoiding.

A few other tidbits caught my eye: peanut allergies are especially severe and, fortunately, I'm seeing more and more labels that specify this product is (or is not) produced in a peanut-free environment. Wheat protein allergies are not synonymous with celiac disease, so those having such allergies may not react to gluten in oats, rye and barley. And fish allergies, which tend to start after childhood, can be another very severe problem.

I give my wife her allergy shots at home, so I keep Benadryl and an Epi-Pen handy. Food allergies are nothing to sneeze at (no pun intended), so if there is a family history of them or you or your child have eczema or asthma, make sure you get a thorough evaluation by a qualified physician.

Two thirds of us can benefit

Saturday, December 11th, 2010

I just read an article in the Annals of Internal Medicine, the journal published by the American College of Physicians. Although I've been retired since 1998, I still am a Fellow of the ACP and their publication is the only medical journal I subscribe to and read (at least scan) regularly.

Counseling session in progress

This months Annals had a meta-analysis, a review of multiple papers, on the subject of behavioral counselling and its effects on cardiovascular disease. I scanned it and wasn't overwhelmed; then I read it in detail and was highly impressed.

The authors, two physicians, one PhD and a person with a Masters degree in science, reviewed 13,562 abstracts and 481 articles, looking at the effects of low-level, intermediate-intensity and high-intensity counseling that was intended to promote either an increase in physical activity or a healthy diet or both.

They were looking at the effects counseling produced in patients who did not have cardiovascular disease, hypertension, diabetes or abnormal blood lipids. Some did have borderline high blood pressure or other risk factors, most did not.

At first I thought the relatively small results meant that the time wasn't well spent. Blood pressure was reduced in most studies, but not by much; the same was true for lipids.

But there were almost no ill effects (they estimated one heart attack would occur per 1.42 million person-hours of exercise, usually in people who started as couch potatoes.

But the unimpressive decrements in blood pressure, especially in those with borderline BPs to start and the relatively small changes in cholesterol and LDLs, when translated to large population groups, were stunning.

A decreased incidence of coronary heart disease (CHD) of 6 to 16%, 30% in those more at risk, from what seemed a tiny change in BP, was impressive. A 25% decrease in CHD from a 10% decrease in total serum cholesterol was also striking.

Most of these counseling session, of course, especially the more intensive and repetitive ones, would be done by someone other than the physician involved.

But I finished reading the article and said, "Counsel on, nurses and therapists." it certainly seems worth it in both normal-weight and overweight, but not obese people. I'm less sure of the results in that group and they didn't appear to be involved in these research projects.

I had thought that most of us blow off the words directed to us in these kinds of medical encounters. Maybe that's changing and it's about time.

When all else fails

Tuesday, December 7th, 2010

Most of my posts are written for those of us who are of normal weight and want to stay there or those who are overweight and would like to lose a few pounds or twenty or forty. As of this morning, for example, I'm twenty-four pounds under my May 2009 peak and sixty-five under my obese 1970 lifetime maximum.

It's the holiday season with Thanksgiving and Hanukkah and Christmas thrown in to a jumble of other parties, gourmet club dinners, symphony events and theatre events. I'm at my upper limit of 153 pounds and have to really watch carefully to avoid all the temptations.

Many of you are in the same mode, I bet, but overall doing okay with your weight.

Then there's an entirely different group. I saw an article on Lap-Band surgery for those people who are obese and haven't managed with diets, counselling, support groups and perhaps even medication to lose the pounds they desperately need to shed.

Does this man need Lap-Band surgery?

Now I'm an Internal Medicine doc and a retired one at that, so I looked at the Mayo Clinic website, an Australian website, one for a nearby hospital and MedlinePlus, an online information source sponsored by the NIH and the National Library of Medicine. I wanted to know more about this surgical strategy for the obese.

First off it's not cheap with prices varying from $13,000 to $25,000 in the United States. Some people go south to Mexico where the prices are lower, but I wouldn't be likely to do that if I were seeking out this procedure.

It's done under general anesthesia using a laparoscopic approach. That means several small incisions are made in the abdominal wall and a small camera in inserted to allow the surgeon to see what he or she is doing. A band is then positioned around the stomach so that the upper portion of that organ forms a small pouch with a narrow opening to the rest of the stomach.

It doesn't require internal staples or cutting and, if the surgeon is experienced may take only 30 to 60 minutes. The 2,700-person Australian series I read about reported no deaths.

Lap-Band surgery has been restricted to the very obese with a Body Mass Index over 40 (mine is 20.5), or the fairly obese who have complicating diseases such as diabetes, heart disease or sleep apnea.

But, after the surgery people have to stick to a diet and should exercise. Plus there are complications with half the patients in one large series reporting nausea and vomiting, a third having reflux, a quarter of the bands slipping and requiring repositioning and perhaps 10% experiencing some blockage near the band.

The band is adjustable; the physician can tighten or loosen the stricture by adding or removing saline.

And this is the least invasive surgery for severe obesity. I also read where some proponents (and the company that makes the device) want to loosen restrictions on its use. They'd like it to be approved for use in people with a BMI over 35 or over 30 with complicating diseases. That would include over 25 million Americans.

I'll certainly stay out of that debate and stick to my diet and exercise concepts.

Two successes, one failure and a lesson

Friday, December 3rd, 2010

My newest reminder card

Travel is tough on my dieting, but, I've learned recently, so are the events I go to. I had weighed 153 when we left for our trip to Texas where friends hosted dinners, fed us well, too well. I returned at 157 pounds, four over what I now consider my upper limit. I know that I re-started my diet at 177 in May of 2009 and so I'm considerably slimmer, but 157 annoyed me.

So I was concerned; we had Thanksgiving dinner, a series of parties, a Thank the Donors event for the capital campaign I've been running and then would come some holiday events. What could I do to not only lose the four pounds at least, (my real goal weight is 149-150), but to also avoid gaining more. I needed a gimmick.

One of the background books I've been reading is on "mindless eating," the kind of frenzy of ingestion I recognized well. I used to get into this pattern frequently, forty years ago in when I weighed 218.

What I needed was another STOP sign. I already had my red 1/3 cup measure sitting on my kitchen island. Now I needed something for events and occasions. And, when I thought about it, one of those is my weekly writers' critique group. Most of us bring something edible to share and sometimes I get hooked on cookies or something else I wouldn't normally eat.

So I took two three by five inch cards and wrote "Don't Snack!" on one of them and "Don't Eat or Overeat" on the other.

my other card

One card leans up against my popcorn holder which itself is surmounted by the red measuring cup. Eating at home hadn't usually been a problem, but it wouldn't hurt to have an extra reminder.

The other I put into the cup holder of my car. I'd look at it just before going into a house where we were joining an ongoing party or before entering, twice this week alone, the local country club, where we were attending a luncheon for symphony donors and, later in the week, the Thank the Donors event.

Oh, and there was one more event, a baby shower I wouldn't normally have attended. In this case it was for the wife of a young relative. We hadn't seen him since his high school graduation and I felt it was important to go to his spouse's shower.

So here's my score card and the lesson I learned. I looked at the card in my Prius just prior to entering the country club for the luncheon. I ate three fourths of my salad and half my entree and said, "No thanks" to the dessert. I did even better at the donor event. I pre-ate a bowel of cereal and a piece of fruit. At the event itself I ate nothing and drank one third of a glass of Merlot.

But the shower, held at a pizza parlor, was another matter entirely. I didn't remember to look at the card hat evening, shared an appetizer with my nephew and his fiancee and had three large slices of pizza, even eating the dry crusts.

Actually the donor event was last night and today I'm down in my safe zone again. I'm going to lunch with friends at our favorite Thai restaurant, but before I leave my car I'll look at the card.

Lesson learned. I'll bring the "Don't Snack" card to my writers' group next week and look at it just before I leave my car.