High-tech Care with Old-Fashioned Values

Is Soy a wonderfood or a danger?

Soy is everywhere these days. It must be good for you, right? Soy=tofu right? Milk formula allergies are common and soy is a good choice, right? Many of these issues have not been fully explored by research before Americans jump in with both feet (and their wallets). It is alarming that the public knows so little about a product that is used so widely. Let's look at some data. (I recommend a nice brochure with some basics.) Since the site to which I refer you is so good I will just highlight a few items. First soy as it was and is traditionally consumed in Asia is FERMENTED soy. The process of fermentation actually reduces some of the toxic substances found in the processed bean paste. This renders the product much safer for human consumption. Second traditional used of fermented soy was as a condiment not a main course. his means much less soy is consumed in a traditional Asian diet than in a modern Vegan diet. Third, the osteoporotic benefits of soy are overblown. Look at some of the items in the link and see how bone formation may actually be harmed by soy intake. Finally big worry. By 1998 almost 25 % of US babies were using soy formula. That number has now grown. With the advent of "reflux" as a fad diagnosis in infants these days misguided WIC and other nutrition advocates for children have pushed soy formula as an alternative. AT THE SAME TIME we are promoting phytoestrogens (like those found in soy) as a way to relieve some of the effects of menopause in older women. We cannot have it both ways. SOme countries in the European Union agree and have now issued warnings against the widespread use of soy IN MALE INFANTS. It seems logical that the estrogen effect of these product on male infants can have widespread and long term effects on males. MOM READ FIRST before you given your child, especially your male child, a daily continues phytoestrogen dose.

Prozac and Pregnancy

This week's issue of the New England Journal of Medicine has 2 articles on the risks of birth defects in children born to women who take "Seletive Serotonin-Reuptake Inhibitors" (SSRI's). Since depression is common among women of childbearing years and may affect up to 10% of women who are pregnant, the issue of what constitutes safe treatment for mother and developing child is an important topic. SSRI's became available in the late 1980's and became the dominant medical intervention for depression by the 1990's. They promised less potential side effects, a possible faster onset of effective action and less potential for death by overdose. It became logical that women taking SSRI's might become pregnant and early studies suggested that SSRI's could produce omphalocele, craniosynostosis and heart defects. Obviously no one wants to keep a women on such a teratogen and drug companies want to play down effects that cannot be clearly linked to their products.

The first study by Louik et al has been ongoing since 1976. Five study centers (Boston, Philadelphia, Toronto, San Diego and portion of New York State are involved. Cases of birth defects are identified and then exposure is assessed using an interview within 6 months of delivery that questions mothers about demographics, reproductive and medical factors, cigarette smoking and the consumption of alcohol and caffeine. Medication (both prescription and over the counter), vitamin, mineral and herbal intake are also reviewed. Pregnancy history including questions about specific conditions occurring in pregnancy and the medications used for those conditions is reviewed. These cases were then matched with controls with similar demographics.

The current paper from this study looked at women whose last menstruation was between 1/1/93 and 12/31/04. Cases of defects excluded those who had know inherited disorders, syndromes, defects with known causes and metabolic disorders (like PKU). About 23% of the case mothers did not participate as did about 25% of the control mothers. An additional 15% of case mothers and controls did not respond or were unavailable to interview.

The researches looked specifically at exposure in the first trimester which they defined as use of any SSRI from 28 days before the last menstrual period through the fourth lunar month (112 days after the last menstrual period.) Of note the researchers excluded 79 women who took MORE THAN ONE SSRI during this period. A total of 9849 infants with malformations and 5860 control infants were included in their statistical analysis.

Although overall use of SSRI's by their analysis was not shown to increase the overall risk of the birth defects described above, the authors do point to an associated risk of the use of sertraline and omphalocele and septal defects as well as an increased association between paroxetine and right ventricular outflow tract obstruction. Of note was the fact that overall risk of defects was quite small.

The second study by Alwan et al used a more exhaustive list of defects and data. They also found little association with the defects mentioned in the first study but noted a potential association between SSRI use and the occurrence of anencephaly , crainiosynostosis and omphalocele. This study outlines some of the theories as to why an association with these conditions may exist.

Bottom line? As with most conditions during pregnancy you must carefully weigh the risks of treatment vs non-treatment. Depression with potential for suicide, poor nutrition, abuse by spouse and other likely unknown effects on the mother and fetus must be weighed against the drug risks. In this case we know the risk, as it appears to exist, is relatively small. Careful use of medications and use of those least linked to these defects is the most prudent course of action.

Here Comes the Sun

Check out our featured web site this week. The site is the Vitamin D Council. At their site they nicely summarize many of the scientific studies that have been in the news recently. Vitamin D deficiency that causes rickets is well know but unusual in this day and age. Vitamin D deficiency causing other previously unrecognized illness has not been so widely known. Recent credible research now links low vitamin D levels with increased risk of cancer and a myriad of mental health/neurolocial conditions including ADHD, Depression and Alzheimer's disease. Check out the site and read about the research.

One very interesting fact is that humans can make vitamin D with the help of the sun on their skin. Covering up and coating ourselves with sunscreen, however block our body's natural ability to create vitamin D. Our paranoia about skin cancer has caused large numbers of us to be depleted in this important vitamin. As little as 15 minutes of full midday summer sun on the torso can give you the vitamin D you need. Of particular interest is the cancer link. In a future blog I will talk about melanoma and the potential link of getting TOO LITTLE SUN as a potential cofactor in its development. For today just sit back and get your 15 IS good for you. If you feel you cannot get in the sun supplements are available but must be absorbed through the gut. I recommend at least 1200IU of vitamin D per day although mega-doses weekly are also used. Good quality cold processed cod liver oil is an excellent source of vitamin D.

B12 Fact or Fiction?

Vitamin B12 is a unique molecule as it contains a carbon bonded to a metal, cobalt which gives it its red color. . It is the largest known biomolecule. Vitamin B12 is involved in many of our body functions (often in conjunction with folic acid) like development of red blood cells, insulation of nerve cells, and nerve conduction. When depleted anemia (known as pernicious anemia) and neurological complaints like numbness, burning, muscle fatigue, irritability and memory loss may occur. Absorption of B12 is quite complex and involves pepsin, hydrochloric acid, intrinsic factor and a protein known as R-protein. Deficiency of any of these substances can result in suboptimal absorption and deficiency. Recent studies in England have shown larger than expected numbers of elderly women lacking substances that aid in B12 absorption. Chronic use of antacids or other mediations used for gastric reflux may also contribute to lower than needed absorption.

Since B12 is mostly found in animal tissues. Foods especially dense in B12 include bivalves (clams, muscles and oysters),liver, kidney, eggs and milk products. Unfortunately pasteurized milk while containing B12 has much less and has fewer intact proteins to aid in its absorption). Because of these facts, vegetarians must be extra careful to get adequate B12 from their diet by using eggs and milk products. Children are especially at risk when on diets low in B12 so parents encouraging children to vegan or vegetarian diets must be careful to supplement B12.

B12 can be measured in the blood but most laboratory assays have wide ranges of normal. Deficiency generally is said to occur with blood levels lover than 200 pg/mL but most experts would encourage keeping a blood level higher than 500 pg/mL. Although traditionally supplemented with injections for pernicious anemia, there is a solid body of literature that supports the use of oral supplementation for people at risk of deficiency. Doses ranging from 100 mcg per day or higher have been touted. Levels can be checked to assess efficacy.

Since B12 deficiency due to poor diet, medications and aging is more common that previously appreciated, you should ask you doctor to assay your level and, if appropriate supplement. You can avoid B12 deficiency by eating more liver, shellfish (one serving per week), avoiding over intake of spirulina and soy, antacids or acid blocking medications. Medications like metformin may interfere with absorption. Remember that excessive folic acid intake may block B12 absorption as can artificial Vitamin C products. Smoking will deplete B12 as can oral contraceptives.

Finally, if you exhibit fatigue, weakness, infertility, tinnitus, numbness/tingling of the hands, anemia, irritability ask your doctor if B12 could be the cause.

Body, Mind AND Soul

I have been going through a period of spiritual seeking and reawakening. I know I am not alone in that regard. Americans purchase large amounts of books on the subject, films dealing with spiritual issues have been box office hits and political debates around moral issues continue to get large amounts of press. My own recent journey was initiated by stresses at work, at home and in the lives of people for whom I care deeply. During these times of stress we either reach out spiritually and grow or we sit in the dust like Job and question. I tend to be Job. I find it easy to tell myself lies and hopeless stories rather than searching for victory in the midst of pain.

As a physician I too often become numb to the pain and suffering of my patients and those around me. This develops because caregivers tend to try to shield themselves from pain to avoid the burnout that often comes in our profession.
All my patients will die from the infant that comes in for vaccines to the 98 year old who comes in because her family made her do so. Some will die sooner than others but they all die. Many will suffer long and painfully before they leave this earth and others will depart quickly. When I seen death and disease as the enemy I fail because they are inevitable.

But I do not have to choose that view. I can see my life and the lives of my patients as journeys during which lessons are learned and relearned. The natural cycle of God's creation involves birth, growth, diminution and death followed by renewal and birth again. This helps me reframe my roll as a caregiver. I am there to help my patients along their life journey. Sometimes I help with the selection of a drug or test or consultant that will treat a condition. Other times I can listen and offer advice or sympathy. I can coach someone trying to change a habit and I can just listen sometimes to the worry of a parent.

Much of my role is working with physical and mental health issues but as a Christian who is trying to learn and grow, I also must be aware that the spiritual health of my patients (and myself) are crucial to the way their journey progresses. In my own case my recent spiritual drought caused sleepless night, irritability and emotional upheaval. Gratefully others saw my need. They were praying and supporting me even though I was not very lovable. My partner in the practice, Holly, had just had a spiritual reawakening and her example lifted me up allowing me to get out of the dust.

Recently, I went home where our farm is experiencing a climatic drought and as I was trying to water our pasture with a hose (doomed to failure) a downpour of rain like we hadn't had in months suddenly appeared dwarfing my attempts to water. It was as if God, in response to my questions about my spiritual drought had shown me just how much more He was willing to give me if I just was open to His blessing. I wanted a hose and He offered a cloudburst. Talk about being hit over the head.

I hope that in the future I will continue to grow closer to the God who loves me so much He sent His Son to die in my place. I know the journey will not be smooth. I also know that the bumpy times can teach more than the smooth times. I hope that I will be able to show that love to my family, friends and patients. I know that my spiritual health, just like the spiritual health of my patients is key to living a full and joyful life. I hope that you will see and feel that love when you enter our practice.


Why Consuming Health Care Is Bad

In America we grow consumers. If we are number one at anything in the world it is consuming. We consume entertainment, food, fuel and information. We became a healthcare consuming nation with the rise of three things that grew in the 1960's and 1970's namely specialized medical care, technological advancements (including pharmaceuticals) and advertising/marketing. These advancements were coupled with an aging population and the rise of baby boomers (who in general were the world's most prolific consumers) moved us from a nation who used health care to one that consumed it. We began to seek out care for issues related to aging or to rectify the effects of poor lifestyle or to delay diseases that the health care industry and Madison Avenue were only too happy to shake in our faces. Early on many people were still covered by legacy insurance or government programs that shielded them from the actual costs of their consuming. Most doctors as well were blissfully unaware of costs that their increasingly high tech care were generating. In fact under older fee-for-service systems physicians and hospitals could be paid based on their charges meaning that if a patient stayed longer in the hospital it generated more income. In a perverse way then doctors who were substandard and slow in their decision making could actually generate more revenue than doctors who were efficient and effective.

Naturally the rising costs eventually caused industry and government to slowly respond. Chrysler said it could not compete with Japan because our health care costs in America were adding too much to the sticker price of their cars. Managed care (not managed competition like most industry) was born and the impression that prevention and wellness would be the goal rather than "illness care" was promoted. We had too many consumers, sick aging non-workers and diversity to allow this approach much traction and the industry of health care found the areas of profit and skimmed it until the public made its hatred of managed care and HMO's clear. All the while we had not addressed the basic issue: MORE SPENDING ON HEALTH CARE AND MORE CONSUMING OF HEALTH CARE HAS NOT BEEN SHOWN TO PRODUCE GAINS IN POPULATION HEALTH THAT MAKE THE SPENDING WORTHWHILE.

Let's take the drug industry as an example. We all know people who have been saved or have had their lives prolonged due to an intervention with a drug. We also know that medical errors (Mainly Drug errors) cost America as many lives as traffic accidents. We do not make the connection beyond intellectually. Just go to a local pharmacy or supermarket to see the rows and rows of over the counter drugs that complement the pharmacy that most stores now have. In the small town of near my home we have (by my count) 5 major pharmacies that are chains or in supermarkets AND we have 5 small private pharmacies. This roughly a pharmacy for every 800 folks AND THEY ALL ARE BUSY. Residents take medication....lots of medication and we are not a healthy city by any measure....but we take our drugs. I frequently see patients who are on 10 or more meds: for sleep, for restless legs, for impotence, for osteoporosis, for depression, for irritable bowel, for obesity as well as for other diseases. AND THEY ARE RELUCTANT TO STOP OR CUT BACK BECAUSE THEY HAVE BEEN CONVINCED THAT THEY ARE ILL AND NEED MEDICATION. Most do not or have not exercised, smoke, eat poor processed and carbohydrate-laden foods and will not change lifestyle as long as they can get their medications.

I want you to think about consuming health care vs living healthy. Living healthy means drinking clean water, exercising DAILY, eating fresh fruits and vegetables, cutting back on carbohydrates and trans-fats and living in community with meaningful work. Many of our "illness" would go away and maybe I would be out of a job! Now that's a thought!