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Thursday, April 21, 2011

Dousing the fire: Resolving the many causes of high weight gain

Dr. David Edelson describes one of his best patients:

She had a whole series of issues: sleep apnea [blockage of the airway, cutting off breathing for 20 seconds or more], hypothyroidism [a slowing of bodily processes due to an underactive thyroid gland], insulin resistance [misuse of the insulin produced in the body], binge and impulse eating. She wasn't exercising and was slightly depressed; she had a whole spectrum of different issues.

One by one, we worked through them, both with lifestyle changes and others. In our practice we have a gym with a personal trainer, so she'd work out with him/her two days a week. We have a nutritionist, who put her on a low-carbohydrate, higher omega (heart-healthy) fat diet. She'd been a terrible carb addict, and was pre-diabetic, with metabolic syndrome. For her, eating our Western high-starch, high-fat diet is like throwing gasoline on a roaring fire.

By getting her to eliminate all these white starches, and eat more whole grains, healthier grains, fish, avocadoes, olives, etc., that almost instantly turns off the metabolic syndrome, instantly dousing the fire. It got her metabolism back on line, and her carb cravings under control. The exercise and diet got her to burn her mesenteric (belly) fat. That began the process of getting those issues under control.

Then we added other things: nutritional products to fight the insulin resistance like high doses of fish oil, an herbal product with chromium, and cinnamon, a good insulin sensitizer.

Initially, we started with some medications to tip the energy balance to the right direction. We put her on a combination therapy of low-dose Phentermine and Topamax (that combination is now in development as a single drug called Qnexa). We use that in people with very strong eating urges, and binge-eaters, to help control their eating impulses and reduce their appetite. We also put her on Metformin, which is for people with diabetes and metabolic syndrome, a pre-diabetic condition which she had. That brought the insulin resistance under control.

With the exercise, the diet, the supplements, and stress management, she turned her life around, and adopted better behaviors. We have a Reiki master who does a lot of natural stress reduction, who did weekly sessions with her for a while. That's a cross between hypnosis and energy healing, so people can learn to manage their stress and bring stress out of the body, liberating the internalized stress.

She had sleep apnea, and was a terrible sleeper. She'd stop breathing 50 or 60 times an hour! Her oxygen was in the low 70s; it should be 98%. It was like standing on Mt. Everest without oxygen. That put a huge strain on her body. It even causes weight gain, because it affects a lot of hormones like ghrelin, leptin, and growth hormone secretion; they all get adversely affected.

By treating her sleep apnea with a CPAP machine [providing continuous positive airway pressure], she got normal sleep patterns, which turned her metabolism back on, and gave her more energy during the day. It's classic, like with a car with a lot of different parts that are failing, so you change the filters, tighten the belts, and align everything so it can run properly again.

Now, we can reduce her medications. She has lost 65 pounds, and is close to her ideal weight, with the lifestyle changes fully in place to maintain her weight where it is. She has been exercising to build lean muscle tissue, which has raised her basal metabolism. Now she's burning calories 24 hours a day, so we can wean her off the medications.

My complaint about the diet industry is this: They tell people they can do something on a short-term basis and lose weight permanently. There's a lot of magical thinking going on, since without changing behavior, lifestyle, or identifying the underlying medical causes of weight gain, 98% of dieters regain the weight within two years. A crash diet or drug or supplement is not going to create long-term weight loss. It will get short-term effects, but then the person will regain the weight, and then some. This is the basis of yo-yo dieting.

It's like stretching a rubber band: you can pull on it temporarily, but when you release it, it'll snap back. That's the set point theory: our bodies become set at a certain weight level. The only way to get long-term results is to relocate the set point. As you stretch the rubber band, you take what it's attached to and move it to a new position. This can only be accomplished by finding out why each individual gained the weight in the first place. Then you can address the specific causes, such as lost lean muscle mass, insulin resistance, sleep disorder, depression, injuries, hormonal imbalances…whatever has moved the set point to this new higher position.

So no one practitioner can effect long-term success with weight loss. At HealthBridge, we have an entire team, including medical doctors, sleep disorders experts, a nutritionist, personal trainers, a physical therapist, chiropractor and acupuncturist, a hypnotist and Reiki master, each experts in addressing a specific underlying problem that can arise in weight gain. If someone has a hip problem, or a back problem, they can't exercise, and start gaining weight. Here our physical medicine team would be called in to fix the problem and get them back to the gym for fitness training. I like to call this a plug and play model, with all these components at the same facility. We look at every puzzle piece: fitness, genetics, hormones, sleep – the whole list, and see which pieces are out of alignment, and need to be fixed. We use the individual practitioners, and put the whole puzzle back together.

Dr. Edelson's practice is in Great Neck on Long Island in New York as of May 2011.

Read Aquameliza's weight loss story in Ken Farbstein's book, Getting Your Best Health Care: Real-World Stories for Patient Empowerment, or get it at Amazon.

Wednesday, April 20, 2011

Two Resources for Patient Advocates

My book, Getting Your Best Health Care: Real-World Stories for Patient Empowerment, advises professional and family advocates how to keep their loved ones safe during health crises. Thanks to the advocates and activists who contributed stories, many of which appear in Chapter 12, on finding and working with professional patient advocates.

Second, Dorland Health’s new Professional Patient Advocate Institute offers webinars, newsletters, special reports, a directory, and certification for advocates. Membership has its privileges: notably, two free copies of my book, too. The book is also available a la carte from PPAI at a discount, and on Amazon.

Saturday, April 16, 2011

An attack on my liver: FDA's MedWatch adverse drug reports on Xenical

Dr. Sidney Wolfe of Public Citizen warned against the use of Xenical and Alli (weight-loss drugs in the orlistat class), after reviewing the reports of adverse reactions to them according to the U.S. government's FDA MedWatch reports. Here's the experience of one customer:

Monique Paulwell of Bowie, Maryland said she only took Alli four times before she began feeling fatigue, loss of appetite, a nagging headache and jaundice. "After a battery of tests, [doctors] said there had been an attack on my liver. By the time I was admitted to the hospital, I had 48 hours to live. It was that serious."

She said she thought taking Alli would help her lose a few pounds and maybe boost her acting career. Instead, she had a near-fatal experience her doctors told her was caused by the drug. She said she needed a liver transplant to save her life.

Public Citizen found that severe side effects affected dozens of patients who'd taken the drug, and that the drug's benefits, in any event, were minor, amounting to 4 - 5 pounds of weight loss. That has to be weighed against the 20% chance of side effects, some of which are severe, e.g., liver disease, pancreatitis, and kidney stones. The FDA received 47 reports of acute pancreatitis and 73 cases of kidney stones attributed to orlistats.

As with any drug, one should weigh the likely benefits in light of the possible harm. The advice of a pharmacist can be helpful in this context. A drug like Xenical works by blocking absorption of about a third of the fat enzymes that enter the body. Instead, the fat passes through the body to the gastrointestinal tract until it is excreted. These medications also block fat-soluble vitamins including vitamins A, B, and K.

Advice: For me, it's much easier to give advice like "maintain a healthy weight" than it is to follow my own advice. Yet it is important, especially because the surgical alternative for weight loss has some serious trade-offs, as discussed in my book, Getting Your Best Health Care: Real-World Stories for Patient Empowerment.

Thanks to Lara Salahi of ABC News for some of the background information here from their story on April 14.

Friday, April 15, 2011

Michael Jackson, Tom Brady, and Boris Yeltsin: Getting Your Best Health Care

What do Michael Jackson, Tom Brady, Boris Yeltsin, and Anna Nicole Smith have in common?

They all had health crises with important lessons for protecting your clients’ health, and your family’s health, as told in my new book, Getting Your Best Health Care: Real-World Stories for Patient Empowerment.

How does this book benefit the reader?

The lessons from the dozens of stories of celebrities and others are easy to read and absorb in advance of any health crisis. If the reader is in a health crisis, she can refer to the summary suggestions at the end of each chapter, and the chapter on using a professional advocate, for immediate guidance.

The book also draws lessons by telling the healthcare stories of Dr. Don Berwick, actress Farrah Fawcett, former Pres. George W. Bush, comedian Art Buchwald, Dr. Jerome Groopman, Dr. Peter Pronovost, newsman Ed Bradley, former Rep. Geraldine Ferraro, and many others.

Many doctors and nurses consider themselves patient advocates. What should they do?

My book describes how they can be maximally patient-centered. They can redesign everything from their academic approaches to their wallpaper, and everything from patient orientation and scheduling to end of life discussions.

In 50 words or less, how would you describe your book?

This book teaches patient advocates, both professionals and family members, to partner with their doctors and nurses, through brief stories, each with a lesson. Most chapters feature at least one story about a famous doctor or celebrity.

Who is your intended audience?

Two groups: Professional advocates, and women over 40. The professional audience will consist mostly of patient advocates, geriatric and other case managers, social workers, nurses, doctors, etc. Secondly, women usually serve as the guardians of their family’s health, so they’re the most likely readers. Women who are sandwiched, pressed between the needs of their elderly parents and their children, are the primary audience. Men who take responsibility for their own health, and that of their family, should also read the book.

What does “patient advocacy” mean in today’s healthcare world?

At different times in their work with an ill person, the advocate plays the roles of a teacher, midwife, knight, confidante, and political activist. To me, an advocate is ultimately a champion who helps a single patient get safely through a health crisis.

Why is there an urgent need for a book about patient advocacy right now?

There are three reasons occurring within the last month or so. First is the greater awareness of just how widespread medical errors are. In early April, David Classen, Roger Resar and their team reported in Health Affairs that one-third of hospital patients experience an adverse event. That awareness creates great fear among patients. Knowledge about how patient advocates can keep people safe in hospitals will dispel that fear. Second is the growing appeal of medical procedures that are surprisingly risky, ranging from cosmetic surgery to new ways to use powerful radiation to treat cancer. Third is the broad push by both political parties’ leaders to reduce healthcare costs. President Obama and Rep. Paul Ryan both announced game-changing initiatives in early April. It’s likely this will ultimately impel hard-working clinicians to work even faster, putting patients at risk.

What kind of information can readers expect to glean from the book?

The book is brimming with dozens, if not hundreds, of specific tips, each one presented as the moral of a true story about a celebrity, political figure, family member, or patient advocate. There’s everything from how to find the best Emergency Room, to suggestions for those living with chronic illness, everything from lessons learned in childbirth to how to pass on your wisdom to your heirs.

In the end, what do you hope to achieve through this book?

I have two hopes and dreams. I want to create the new patient, who becomes a partner with doctors and nurses in his own treatment. I want to guide the emerging professional patient advocates.

Where can readers find your book?

Bound books and e-books are available at a discounted price at Dorland Health's Professional Patient Advocate Institute. It’s also available online at Amazon.

Any parting words of advice for patient advocates?

They can rise to the challenge, as did the inspirational heroes in Chapter 12.

Thursday, April 14, 2011

May yield substantial benefits: The fifth birthday of the Massachusetts universal health insurance law

In 1993, John Ayanian and a team of researchers studied the detection and treatment of breast cancer among women in New Jersey with and without health insurance. In their widely cited article in the New England Journal of Medicine about the harm to women's health of the lack of insurance, they concluded, "Comprehensive programs to improve access to early detection and optimal treatment may yield substantial benefits." Little did they know.

Fast forward to 2011, and the recent fifth birthday of the passage in Massachusetts of a state law requiring near-universal health insurance, Chapter 58 of the Acts of 2006. By my calculations, the new coverage for many thousands of women has likely led to the earlier detection and treatment of breast cancer, saving the lives of dozens of women each year, and more than 200 since the law went into effect. It would be interesting to see more precise calculations. Perhaps this could be an exercise for public health students.

Happy Birthday, and many more!

Read about the first birthday of the Massachusetts health reform law.

Monday, April 11, 2011

Grateful every day vs. prolonging my dying: Two views of kidney dialysis

Ruth Silverman's letter:
My husband, a retired neonatologist involved in ethical issues in medicine, suffered acute renal failure at 87. He was hospitalized briefly and underwent several dialysis treatments during this time.

His urologists (three of them) told him that they were arranging dialysis for him three times a week upon discharge from the hospital. He confronted them with these words:

"I am 87 years old. It is a waste of the resources of this nation to provide me with dialysis three times a week. You will not be prolonging my life. You will be prolonging my dying. That is not the quality of life I choose."

My husband had executed an advance medical directive several years earlier in which renal dialysis had been specifically excluded, so this was not a hasty decision. He returned to our home and his own bed.

Our three adult children joined us, and my husband received wonderful, competent and tender care, made possible by our local hospice. He assured us that he had no regrets about his decision and died peacefully and pain-free two weeks later.

Philip Stopol's letter:
As an 87-year old undergoing my fifth year of dialysis, I am grateful every day for the opportunity to benefit from the results of this treatment. My goal has always been to lead a satisfying and productive life.

For 23 years, I have been enrolled in the Hofstra University PEIR group (Professionals and Executives in Retirement), in which I both attend and teach classes.

Weather permitting, I occasionally play either 9 or 18 holes of golf.

I frequently drive to Manhattan to enjoy a museum or Broadway show.

I refuse to accept dialysis treatment as a death sentence because I have proved that it is not.

Read a story about informed medical decision-making. Thanks to the New York Times editor, who published these letters in today's issue.

Sunday, April 10, 2011

They're horrified: Deaf parents and appropriate cochlear implant surgery

Prof. Harlan Lane's take on disability, tolerance, and appropriate surgery for the deaf:

Question by Margot Sanger-Katz: Nine out of ten deaf people marry other deaf people. Why?

Answer by Prof. Harlan Lane: That's very significant. People who are blind as a rule do not want to marry other blind people. It's a positive value being deaf. When a culturally deaf woman is pregnant, she is hoping, "I'll love this child; it will be my child. But if it was deaf that would be really nice." That's one bit of evidence that deaf people don't view themselves as disabled.

Q: Does that mean they tend to oppose medical interventions for their deaf children, like cochlear implants?

A: Yes. There have been some surveys. And I've spoken with deaf adults, both those who have deaf children and those who don't. And they're horrified. To give an analogy, if we told pygmies we can make life a little easier for your kid if we administer this growth hormone to them, so they'll be taller, they would mostly be offended. Likewise with black Americans, if we told them we can make life a little easier for your kid because with a little plastic surgery and some skin lightening, which we can do now, they're going to "pass" more easily, I might get punched, and justifiably so.

If you're talking about the deaf as an "ethnic group," and what you're offering them is to try to change them to make them more like the majority, because life is easier for the majority, that's unethical.

It all turns on the definition of disability. The surgeons, especially, can only see disability. And, of course, if you can mitigate a disability, that's a good thing. But I, and deaf people, and others who know the deaf well, see that there's no disability here. There's a physical difference, which many minorities have.

We should allow the deaf to make their own decisions about surgery even if they decide differently than we would.

Read a story about href="http://www.PatientSafetyBlog.com/2010/05/when-you-buy-car-inappropriate-surgery.html">saying No to surgery. Thanks to Margot Sanger-Katz, whose interview appeared in today's Boston Globe.