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/