Which Diet is Best for Weight Loss?

Now there is the million dollar question, right? Interestingly, despite billions of health care dollars being spent on "diets", there are not recent high level studies in the medical literature to support touting one weight loss diet highly above all the rest. In 2001, there was a scientific review of popular diets by Freedman, King, & Kennedy, that concluded "low fat, low calorie diets are the most successful in maintaining weight loss." Note- this is in MAINTAINING weight loss, not LOSING weight. Ultimately, as should come as little or no surprise, CALORIC BALANCE is the major determinant of weight loss, regardless of the composition.

So...which diet? HIGH protein, LOW carb diets have a very high satiety effect- you are simply not as HUNGRY when you restrict calories if there is a high protein content. Several studies have demonstrated that the less hungry (more satiated) people are, the higher their compliance rate with a calorie restricted diet. This sounds rather obvious- if you are not hungry, you won't "cheat"- BUT...remember most of us do not eat because we are hungry. We eat because we are happy, sad, mad, bored, distracted- you name it. (See related post "Break the Eat, Repent, Repeat Cycle").

Are high protein diets safe for the kidneys?  A 2012 study at the Indiana School of Medicine confirmed that low carb, high protein diets do NOT cause any harm to the kidney function in obese patients who had healthy kidneys at the start.

What about the heart? A very large study this year in Sweeden (>40,000 women) did show that women do develop an increased risk of cardiovascular disease (heart attacks & stroke) if they stay on a low carb/ high protein diet long-term.  However, in the short term (at one year), low carb/high protein diets are more effective in weight loss and reducing cardiovascular disease risk.

BOTTOM LINE: Low carb/ high protein diets may help you lose weight in the short term (~ a year), but for long-term weight maintenance or continued weight loss, go for what you know to be healthy- MORE fruits & vegetables & a lean protein source. 

Does Your Holiday Travel Include a Flight?

As the holidays are upon us and travel plans are ramping up, I thought I’d share some health-related flying tips. Since flu season is under way, I’d be remiss not to start with the basic advice that you should NOT fly if you have a fever or a productive cough (or other flu symptoms such as headache, sore throat, and body aches.) That being said, there are many times that you may need to fly when you have mild cold or allergy symptoms, and there are a few tricks that may be helpful.

The one time that I actually recommend over-the-counter nose sprays (like Afrin) is if you have a stuffy head/nose/ears and need to fly. Make sure to put it in ziplock bag to take it through security, but then use it when you are seated on the plane to reduce ear discomfort upon takeoff. Gum, mints or any beverage will help clear your ears as well- whatever helps you to swallow repeatedly.

I also suggest sucking on the zinc lozenges- any variety- I happen to like the ones combined with vitamin C. Zinc oral dissolvable products have been shown to reduce acquisition of respiratory viruses. Unfortunately, simply taking a zinc supplement that you swallow has not been shown to provide equal benefit.

If you have no contraindication to taking aspirin, a baby aspirin taken the day of your flight will reduce your risk for blood clots that can occur with prolonged sitting. Try to get up every hour or two and walk to the bathroom- that will help, too.

Nervous about flying? Talk to your doctor about a short-acting mild sedative or sleep aid (if the flight is long enough.) No need for embarrassment, as fear of flying is very common. I’d estimate I get this request close to once per week (and much more often this time of year!)

Should you wear a mask? I suppose if either YOU have a cough or your seatmate does, that is reasonable.

BOTTOM LINE: If your travel plans include flying, create your own "flying first aid" kit to take with you!

Exercise and Strokes

Hooray! We have yet ANOTHER great reason to exercise. The journal Neurology has published a study this week that showed older people (mean age 70) who participate in moderate to intense levels of exercise have nearly HALF the risk of silent stroke compared with their less active peers. This study looked at 1200 adults with no clinical signs of stroke. The participants had brain MRI scans, and nearly 200 of them had evidence of a silent stroke. All the study patients were interviewed about their regular activities, from golf to hiking or other vigorous exercise. In fairness, 43% who had normal brain studies did no regular exercise at all. However, it is impressive that those people who regularly had significant aerobic activity had a 40% DECREASED RISK of silent stroke- even when this risk factor was isolated from other risks such as high blood pressure or cholesterol.

Exercise has so many benefits- from improving our mood, to increasing energy, to decreasing stroke risk. And it's never too late to START exercising! The more "out of shape" you are, the more important it is for your overall health to get moving. Simply "start low, and go slow" to avoid injury. In practical terms, I'd suggest starting with WALKING and consider getting a PEDOMETER (grab a pedometer app on your iPhone and get started counting steps right now!)

BOTTOM LINE: Exercise benefits include decreasing your risk of silent stroke, so if you value your brain cells, get moving!

Getting that "Base Tan" for Summer Vacation?

Marketing is everything, isn't it? How many of you have headed to a tanning booth to get that "base tan" before heading out for a beach vacation? Here's a note- that notion has no scientific basis, nor support from dermatologists. In fact, the American Academy of Dermatology (AADA) testified recently at FDA hearings about the risks of indoor tanning. These devices have shared the same low risk category as bandaids and tongue depressors, yet we have had medical evidence for years that they clearly cause skin cancers.

Melanoma rates are increasing across the board, and melanoma is now the number one cancer in young people aged 25-29, and the second most common cancer in 15-29 year olds. Use of a tanning bed before the age of 35 increases your risk of developing melanoma by a whopping 75%! I can personally attest in my own practice that I have diagnosed 3 cases of melanoma just in the past few months, primarily in people younger than I am- which really hits home. (I'm 45.) Having lost a friend to melanoma many years ago, I am very aware that skin cancers are not simply cosmetic nuisances.

Tanning beds are not "safe", and they target young people (especially women) with their ads. Many tanning salons promote their "safe" or "harmless" type of UV radiation, but the UVA rays cause damage in the same fashion as UVB rays- only a bit more slowly and more deeply.

The American Academy of Dermatology hopes the FDA will ban indoor tanning devices all together, but at the least, should require a minimum age of 18 for ANY indoor tanning and should mandate obtaining informed consent from clients AFTER educating them about the real risks of skin cancer. The AADA also strongly recommends changing the risk category of these machines to match the health risks they create.

BOTTOM LINE: TANNING is NOT SAFE! Use sunscreen and stay away from tanning beds all together.

The Perfect Diet Pill

Ready to sign up? I think we're all looking for that pill that let's us skip exercise and eat whatever we want, but still allow us to lose weight effortlessly- and oh yes, with no side effects. Sigh. I hate to disappoint you, but no such pill exists. I often think patients believe we doctors are hoarding this mysterious pill somewhere, keeping it for our own use! But seriously, if there were such a pill, there would be no overweight or obese doctors, right? And look around...doctors struggle with their weight as much as the next person.

What IS out there, and why don't we use it more? The main drug still on the market for weight loss is phentermine. The common brand names are Adipex, Fastin, Obenix, and Oby-Trim. Phentermine is a very effective appetite suppressant. It is a stimulant (similar to amphetamine) and can be addictive. It doesn't magically speed up your metabolism, it simply suppresses your appetite so you consume fewer calories. In the past, it was combined with another diet medications (fenfluramine and dexfenfluramine) but this combination turned out to potentially cause pulmonary hypertension- a very serious and possibly fatal lung disease. By itself, however, phentermine is usually well-tolerated, though it has it's own list of side effects, and it cannot be taken along with many antidepressants. Phentermine is thought to raise blood pressure, increase heart rates, and increase your risk for heart disease. A study published last month in Obesity, however, suggests that these cardiac effects may not be significant, or in fact, may not be there at all. While this was not our highest quality study, its numbers (300 patients) and methods are enough for us to take note.

So, if you don't have heart risk factors (beyond obesity) and you are not taking an antidepressant, should you rush to your doctor for a phentermine prescription? Probably not. If you need to jump start a weight loss program and you are ready to really improve your diet quality and quantity along with pursuing a solid exercise program - maybe. It's worth a discussion. However, you need to know from day one that most people REGAIN the weight when they go off the drug. Again, not magic, just they quit suppressing their appetite so they are more hungry, and they eat more.

I rarely prescribe phentermine, probably less than five patients per year. My personal standards are that the patient needs to be seeing a registered dietician and demonstrate that they are exercising daily for a least a month. I see the patient back in one month, and will not prescribe phentermine for more than two months. This is not a "cure all" drug, but in selected patients, it can be a wonderful jump start towards better health.

BOTTOM LINE: If you feel overriding hunger is truly keeping you from losing weight, open the discussion with your doctor about considering a prescription appetite suppressant.

Alzheimer's Disease- Why So Hard to Diagnose?

Alzheimer's disease (AD) should be simple to diagnose, right? How hard can it be for a doctor to decide if memory loss is a normal part of aging, or if it is severe enough to "count" as Alzheimer's? Well, if diseases only occurred one at a time, it might be simple. Unfortunately, as old Texas doc's say, when you itch, it's possible you've got ticks AND fleas. I find in family medicine, it's rare we see any disease state by itself, and Alzheimer's is no exception.

Many different issues can affect memory. Depression and/or anxiety very frequently preoccupy the brain so much that short term memory loss can be a predominant issue. Low thyroid levels can decrease memory. B12 deficiency is another cause. The list of medications that can affect memory seems to be growing each year as well.

When my mother first noticed significant memory issues at the age of 61, she was convinced she had Alzheimer's. I literally laughed when she told me her concerns...We had no family history of early or even late onset dementia. She had recently started a medication known for impairing memory (Digoxin.) As her medical workup progressed, I was relieved to find out she had not only that medication as a possible cause, but literally every cause I listed above- B12 deficiency, hypothyroidism and depression. I felt confident that as we addressed each of these problems, her memory would improve. In many cases, that would have been true, but unfortunately for Mom, she did indeed have underlying Alzheimer's, which took roughly another two years to fully decipher.

If you are concerned about memory loss, please make an appointment with your family physician to address your concerns. Head to the Alzheimer's Association website and review the 10 Warning Signs of Alzheimer's. Until those biomarkers for AD become more refined, physicians will not have a quick or simple answer, but a thorough history and exam, combined with possible neuropsychiatric testing, will take us a long way in the right direction.

BOTTOM LINE: Memory loss can have many different causes, and these causes can and frequently do overlap.

How Safe is Gardasil?

Parents are appropriately concerned about vaccines, but I get frustrated with the enormous amounts of negative popular press that immunizations are receiving these days. Vaccines are not only saving lives, but they are improving the quality of our lives dramatically with every decade. Today I'd like to discuss the statistics with Gardasil, a vaccine that protects against four strains of the human papilloma virus which cause genital warts and cervical cancer.

Gardasil was FDA approved and recommended in June of 2006. Since that time, over 32 million doses of the vaccine have been administered. There have been over 17,000 "adverse events" reported, including roughly 1000 "serious" events. The mild to moderate events (over 90%) include transient local swelling or pain, mild and moderate fevers, and nausea or fainting.

So what about the serious events, including 56 deaths? The serious events included primarily Guillian-Barre syndrome (a severe neurologic disorder) and blood clots. The numbers of GBS are no higher than expected in the age group receiving the vaccine, and the girls with blood clots typically had other risk factors for clotting, such as taking the birth control pill. Though deaths in young people are tragic REGARDLESS of the cause, there has been no identifiable pattern in these deaths to suggest that the vaccine caused them. If you look at any age population of 10 million people (32 million doses divided by the 3 shots in a series), sadly, you will see certain lethal cancers, neurological diseases, and other rare ailments.

It is important to understand that in order to figure out side effects from vaccines, any and ALL events that happen within a month (or up to a year) after receiving an immunization can and should be reported- even if it looks like they are completely coincidental. For example, if you get a flu shot today, and are diagnosed with advanced leukemia tomorrow, it gets reported as an "adverse event" of the flu shot- even though it obviously was going on before your shot. Why do this? Because we want to be SURE that there is NOT a relationship between any serious diseases and vaccines, and the only way to know is to collect all the data.

BOTTOM LINE: For Gardasil, look at these numbers and remember there are 1 million new cases of genital warts per year, 12,000 cases of cervical cancer and 4000 deaths from cervical cancer. You do the math. We are choosing to immunize our daughters.

Doc, Have You Heard of This New Drug?

Often patients ask me about a new drug they heard or read about, and would like a prescription to "try it out". Sometimes, the new drug works wonders, but most of the time, there is no such luck. Obviously pharmaceutical companies are spending more money on direct advertising to the public, and it's working! Our country spends staggering amounts of money on drugs.
Today I'd like to share a pneumonic from the AAFP that helps doctors assess new medications: STEPS.

S: Safety- what are the drug interactions and side effects?
T: Tolerability- how many people stop taking the drug because of side effects?
E: Effectiveness-this may seem obvious, but really: does this drug not only change a LAB VALUE (or blood pressure, etc.) but DOES IT IMPROVE PATIENT QUALITY OF LIFE or HELP PATIENTS LIVE LONGER?
P: Price: Is it worth the cost?
S: Simplicity: How many times per day is it required? With or without food? Can it be taken with other medications?

BOTTOM LINE: Together with your doctor, discuss these issues before you add another medication to your daily routine. </span>

Weight Loss Drug REMOVED from Market

Ah yes, it's becoming the all-too frequent headlines: Drug X removed from the market! This week, it's MERIDIA (sibutramine ), a weight loss medication by Abbott that has been available in the United States since 1997. A research study called SCOUT- Sibutramine Cardiovascular OUtcomes Trial- revealed a 16% increase in the risk for serious cardiovascular events such as nonfatal heart attack or stroke, the need for resuscitation (after the heart stopped), and even death, in patients who took sibutramine compared with those patients on a placebo.

Isn't obesity a risk factor for heart disease, though? Are you better off losing weight using a drug that might increase your cardiovascular risk versus simply staying overweight and being at risk from that? Researchers in this study say no. They believe the drug itself caused more increased risk than any benefit that might be derived from the weight loss itself. This was a large study, with over 10,000 men and women over the age of 55, who were significantly overweight and had a history of heart disease, diabetes, or other cardiovascular risk factor. As such, if you took Meridia and are overweight but have NO other risk factors, we do not know how much this drug might increase your risk.

What should you do if you took Meridia in the past? Let your doctor or FDA's Medwatch program know if you have developed any cardiovascular complications. If you are currently taking Meridia, you will need to discontinue it, and discuss an alternative weight loss program with your physician.

For the record, people in the study who received the real drug (not placebo) lost 2.5% more of their body weight over the five years of the trial. I would like to point out that following the MORE principles of increasing your fruit and vegetable intake plus adding in daily exercise will get you to the same or greater endpoint, with NO increase in cardiovascular risk!

BOTTOM LINE: The weight loss drug Meridia has been recalled- see the FDA report for further details, and contact your doctor if you are now or in the past took this medication.

Avandia Latest News

Last week, the FDA issued more restrictions regarding the diabetes medication Avandia (rosiglitazone). You can read the full notice at FDA.gov, but I will try and hit the highlights for you.

Avandia is a "TZD" which is a class of medications that helps to increase the body's sensitivity to insulin in diabetics. We have seen that it is very effective at lowering blood sugars. Unfortunately, it was discovered that this class should NOT be used in diabetics who also have congestive heart failure. Now, additional studies have shown that there is also an increased risk of heart attack and stroke in patients who took Avandia. At this time, the other drug in the same TZD class, Actos (pioglitazone) is not proven to have the same risks, though many experts are concerned this will be a class effect. Europe has completely withdrawn Avandia from the market, but in the United States, patients doing well on Avandia may discuss the risks with their physicians before making a decision whether or not to continue this drug.

What should YOU do if you take Avandia? There is no need to panic, but schedule an appointment with your doctor to discuss what is best for you. My advice is to take this news as a wakeup call that it is time to STOP LOOKING TO PILLS for an answer for your diabetes, and get serious about the behavior modifications in your diet and exercise that are necessary to reverse your disease! Yes, there are patients with adult onset diabetes who are thin and fit (I have three such patients in my practice) but the vast majority are significantly overweight. The GREAT news is that I have seen time and time again that when patients really embrace healthy eating and daily exercise ("MORE") the high blood sugars, high blood pressures, and high lipids (cholesterol) not only improve, but often disappear!

In Western medicine, we are conditioned to find the quick fix for disease states by prescribing the "right" pill. We have invented wonderful medications that improve the quality and quantity of life. However, the longer people take them, the more long term side effects we identify. What is safe and the "best" practice today is often the next great lawsuit tomorrow. I am NOT anti-medication, but I am most definitely PRO-behavior modification when that choice exists to treat the same problem.

BOTTOM LINE: If you take AVANDIA, please schedule an appointment with your physician and ask for concrete suggestions for a healthier lifestyle!
PS. For a jump start towards "MORE" health, check out my January 2010 blogs: More, More Exercise Buddies, More Fun, When is a pound really gone, etc.

Now CALCIUM is Dangerous??

Have you heard about the latest study that showed CALCIUM supplements may increase your risk of heart attacks? What's next, finding out Vitamin C makes you sick? Okay, I'm being facetious here, but let's talk about this news from a couple different angles.
First of all, here is what the study from the BMJ (British Medical Journal) says. They looked at a bunch of studies with a total of roughly 12,000 patients and assessed whether those people who took calcium supplements of 500mg or more (without Vitamin D) had more or less heart attacks compared with those who took placebo pills. There were a total of 296 people who suffered heart attacks- 166 on calcium supplements, and 130 on placebo pills. Does this mean placebos CAUSED 140 heart attacks? NO. Does it mean that calcium supplementation by itself CAUSED heart attacks? No- but it does show "an association" with heart attacks, one that may or may not be present if you add Vitamin D, which plays a role in calcium absorption, bone health, and cardiac protection.
There is NO association of heart attacks with increased purely dietary calcium intake (meaning high calcium intake through eating dairy and other calcium-containing foods). What does this tell me? Once again, we are spending a zillion dollars to PROVE THAT GETTING OUR NUTRITION FROM WHOLE FOODS, RATHER THAN SUPPLEMENTAL PILLS, IS BETTER FOR OUR HEALTH.
We've got to stop looking for a quick fix, and start improving our diets (MORE fruits and veggies, less of everything else) and increasing our exercise. Common sense AND scientific studies have proven this over and over.
In the meanwhile, realize that medicine is constantly evolving. What we preach as doctrine today may be heresy tomorrow. Look at what we have recommended for positioning of newborn babies in the last couple decades as an example- first we said on their stomachs (so they don't choke if they spit up), then their sides, and now their backs. Each time, we are SURE we have the answer. Remember that doctors used to recommend smoking to relax- how crazy is THAT?
BOTTOM LINE: Calcium supplements are unlikely to be your greatest risk factor for heart disease- talk with your doctor about your total health picture before you decide whether or not to take ANY supplement!

Is a TATTOO for you?

From Angelina to Jesse, tattoos are in the news. The popularity of tattoos has soared in the last decade. I'd estimate in my suburban Austin practice that somewhere between 50-75% of my patients under the age of fifty sport a tattoo somewhere on their body. Many are discreet- a simple musical note above the ankle, or a heart or butterfly tucked away in a typically clothing covered area. The twenty-somethings often prefer what is jokingly referred to as the "tramp stamp," which is the tattoo centered in the back, peeking out above their low cut jeans and thongs. Another favorite spot for women is the back of the neck, only revealed when they wear their hair "up".
Some people take their tattoos to the extreme, including full body art work that literally takes decades to complete.
What is my medical advice regarding tattoos? Well, I've seen a few nasty skin infections in fresh tattoos that end up leaving the owner with a very disappointing outcome, but with proper skin care (and antiseptic technique during its creation) most tattoos are relatively safe. But please note that I say relatively! Why? Because any time you are dealing with breaking the barrier of the skin, there can be transmission of infection. For example, though it is uncommon, we do know that there are cases of hepatitis C that have been transmitted from tattoos. Make sure the tattoo artist is not only using clean needles, but fresh ink as well!
My motherly advice includes the suggestion that you pick a location on your body that is not always visible. Neck, hand, forearms and lower leg tattoos may clash with business attire in a future job interview, and "perky" young body parts do not always stay quite so...young. I'd advise trying a few long lasting, but non-permanent tattoos (henna) before making the life-long commitment of a "real" tattoo. Remember, there is reason that you see so many ads for laser tattoo removal!
BOTTOM LINE: Single, professionally-crafted tattoos pose little (but not NO) true medical risks, and need to be considered a permanent choice (translation, do not make this an impulsive, perhaps alcohol-enhanced decision!)