Sunday, October 31, 2010

Medical Marijuana

When I was an Intern I took care of an elderly gentleman who was dying of lung cancer.  Mr. Washington had spent much of his life as a sharecropper in the deep South.   Mr. Washington was alone without family and his cancer had spread to his bones and his brain.   He no longer had a wife and his grown son had died several years ago. He had stopped eating and was just skin and bones.  I could see

Happy Halloween

Friday, October 29, 2010

Red Yeast Rice Supplements for High Cholesterol

People are always on the search for "natural" ways to stay healthy and reduce cholesterol.  Chinese red yeast rice supplements have been touted as a natural, safer way to lower cholesterol compared to statin medications.  The yeast that grows on a particular type of rice contains a family of substances called monocolins, which lower cholesterol by inhibiting cholesterol production in the liver in

Thursday, October 28, 2010

The Man with the Eyeball Tattoo

There seems to be no end to stupidity and this man from Toronto, Canada is right up there at the top for crazy ideas.  He actually tattooed his eye by injecting the sclera with ink.  It took 40 injections of ink to complete the color transformation.  Despite the painful appearance, the eye can be easily anesthetized (numbed) so the needle does not hurt.

Despite the fact that this is reported as

Tuesday, October 26, 2010

What Caused This Woman to Faint?

 Dear Dr. Brayer;
My mother, age 66, fainted while she was at work.  She was taken to the emergency room and was evaluated for hours, including a CT scan of her head.  They could not find a reason and sent her home.  Could it have been a stroke that didn't show up?  
Thanks, Heidi

Dear Heidi,
The medical term for fainting or sudden loss of consciousness is syncope.  It occurs when the blood flow

Sunday, October 24, 2010

First Do No Harm

One of the ancient principles of medicine is Primum non nocere, the Latin phrase that means "First, do no harm".  It means that sometimes doing nothing is a better decision than doing something that might cause more harm than good.  It is an ethical precept for physicians, but it becomes harder and harder to adhere to as more and more exotic tests and treatments are at our disposal. 

But just

Saturday, October 23, 2010

Cholera in Haiti

I still follow the aftermath of the Haiti earthquake closely and have continued contact with our Haitian interpreters that I met this year on the Sutter Health Helps Haiti medical mission.  Our physicians and nurses worked in St. Marc, (three hours north of Port-au-Prince) at St. Nicholas Hospital, the epicenter of the new Haitian Cholera outbreak.  Boston based Partners in Health (PIH) runs the

How Do You Hide $100 From a Doctor?

How do you hide $100 from a surgeon?          Put it in the patient's chart, next to the lab.How do you hide $100 from an orthopedist?          Put it in a text book.How do you hide $100 from a neurosurgeon?          Tape it to his kid.How do you hide $100 from an OB/Gyn?          Tape it to the patient's head.How do you hide $100 from an internist?          Stick it under the patient's

Thursday, October 21, 2010

How Not to Raise a Baby

I seem to be on a baby theme.  Here are Baby Dont's.  Remember to be safe with Baby.

Wednesday, October 20, 2010

Should You Share a Bed With Baby?

I've watched the pendulum swing back and forth on the wisdom of mom sharing her bed with a baby.  The American Pediatric Society has come out against the practice, because of a higher incidence of Sudden Infant Death.   But nearly half of all British moms sleep at times with their baby and 1/5 share a bed regularly during the first year.

According to a British study published in Pediatrics, the

Obesity and the Brain

Nature Genetics just published a paper that caught my interest (1). Investigators reviewed the studies that have attempted to determine associations between genetic variants and common obesity (as judged by body mass index or BMI). In other words, they looked for "genes" that are suspected to make people fat.

There are a number of gene variants that associate with an increased or decreased risk of obesity. These fall into two categories: rare single-gene mutations that cause dramatic obesity, and common variants that are estimated to have a very small impact on body fatness. The former category cannot account for common obesity because it is far too rare, and the latter probably cannot account for it either because it has too little impact*. Genetics can't explain the fact that there were half as many obese people in the US 40 years ago. Here's a wise quote from the obesity researcher Dr. David L. Katz, quoted from an interview about the study (2):
Let us by all means study our genes, and their associations with our various shapes and sizes... But let's not let it distract us from the fact that our genes have not changed to account for the modern advent of epidemic obesity -- our environments and lifestyles have.
Exactly. So I don't usually pay much attention to "obesity genes", although I do think genetics contributes to how a body reacts to an unnatural diet/lifestyle. However, the first part of his statement is important too. Studying these types of associations can give us insights into the biological mechanisms of obesity when we ask the question "what do these genes do?" The processes these genes participate in should be the same processes that are most important in regulating fat mass.

So, what do the genes do? Of those that have a known function, nearly all of them act in the brain, and most act in known body fat regulation circuits in the hypothalamus (a brain region). The brain is the master regulator of body fat mass. It's also the master regulator of nearly all large-scale homeostatic systems in the body, including the endocrine (hormone) system. Now you know why I study the neurobiology of obesity.

* The authors estimated that "together, the 32 confirmed BMI loci explained 1.45% of the inter-individual variation in BMI." In other words, even if you were unlucky enough to inherit the 'fat' version of all 32 genes, which is exceedingly unlikely, you would only have a slightly higher risk of obesity than the general population.

Tuesday, October 19, 2010

Cool Medical Apps

The best thing about the iphone and ipad are the cool apps.  I am learning about new ones all the time but here are a few Medical Apps that I like and I think they are all free.

Lose it!  This is a great app for dieters.  It is easy to use and intuitive and you can track your caloric intake and exercise.  Just set your goal and how many calories you want to eat a day and it maps out how long it

Monday, October 18, 2010

Medicare Fraud

There are few things that grind my gears more than Medicare Fraud.  These scams pop up every couple of years and I am so glad when the perpetrators get caught and arrested.  The latest is a large crime syndicate lead by Armen Kazarian, the godfather of Armenian gangsters.  More than $160 million fake  Medicare invoices were generated from 118 fake medical clinics in 25 states, said U.S. Attorney

Wednesday, October 13, 2010

Drug Shortages in the United States

One of our pharmacists asked me "Are we now in Sudan?"

It seems like we are a third world country because we are dealing with serious and nationwide pharmaceutical shortages for needed drugs.  Medications like Propofol (yes, the one that killed Michael Jackson) and Succinylcholine, a neuromuscular drug that is commonly used in surgery, are in such short supply that we are canceling surgeries and


I'll be out of town until the beginning of November, so I won't be responding to comments or e-mails for a while. I'm going to set up a post or two to publish while I'm gone.

As an administrative note, I get a number of e-mails from blog readers each day. I apologize that I can't respond to all of them, as it would require more time than I currently have to spare. The more concise your message, the more likely I'll read it and respond. Thanks for your understanding.

Tuesday, October 12, 2010

Get Healthy Compliments of Uncle Sam

It makes my blogging life easier if I can just direct readers to a cool site compliments of....drumroll...the U.S. Government! 

This site, called Smallstep Adult and Teen,  is filled with great health, eating and exercise tips.  Check it out and click around a bit.  Don't ya' just love the internet?

Monday, October 11, 2010

Sleep Post Correction

An astute commenter pointed out that I misread the numbers in the paper on sleep and fat loss. I wrote that out of the total 3.0 kg lost, the high-sleep group lost 2.4 kg as fat, and the low-sleep group lost 1.4 kg of fat out of 2.9 kg total.

In fact, the high-sleep group lost 1.4 out of 2.9 kg as fat, and the low-sleep group lost 0.6 out of 3.0 kg as fat. So I got the numbers all mixed up. Sorry for the mistake. The main point of the post still stands though: sleep deprivation negatively influences body composition.

The correct numbers are even more interesting than the ones I made up. Even in the high-sleep group, nearly half the body weight lost by simple calorie restriction was lean mass. That doesn't make calorie restriction look very good!

In the sleep-deprived group, 80% of the weight lost by calorie restriction came out of lean mass. Ouch!

That illustrates one of the reasons why I'm skeptical of simple calorie restriction as a means of fat loss. When the body "wants" to be fat, it will sacrifice lean mass to preserve fat tissue. For example, the genetically obese Zucker rat cannot be starved thin. If you try to put it on a severe calorie-restricted diet, it will literally die fat because it will cannibalize its own lean mass (muscle, heart, brain, etc.) to spare the fat. That's an extreme example, but it illustrates the point.

The key is not only to balance energy intake with expenditure (which the brain does automatically when it's working correctly), but to allocate energy appropriately to lean and fat mass.

Positively Quit Smoking

I hold my breath when I walk into the hospital and see a small group of people in the "smoking area" puffing hard on cigarettes. The hospital (and other office buildings) are smoke free, but that doesn't mean everyone has stopped smoking.  They just have to stand out in the fog or the cold like lepers.  I know in other parts of the country, smoking is more tolerated and even more smoking occurs.

Saturday, October 9, 2010

Internal Medicine Poem

I am frequently asked:  What is Internal Medicine?  The answer: "I am thd doctor for adults" or I am the primary care physician", just doesn't seem to cover it.  I think this poem from the Journal of American Medical Association (JAMA) does:

Today I Saw

diabetes in a brown pantsuit
recently widowed, bringing her daughter
for the first time.

Bladder cancer still working
full time after surgery

Tuesday, October 5, 2010

Flossing Toothbrush

Being the world famous popular blog it is, EverythingHealth gets lots of solicitations to place ads, promote books, authors, medical supplies, drugs and other websites.  The answer to most of these requests is "Thanks, but no-thanks".  I like to keep the blog pure and you know that my advice is not tainted by outside influence. (Also known as $$$$)

But since October is National Dental Hygiene

Monday, October 4, 2010

The Big Sleep

This blog usually focuses on diet, because that's my specialty. But if you want Whole Health, you need the whole package: a diet and lifestyle that is broadly consistent with our evolutionary heritage. I think we all know that on some level, but a recent paper has reminded me of it.

I somehow managed to get on the press list of the Annals of Internal Medicine. That means they send me embargoed papers before they're released to the general public. That journal publishes a lot of high-impact diet studies, so it's a great privilege for me. I get to write about the studies, and publish my analysis at the time of general release, which is the same time the news outlets publish their stories.

One of the papers they sent me recently is a fat loss trial with an interesting twist (1; see below). All participants were told to eat 10% fewer calories that usual for two weeks, however half of them were instructed to sleep for 8 and a half hours per night, and the other half were instructed to sleep for 5 and a half hours*. The actual recorded sleep times were 7:25 and 5:14, respectively.

Weight loss by calorie restriction causes a reduction of both fat and lean mass, which is what the investigators observed. Both groups lost the same amount of weight. However, 80% of the weight was lost as fat in the high-sleep group (2.4/3.0 kg lost as fat), while only 48% of it was lost as fat in the low-sleep group (1.4/2.9 kg lost as fat). Basically, the sleep-deprived group lost as much lean mass as they did fat mass, which is not good!

There are many observational studies showing associations between insufficient sleep, obesity and diabetes. However, I think studies like that are particularly vulnerable to confounding variables, so I've never known quite what to make of them. Furthermore, they often show that long sleep duration associates with poor health as well, which I find highly unlikely to reflect cause and effect. I discussed one of those studies in a post a couple of years ago (2). That's why I appreciate this controlled trial so much.

Another sleep restriction trial published in the Lancet in 1999 showed that restricting healthy young men to four hours of sleep per night caused them to temporarily develop glucose intolerance, or pre-diabetes (3).

Furthermore, their daily rhythm of the hormone cortisol became abnormal. Rather than the normal pattern of a peak in the morning and a dip in the evening, sleep deprivation blunted their morning cortisol level and enhanced it in the evening. Cortisol is a stress hormone, among other things, and its fluctuations may contribute to our ability to feel awake in the morning and ready for bed at night.

The term "adrenal fatigue", which refers to the aforementioned disturbance in cortisol rhythm, is characterized by general fatigue, difficulty waking up in the morning, and difficulty going to sleep at night. It's a term that's commonly used by alternative medical practitioners but not generally accepted by mainstream medicine, possibly because it's difficult to demonstrate and the symptoms are fairly general. Robb Wolf talks about it in his book The Paleo Solution.

The investigators concluded:
Sleep debt has a harmful impact on carbohydrate metabolism and endocrine functhon. The effects are similar to those seen in normal ageing and, therefore, sleep debt may increase the severity of age-related chronic disorders.
So there you have it. Besides making us miserable, lack of sleep appears to predispose to obesity and diabetes, and probably sets us up for the Big Sleep down the line. I can't say I'm surprised, given how awful I feel after even one night of six hour sleep. I feel best after 9 hours, and I probably average about 8.5. Does it cut into my free time? Sure. But it's worth it to me, because it allows me to enjoy my day much more.

Keep your room as dark as possible during sleep. It also helps to avoid bright light, particularly in the blue spectrum, before bed (4). "Soft white" bulbs are preferable to full spectrum in the evening. If you need to use your computer, dim the monitor and adjust it to favor warm over cool colors. For people who sleep poorly due to anxiety, meditation before bed can be highly effective. I posted a tutorial here.

1. Nedeltcheva, AV et al. "Insufficient Sleep Undermines Dietary Efforts to Reduce Adiposity." Annals of Internal Medicine. 2010. Advanced publication.

* The study was a randomized crossover design with a 3 month washout period, which I consider a rigorous design. I think the study overall was very clever. The investigators used calorie restriction to cause rapid changes in body composition so that they could see differences on a reasonable timescale, rather than trying to deprive people of sleep for months and look for more gradual body fat changes without dietary changes. The latter experiment would have been more interesting, but potentially impractical and unethical.