27 December 2017: Food: The Good, The Bad and The Ugly

Food: The Good, The Bad and The Ugly

or Stop Eating Empty Calories

By Nat Pernick, M.D.

27 December 2017

This time of year we focus much of our time and energy on eating, so it is important to think about what we are eating and how it affects our health. All food is not created equal. In my recent paper, How Cancer Arises Based on Complexity Theory, I describe the Western diet (high fat, low fiber, low consumption of vegetables and fruit) as one of nine “chronic pressures” that cause most cancer cases. With apologies to Sergio Leone, in this paper I divide food into The Good, The Bad and The Ugly.

Most Americans can now easily get enough calories with all required nutritional components through a balanced diet. High quality food, not contaminated by microorganisms, parasites or toxins, is relatively inexpensive and available 24/7. Thus, we need not worry about eating to survive. Instead we should focus on eating to maximize our health.

The “good” foods are not controversial: vegetables, fruit and whole grains. This is the recommendation of US governmental agencies (Health and Human Services, USDA), the American Cancer Society and the American Heart Association. Each meal should be centered on eating vegetables, fruit and whole grains - they should not be an afterthought. This is a complete reversal of how we were taught to eat, in which protein must dominate a meal, and then we throw in some vegetables and fruit. It necessitates a major shift in our thinking and behavior that will require time to implement but is important for our optimal health.

Some foods are “bad” because they are simply empty calories. They don’t provide the anti-cancer, anti-heart disease factors found in vegetables, fruit and whole grains. Most people are obsessed with protein; their meals must be centered around meat, poultry, fish, eggs or dairy. But as the American Heart Association notes, “You don't need to eat foods from animals to have enough protein in your diet. Plant proteins alone can provide enough of the essential and non-essential amino acids, as long as sources of dietary protein are varied and caloric intake is high enough to meet energy needs.”

Foods are “ugly” that statistically have been found to contribute to cancer, heart disease or other serious diseases. They include foods high in fat, sugar, refined grains or that are highly processed. Many of these ugly foods are considered to be “proinflammatory” according to The University of South Carolina Cancer Prevention and Control Program, which developed the dietary inflammatory index (Shivappa 2014a). A proinflammatory diet is associated with a higher death rate due primarily to digestive cancer, cardiovascular disease and chronic obstructive pulmonary disease. Food groups associated in one study with the highest inflammatory index were butter, beer, coffee, fried food, liquor, high sugar beverages and french fries; those with the lowest inflammatory index were vegetables other than potatoes, low fat dairy, fish, fruit (not juice) and nuts (see Table 2).

Eating healthy is a continuous process of behavior change that takes years to optimize. We should choose more healthy foods, limit empty calories, stop eating when 70% full, resign from the “clean plate” club, avoid processed food, not eat for psychologic reasons, avoid unhealthy food even if easily available and monitor our caloric intake to maintain a body mass index (BMI) of 18.5 to 24.9.

Let’s start today!

26 November 2017: How Cancer Arises Based on Complexity Theory

I have written a new paper, How Cancer Arises Based on Complexity Theory, that I have been working on for many years. It is 37 pages and technical, but there is an Executive Summary that is easier to read. See http://www.natpernick.com/HowCancerArises.pdf.

Send comments to NatPernick@gmail.com (but unfortunately I cannot give personal advice on an individual's medical problems).

6 September 2017: Vitamin Supplements Can Be Harmful to Health

A recent article confirms prior studies that high dose supplements by men of Vitamins B6 and B12 (individual supplements, not multivitamins) is associated with an increased risk of lung cancer, particularly in smokers, see https://www.ncbi.nlm.nih.gov/pubmed/28829668. These daily doses (vitamin B6: > 20 mg; vitamin B12 (> 55µg) are much higher than the recommended daily doses for men (vitamin B6: 1.3 to 1.7 mg; vitamin B12: 2.4 µg), see https://ods.od.nih.gov/factsh…/VitaminB6-HealthProfessional/ and https://ods.od.nih.gov/facts…/VitaminB12-HealthProfessional/, but they are sold at major retailers without a prescription, see, for example, https://www.walgreens.com/q/vitamin+b6. The authors conclude "This sex- and source-specific association provides further evidence that vitamin B supplements are not chemopreventive for lung cancer and may be harmful." Of course, the best way to reduce risk for lung cancer is to stop smoking, which causes 80-90% of lung cancers. In addition, the Mayo Clinic recommends reducing exposure to second hand smoke, testing your home for radon, eating more fruits and vegetables and getting sufficient exercise, http://www.mayoclinic.org/…/…/basics/prevention/con-20025531, which are standard recommendations in the medical community.

18 June 2017: Life in the Detroit Suburbs Without a Car

18 June 2017

It’s been 2 months since I gave my car to my daughter to drive to Alaska for a summer job.  The initial reason was guilt - I feared her 1999 Civic with 170K miles wouldn’t make the 4,200 mile trip.  But part of me also wanted to relive my experience as a medical student in Ann Arbor in the early 1980’s, when I also gave up my car.  I also consider it my contribution to fighting climate change.

I live near 10 Mile and Coolidge, by myself.  Here is how I get around.

SMART bus: I ride the bus to work.  I took a picture of the schedule and put it on my phone.  I walk 15-20 minutes to 11 Mile and Coolidge to take the 740 bus.  It takes me to 12 Mile and Telegraph (15 minutes), and I walk 0.5 miles to my office.  I use a $22 bus pass (costs $20 + $2 handling, ordered online, takes about 4 business days to receive), for 11 fares @ $2.  The bus is usually within 5 minutes of the schedule.  SMART has a free app, whose tracker gives a map of where the bus actually is on the route, but ~5% of the time, the tracking function does not work.  Lyft (similar to Uber) is my backup, but I only used it once when the bus was 20 minutes late, and the tracking did not work, so I did not know if the bus was broken down or not (next time I will call SMART to ask before using Lyft).  The bus drivers are nice, and the ride is air conditioned and mostly comfortable, but I do feel all the bumps in our sorry roads.

Bicycle: For me, there actually is a “high” from bicycling.  I bike 8-10 miles to and from work if the weather does not call for rain, and if my schedule permits.  I bike on subdivision streets and the 12 Mile bike path, not major streets.  I wear a helmet, gloves and a yellow jacket to ensure that drivers, who appear to be focused on their cell phones and not the road, will see me.  I have been doing this for years, so the distance is not a problem.  I can shop in Royal Oak while bicycling, but only can buy what fits in two carrier bags.  I do not bike at night, and prefer to not leave the bike somewhere I cannot see it, even though I lock it up and it is not valuable.  I carry extra tubes and a pump to fix a flat, but if that doesn’t work, or I find myself biking in the pouring rain, I call Lyft to pick me up, but first call the driver to make sure the car has a back seat that folds down to fit my bike (my front tire has a “quick release”).

Walk: It is very pleasant to walk to the bus stop first thing in the morning, listing to the birds and watching the joggers, walkers and cyclists.  If, using the tracker, I see that I am very early for the bus, I walk to the next stop(s), to get more exercise.  I carry a backpack with an umbrella, poncho, cell phone backup battery and reading material for the bus.

Lyft: I use this smart phone app several times a week, and typically spend $200 to $300 per month (the app keeps track of ride histories).  I usually give a $2 tip.  Most rides are $10 to $20, whether to work or downtown.  The drivers are polite (because we rate them at the end of the ride), and the cars are in very good shape.  This was not my experience much of the time when I took taxis.  Last weekend, I took Lyft to Midtown and walked around.  Compared to a car, it was a much better experience.  As a passenger, I don’t care about construction or traffic slowdowns.  I like talking to the drivers about their lives.  I don’t have to spend 15 minutes looking for a parking spot.  When leaving a big event, such as a concert, I typically walk away from the crowd, to make it easier to spot the driver, and for the driver to find me.

I try to be strategic about using Lyft.  If I plan to use it to go home, I think about shopping at the same time, particularly for heavy items that I could not carry or put on the bike.  You can have multiple destinations with Lyft, so I use it to pick up people and go to lunch.  Leaving the restaurant, I use Lyft to drop us off.

At first, I worried about short rides being bad for the drivers since their cost is minimal, but the drivers don’t mind.  Lyft pays bonuses based on the number of rides they provide, and the drivers can do more rides if they are short.

No money changes hands using Lyft.  It is charged to my credit card, and I can see the cost of rides at any time.

I try to pay attention to where we are going - if I put the wrong address in Lyft, the driver will take me to the wrong place.  Sometimes drivers don’t know the area well, so I guide them.  Some drivers don’t speak much English - this was mainly a problem when in Miami, not Detroit.  I have not had any problems with rude, threatening or inappropriate drivers, or vehicles that seemed deficient.

Initially I used Uber, but I could not get reception several times.  Perhaps it is just me.  I have not had problems using Lyft.

Friends / family: I am happy to use Lyft or walk, but friends / family may offer to take me home or closer to home if they are in the car anyway.  I do not rely on this, and am always grateful if they offer.

The advantages of not having a car are: (a) financial - no car payment, no car insurance, no maintenance, no gas, no worrying about tickets, accidents, parking or tolls; (b) physical - more exercise; (c) a better quality of life, at least for me.  When I get to work, I am not anxious because I have fought traffic on I-696 for 20 minutes.  I don’t worry about crazy drivers (well, perhaps a little when bicycling).  My life is not centered on my car, which makes me feel better. It is easier for me to avoid doing things I really didn’t want to do anyway.  I also try to avoid errands by doing them online, or bunching them together; (d) safety - the drivers are typically better than me.  As a driver, I would get tired, or think about the events of the day, and not be as alert as I should have been.

The disadvantages are: (a) financial - at times, I would prefer not to spend the $10 to $20 for Lyft; (b) picking up people and going somewhere with Lyft takes a little getting used to; (c) my mother and some friends say I will never get a girlfriend without a car, but this is me now, and I view it as a screening test; (d) long trips will require me to rent a car, but that doesn’t happen too often, and there are several Enterprise and other car rentals nearby, which will pick me up at my door (or I could use Lyft).; (e) other people may not consider me as reliable since I don’t have a car, but I think using Lyft actually makes me more reliable, since I don’t have to worry about my car’s condition or my ability to drive.

13 April 2017: My stay in the ICU

On Wednesday, 5 April 2017, at about 4pm, after running some errands, I decided to see my personal physician, who was nearby, to make sure I didn't have pneumonia or something serious.  I had a one week history of flu-like symptoms, including mild weakness and fatigue, but also isolated examples of shortness of breath going up the stairs, drenching sweats and shaking chills at night. I had gained 7 pounds in the past week, despite a diminished appetite.  I felt cold but had no fever (at least with my somewhat dated digital thermometer), had no pain and no cough.  I did have some mild chronic rib pain, which I attributed to a bad mattress, that had just been replaced.  When not feeling well, my ribs would hurt on the soft mattress, but I had just came back from a trip to Florida, sleeping on a different mattress, where the rib pain had disappeared. 

Since my doctor was not in, I went to the walk in clinic.  Six months previously, I went to this same clinic for a swollen right leg on a Friday, and the next night, when I was attending Carmen at the Detroit Opera Theatre, they called me to rush to the emergency room for a possible blood clot based on a mildly elevated D-dimer blood test, see https://en.wikipedia.org/wiki/D-dimer (which I did not do).  Back to the present, they took my history, did a short exam, ordered an EKG, and then all hell broke loose.

The EKG indicated:

ST elevation, consider inferolateral injury or acute infarct
** ** ACUTE MI / STEMI ** **

They called 911, EMS came, asked me some questions, and then took me, with sirens blasting, to the Henry Ford West Bloomfield Hospital Emergency Department.  If I didn't have a heart attack, this might have triggered one.  In Emergency, they asked more questions, and started contacting physicians to do a cardiac catheterization, which maps out the inside of the coronary blood vessels to determine if I was having a heart attack.

I did not think I was having a heart attack.  I had no symptoms.  The rib pain was from my mattress, at least in my mind, although I don't think anyone believed me.  But it also had none of the characteristics of heart attack pain (it was dull and constant, exercise did not make it worse, etc.).  Other than being 59 and male, I had no risk factors for coronary artery disease.  I am thin (BMI 21-22), a bicyclist (100-150 miles per week in season), vegan, with a low blood pressure (usually 105/65), good LDL (83), good HDL (54), no diabetes, no smoking, no alcohol.  I told them I did not want a cardiac cath. The first blood test for heart damage (troponin) was negative, which made me more confident.  They did a bedside chest Xray which showed bilateral pleural effusions (fluid at the base of both lungs) and an enlarged heart shadow (abnormal, cause unclear).  The D-dimer blood test done today was more elevated than the last time, so they were worried about a pulmonary embolism (blood clot), although I had no blood clots elsewhere in the body.  A second troponin test was also negative.

A chest CT gave the diagnosis of a pericardial effusion, fluid surrounding the heart due to an inflamed pericardium (acute pericarditis), which is the membrane lining the heart.  This is usually due to a virus, but as in my case, the cause usually cannot be determined.  The virus causes inflammation, which causes fluid to accumulate.  The danger is that the fluid can press on the heart, and prevent it from beating normally, a condition called cardiac tamponade.  At that point, it was clear that a cardiac cath was not indicated, and I was transferred to the ICU for monitoring, which happened Thursday morning at about 12:30 am.

In the ICU, I was hooked up.  An IV is mandatory (two is preferable but I had "bad veins").  There was also a "pulse ox" (a monitor attached to a finger tip to measure the amount of oxygen in the blood), a blood pressure cuff that inflated automatically, and a cable attached to electrodes taped to my chest, to monitor my heart.  Then it was time to sleep!  At this hospital, every room, even the ICU, is private, and has its own bathroom and shower.  They allowed me to use the bathroom and not a bedpan.  I just had to disconnect the 3 cables, and bring the IV pole (which had wheels) with me.

On Thursday morning at about 9am, I had my first echocardiogram, an ultrasound of the heart.  The cardiologist said I had a large amount of fluid surrounding the heart, although the heart wall and the values themselves were fine, with no evidence of any damage.  However, the amount of fluid appeared to be mildly affecting the function of the heart, so it would have to be tapped, which could be done today or tomorrow.  Tapping means sticking a needle in the chest next to the heart, to drain the fluid.  The risk was low (~ 1% complication rate), particularly because there was so much fluid.  Today or tomorrow: I chose tomorrow.  They would monitor me until then.  Since I am not great at sitting around doing nothing, I changed into my street clothes, set up an "office" and did some work.  Then I walked around the ICU with my IV pole, and one of the male nurses had a hissy fit:  "This is so inappropriate - you should not be in the unit", he started to rant.  I ignored him.  Later that day, Rachel and Sam visited and brought food.  Others visited too, which lifted my spirits, although hospital visits are quite tiring.  I ordered off the hospital menu - the food was pretty good.  For the pericarditis, I was given high dose aspirin (2 regular aspirins every 6 hours) plus colchicine, an anti-inflammation drug used for gout.  I went to sleep thinking about tomorrow's tap.

On Friday morning, I had my second echocardiogram.  The fluid had lessened, and the cardiologist indicated the tap could wait.  I would be monitored over the weekend, and could be transferred to a less intense unit  The IV was kept in, but was disconnected from the IV pole.  The pulse ox and the automatic blood pressure monitor were discontinued.  That afternoon, I walked with a staff to the telemetry unit, which had a similar room, but a smaller nurse to patient ratio.  I was seen by cardiology Saturday and Sunday morning.  On Sunday morning, I had a third echocardiogram, which showed continued reduction in fluid, and they agreed to discharge me.  I had gained an additional 9 pounds in the hospital (confirmed on my doctor's scale at home).  At about 12:30 pm, I stepped outside, waiting for Leah to pick me up.  Then I "lost it" for a few minutes.

I am now taking aspirin (only 325 mg every 6 hours) and colchicine, with a repeat echocardiogram and cardiology visit in 2 weeks.  I was told to "take it easy", which to me means no bicycling (except short easy rides), no fast walking and no weights at the gym.

I am no longer "shaky" due to the experience, but it's hard to believe a week ago I was in the ICU.

There are probably some life lessons from this experience.  Here is what I have compiled to date:

1. Exercise, eat healthy, stay thin, and follow your doctor's advice (when rational), and be in the best health you can be.  It may not prevent all problems, such as I had, but will probably limit the damage when they occur.

2. Replace your bad mattresses.

3. Make sure you have a working digital thermometer, and your over the counter medications are not expired.

4. Being in the ICU, or perhaps being sick in general, is when you most need (want) a significant other.  I am not sure what to do about this - for me, dating is quite miserable.

5. Make an extra effort to stay on good terms with your family members and friends.

6. My personal philosophy is to delay procedures if at all reasonable.  I avoided two procedures that turned out to be unnecessary.  Perhaps they would have gone well, but you never know.

7. If you are rational in crisis situations, use your brain and ask questions.  In general, medicine should make sense.  If you are not rational (or are always right, or know everything), listen to your doctors and hope for the best.

8. Pack a "personal bag" for emergencies, with toiletries and clothes for a day, for someone to pick up for you if needed.

9. Count your blessings - you never know when things will get much more difficult.

- Nat

17 March 2017: Eat healthier for colon cancer awareness month

March has been designated as colon cancer awareness month since 2000.  Colon cancer is projected to cause 50,260 deaths in the US in 2017, with 1,680 in Michigan (see Cancer Facts & Figures 2017 at pages 4 and 6), although the death rate is declining (see Cancer Facts & Figures 2017 at pages 2 and  3).  Overall, colon cancer is the #2 cause of cancer deaths in men in the US (projected deaths in the US in 2017 are lung: 84,590, colon: 27,150, prostate: 26,730) and #3 in women (projected deaths in the US in 2017 are lung: 71,280, breast: 40,610, colon: 23,110, see Cancer Facts & Figures 2017 at page 10).

Colon cancer is strongly influenced by diet.  According to Dr. Joel Kahn, my medical school classmate (University of Michigan, 1983), cardiologist and owner of Green Space Cafe, dietary and lifestyle changes can modify your risk:

Six dietary and lifestyle recommendations: 1) lower body weight 2) increased physical activity 3) reducing daily calories 4) eating lots of plant foods 5) reducing red and processed meat and 6) limiting alcohol were examined over 8 years in 66,920 adults aged 50-76 years with no history of CRC [colorectal cancer]. The study found that following between one and three of the lifestyle steps resulted in a 34-45 percent lower risk of CRC while meeting four to six of the targets resulted in a stunning 58 percent lower incidence of CRC. The lowest CRC risk for women related to lower body fatness and reduced red and processed meat in the diet while for men it was avoiding excessive alcohol intake and reducing red and processed meat in the diet.  See BLOG: Dr. Joel Kahn Talks Colon Health For Colon Cancer Awareness Month, dbusiness, 16 March 2017 and Cancer Causes Control. 2016 Nov;27(11):1347-1359

Why does diet make a difference?  As recently reported by Columbia University researchers, our diet affects the microbiota (the mix of microorganisms found in and on all multicellular organisms) in our gut, which influences disease:

Microbiota and host form a complex 'super-organism' in which symbiotic relationships confer benefits to the host in many key aspects of life. However, defects in the regulatory circuits of the host that control bacterial sensing and homeostasis, or alterations of the microbiome, through environmental changes (infection, diet or lifestyle), may disturb this symbiotic relationship and promote disease. Increasing evidence indicates a key role for the bacterial microbiota in carcinogenesis.  See Nat Rev Cancer 2013 Nov;13(11):800-12.

A friend of mine once said "What's the point of living if you can't eat the foods you like?"  There certainly is some truth in that.  But it is also true that many of us would rather find ways to modify our diet and lifestyle that we could accept, if we could avoid certain diseases (overweight / obesity, high blood pressure, diabetes, coronary heart disease, reflux) that are far more troubling.  Personally, I find it hard to make major changes in my life.  But I can make a small change today, which not only may make a difference, but gives me a new outlook on the future.