The Top Ten Prescribed Drugs in the U.S.

 The top 10 prescribed drugs in the U.S. for 2010 in order of prescriptions written are:
  
Hydrocodone (combined with acetaminophen) -- 131.2 million prescriptions
Generic Zocor (simvastatin), a cholesterol-lowering statin drug -- 94.1 million prescriptions
Lisinopril (brand names include Prinivil and Zestril), a blood pressure drug -- 87.4 million prescriptions
Generic Synthroid (levothyroxine

Physicians Complicit in Gitmo Torture

As more and more facts come out of Guantanamo Bay prison, one of the worst is that physicians caring for the detainees may have been part of torture of the inmates.  Physicians for Human Rights researchers examined medical records, affidavits and third party examinations of nine prisoners who claimed they were tortured at Gitmo.  They found injuries that were highly consistent with torture and

Food Reward: a Dominant Factor in Obesity, Part I

A Curious Finding

It all started with one little sentence buried in a paper about obese rats. I was reading about how rats become obese when they're given chocolate Ensure, the "meal replacement drink", when I came across this:

...neither [obesity-prone] nor [obesity-resistant] rats will overeat on either vanilla- or strawberry-flavored Ensure.

The only meaningful difference between chocolate, vanilla and strawberry Ensure is the flavor, yet rats eating the chocolate variety overate, rapidly gained fat and became metabolically ill, while rats eating the other flavors didn't (1). Furthermore, the study suggested that the food's flavor determined, in part, what amount of fatness the rats' bodies "defended."

As I explained in previous posts, the human (and rodent) brain regulates the amount of fat the body carries, in a manner similar to how the brain regulates blood pressure, body temperature, blood oxygenation and blood pH (2). That fact, in addition to several other lines of evidence, suggests that obesity probably results from a change in this regulatory system. I refer to the amount of body fat that the brain defends as the "body fat setpoint", however it's clear that the setpoint is dependent on diet and lifestyle factors. The implication of this paper that I could not escape is that a food's flavor influences body fatness and probably the body fat setpoint.

An Introduction to Food Reward

The brain contains a sophisticated system that assigns a value judgment to everything we experience, integrating a vast amount of information into a one-dimensional rating system that labels things from awesome to terrible. This is the system that decides whether we should seek out a particular experience, or avoid it. For example, if you burn yourself each time you touch the burner on your stove, your brain will label that action as bad and it will discourage you from touching it again. On the other hand, if you feel good every time you're cold and put on a sweater, your brain will encourage that behavior. In the psychology literature, this phenomenon is called "reward," and it's critical to survival.

The brain assigns reward to, and seeks out, experiences that it perceives as positive, and discourages behaviors that it views as threatening. Drugs of abuse plug directly into reward pathways, bypassing the external routes that would typically trigger reward. Although this system has been studied most in the context of drug addiction, it evolved to deal with natural environmental stimuli, not drugs.

As food is one of the most important elements of survival, the brain's reward system is highly attuned to food's rewarding properties. The brain uses input from smell, taste, touch, social cues, and numerous signals from the digestive tract* to assign a reward value to foods. Experiments in rats and humans have outlined some of the qualities of food that are inherently rewarding:

• Fat
• Starch
• Sugar
• Salt
• Meatiness (glutamate)
• The absence of bitterness
  
• Certain textures (e.g., soft or liquid calories, crunchy foods)
• Certain aromas (e.g., esters found in many fruits)
• Calorie density ("heavy" food)
  

We are generally born liking the qualities listed above, and aromas and flavors that are associated with these qualities become rewarding over time. For example, beer tastes terrible the first time you drink it because it's bitter, but after you drink it a few times and your brain catches wind that there are calories and a drug in there, it often begins tasting good. The same applies to many vegetables. Children are generally not fond of vegetables, but if you serve them spinach smothered in butter enough times, they'll learn to like it by the time they're adults.

The human brain evolved to deal with a certain range of rewarding experiences. It didn't evolve to constructively manage strong drugs of abuse such as heroin and crack cocaine, which overstimulate reward pathways, leading to the pathological drug seeking behaviors that characterize addiction. These drugs are "superstimuli" that exceed our reward system's normal operating parameters. Over the next few posts, I'll try to convince you that in a similar manner, industrially processed food, which has been professionally crafted to maximize its rewarding properties, is a superstimulus that exceeds the brain's normal operating parameters, leading to an increase in body fatness and other negative consequences.


* Nerves measure stomach distension. A number of of gut-derived paracrine and endocrine signals, including CCK, PYY, ghrelin, GLP-1 and many others potentially participate in food reward sensing, some by acting directly on the brain via the circulation, and others by signaling indirectly via the vagus nerve. More on this later.

Insurance Hall of Shame Award

I am giving this weeks Shame award to Cigna HealthCare.  They are most deserving for their insurance product that someone actually pays for.  I do not know what the monthly premium is but I would sure love to know.  The physicians bill was $306.00.  Of course the insurance company paid zero.  This is not unusual at all.  First they disallowed some of the bill as "Not Covered/Discount."  The

Good News for Coffee Drinkers

According to research published in the American Journal of Clinical Nutrition, habitual drinking of 3 cups/day or more of coffee is not associated with an increased risk for hypertension compared with less than 1 cup/day.  The study did a meta-analysis of six different trials that looked at a total of 172,567 participants.  They did find, however, a slight increase in hypertension in people who

How Drug Marketing Influences Use

There is do doubt that the way pharmaceutical companies market drugs to both doctors and consumers sways prescribing and drives up health costs.  Prescription drug costs have outpaced other health care spending and are predicted to exceed the growth rates for hospital care and physician services going forward from 2010-2019.

Two researchers (Howard Brody, MD, PHD, University of Texas Medical

Limiting IVF Embryo Transfers

Everyone knows about "Octomom" and her octuplets born after in-vitro fertilization (IVF).  That was an extreme case, but multiple births resulting from unregulated artificial reproductive technologies have skyrocketed over the last decade.  The increased rate of twins, triplets and even higher multiples are due to in-vitro treatments and those women and infants are at much higher risk of

Aqueduck for Kids

The management (that would be me) at EverythingHealth gets lots of solicitations for product review and placement.  I decline most of them,  but I did say yes to a nifty little device for kids called Aqueduck.  I figured I had a build in tester in my little grand-daughter.   We all know that hand-washing is the best way to prevent colds, flu and other infections.  Anything we can do to make it

Elbow Bursitis

 

My lovely 87 year old patient took a tumble and sustained some bruises a few weeks ago.  Fortunately she had no broken bones but she did land on her right elbow.  The elbow swelled up and was tender and warm to the touch.  The fluid was drained and it was bloody.  In her case the fluid reaccumulated.  Now several weeks later this is what it looks like.  It is cool to the touch and not tender.

Medical Grand Rounds

Check it out.  Grand rounds is up at Bedside Manner.  Go here to read the best of this weeks blogosphere on patient centered health.  Of course EverythingHealth is selected also!

Upcoming Talks

I'll be giving at least two talks at conferences this year:

Ancestral Health Symposium; "The Human Ecological Niche and Modern Health"; August 5-6 in Los Angeles. This is going to be a great conference. Many of my favorite health/nutrition writers will be presenting. Organizer Brent Pottenger and I collaborated on designing the symposium's name so I hope you like it.

My talk will be titled "Obesity; Old Solutions to a New Problem." I'll be presenting some of my emerging thoughts on obesity. I expect to ruffle some feathers!

Tickets are going fast so reserve one today! I doubt there will be any left two weeks from now.


TEDx Harvard Law; "Food Policy and Public Health"; Oct 21 at Harvard. My talk is tentatively titled "The American Diet: a Historical Perspective." This topic interests me because it helps us frame the discussion on why chronic disease is so prevalent today, and what are the appropriate public health measures to combat it. This should also be a great conference.

Prominent Surgeon Resigns Over Semen Reference

Dr. Lazar Greenfield, the inventor of the Greenfield filter, has now resigned as President of the American College of Surgeons for a big oops.  Dr. Greenfield wrote an editorial for Surgery News, a publication for Surgeons from the American College of Surgeons.  In the now famous Valentine's Day issue he said semen was a "mood enhancer" for women and would be a better gift than chocolate.   He

Walking Challenge

The New York Times had an article recently about what is the single best exercise.  Lots of experts weighed in about what for is best to build endurance and strength.  There are advocates for old fashioned calisthenics, biking and resistance training but many times people don't sustain these types of activities as they get older.  The demands of jobs, adult life, parenthood and just plain aging

Obesity and the Fluid-in, Fluid-out Therapy for Edema

I recently attended a lecture by Dr. Arya M. Sharma here at the University of Washington. Dr. Sharma is a Canadian clinician who specializes in the treatment of obesity. He gave the UW Science in Medicine lecture, which is a prestigious invited lecture.

He spent a little bit of time pointing out the fallacy behind conventional obesity treatment. He used the analogy of edema, which is an abnormal accumulation of fluid in the body.

Since we know that the amount of fluid contained in the body depends on the amount of fluid entering the body and the amount of fluid leaving the body, the treatment for edema is obvious: drink less, pee more.

Of course, this makes no sense. It doesn't address the underlying cause of edema and it will not help the patient. Yet we apply that exact same logic to fat loss. Since the amount of energy contained in the body (in the form of fat) depends on the amount entering and the amount leaving, the solution is easy: eat less, move more. Well, yes, if you can stick to that program it will cause fat loss. But that's equivalent to telling someone with edema to drink less water. It will cause a loss of fluid, but it won't correct the underlying problem that caused excessive fluid retention in the first place.

For example, if you have edema because your heart isn't pumping effectively (cardiac insufficiency), the heart is the problem that must be addressed. Any other treatment is purely symptomatic and is not a cure.

The same applies to obesity. If you don't correct the alteration in the system that causes an obese person to 'defend' his elevated fat mass against changes*, anything you do is symptomatic treatment and is unlikely to be very effective in the long term. My goal is to develop a method that goes beyond symptomatic treatment and allows the body to naturally return to a lower fat mass. I've been doing a lot of reading and I have a simple new idea that I feel confident in. It also neatly explains the results of a variety of weight loss diets. I've dropped a few hints here and there, but I'll be formally unveiling it in the next couple of months. Stay tuned.


* The body fat homeostasis system. The core element appears to be a negative feedback loop between body fat (via leptin, and insulin to a lesser degree) and the brain (primarily the hypothalamus, but other regions are involved). There are many other elements in the system, but that one seems to set the 'gain' on all the others and guides long-term fat mass homeostasis. The brain is the gatekeeper of both energy intake and energy expenditure, and unconscious processes strongly suggest appropriate levels for both factors according to the brain's perceived homeostatic needs. Those suggestions can be overridden consciously, but it requires a perpetual high degree of discipline, whereas someone who has been lean all her life doesn't require discipline to remain lean because her brain is suggesting behaviors that naturally defend leanness. I know what I'm saying here may seem controversial to some people reading this, because it's contrary to what they've read on the internet or in the popular press, but it's not particularly controversial in my field. In fact, you'll find most of this stuff in general neuroscience textbooks dating back more than 10 years (e.g., Eric Kandel and colleagues, Principles of Neuroscience).

EverythingHealth on a Break

EverythingHealth is still on a break while we deal with repairs from a sprinkler line break.  Please click on the links on the right and you will find the best of health blogs.  Check back daily and we'll be back soon.  All is well.

US Omega-6 and Omega-3 Fat Consumption over the Last Century

Omega-6 and omega-3 polyunsaturated fats (PUFA) are essential nutrients that play many important roles in the body. They are highly bioactive, and so any deviation from ancestral intake norms should probably be viewed with suspicion. I've expressed my opinion many times on this blog that omega-6 consumption is currently too high due to our high intake of refined seed oils (corn, soybean, sunflower, etc.) in industrial nations. Although it's clear that the quantity of omega-6 and omega-3 polyunsaturated fat have changed over the last century, no one had ever published a paper that attempted to systematically quantify it until last month (1).

Drs. Chris Ramsden and Joseph Hibbeln worked on this paper (the first author was Dr. Tanya Blasbalg and the senior author was Dr. Robert Rawlings)-- they were the first and second authors of a different review article I reviewed recently (2). Their new paper is a great reference that I'm sure I'll cite many times. I'm going to briefly review it and highlight a few key points.

1. The intake of omega-6 linoleic acid has increased quite a bit since 1909. It would have been roughly 2.3% of calories in 1909, while in 1999 it was 7.2%. That represents an increase of 213%. Linoleic acid is the form of omega-6 that predominates in seed oils.

2. The intake of omega-3 alpha-linolenic acid has also increased, for reasons that I'll explain below. It changed from 0.35% of calories to 0.72%, an increase of 109%.

3. The intake of long-chain omega-6 and omega-3 fats have decreased. These are the highly bioactive fats for which linoleic acid and alpha-linolenic acid are precursors. Arachidonic acid, DHA, DPA and EPA intakes have declined. This mostly has to do with changing husbandry practices and the replacement of animal fats with seed oils in the diet.

4. The ratio of omega-6 to omega-3 fats has increased. There is still quite a bit of debate over whether the ratios matter, or simply the absolute amount of each. I maintain that there is enough evidence from highly controlled animal studies and the basic biochemistry of PUFAs to tentatively conclude that the ratio is important. At a minimum, we know that excess linoleic acid inhibits omega-3 metabolism (3, 4, 5, 6). The omega-6:3 ratio increased from 5.4:1 to 9.6:1 between 1909 and 2009, a 78% increase.

5. The biggest factor in both linoleic acid and alpha-linolenic acid intake changes was the astonishing rise in soybean oil consumption. Soybean oil consumption increased from virtually nothing to 7.4% of total calories, eclipsing all sources of calories besides sugar, dairy and grains! That's because processed food is stuffed with it. It's essentially a byproduct of defatted soybean meal-- the second most important animal feed after corn. Check out this graph from the paper:

I think this paper is an important piece of the puzzle as we try to figure out what happened to nutrition and health in the US over the last century.

Answer to the Medical Challenge

The answer is varicella (chickenpox) in a teenager who had not been vaccinated.

Your diagnostic acumen was right on and I initially thought it might be dermatitis herpetiformis too, but Chickenpox it is.  For more info on Varicella, check out my old post.



I am sorry for the delay with the answer.  This disaster zone is what has been keeping me busy at EverythingHealth.

P.S. that is not me in

Diagnostic challenge

What is the diagnosis:
1.  Dermatitis herpetiformis
2.  Impetigo
3.  Measles
4.  Secondary syphilis
5.  Varicella  (Chickenpox)

Make your best diagnosis and commit in a comment.  The answer will be posted tomorrow!!!

(Image from NEJM)

GOP Health Plan

I am all for any proposal that will improve heath care in America.  Improvement means controlling costs, covering all Americans so no one has to worry about going bankrupt to pay for health care.  Improvement means access to quality care without having to worry about losing your job, which means losing your coverage.  Improvement means a system where all incentives are aligned to prevent disease,

Fat-ten-u

I recently bought the book Food in the United States, 1820s-1890. I came across an ad for an interesting product that was sold in the late 1800s called Fat-ten-u. Check your calendars, it's not April fools day anymore; this is for real. Fat-ten-u was a dietary supplement guaranteed to "make the thin plump and rosy with honest fleshiness of form." I found several more ads for it online, and they feature drawings of despondent, lean women and drawings of happy overweight women accompanied by enthusiastic testimonials such as this:

"FAT-TEN-U FOODS increased my weight 39 pounds, gave me new womanly vigor and developed me finely. My two sisters also use FAT-TEN-U and because of our newly found vigor we have taken up Grecian dancing and have roles in all local productions."

I'm dying to know what was in this stuff, but I can't find the ingredients anywhere.

I find this rather extraordinary, for two reasons:

• Social norms have clearly changed since the late 1800s. Today, leanness is typically considered more attractive than plumpness.
• Women had to make an effort to become overweight in the late 1800s. In 2011, roughly two-thirds of US women are considered overweight or obese, despite the fact that most of them would rather be lean.

A rhetorical question: did everyone count calories in the 1800s, or did their diet and lifestyle naturally promote leanness? The existence of Fat-ten-u is consistent with the idea that our bodies naturally "defended" a lean body composition more effectively in the late 1800s, when our diets were less industrialized. This is supported by the only reliable data on obesity prevalence in the 1890s I'm aware of: body height and weight measurements from over 35,000 Union civil war veterans aged 40-69 years old (1). In that group of Caucasian men, obesity was about 10% of what it is today in the same age group. Whether or not you believe that this sample was representative of the population at large, I can't imagine any demographic in the modern US with an obesity prevalence of 3 percent (certainly not 60 year old war veterans).

Here are two more ads for Fat-ten-u and "Corpula foods" for your viewing pleasure:

Breast Cancer Complexity in Personalized Medicine

Scientists at Washington University School of Medicine in St. Louis have conducted the single largest cancer genomics investigation to date by sequencing the entire genomes of tumor from 50 breast cancer patients.  They compared the cancer DNA to healthy cells in the same patient and found mutations that only occurred in the cancer cells.  They uncovered incredible complexity in the cancer

Great New Product

Do you feel sad sometimes? Are you tired when you get up in the morning? Do you get winded running sprint intervals? I've just found a great new product that I think can help. It's called bozolol.

Bozolol is an amazing nutritional supplement extracted from the bozolol berry, harvested wild in the heart of the Amazon rainforest. To the native Ilotaca tribe, the bozolol berry is sacred because it alters the molecules in your brain to make you smarter AND sexier.

Here's how it works: bozolol actually increases the uptake of fat-soluble vitamins from your food, while reducing inflammation in the arteries and helping you shed fat faster than a pork roast! Guaranteed! Learn more about it here. 

April fools!