Metabolic Health

This quarter I have the pleasure of working with Dr. Cristina Romero-Bosch. Her practice is focused on “metabolic health.” What does that mean exactly? The word metabolism usually makes you think of people with self-proclaimed “slow” or “fast” metabolisms, referencing the manner in which they burn their food, or calories. The lucky “fast” metabolism people seem to eat whatever they want and remain at a healthy weight. But what if metabolism wasn’t just the luck of the draw and the real players in the metabolic game were actual measurable and could be manipulated? That is in fact the case and I am beginning to see many examples of this.

To begin with, there are core factors that are the foundation for health. Things like diet, lifestyle and mental/emotional health that most definitely influence the way we feel. Maintaining balance in these areas is difficult considering our modern American lives and relies on our personal willpower to make the “right” choices, exercise, make time to relax, etc. When willpower goes by the wayside, this can create fatigue on the signaling pathways responsible for maintaining our basal metabolic rate. From there, a downward spiral can occur. We feel more lethargic, get less sleep, eat more poorly, etc. By measuring the function of the adrenal glands, thyroid gland and levels of sex hormones it IS possible to see biochemical reasons behind feelings of fatigue, weight gain, insomnia, depression, and low libido. How many Americans have these types of concerns? (!!)After any disturbances in these signaling pathways are corrected, it might be possible to truly rebuild the foundation of health—where the “will” is no longer about power, but natural ability and desire.

I subscribe to Natural Solutions magazine, which recently featured and article titled, “The Hidden Epidemic: Is Your Thyroid Making You Fat?” I excitedly thumbed to this headline article when the magazine appeared in my mailbox-- having seen this work in action with Dr. Bosch. This is a good summary of one aspect of the multi-factorial approach to metabolic health. It brings to light the fact that there are considerations outside of basic labs, like symptoms, and additional lab tests that are not always standard, that can be taken into consideration when addressing thyroid health specifically. This is a must read! Take charge of your metabolic health! :)

My Final, Final

This past term I only had one course and it was a psychology class, which I did enjoy. I especially enjoyed finals week, where I only had one final and it was my last final—EVER! From here on out, I will only be doing rotations at the clinic and at elective sites. I still do have looming board exams ahead, but I have until August to study.

In my psychology class we touched on all of the various psychological conditions and became acquainted with the DSM-IV. This class was a great compliment to the patients I was seeing on Dr. Raymers rotation, which had an emphasis on psychology. One of the most interesting patients I saw was a woman who has dysthymia. She was currently taking a prescription medication to enhance her mood, but she wanted to wean down off the drug. We helped her do just that and integrated naturopathic supportive therapies into her care. One therapy was asked her to try was hydrotherapy. We are taught constitutional hydrotherapy in our clinic. The theory behind this type of hydrotherapy treatments is that they normalize the blood and lymph by promoting circulation through the tissues. Aiding the flow of blood and lymph can help move toxins and waste through the body’s organs of elimination (skin, liver, kidneys, lung, and colon) more quickly to improve health.  Hydrotherapy was one of the main treatment methods in the 1920’s and 1930’s and continues to be useful today as in my patients case. Constitutional hydrotherapy can also be useful in digestive problems like Crohn’s, respiratory conditions like chronic asthma, and immune deficiency problems—just to name a few indications. One modern day indication of these treatments is that it forces people to slow down and take time to relax. Rest and relaxation are a vital component to healing and often a luxury in our busy lives!

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