Good Fats and Bad Fats: Where do we Stand Now?

Most of you have by now heard recent media stories that claim to debunk long-established beliefs that saturated fats do not cause heart disease and that the vegetable oils that we’ve been encouraged to use instead may actually promote it.

But the best-established facts on dietary fats say otherwise. How well polyunsaturated vegetable oils hold up health-wise when matched against saturated fats like butter, beef fat, lard and even coconut oil depends on the quality, size and length of the studies and what foods are eaten when fewer saturated fats are consumed.

So before you succumb to wishful thinking that you can eat with abandon well-marbled steaks, pork ribs and full-fat dairy products, you’d be wise to consider the findings of what is probably the most comprehensive and untainted review of the dietary fat research yet published. It can be found in a 26-page advisory prepared for the American Heart Association and published last June by a team of experts led by Dr. Frank M. Sacks, professor of cardiovascular disease prevention at the Harvard School of Public Health. The report helps to explain why the decades-long campaign to curb cardiovascular disease by steering the American diet away from animal fats has been less successful than it might have been and how it inadvertently promoted expanding waistlines and an epidemic of Type 2 diabetes.

When people cut back on a particular nutrient, they usually replace it with something else to maintain their needed caloric input. Unfortunately, in too many cases, saturated fats — and fats in general — gave way to refined carbohydrates and sugars, the so-called SnackWell phenomenon that prompted fat-wary eaters to overindulge in high-calorie, low-nutrient foods. Most people do miss their unhealthy fats and, in the latest rage, many have latched onto coconut oil in the mistaken belief that its main highly saturated fat, lauric acid, and other nutrients can enhance health rather than undermine it.

As documented in the new advisory, misleading conclusions that saturated fats do not affect the risk of developing and dying from cardiovascular diseases have largely resulted from studies that failed to take into account what people who avoided saturated fats ate in their place. Several of the otherwise well-designed trials involved too few participants or did not last long enough to reach a scientifically valid conclusion. It can take up to a decade or longer to show that consuming healthier fats can produce a decline in cardiovascular deaths, and few well-controlled clinical trials last that long.

Some studies may have failed to show a benefit from reducing saturated fats because participants substituted margarine and other partially hydrogenated vegetable oils containing trans fats that were later shown to be even more damaging to blood vessels than animal fats. This was a problem in the Sydney Heart Study, conducted from 1968 to 1973; the experimental group was given margarine high in trans fats, resulting in more cardiovascular events than among those who continued to eat lots of saturated fats like butter.

On the other hand, the results of four “core” trials conducted in the 1960s, lowering saturated fat and replacing it with vegetable oil rich in polyunsaturated fat, primarily soybean oil free of trans fats, lowered coronary heart disease by 29 percent, similar to the benefit from taking a statin to reduce cholesterol.

In later studies, the most important influence on the results was the types of foods study participants ate in place of saturated and other fats. For example, in a study of 252 British men who had suffered heart attacks, following a low-fat, high-carbohydrate diet reduced cholesterol levels by a meager 5 percent and had virtually no effect on future heart attacks. The carbohydrates they ate were mainly refined, low-fiber flours and sugars that promote weight gain and diabetes, two leading risk factors for heart disease. In North America and Europe, the effect of lowering saturated fat was essentially negated by people’s consumption of more “refined grains, fruit juice, sweet desserts and snacks, sugar-sweetened beverages, and other foods” that hardly promote good health.

Unfortunately, there have been no trials to date testing the cardiovascular benefits of replacing dietary fat with “healthful nutrient-dense carbohydrates and fiber-rich foods such as whole grains, vegetables, fruits and legumes that are now recommended in dietary guidelines. The most recent studies conducted that analyzed the effects of specific nutrients showed that when 5 percent of calories from saturated fats were replaced by an equal number of calories from polyunsaturated fats, monounsaturated fats (like olive and canola oils) or whole-grain carbohydrates, the risk of coronary heart disease was reduced respectively by 25 percent, 15 percent and 9 percent. Furthermore, when polyunsaturates and monounsaturates replace saturated fats, death rates decline from cancer, dementia and lung diseases as well as from heart disease and stroke. In other words, if you are truly concerned about preserving good health overall, focus on a Mediterranean-style diet heavy on plant foods and unsaturated vegetable oils, with whole grains, fruits and vegetables as the main sources of carbohydrates.

Thus information stemming for the best research is straightforward: consume few saturated fats like butter, full-fat dairy, beef and pork fat, and coconut, palm and palm kernel oils and replace them with natural vegetable oils high in polyunsaturates — corn, soybean, safflower, sunflower, peanut, walnut and grapeseed oils. Also healthful are canola and olive oil, rich in both monounsaturates and polyunsaturates.

Based on the National Health and Nutrition Examination Survey, almost half the calories in the American diet come from carbohydrates, and of those 80 percent are from refined starches, sugar and potatoes. Sadly, the average American diet is not very healthy, to say the least.

Although dairy fat as not optimal, it is not nearly as good as plant fats, but not quite as bad as other animal fats. Thus you don’t have to totally abandon cheese, but dairy foods should be limited to one serving every one to three days, not thee servings a day.

As for coconut oil, it may be the nutritional fat du jour but it has not been proven to be healthful. It is fine to use on your body as a moisturizer for skin or hair, but not necessarily in your body, although consuming small amounts is unlikely to be harmful.

So here we are again back to square one, but now with with important qualifications as noted above!

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EVER THOUGHT OF LIVING FOREVER? WELL, DON’T!!

This was the intriguing subject of an article by Dara Horn1 appearing recently in the New York Times. In it, Horn describes how several billionaires have sunk lots of money into projects called “life extension,” or “end aging forever.” These aspirants seem to be composed of mainly billionaire men, possibly owing to the likelihood that women would prefer not to be around with the likes of such man for such a lengthy period. These men seem to believe that interminable life does not “violate the laws of physics.” Ironically, they seem to have gained some support from a woman, Elizabeth Blackburn, who received the Nobel Prize for her work on telomeres, which are protein caps on chromosomes (cellular elements) that may be a key to understanding aging. But Professor Blackburn admits that her important research, while allowing for a better understanding of aging, does not suggest living to one’s hundreds, stating that “everyone’s cells become old and eventually we die,” which suggests that her research may allow a better chance for us all to live a long and healthy life.

But in the extraordinary unlikely event that eternal life could be achieved, what would be its practical implications? First, as suggested by the billionaires, it would extremely costly and likely limited to the very affluent, sowing the seeds of severe social unrest. As a result, those who possess limited resources would be left “out in the cold,” and likely and foolishly demand that immortality be covered by medical insurance. But suppose eternal life were to become cost-effective. This planet would then be overcrowded so severely that all resources would be exhausted and new births all but prohibited. The environment would take a severe drubbing with global warming, disastrous environmental desecration, inundating sea water levels, and insufferably high temperatures.

Then there is the matter of evolution: Human development, lacking generational replacements, would be halted, thus preventing us to from becoming a better and more adaptable species. (We could certainly use some betterment, at least in politics!) At the same time various animal species would presumably continue to evolve, and maybe some of our higher relatives might equal or pass us up, resulting in a planet of apes?—or dolphins?

So, as enticing as eternal life may seem to each of us, it is simply not to be, not now and not forever!

But now we get practical and examine the issue of present longevity.

This is also an even more intriguing subject, and while there are obviously no clear answers, it brings up two important questions: 1) How long would we survive if all presently known diseases were eradicated? 2) How far could science take us, provided we have emerged victorious over these diseases? So let’s look at each question separately.

Life Expectancy in the Absence of Disease

In 1900, average life expectancy in the USA was approximately 47 (women living about 2 years longer than men). By 1998, the average had risen to around 76 (women doing better by about 5 1/2 years. But note from the chart below that we made most of this progress between 1900 and around 1970. The early rapid progress was primarily attributable to our victory over infectious diseases, which was halted temporarily by a drop in mortality in 1918 resulting from the influenza epidemic (note in the chart) . Since 1970, the curves are rising more slowly because of the more formidable challenges than posed by the various non-infectious diseases.

Now our biggest killers are related to cardiovascular diseases, (heart disease and strokes) caused primarily to arteriosclerosis (hardening of the arteries), and cancers of all types. Based upon the numbers, if we could wipe out cardiovascular disease and cancer, we could allow most folks to live out a maximum number of years based upon our current understanding of human physiology.

Causes of Death in the USA in 2010

  • Heart disease: 597,689
  • Cancer: 574,743
  • Chronic lower respiratory diseases: 138,080
  • Stroke (cerebrovascular diseases): 129,476
  • Accidents (unintentional injuries): 120,859
  • Alzheimer’s disease: 83,494
  • Diabetes: 69,071
  • Kidney Diseases, nephrotic syndrome, and nephrosis: 50,476
  • Influenza and Pneumonia: 50,097
  • Intentional self-harm (suicide): 38,364

Based upon published information together with my medical knowledge, I believe that we could reach an average age of 100-110, provided that at least these two major disease categories, mentioned above, could be eliminated.

In the case of cardiovascular diseases, we have the answers now, provided that the various lifestyle problems and predisposing conditions could be corrected. They include improper diets, obesity, smoking, hypertension, lack of exercise, and others of lesser importance. It’s generally conceded that prevention offers a far more effective strategy than do medications and surgical procedures to reduce mortality. Thus treatments of all types are only of limited importance. A recently reported counter trend slight fall in lifespan is likely not indicative of a major trend shift, but if sustained, would be likely due to poor lifestyle choices, especially advancing obesity.

Cancer provides a formidable challenge, possibly because it is likely multi-factorial in cause and often extremely difficult to treat with our current methods. With advances in our understanding cell biology, including DNA makeup and manipulation, together with controlling immune reactions, we are likely to solve this riddle within the next few years—probably not soon enough in my judgment.

How Far Could Science Take Us Next?

The answer to this question takes us into the realm of science fiction, but, for what it is worth, here are my thoughts.

Despite the great advances in such areas as organ transplantation, cell mechanics, surgical procedures, and many others, I believe that the maximum life expectancy will remain capped in the area of 110. I say this because, as noted in the chart below, we are already beginning to level off, and despite many advances in organ transplantation and other potential treatments, various targeted methods and replacements cannot support the entire body, such as muscles, bone, brain and others. Thus the entire body continues the inexorable process of aging. For this reason, we are likely to be restricted by such limitations in lifespan as determined by evolution.

The assumptions stated above are merely that, but in order to advance beyond these limits we would need extreme and game changing advances that are not possible to foresee at this time. But who knows?

In the meantime, be careful what you wish for!

                      Violet line = Females.   Black line = Males.

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1Horn D. The men who want to live forever. N.Y. Times, January 28, 22018. p. 9

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CONSUMING RAW WATER: ANOTHER NUTTY IDEA!!

You may have recently heard that drinking “raw water” is the latest health panacea. Advocates are claiming great health benefits to be derived from this source, among which are the elimination of that nasty fluoride, the acquisition of beneficial probiotic bacteria, and lord knows what else! And paying big money to boot! Their claims seem to fall in line with those zealots who are touting raw milk, an equally nutty claim that I have covered in a previous post: http://www.mortontavel.com/2013/12/03

Our municipal water is filtered for a reason. Untreated water may contain bacteria, viruses and parasites. Resulting health problems can range from mild gastrointestinal discomfort to diarrhea, dehydration and death. The bacteria that cause cholera, typhoid, dysentery and others can thrive in “natural” water, meaning raw water could provide a long trip to the toilet at best—and the hospital or morgue at worst. Water contains radon in many areas of the U.S., and 25,000 people die each year from radon exposure and consumption. Since raw water isn’t treated or tested, you may be ingesting potentially damaging levels of naturally occurring radon, as well as other unidentified chemicals and bacteria.

Proponents of raw water insist that their supply comes from pure springs that have no traces of diarrhea-inducing diseases, and they feel that the water’s natural probiotics and lack of fluoride outweigh the risk of contamination. But fluoride in water has never been found to be a risk to health, The Centers for Disease Control showed that tooth decay is down in the 70 years since routine fluoridation started. As for probiotics, it’s true that tap water filters out bad microbes like giardia, but also takes away less harmful bacteria that could be good for gut flora. Sadly, however, the probiotics in raw water won’t necessarily help fend off any diseases, and even though some research suggests that probiotics may be beneficial to health, one can obtain these microbes in a far safer fashion from products such as cultured yogurt.

I would simply conclude by asking a simple question: Would you be willing to drink raw water that might be no different from that attained from either a third-world country or your own toilet bowl? If so, go ahead at your own risk; in any event, your local hospital or funeral director will be more than willing to assist you.

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ENERGY DRINKS: WHAT EVERYONE SHOULD KNOW

They are all over the place, brazenly claiming to keep you revved up, energized, and alert. But controversy is now raging over these products, for several deaths have reportedly followed their use and more problems keep surfacing. So we need to explore the facts about these drinks.

First, how do they accomplish this energy infusion? I can answer with a single word—caffeine! We all know it is the active ingredient in coffee. An 8 ounce cup of coffee contains about 100 milligrams of caffeine. By contrast, a 16-ounce Starbucks Grande contains about 330 milligrams. That’s why most people drink coffee in the morning: It’s a helpful “waker-upper” to get them started and ready to attack the day with a head of steam.

Although caffeine can make you feel more alert, boost your mental and physical performance, and even elevate your mood, it can also make you jittery, keep you from sleeping, cause rapid pulse or abnormal heart rhythms, and raise blood pressure. Safe limits of caffeine consumption are still being studied, but data suggest that most healthy adults can safely consume up to 400 milligrams per day; pregnant women, up to 200 milligrams; and children, up to 45 to 85 milligrams depending on weight.

The content of caffeine in the various “energy” products is not always listed, but from what we know, caffeine content varies greatly, ranging from about 6 milligrams to as much as about 250 milligrams per serving.

Various scientific groups have for years urged the Food and Drug Administration to require disclosure of caffeine levels on these products, but the agency says it lacks the authority to do so. Also, some energy drinks include additional ingredients such as taurine, L-carnitine, and high amounts of B vitamins, such as niacin and vitamin B6, ingredients that are not of real benefit, but they may present additional problems.

Now comes more bad news about these drinks: More than half (55.4%) of young people who have ever consumed an energy drink have experienced at least one adverse reaction, according to a study published recently in a medical journal.
The research was conducted online among over 2,000 adolescents and young adults (age 12 – 24) in Canada. Most (73.8%) reported having ever consumed an energy drink, and, of these, 55.4% reported experiencing at least one adverse reaction. The most commonly reported reactions were rapid heartbeat (24.7%), difficulty sleeping (24.1%), headache (18.3%), nausea/vomiting/diarrhea (5.1%) and chest pain (3.6%). About 3% of respondents who suffered an adverse event had sought or considered seeking medical help for an adverse reaction. Those who reported having ever consumed an energy drink were almost three times more likely to report an adverse event than those who reported having ever consumed coffee. According to the authors, the current findings are consistent with those of Health Canada’s Expert Panel on Caffeinated Energy Drinks, which concluded that, although the probability of serious adverse events is low, given the high volume of use, the risk of adverse events is considered to be a public health issue.
Previously, a 2015 study published in the Journal of the American Medical Association concluded that drinking a single energy drink may increase cardiovascular risk, and the drinks have been associated with cases of brain hemorrhage, acute hepatitis, and vitamin B6 toxicity. Disconcertingly, a 2017 study published in Journal of Medical Toxicology found children under the age of six accounted for almost 45% of energy product exposures reported to poison control centers in the U.S.

Conclusion: My advice: Stick to coffee, considering the caffeine limits cited above. Forget the “energy drinks.” They are not only a waste of money but also a danger to health!

 

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TRUMP’S MEDICAL “CHECKUP”: IS HE REALLY IN EXCELLENT HEALTH?

We physicians are often asked to conclude two things from a regular “checkup” of someone who has no symptoms to suggest present disease: 1) What is the likelihood that one is harboring an unrecognized but hidden disease? 2) What is the likelihood that disease will develop in the future?

In the absence of complaints, information from a physical exam seldom discloses unrecognized diseases, and routine laboratory screening tests seldom add much of additional value. Thus the results of Trump’s exam tell us very little about any present physical diseases, especially in the absence of psychological testing. But can his findings tell us anything about his chances of impending future health disasters? Based upon his lifestyle choices and family history, his greatest chances of future diseases are cardiovascular events (heart attacks, stroke, etc.) and dementia (Alzheimer’s disease).

With regard to cardiovascular risk (our largest killer by far), using the various charts supplied by the American Heart Association and others, which include age, sex, blood pressure, and certain blood tests, Trump’s chances of developing serious cardiovascular events within the next ten years are approximately 15%. At his age, less than 10% is considered reasonably low.

But additional factors must be added that include his coronary artery calcium score of 133 (on CT scans), a number that means he already has asymptomatic cardiac vascular disease.  The calcium score directly correlates with the risk of overt future cardiac events. People with higher scores have greater plaque burden on the linings of these arteries, carrying a higher risk for cardiac events regardless of whether symptoms are present. For asymptomatic individuals, a calcium score of 0 indicates absence of detected calcium and an extremely low likelihood (<1%) of any coronary arterial disease. The odds ratio (ratio of events in an interest group vs. events in a baseline population) of developing symptomatic cardiovascular disease is 3:1 for people with scores of 1 to 80 (where the zero score group is the baseline population), 8:1 for people with scores between 80 and 400 (Trump’s group) and nearly 25:1 for people with scores above 400. In fairness, Trump is taking “statin” drug and aspirin to minimize this risk, but, nevertheless, the dangers are clearly present.

What may be more damming, however, is Trump’s widely publicized poor diet with obesity (yes, folks, despite his denials, according to the published charts, he is obese), and lack of regular exercise, factors that, while difficult to quantify, when coupled with the presence of coronary calcium, would raise his overall odds of serious cardiovascular events to at least 20-30% over the next ten years (three years obviously being a substantial portion of this number). Obesity, per se, raises his odds significantly for developing various cancers: https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/.

But what if we add his chances of present mental disorder or future dementia? Based upon his family history (his father suffered from Alzheimer’s disease), it is entirely possible that Trump himself already is manifesting its early phases or, at least, has greater chances of developing dementia soon in comparison with the general population.  Despite Trump’s examining physician’s recent claim that his “cognitive ability” is normal, it is widely acknowledged that there is little correlation between cognition (intelligence) and insanity. This information, coupled with Trump’s erratic behavior, should mandate an immediate and comprehensive neuropsychiatric examination, which, sadly, is likely to be denied.

Does this information justify the declaration by the White House that Trump is in “excellent health”? For the present, maybe so, maybe not. But for the future, I’m taking no bets, and neither should you!

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EXERCISE: THE INFORMATION CONTINUES TO MOUNT

     For the past sixty plus years, we have known that exercise—in almost all forms—is beneficial to health. The European Guidelines on Cardiovascular Disease Prevention, the World Health Organization, and the Physical Activity Guidelines for Americans all recommend that healthy individuals engage in 150 minutes per week of moderate intensity exercise, such as brisk walking, or 75 minutes of high intensity exercise, such as jogging. But recent research has also hinted that there may be added benefit from pushing yourself intermittently, at least a little extra, bringing about changes deep within our body’s cells—those tiny building blocks that constitute all of us. Exemplifying this idea is the case of Robert Marchand, a diminutive French centenarian who took up competitive cycling as a retiree and began setting age-group records. After he was advised to add intermittent strenuous pedaling, Mr. Marchand decisively bettered his own records and, at the age of 103, set a new world mark for the most miles pedaled in an hour by a centenarian.

His efforts help to refute entrenched beliefs about older people, that physical performance and aerobic capacity inevitably decline with age and that intense exercise is inadvisable and does not apply to the elderly.

For instance, one study disclosed that frail elderly mice were capable of completing high-intensity running on little treadmills. After four months of this kind of training, the exercised animals were stronger and more aerobically fit than other mice of the same age, especially if that exercise was supplemented with high-intensity interval training.

Extending these observations to people, scientists at the Mayo Clinic compared differences in gene expression inside muscle cells after younger and older people had completed various types of workouts. The greatest differences were seen in the operations of genes after people had practiced high-intensity interval training for 12 weeks. In younger people who exercised this way, almost 275 genes were firing differently now than they had been before the exercise. But in people older than 64, more than 400 genes were working differently now and many of those genes are known to be related to the health and aging of cells. In effect, the intense exercise seemed to be changing muscle cells in ways that theoretically could affect biological aging.

At this point, I should probably pause and explain that intensity in exercise is a relative concept. The word intense can seem daunting, but in practice, it simply means physical activity that is not a cinch for you.

For medical purposes, intensity is based on percentages of someone’s heart rate maximum. But you can ignore these technicalities and pay attention to how you feel. Exercise is easy if you can talk and sing while participating in it.

During relatively moderate exercise, singing becomes difficult.

And during intense exercise, you will find it difficult to speak without gasping.

We all should get regular exercise, but no matter what your routine, you might consider increasing its pace for a few minutes at a time, until you no longer can easily converse. The latest science suggests that your cells will thank you.

But as always, the most compelling exercise-related research this year reminds us that activity of any kind is essential for human well-being. One study of 2017 found that people reported feeling happiest during the day when they had been up and moving compared to when they had remained seated and still. The benefits of exercise extend even to those suffering from various degrees of depression, providing with another means to combat this malady.

Another memorable study concluded that, statistically, an hour spent running could add about seven hours to our life spans. These gains are not infinite. They seem to be capped at about three years of added life for people who run regularly.

But these results should inspire all of us. If Mr. Marchand can gain fitness and speed after turning 100, that should be incentive to all of us with still a half-century or more to spare.

And even if we don’t succeed in adding years to our lives, we can at least add life to our years!

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Assessing Presidential Fitness: Thoughts that have come 230 years too late—but better than never!

Several weeks after former President Ronald Reagan announced his Alzheimer disease diagnosis in 1994, his predecessor, Jimmy Carter, appealed to the medical community. But Carter, the 39th president of the United States, didn’t urge physicians to take up a fight against this neurodegenerative disease. Instead, Carter attempted to tackle presidential disability and the 25th Amendment of the US Constitution.

In a published commentary, Carter contended that Section 4 of the amendment—a mechanism that allows the vice president and a majority of Cabinet members to pronounce a president “unable to discharge the powers and duties of his office”—is inadequate. They would need accurate, unbiased medical advice from qualified physicians, Carter wrote. It would require those physicians to delicately balance patient confidentiality, personal interest, and the country’s well-being.

“We must find a better way,” he stated.

His suggestion: create a nonpartisan group of medical experts not directly involved in the president’s care to determine presidential disability. Twenty-three years later, Carter’s proposal hasn’t come to fruition. But it’s no longer lying dormant.

Rep Jamie Raskin (D, Maryland) introduced a House bill in April to create an 11-member “presidential capacity” commission composed of psychiatrists, other physicians, and retired government officials selected by leaders in Congress. “Now is the time to do it,” Raskin said in a statement.

In a recent bestselling book, 2 practicing psychiatrists offered an alternative proposal, recommending that a 7-member expert panel be established to evaluate presidential fitness.

During an interview with JAMA, a leading medical journal, one of these psychiatrists discussed the issue of presidents’—past and present—fitness to serve. An edited version of that conversation follows.

Question: Why did you decide to wade into the territory of presidential fitness?

Answer:  President Trump’s mental status engendered controversy among our colleagues because of the Goldwater rule. During Barry Goldwater’s run for president in 1964, a magazine polled about 1100 psychiatrists who rendered opinions about his mental fitness without seeing him for an evaluation. Afterward, Goldwater sued the magazine for libel and won. As a result, the American Psychiatric Association instituted the Goldwater Rule, which prohibits psychiatrists from diagnosing an individual without a face-to-face evaluation. When mental health professionals began to raise concerns about President Trump’s mental stability, the APA added a further proscription against offering any opinion about his mental health. In April, Dr Bandy Lee (assistant clinical professor in the Law and Psychiatry Division, Yale School of Medicine) chaired a conference at Yale to discuss psychiatrists’ “duty to warn.”

Question: What is duty to warn, and could you explain how the concept came about?

Psychiatrist’s answer: This obligation is derived from the landmark [Tarasoff v Regents of the University of California] decision by the California Supreme Court in 1976. It states that if patients disclose to their therapist that they intend to injure specific individuals, the therapist has a duty to warn those individuals. The Tarasoff decision ultimately created a legal duty to protect that overrode the confidentiality of the patient-therapist relationship. This duty was subsequently adopted in other states in various forms and has become a standard of mental health practice.

Question: To what other US presidents would a presidential fitness commission have been applicable?

Answer: A review of US Presidents from 1776 to 1974 found that 49% of those 37 presidents met criteria that suggest neuropsychiatric disorders. For example, Presidents Franklin Pierce and Abraham Lincoln had symptoms of depression; Nixon and Johnson, paranoia; and Reagan, dementia. President Woodrow Wilson suffered a massive stroke in office that resulted in severe cognitive impairments. Although military personnel who are charged with relaying and executing nuclear orders from the president must undergo rigorous medical, psychological, and financial evaluations to determine their fitness for duty, no such evaluation is necessary for their commander-in-chief. We feel that this glaring omission can be remedied.

Question: What is the remedy?

Answer: The 25th Amendment to the Constitution addresses presidential disability and succession. Section Four of this amendment has never been invoked to evaluate whether a president is fit to serve. We exhort Congress to use this section of the 25th Amendment to impanel an independent, impartial group of experts to evaluate whether the current and future presidents and vice presidents are mentally fit to fulfill the duties of office.

Question: Who would serve on such a panel and how would the members be chosen?

Answer: The panel should consist of 3 psychiatrists—1 clinical, 1 academic, and 1 military; 1 clinical psychologist; 1 neurologist; and 2 internists. Panel members should be nominated by the nonpartisan, nongovernmental National Academy of Medicine. The experts should serve 6-year terms with the provision that 1 member per year be rotated off and replaced. Congress should enact legislation to authorize this panel to perform comprehensive mental health and medical evaluations of the president and vice president on an annual basis. The legislation should require the panel to evaluate all future presidential and vice presidential candidates. The panel should also be empowered to conduct emergency evaluations should there be an acute change in the mental or physical health of the president or vice president. The evaluation should be strictly confidential unless the panel determines that the mental health or medical condition of the president or vice president renders him or her incapable of fulfilling the duties of office. We feel that this process should be initiated immediately.

Question: How did you decide on the types of experts that should be on the panel?

Answer: Psychiatrists would be able to evaluate someone’s mental status and diagnose any significant mental disorders and also to evaluate for potential dangerousness. The clinical psychologist is usually a specialist in psychological testing, and a neurologist could help evaluate cognitive and brain functioning. Of course, internists would look at the general medical status of the person. We figured that would cover all the bases that we would need to be concerned about.

Question: Why did you want to have a military panel member?

Answer: We thought it would be fair to have someone who may have a better sense of the kinds of situations that a president would face in terms of handling the nuclear arsenal.

Question: Would nominations to the panel require approval by Congress or some other body?

Answer: Since this is brand new territory, I suspect that it would be incumbent upon the Congress to impanel this group of professionals. But I think it could be difficult, so in my opinion, it would be better if Congress would rely on the National Academy of Medicine to come up with these experts. You want it as nonpartisan as possible.

Question: You’ve shared your ideas with President Obama and some members of Congress. Did you consider that part of your duty to warn?

Answer: Yes. We believe that we have a higher duty to warn if we feel that the US president presents a danger to others—others being this country and the world.

CONCLUSION

From a medical perspective, I believe these suggestions are quite reasonable and should be implemented quickly. In today’s toxic political environment, however, this may be a pipe dream. But, nevertheless, it could at least serve to identify those voting against such a plan as certifiably insane and legitimate candidates for the loony house! Now which party do you suppose could comprise the lion’s share of those “no” votes?

 

 

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DON’T FORGET YOUR FLU SHOT!

        

 Since 2010, the flu has resulted in about 500,000 hospitalizations yearly and contributed to about 25,000 deaths. That’s why the CDC (Centers for Disease Control) urges everyone 6 months and older to get vaccinated. But a recent survey disclosed that only 48% of adults said they had received a flu shot in the previous 12 months.

One reason for not receiving this valuable protection is based on the premise that the shot “doesn’t work,” but actual research indicates that the shot cuts your risk by about 50% or more. And even if you contract the flu, the symptoms will be mitigated with a reduced likelihood of serious complications—including death!

Another reason frequently given is that the shot may actually cause the flu. However, all the flu vaccines in use today contain an inactivated virus that can’t trigger the flu. But since the vaccine doesn’t eliminate entirely your chance of getting the flu, some people who develop flu-like symptoms after getting the shot wrongly blame the vaccine, or might be suffering from a condition that only mimics the flu.

Another excuse I hear for not getting the shot is that is contains a harmful amount of mercury. But this is a mercury-containing preservative called thimerosal found in some vaccines, but if present, only in trace amounts. This kind of mercury—ethylmercury—is eliminated by the body more quickly than is methylmercury, the form in some seafood. Moreover, no research has ever linked this substance to any complications, including autism.

WHICH VACCINE SHOULD YOU RECEIVE?

    For teens and adults: a quadrivalent vaccine is recommended, which protects against four flu strains.

For people 50 and older: Flublok Quadrivalent, which has triple the dose of other quadrivalents.

For people 65 and older: They have two choices—Fluzone High-Dose and Fluad. Both protect against three strains, but Fluzone has four times the dose and Fluad adds an ingredient to boost the immune system’s response, a property that leads me to recommend this latter choice.

Under all circumstances, do not fail to consider this protection, which can be obtained from you doctor, but also quickly and easily in many pharmacies such as Walgreen’s and CVS.

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BEWARE OF CELEBRITIES SHARING THEIR MEDICAL EXPERIENCES!

Soon after her husband died of colon cancer in 1998, Katie Couric, the journalist and television personality had a televised colonoscopy to promote the test. Rates of screening colonoscopies soared for at least a year. Or, call it the “Angelina Jolie effect”. In 2013, the actress wrote an editorial in the New York Times about the tests she had for genes (called BRCA) linked with breast and ovarian cancer, and how the positive result led her to have a double mastectomy. Soon after, rates of BRCA testing jumped.

Whatever you call it, the effect is real. When it comes to matters of health, celebrities can have an enormous impact.

It’s good when celebrities do good

The impulse to take a challenging or tragic medical experience and turn it into something that helps others is commendable. It may be easier to keep such matters private or avoid talking about them in public. But time and again, we see celebrities joining forces with health-promoting organizations, speaking out, and sharing their stories to help others in making decisions. Many have credited Katie Couric with removing the embarrassment associated with colonoscopy and showing how apparently easy it is.

But there is a downside

There are a number of ways celebrity pronouncements on matters of health can go wrong. For example, the information can be faulty or confusing. The forays of Jenny McCarthy (who claimed vaccines cause autism) and Gwyneth Paltrow (who recommended vaginal steams to “cleanse the uterus”) into matters of health and illness are examples of influence most doctors would consider unhelpful or even dangerous.

Although Katie Couric’s colonoscopy experience seemed like a brave and unique way to get her message across, she was 43 years old at the time. Since guidelines suggest people begin routine screening at age 50, she was actually not a good candidate for the test. Unless she had symptoms (such as intestinal bleeding), a strong family history of early colon cancer, or some other special circumstance that put her at higher than average risk for colon cancer, her colonoscopy could be considered unnecessary testing. And that could have led others to have unnecessary testing as well.

A recent study raises a similar concern about Angelina Jolie’s BRCA testing. It found that in the weeks after her editorial was published, testing increased by more than 60% (at an estimated cost of $13.5 million). However, mastectomy rates actually fell over the next two to six months, leading the authors to suggest that most of the additional women who had testing had negative results and therefore may have been poor candidates for testing in the first place. Of note, the study did not confirm whether those having the BRCA test had risk factors (especially a family history of early breast or ovarian cancer) that would make the test appropriate. Critics of the study have suggested that mastectomy rates within six months of testing is not an adequate measure of whether the tests were appropriate. Still, the point is worth considering. When a celebrity recommends a medical test or treatment, the audience is not limited to those who are most likely to benefit.

But this is only a small sample of so much mischief reverberating in our media. Both Dr. Mehmet Oz and Dr. Travis Stork and his co-hosts (The Doctors) are licensed physicians (celebrities?), but despite their credentials, seem to be willing to dispense unproven, false or misleading information. Many other so-called “authorities” lack even these credentials and, as you might anticipate, they dole out copious misinformation to an unsuspecting—and often uncritical—public. One example (of many) concerning Ozy was a charge brought by the U.S.  Federal Trade Commission (FTC) that he was involved in a scam to deceive consumers through fake news sites and bogus weight loss claims: Oz had touted the use of the dietary supplement Pure Green Coffee as a potent weight loss treatment that supposedly burns fat. He claimed falsely that users of this product could lose 20 pounds in four weeks, 16% of body fat in 12 weeks, and 30 pounds and four-to-six inches of belly fat in 3 to 5 months. Sounds too good to be true—yes it was! According to representatives of the FTC, “Not only did these defendants trick consumers with their phony weight loss claims, they also compounded the deception by advertising on pretended news sites.”

The bottom line

For any medical test or treatment, ask whether it’s likely to be helpful. The answer may be straightforward. For example, a well-studied and well-accepted screening test may be recommended based only on your age and gender. But in many cases, the answer may rely on a considerable amount of judgment based on how likely it is that you have—or may develop—a particular condition, the ability of the test to detect it, and the impact of the test result on treatment decisions. For example, if a person has knee pain that’s mild and well-controlled with exercises, it may make little sense to have an MRI, as the results are highly unlikely to affect treatment.

If your doctor recommends a test or treatment, make sure you understand why. And if it’s a celebrity making the recommendation, do yourself a favor: run it by your own doctor—and not the TV variety!

 

 

y http://www.mortontavel.com/2014/05/28/

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EATING RAPIDLY: CAUSE OF OBESITY?

      Skipping breakfast, unhealthy diets, and overeating are known to contribute to weight gain, but new research suggests the simple act of eating too fast may also promote obesity.

After 5 years of follow-up of 1083 Japanese men and women who rated their eating speed during a yearly health exam, new-onset obesity was diagnosed in 11.6% of fast eaters, 6.5% of normal eaters, and 2.3% of slow eaters. Fast eaters also saw greater gains in waist circumference as well as overall body weight, according to data reported at the American Heart Association 2017 Scientific Sessions.

“If you feel your own eating speed is faster than other people in daily life, you may have a risk factor for obesity, a risk factor for diabetes”, according to author Dr Takayuki Yamaji (Miyoshi Central Hospital, Hiroshima, Japan)..

This is not the first time the association has been observed, with another study, among 8941 Japanese adults reporting that fast eating correlated with a 30% risk-adjusted increase in obesity compared with slower eating. Several studies have also shown that fast eating contributes to the new onset of obesity, in part because it prompts overeating.

“If you chew your food many times, you spend more time at meals, you’re more likely to feel full,” Yamaji said. “It takes about 20 minutes for signals from your stomach indicating that you are full to reach your brain.”  Eating fast also causes acute glucose fluctuations, he said. As a result, oxidative stress is increased which leads to increased insulin resistance, decreased insulin secretion, and can further lead to hyperglycemia (elevated blood sugar levels). Fast eaters were also significantly more likely than slow eaters to have higher levels of fasting blood glucose (sugar) and lower levels of HDL (good) cholesterol, though triglycerides and blood pressure were similar.

Fast eaters were less likely than normal or slow eaters to report drinking alcohol everyday but also significantly more likely to eat dinner 2 hours before sleeping at least three times a week, snack after dinner three or more times a week, and to have gained weight in the past year.

Even after adjustment for multiple potential confounders, however, risk of new-onset obesity remained significantly higher among fast eaters than normal eaters or slow eaters.

Dr Scott Grundy (University of Texas Southwestern, Dallas), who was not involved with the study, said “This is not a subject that I’ve seen in the literature, but it’s worth consideration and future research. It’s an interesting idea.” He also noted that it seems reasonable that people who eat too fast may also eat too much.

Yamaji suggests this can be particularly perilous as Americans consume holiday meals, where the sentiment is often whoever eats the fastest gets the most. “Festive meals tend to have more calories. Please eat slowly and be careful not to eat too much,” he cautioned.

CONCLUSION

This information raises the age-old question: Does correlation mean causation? That is, does fast eating cause obesity, or do people who eat rapidly possess other (maybe unknown) characteristics that destine them to become obese even if they were to slow their eating pace? Moreover, do Japanese differ in other ways that may invalidate these conclusions? Such questions extend to all sorts of scientific investigation—even political—as exemplified our rising stock market since the election of Trump. Did Trump cause the market to rise, or would it have risen anyway of its own volition. You can supply lots of other examples by observing a plethora of current and historical events. Unfortunately, in these historical or societal situations, there is almost no way to gain definitive answers.

In the case of rapid eating, however, we could design an intervention in which we enlist two normal groups—one instructed to eat slowly, and the other, to eat rapidly. After several months of careful follow-up, weight differences between the groups are tabulated. If, after such study, excessive weight accumulation is found in the rapid-eaters, then we are positioned to form a more accurate conclusion that eating fast truly causes more weight gain.

In the meantime, it certainly doesn’t hurt to eat slowly and chew your food well!

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MASS MURDERS AND INSANITY

The NRA party line is that people who commit mass firearm homicides are simply insane. Therefore, the problem of firearm homicide is basically a public health issue; if we were sufficiently adept at identifying and treating mental illness, the problem of mass firearm homicide would go away. Not so, say experts in mental illness. Most mass murderers are not insane, and Americans are not more prone to mental illness than citizens of other countries in which mass firearm homicide is almost nonexistent. The explanation for the daily occurrence of mass firearm homicides in the United States is simply this: the easy availability of military grade weapons with high capacity magazines.

If what people do is any reflection of who they are, then Devin P. Kelley, who slaughtered 26 churchgoers recently in Texas, surely was a madman.

Before the atrocity, he had attempted to sneak weapons onto an Air Force base after making death threats to his superiors, according to a local police report. In 2012, he had escaped from a mental hospital in New Mexico to which he had been sent after assaulting his wife and fracturing his stepson’s skull. A video of the church killing reportedly shows Mr. Kelley working his way methodically through the aisles, shooting some parishioners, even children, at point-blank range.

“I think that mental health is your problem here,” President Trump told reporters after that particular killing spree.

It is true that severe mental illnesses are found more often among mass murderers. About one in five are likely psychotic or delusional, according to Dr. Michael Stone, a forensic psychiatrist at Columbia University who maintains a database of 350 mass killers going back more than a century. Although the figure for the general public is probably closer to 1 percent, many experts place that at a higher number.

Most of these murderers do not have any severe, diagnosable disorder. Though he was abusive to his wife, Omar Mateen, who killed 49 people in an Orlando nightclub, had no apparent serious mental illness. Neither did Stephen Paddock, who mowed down 58 concertgoers from a hotel window in Las Vegas.

Ditto for Dylan Roof, the racist who murdered nine African-American churchgoers in South Carolina in 2015, and Christopher Harper-Mercer, the angry young man who killed nine people at a community college in Oregon the same year.

Nor does anything in these criminals’ history — including domestic violence, like Mr. Kelley’s — serve to reliably predict their spectacularly cruel acts. Even if spree killers have committed domestic violence disproportionately more often — and this assertion is in dispute — the vast majority of men who are guilty of that crime never proceed to mass murder.

Most mass murderers instead belong to a rogue’s gallery of the disgruntled and aggrieved, whose anger and intentions wax and wane over time, eventually culminating in violence in the wake of some perceived humiliation.

“In almost all high-end mass killings, the perpetrator’s thinking evolves,” said Kevin Cameron, executive director of the Canadian Center for Threat Assessment and Trauma Response. “They have a passing thought. They think about it more, they fantasize, they slowly build a justification. They prepare, and then when the right set of circumstances comes along, it unleashes the rage.”

This evolution proceeds rationally and logically, at least in the murderer’s mind. The unthinkable becomes thinkable, then inevitable.

Researchers define mass killings as an event leaving four or more dead at the same place and time. These incidents occur at an average of about one a day across the United States; few make national headlines.

At least half of the perpetrators die in the act, either by committing suicide (Mr. Kelley is said to have shot himself in the head) or being felled by police.

Analyzing his database, Dr. Stone has concluded that about 65 percent of mass killers exhibited no evidence of a severe mental disorder; 22 percent likely had psychosis, the delusional thinking and hallucinations that characterize schizophrenia, or sometimes accompany mania and severe depression. (The remainder likely had depressive or antisocial traits.)

Adam Lanza, who in 2012 killed 26 people at Sandy Hook Elementary in Newtown, Conn., exhibited insanity characterized by extreme paranoia in the months leading up to his crime, isolating himself in his room.

But what to make of John Robert Neumann Jr., who in June shot and killed five former co-workers at a warehouse in Orlando before turning the gun on himself? Mr. Neumann was not overtly psychotic, as far as anyone knows, and this is far more typical of the men who commit mass killings generally.

“The majority of the killers were disgruntled workers or jilted lovers who were acting on a deep sense of injustice,” and not mentally ill, Dr. Stone said of his research.

In a 2016 analysis of 71 lone-actor terrorists and 115 mass killers, researchers convened by the Department of Justice found the rate of psychotic disorders to be about what Dr. Stone had discovered: roughly 20 percent.

The overall rate of any psychiatric history among mass killers — including such probable diagnoses as depression, learning disabilities or A.D.H.D. — was 48 percent. About two-thirds of this group had faced “long-term stress,” like trouble at school or keeping a job, failure in business, or disabling physical injuries from, say, a car accident.

Substance abuse was also common: More than 40 percent had problems with alcohol, marijuana or other drugs.

Looking at prior studies, and using data from his own work, J. Reid Meloy, a forensic psychologist who consults with the F.B.I., has identified what he believes is a common thread: a “paranoid spectrum,” he calls it.

At the extreme end is patent psychosis. But the majority of people on this spectrum are not deeply ill; rather, they are injustice collectors. They are prone to perceive insults and failures as cumulative, and often to blame them on one person or one group. “If you have this paranoid streak, this vigilance, this sense that others have been persecuting you for years, there’s an accumulation of maltreatment and an intense urge to stop that persecution,” Dr. Meloy said. “That may never happen. The person may never act on the urge. But when they do, typically there’s a triggering event. It’s a loss in love or work — something that starts a clock ticking, that starts the planning.” Mental health treatment might make a difference for the one in five murders who have severe mental disorders, experts say. Prevention is also possible in a few other cases — for instance, if the perpetrators make overt threats and those threats are reported.

But other factors must be weighed. “In my large file of mass murders, if you look decade by decade, the numbers of victims are fairly small up until the 1960s,” said Dr. Stone. “That’s when the deaths start going way up. When the AK-47s and the Kalashnikovs and the Uzis — all these semiautomatic weapons, when they became so easily accessible.”

               THE BOTTOM LINE?

Attempting to discover the vast numbers of people who possess mental disorders that might be potential murderers is clearly impossible. Even if we could detect those most likely to perform such acts, society’s rules usually preclude any attempts to force them to undergo treatment prior to any acts of violence. Thus the only possible countermeasures are—prior to all firearms purchases—careful background checks for past mental disorders or violent and/or other antisocial acts. This must also be coupled with rigorous general restrictions of assault weapens capable of rapid repetitive fire into multiple targets.

Perhaps the demented leaders of the N.R.A. should be brought in for mental evaluations prior to more mass shootings!

The ultimate irony? If one believes that insanity should disqualify all persons from gun ownership, then the opinions of 27 mental health experts (http://www.mortontavel.com/2017/10/09/) should be enough to prevent Trump himself from getting his hands on any lethal weapons, especially of the nuclear variety!

 

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THE REAL CAUSE OF OUR BROKEN HEALTHCARE SYSTEM

This nation spends 3 trillion dollars yearly on healthcare, representing 17% of our total economy, which is—per capita—about double that of other western nations. Of that total, 40-50% goes to hospital charges, 20-30%, to tests and other services, 20% to doctors, 15% to drugs and devices, and 5% to nursing homes.

Conventional wisdom teaches us that prices for healthcare should come down when subjected to “free-market” forces, i.e. supply and demand, like the pricing of automobiles, household goods, etc. But nothing could be further from the truth! When did we see hospitals advertise the lowest rates in town, or healthcare purveyors state that hip replacements or cataract surgery was going on sale next month—or any month? Or, when confronted by an emergency, the cost of an ambulance would be based upon a prearranged lowest competitive price to transport a stricken patient to a nearby hospital offering competitive daily occupancy rates? And this extends to virtually all of healthcare. If we are lucky enough to possess good insurance, we may not worry about these charges, but history shows that once a procedure is covered by insurance, its sticker price generally goes up because patients (and physicians) are largely insulated from the costs, and this further prevents a “free market.”

In the face of rising healthcare costs in the early 20th century, Medicare first entered the market and covered usual charges from 1965 until the 1990s, but because of rapidly increasing charges, Medicare began limiting payouts, which served as a partial restraint on some of the rising charges: For instance it applied a system to bundle and restrain allowable hospital charges for given diseases/and or treatments. Also Relative Value Units extended to physicians’ compensation. But such limits don’t extend to private insurance or to the uninsured, unless by negotiated agreement.

Working through private insurers, the ACA (Obamacare) has provided some financial support for people needing insurance, but it also provided no effective means to control healthcare charges, which are continuing to spiral even higher. Notwithstanding Medicare, there are no real limits on most charges, meaning that most healthcare facilities can charge what they wish, free of any governmental or outside interference.

For instance, hospitals can pad their bills through the use of inscrutable charges that include all sorts of add-ons such as “facility fees,” needles, pills, laundry, multiple doctors, various tests etc. Moreover, excessive hospital charges encompass administration that often rewards CEOs with millions of dollars yearly, includes billing and collection costs, extensive gardens and physical additions, etc. Despite their being called “non profit,” most hospitals are de facto private entities, calling profits “operational excesses” and reaping the benefits of the avoidance of local taxes, while, at the same time, encouraging tax deductible contributions.

With regard to drug prices, there are no effective restraints on pharmaceutical companies’ charges. Unlike other countries, our government-run Medicare program is prohibited by federal law from negotiating lower drug prices with manufacturers. Prices for newer patent protected drugs are often excessive, and overcharges for older, generic drugs are also commonplace. In the case of certain cheaper generic drugs whose interest and availability are waning, they may become subject to a single company’s seizure of exclusive control of limited supplies, and then becoming a de facto monopoly, allowing for prices to suddenly surge to stratospheric levels. Collusion between competitors has also been alleged as another means to raise these latter prices.

In contrast with all western countries save New Zealand, pharmaceutical companies in the U.S. are legally allowed to advertise prescription drugs on television, provided that they list various side effects and dangers as well. Predictably these products are regularly expensive and may or may not be superior to older generics. Advertising costs these drugs generally account for about 30% of the companies’ expenditures, whereas research in new drug development amounts to a paltry 15%.

In order to deal with our broken healthcare system, we can learn from other countries’ experiences. Although some pundits claim otherwise, our outcomes are clearly not better than those of other advanced countries, meaning that our profuse money outlay is largely wasted. Although there are several contrasting methods, they all contain governmental price controls and universal participation. The best examples are provided by Germany, Japan and Belgium, in which rates for all services are set that include upper caps. In Germany, for instance, most individuals must purchase state sponsored insurance, with premiums based upon one’s income. Private insurance is allowed and may supplant the base insurance for the few who can afford deluxe services. Canada, Australia, the United Kingdom and Denmark, use variants of a single payer system, all of which couple price limits for services together with a mandate that the entire population will be insured.

The U.S. could adopt any of these methods, but a single payer (“public option”, or Medicare for all) would seem to be the most cost-effective. Administrative costs for Medicare average about 2-3%, in comparison to about 20-30% of most private insurers.

Expanded Medicare would not preclude the addition of supplemental private insurance, as we now have in combination with its basic coverage. An overall plan directed by the single payer must be empowered to control prices for all methods and procedures, allowing us to approach costs of other western countries. A single payer system would also simplify record keeping and unify documents, reducing time required by physicians and office personnel. It could be phased in gradually by lowering age eligibility for Medicare.

Given these facts, the underlying problem becomes clear: We are overpaying for virtually all components of our health care system, and governmental restraints on charges are necessary. This must be coupled with universal participation.

 

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