Empire State of Mind…for a Week

Over my break, which was the week of October 26-30th, I traveled to New York. I had the opportunity to reconnect with long time friends, listen to some great music, and learn about naturopathic medical practice.

I was able to shadow Dr. Donielle Wilson in Manhattan and Stamford, Connecticut. I saw a variety of patients with concerns ranging from infertility to halitosis, but saw a common theme in all of their treatments: nutrition.

I am not sure if and how doctors can emphasize the importance of nutrition enough. Sometimes I feel wrapped up in planning what I am going to “give to” or “do for” a patient and overlook the simple idea that re-establishing the basis for health starts with a properly nourished body. Nutrition counseling and analysis should be a top priority in a treatment plan.

One way to go about ensuring proper nutrition is to perform a food allergy test. This was one test I saw utilized with almost all patients I saw during my New York visit. This is different from testing that looks for hypersensitivity allergic reactions (like a peanut allergy that causes breathing problems, for example). Food allergy tests look for delayed sensitivity reactions. By taking a blood sample, the blood is analyzed for immune reaction to a variety of foods and a list of reactive and non reactive foods is generated. Another way to determine possible allergens is to do an elimination diet. This involves eliminating the most common sources of allergy, like wheat (and other gluten containing grains), dairy, eggs, soy, and citrus. Then after eliminating these foods, they are  reintroduced one by one. Symptoms can be evaluated as possibly related to potential foods as they are introduced in an otherwise allergy free diet. On the other hand, a food allergy test will show exactly what foods are reactive and there will be no guessing as to which foods may or many not be causing problems.

Some common symptoms of food allergy or intolerance might have an obvious association, like irritable bowel for instance. Other symptoms might range from headaches, to weight gain, to fatigue. By determining if food is the underlying cause of troubling conditions such as these, the offender can easily be removed from the diet and the body can begin to heal.

All this talk about nutrition and health makes me think of the age old adage—you are what you eat. And your body will tell you if it likes what you eat in subtle or obvious ways.

A (Homebirth) Baby Story

After I took obstetrics class the second quarter of my third year, I was eligible to sign up for a birth rotation. I put my name in the hat and got a call in May that I was assigned to a 26 year old pediatric nurse expecting her first child. Her due date was October 7th which seemed to be forever in the future. Leading up to her labor, I would attend all of her appointments at the naturopathic obstetrician’s office and be ready to drop my life when the time came to help deliver the baby. That time came at 3:30 in the morning on Friday October 9th.

24 hours after the initial call, still no baby and little progression. We took mom to OB triage at the local hospital thinking an augmentation with Pitocin would be best to help make progress. The ER doc believed that she was simply having a prolonged latent phase of labor and thought that starting Pitocin would actually be more like an induction rather than augmentation. They decided to give an injection of morphine to ease her pain and send her home to hopefully get some rest. Saturday morning her contractions became more intense and lasted longer. This meant that she was actually in active labor. By the time we arrived at her home, she was 7 cm dilated. After that, the labor was textbook. Around three o’clock, she was exhausted and stated that “she couldn’t do it any longer.” Those words usually mean it’s time to push. We had her sit on the birth stool which helps open the pelvis and puts the mother in an ideal vertical position to deliver. She pushed for a total of 11 minutes and a beautiful baby girl (Surprise! Nobody knew the sex!) was brought into the world. Immediately we put the baby into mom’s arms, she let out a healthy cry and the room full of family and friends burst into tears as well. 44 hours of total labor time had culminated in the gift of life.

I learned from this experience that freedom of choice and safety are top priorities when deciding where to deliver a baby. According to a 2000 Cochrane Library study, “There is no strong evidence to favor either home or hospital birth for selected, low risk pregnant women. In countries and areas where it is possible to establish a home birth backed up by modern hospital system, all low risk pregnant women should be offered the possibility of considering a planned home birth and should be informed about the quality of the available evidence to guide their choice.” Mom was able to lay, walk, eat, and sleep in her home. She was comfortable and had the freedom to labor however she felt.

The lithotomy position has been shown to be an ineffective position to labor and push, actually works against gravity and can lead to complications like episiotomy and perceived dystocia. My Family Practice Obstetrics text states that, “Four of seven randomized controlled trials and several case study series have shown shorter labor duration and greater uterine contraction intensity in vertical positions.” Horizontal supine positions are really most convenient for doctors and procedures and do not provide much benefit to the mother.

After the birth, mom was immediately able to hold the baby; an important event that often is interrupted by hospital procedures. She also declined erythromycin eye ointment, a legal requirement in most hospitals, because she did not have gonorrhea or chlamydia, the reason ointment is applied in the first place. Recently there has been a shortage of erythromycin ophthalmic. The CDC’s website provides a substantial list of alternative ointments and culminates the discussion by adding, “STD guidelines outline recommended prophylactic treatment for infants whose mothers have gonococcal infection and for management of infants born to mothers who have untreated chlamydia. Empiric treatment is recommended for infants exposed to gonorrhea, while monitoring for development of symptoms prior to initiating treatment is recommended for infants exposed to chlamydia. Screening mothers will allow providers to identify infants with known exposure.” In essence, if you don’t have gonorrhea or chlamydia, it may be an unnecessary procedure.

Baby received oral vitamin K drops, Apgar scores of 9 and 10, and was surrounded by the love of her mother, father, family and friends. The baby must have felt incredible energy and love when she entered the world. This was a safe decision because the mother was a low risk patient, had proper prenatal care, and had an uncomplicated pregnancy. I believe that birth does not have to be an overly medical event. In this case, we were lucky to have a hospital nearby to take over for a perceived complication and valuable second opinion. I would urge any expecting mothers to consider birth at home, in a birthing center, or by a midwife as a top choice depending on risk factors. My experience exemplified an ideal birthing situation and even more fun story to tell.

When I Grow Up...

“Something mystical happens when we stop forcing our way through life and surrender to each moment.”

I had a great conversation with an old friend tonight. She just headed back to school for the first time in years, works a full time job, and still ponders the age old question, “What do I want to be when I grow up?” I often consult Google with difficult questions such as these, so I searched, "what do I want to be when I grow up?" and  got 54.6 MILLION results, which included one inspiring song.

Our conversation reminded me of an interesting, and somewhat uncomfortable, experience with a patient this week. His chief concern was hypertenstion, hyperlipidemia and weight gain. I was observing the interaction between him and the supervising physician as she explained what he needed to do in order to make the necessary lifestyle and nutritional changes to successfully address the problem. His resistance and anger was evident throughout the visit (especially when he yelled at the doctor!) and no matter how the treatment plan was described-- the message just was not getting through. We later learned that his father was dying of cancer, work is slow and he is not making much money, and he hates his job. He stated that he didn’t know how he got to this place; it was not what he planned for and now felt trapped by his life. As a listener, it was easy to see a change he could make to start with-- he needed a new job or to change his job somehow so that it was enjoyable for him. He clearly didn’t know what he wanted to be when he grew up, or somehow his current situation wasn’t fitting his vision for life.

This man could not see the dots. He just saw himself frustrated and alone with his problems. People, places, circumstances, and things are put into our lives often for unknown reasons until we can look back and see the dots connecting. At some point, the dots line up and we realize we have what we wanted. Did it take growing up? Did it take trying on different hats to find out what to "be"? Showing up and being present for life? In the case of my frustrated patient, his limiting thoughts and anger made it hard for him to be present to deal with this difficult time and constructively make change.

This experience exemplified my belief that the doctor must always meet the patient where they are. For this man, no amount of diet and exercise counseling was going to make a difference at this visit and frankly, it wasn't important. What he needed was to vent his frustration. He needed to shed a tear, get angry, argue and resist any suggestions we offered. He needed to be in a place where he would be listened to, not judged, and be given empathy. When I grow up and am officially a doctor, I will remember that a listening ear is often the best and only therapy a patient needs; because to truly be heard is something that is often complicated and difficult to find.

Candy...Corn?

FINALLY it’s starting to cool off in Arizona. The rest of the states have been experiencing Fall weather for at least a month or so by now, but I only realized it was Fall the other day when I walked into a grocery store and saw Halloween candy lining the shelves. It’s candy corn season!

We seem to have a candy for every holiday and season in America. Candy corn frequently comes in the form of “Reindeer Corn” at Christmas time along with candy canes, “Cupid Corn” for Valentines Day accompanied by heart shaped chocolates and “Bunny Corn” for Easter paired with the Cadbury Egg. The regular orange, white and yellow candy corn variety is usually available year round in the candy aisle, but the Halloween season accounts for 75% of the annual candy corn production. I was curious what is contained in these morsels that bear no actual resemblance to corn, so I wrote down the information from a bag of Brach’s Candy Corn:

In 20 pieces of Brach’s Candy Corn you will consume 150 calories, 0 fat, 75 mg of sodium, 38g of carbohydrates (33g of which are from sugar). The ingredients (in Brach’s variety) include: sugar, corn syrup, confectioners glaze, salt, honey, dextrose, artificial flavor, gelatin, titanium dioxide, color, yellow 6, yellow 5, red 3, blue 1, sesame oil. I did some research on some of the more questionable ingredients and this is what I came up with:

• Corn syrup: corn syrup is made by breaking corn starch with hydrochloric acid and heating it to produce a thick, viscous syrup. It is cheaper than sugar and is about ¾ as sweet as cane sugar. To create high fructose corn syrup (HFCS) the corn syrup is converted using enzymes that turn the dextrose molecules into fructose molecules. The result is a syrup that is much sweeter than sugar, inexpensive to produce and actually harder for our bodies to digest. HFCS is another blog post in itself…
• Confectioners glaze: a food grade shellac that extends a products self life and appearance. It can also be used as a coating for pills to make them more difficult to digest as in “time release” capsule.
• Dextrose: Another name for glucose produced from corn starch.
• Artificial Flavor: The secret ingredient in candy corn—it must be what makes it so addicting. According to the FDA’s code of federal regulations, a artificial flavor is:

“any substance, the function of which is to impart flavor, which is not derived from a spice, fruit or fruit juice, vegetable or vegetable juice, edible yeast, herb, bark, bud, root, leaf or similar plant material, meat, fish, poultry, eggs, dairy products, or fermentation products thereof.”

         So, it’s a chemically manufactured combination of substances that impart a flavor.

• Gelatin: collagen extracted from the skin, intestines, and bones of animals such as pigs and cattle (watch out Vegetarians, Vegans and those that follow Kosher tradition). It can also be made from fish sources and is found in other foods like Jello, gummy candies, and yogurt.
• Titanium dioxide: Hey, that’s in my sunscreen! Why am I eating it too? It’s what makes the nice tip of the candy corn so white and is apparently able to be consumed.
• Color: Some substance other than the explicit colorings yellow 6, yellow 5, red 3, blue 1 that adds color to the corn. There is a complicated set of Federal Regulations about what constitutes an artificial color, and if you are really bored, you can read about it here.
• Yellow 6, Yellow 5, Red 3, Blue 1: These food colorings are FDA regulated color additives used in foods, drugs and cosmetics. Most have complicated chemical names and descriptions. Here is the FDA’s description of food additives. In all of the colorings, there is a specified allowable level of lead, arsenic and mercury as outlined in the above referenced document.

By learning more about this candy, I was able to realize that the candy corn tradition at Halloween is one that I can live without. We are often challenged to make food decisions especially at holiday times regarding items that aren’t necessarily in line with our daily food behaviors. By taking an extra minute to read a label, maybe even do some research, we are able to empower ourselves to make informed decisions about what we allow into our bodies. Food choices are critical in creating optimal health and while there must be a balance in life, careful consideration and education can often make the alternative less appealing.

Sun vs. Skin

I have found myself in a conundrum this term at school—I love the sun, but I love my skin too and want to continue to love it when I am 60. I am completing a rotation with a dermatologist, which has been one of the highlights of my clinical education thus far and has made me realize that I need to pay more attention to sun protection. I listen to her tell all of her patients about sunscreen and recommend that they slather it on daily, whether its sunny, rainy, cloudy, if they plan to be outside, if they plan to be indoors, if they ride in a car, etc. The dermatological experts have strong evidence to make these recommendations given the incidence of skin cancers and the known preventative benefit that sunscreen provides. My question is though, how will anyone following this recommendation ever get enough vitamin D?

Why the sun isn’t enough (and for skin’s sake—shouldn’t be):

• Sunscreen over SPF 8 will block the sun’s ability to make vitamin D
• Caucasians need approximately 20 minutes per day between 10 and 2pm of direct sunlight, most of skin uncovered, to make their daily dose of vitamin D
• African-Americans, or other dark skinned individuals, need approximately 1 hour to make their daily dose
• The ability to make vitamin D depends at latitude and time of year. In areas north of 35-37 degrees latitude, little to no vitamin D is made November to February.

So between the sunscreen, lack of time outside during daylight hours and varying geographical chance of exposure, its no surprise so many people are vitamin D deficient. I was reviewing lab results today for an African American female, living in Arizona, and her vitamin D level (measured as 25-OH D3) was 7 ng/ml—the normal value is between 20-100 ng/mL! Low vitamin D has been associated with conditions ranging from musculoskeletal pain, metabolic syndrome, cardiovascular disease, depression, and immune dysfunction-- just to name a few. According to many, optimal levels for disease prevention should be between 40-60 ng/mL.

The recommended supplemental dose of vitamin D varies by healthcare practitioner and depends on the individual. The recommended adequate intake, according to the Institute of Medicine is 200 IU’s per day, which really is only adequate in that it prevents rickets. According to the American Academy of Dermatology’s position statement on Vitamin D, “Adults who regularly and properly practice photoprotection may also be at risk for vitamin D insufficiency, and may be considered for a daily total dose of 1000 IU vitamin D.”

Diet is the only other source of vitamin D and is found in a limited number of foods. Many people rely on their milk intake as an adequate dose, but unless you find yourself drinking approximately 10 eight ounce glasses of milk fortified with vitamin D per day, you might not be getting a therapeutic dose through diet alone.

Diet, supplementation and sun are the only options in this game. With the potential harm that the sun can cause and the dietary challenge of obtaining therapeutic doses, it seems like an easy solution to the battle is to have blood levels checked and simply take some vitamin D. Here are some additional resources about vitamin D:

Harvard Article on the Need for More D

D Research and Common Conditions Associated with Insufficiency
American Academy of Dermatology Position Statement on Vitamin D

Remembering 9-11

I will never forget where I was eight years ago on 09-11-01. I was a sophomore in college at North Carolina State University in Raleigh, NC. I was up early enjoying my Tuesday weight training class at the gym. I left the gym and went on with my morning. I was sitting in calculus when a friend leaned over and asked if I had heard about what happened in New York at the Twin Towers. Since iPhones or Blackberry’s weren’t yet around and I still took notes on paper, I made a mad dash home after class ended to watch the story on TV and read about it on my desktop computer. I called my family to make sure we didn’t know anyone in NY and to tell them I loved them. A sense of devastation and worry came over me; I was in disbelief and didn’t know what was going to happen next.

Luckily for me, I did not experience any direct psychological trauma as a result of 9/11. Since the event, however, there has been much discussion in the healthcare community about the resulting depression, panic, substance abuse, anxiety, and posttraumatic stress that has affected those directly involved in the rescue efforts, family and friends of those that lost their lives, and those that witnessed or lived in the area of the attack.

Mental health screening tools are a valuable part of an initial assessment in the primary care setting. A study to assess generalized anxiety disorder (GAD) in those affected by 9/11 (1) included the following mental health screening tools (with links to the forms I could find!):

• Life Events Checklist (LEC): screening for various types of common traumatic events
• Patient Health Questionnaire (PHQ): depression, panic disorder, substance use disorders, and GAD
• Patient Health Questionaire-9 (PHQ-9): screening tool for depression
• PTSD Checklist-Civilian Version (PCL-C): Screening for PTSD Symptoms
• Short Form Health Survey (SF-12): perceived physical and mental disability
• Sheehan Disability Scale (SDS): screening for impairment in work, social life, and family life/home responsibilities

As naturopathic doctors address the “whole person” and treat the “root cause” of disease, mental emotional health is an important consideration. Whether it is something we will treat or will refer for treatment by psychiatrists, psychologists, or counselors, it should not be forgotten in an initial assessment. I have had experience using the PHQ-9 on a rotation for a patient who presented for nutrition advice and weight loss. It was a valuable exercise for me as the student doctor and for the patient to see the progress that took place over the course of two months. The patient went from being in the category of “moderately severe” depression at her initial intake to “minimal symptoms.” Although her mental health was not a chief concern of hers nor did we spend much additional time discussing it, we were able to address the mental emotional aspect of her condition in our treatment using the scale as a screening and reference tool. This information about her mental state inevitably resulted in a more favorable treatment outcome.

I am thankful for those persons who helped save lives on 9/11, the military personnel who continue to fight to end terrorism, and those who witnessed the attacks or were otherwise involved and are alive to share their story. For those that are no longer with us, I know that your legacy will live on in the hearts of family and friends as they share your story with the world.

Reference:
1: Ghafoori B, Neria Y, Gameroff MJ, Olfson M, Lantigua R, Shea S, Weissman MM. Screening for generalized anxiety disorder symptoms in the wake of terrorist attacks: a study in primary care. Journal of Trauma Stress. 2009 Jun; 22(3):218-26.

WANTED: True Health and Healing

When I am asked what I do, I often have to ask myself, how much time do I have? I will reply, “I am a naturopathic medical student,” most people look a little confused or thoughtful and then ask some more questions. I too was one of these perplexed and intrigued people when stumbled across a naturopathic doctor in my hometown on my quest to find my calling in life. I had planned throughout college to go to medical school, but naturopathic medicine really caught my eye. I wondered if it could be true-- a healing profession based on treating the whole person? Finding the underlying cause of disease? Focusing on nutrition, mental health and physical health all in one place? I knew that combination of theory all bundled up into the term “doctor” would be the recipe for my success in life.

Defining naturopathic medicine quickly and easily is somewhat difficult. As students, we are often given the task to create a quick introduction speech or tagline to sum up our profession. Mine frequently goes something like this, “naturopathic medicine is a form of medical practice that integrates conventional and alternative medical therapies to provide patients with the best care possible.” If there is more time to talk, I might go on to say, “we are trained to diagnose like any other doctor, but we utilize things like nutrition, supplementation, homeopathy, botanical medicines, acupuncture and physical medicine instead of drugs or surgery to promote the body’s own healing ability.” Those brief explanations ring true to me, but ask anyone else in the profession and you will likely get a different answer.

Here are a few highlights of naturopathic medicine that I would like to elaborate on:

1. We are experts in alternative medical therapies. We study an array of methods used to treat both acute and chronic disease conditions. Our therapies can be and are often used in combination with pharmaceutical drugs, surgeries, or other procedures. Utilizing alternative medicines when going to a surgery, for example, may help speed recovery time and minimize adverse effects. With more and more consumers looking for different answers to their healthcare and more healthcare practitioners working in an “integrative” setting, I believe alternative medicine is becoming more and more mainstream.
2. We take time to get a thorough medical history. Most initial visits to a naturopathic doctor are in the range of one hour in length. This time allowance provides an opportunity to get to see a more complete picture of a problem. Doctor and patient can have a deeper conversation about all issues that may be contributing to a health problem. The intake is patient focused, not problem focused. The doctor has the time to educate the patient about how they can play an active role in their healthcare.
3. We treat the whole person. For example, a patient who has a chief concern of eczema. I won’t elaborate on a medical history, but just ask the end question: do I simply treat the eczema that presents on her skin and send her away? In most cases, not necessarily and not directly. We consider all of the factors that might have caused it. Depending on the patient history, nutrition, environmental factors, and mental/emotional factors may all have a role in the treatment plan. The patient might leave the visit with a supplement of immune boosting vitamin D, a plan to address the toxins that she encounters in her home, a schedule for weekly acupuncture treatments and a homeopathic remedy to help her cope with the loss of her father that happened to occur the same time as her most recent eczema breakout. Before the next follow up visit, labs like food allergy or stool parasitology may be ordered in addition to standard screening blood work like CBC/CMP, thyroid, and lipids. The treatment plan is designed to treat underlying factors and not just what is on the surface.

I have recently been assigned an excellent book to read for class. It is titled, “Integrative Rheumatology—Concepts, Perspectives, Algorithms and Protocols” by Dr. Alex Vasquez. I especially enjoyed chapter two of this book because it goes into great detail about how to re-establish our basis for health, as the chapter title is appropriately named. One quote sums up the theory of naturopathic medicine beautifully, “Health will occur when the conditions for health exist. Disease is the product of conditions which allow for it.” (Dr. Jared Zeff) Too often we allow ourselves to be trapped by disease. By removing obstacles that allow the body to be diseased, true health can be found.

Here is a link to a great article about how a naturopathic physician can play a role in the care of diabetes: http://www.diabeteshealth.com/read/2009/07/24/6286/naturopathic-physicians-up-and-coming-partners-in-diabetes-care/