Obesity is a huge problem. There are controversial ads in my home state of Georgia talking about how dangerous childhood obesity is, talking heads are saying how 30% of children are expected to be obese by 2030, and that this generation of kids will be the first to have a shorter life expectancy than their parents. It almost seems that despite our best efforts, we are headed to a dystopia not unlike the Disney film Wall-E where we are all obese, confined to a chair, plugged into a screen all day, slurping food through a straw.

New data from the National Health and Nutrition Examination Survey (NHANES), a group that has been measuring the height and weight of adults suggest that this astronomical growth in obesity rates is beginning to slow. Yet, far too many people are obese and it will continue to be one of the greatest public health issues of our time. Fortunately, the data from the NHANES study show that the rates of obesity in 2009-2010 for both children and adults has not changed from their 2003-2008 levels for adults (35.5% for men and 35.8% for women) and the 2007-2008 level for children (16.9%).

What caused this slowing? No one is sure yet but there are reasonable guesses. Obesity has a host of factors that contribute to it. Some foresee this new plateau rate of obesity as the new norm – due to family predisposition, crummy diets, and too much screen time. However, I caution against this pessimistic conclusion, because it means we do not have control over how fat we, as a population, get.

I am an optimist. I would like to think that maybe, just maybe, all of the work we have been doing for the past decade or so to educate and empower our population to make good eating choices, and get exercising is beginning to pay dividends. Maybe this is a plateau before the fall of obesity rates, maybe this change is due to our hard work and our desire as a population to be more healthy.

Surely both the optimistic and pessimistic ideas have some truth to them, but I think that this change is a sign that things are improving. It is a worthwhile effort to get people to make healthier choices. This is a sign for us to keep up the good work. This is a mandate to eat more vegetables, skip the soda and snack aisle at the grocery store, and go for a family walk before watching American Idol. If everyone makes little improvements, every day, we can change as a population for the better.

Be Well,

Dr. Bruce Feinberg

–sources–

http://jama.ama-assn.org/content/307/5/491.full

http://jama.ama-assn.org/content/307/5/483.full

Malaria has been a known disease since antiquity. Its name means bad air, “mala aria” in medieval Italian, because it was so pervasive near the smelly swamps around Rome during medieval times. Malaria is caused by the Plasmodium family of parasites and is transmitted by mosquitoes.  While malaria has been largely eliminated in the developed world thanks to mosquito control efforts, the disease still ravages tropical countries, especially in sub-Saharan Africa. Malaria causes severe headache, joint and muscle pain, nausea and vomiting, but it is the high fever that comes and goes in a regular cycle that is the most dangerous and unique sign of the disease. The majority of those who die from malaria are children. The high fever leads to a coma, neurological damage, and death.

In the past several years, malaria has been a huge focus of the global health community. The rates of death from malaria have decreased from efforts to prevent transmission by targeting the mosquitoes that carry the parasite. Pesticide laden mosquito nets in particular have been a huge help in the fight against malaria. Effective medical treatments for malaria exist but are expensive and many of the sickest people live in remote villages with poor roads. A storm during the rainy season could isolate a village for weeks while the mosquito population exploded.

This week, the preliminary results of a massive study taking place in seven sub-Saharan countries investigating the effectiveness of a vaccine against the Plasmodium Falciparum species of the malaria parasite was published. What makes this vaccine unique is that it is the first vaccine against a parasite. Most vaccines are against viruses and a few are against bacteria. The malaria vaccine cuts infection rates in vaccinated children in half and reduces serious, potentially deadly cases by 35% of those who get infected compared to the non-vaccinated children.

While this vaccine will be a powerful new tool in the fight against malaria, it is not perfect. The study has not analyzed the data looking at the effectiveness in babies at this time. Those results will be available in a year from now. It is also unclear how long the vaccine will have its protective effect. Some evidence suggests that the vaccine becomes less effective one year after it is given. That is still being examined and a booster shot is being looked at as a way to combat this potential problem. Vaccinating against parasites is uncharted territory so potential issues could appear from unexpected places.

If no major problems arise, this vaccine could be a powerful new tool in the fight against malaria in the developing world. It is wonderful to see the cool breeze of medical science and technology blowing away the bad air of malaria away.

Be Well,

Dr. Bruce Feinberg

The Prostate Specific Antigen, commonly known as the PSA, is a protein made only by the prostate gland. It was found that patients with prostate cancer had significantly elevated PSA levels. This PSA test was developed in the late ’80s and has been a standard lab test to obtain since then. Many men, including Joe Torre, Rudy Guiliani, Nelson Mandela and Colin Powell, had their prostate cancer cured because they found their disease early. Former Mayor Guiliani claims the PSA test saved his life. Prostate cancer is among the second most common cause of death by cancer in men, so screening for it just makes sense… right?

Earlier this fall, The United States Preventative Task Force (an influential US government sponsored panel that reviews medical data and makes recommendations that guide healthcare providers and insurance companies) stated that the PSA test should no longer be performed on healthy, asymptomatic men.

Why? The test seems like it has little downsides at first glance, but scratch the surface and he head scratching begins. It is simple to administer and sensitive, almost everyone with prostate cancer has an elevated PSA. The test’s specificity, on the other hand, leaves much to be desired, as many as 7 out of 10 men with an elevated PSA do not have cancer.

Prostate cancer is a bit unusual as cancers go, so screening for it is tricky. It is incredibly common, usually slow growing and usually not aggressive. While incredibly common, only 3% of men die from prostate cancer and many never have any symptoms. The fact of the matter is prostate cancer is usually such a slow moving disease that many men who do have it die from an unrelated cause, never knowing they were affected. Despite this fact, most men treat their prostate cancer once they find out they have it. Could you sleep at night knowing you had cancer and you were doing nothing about it?

Cancer is among the most terrible diseases to plague humans, partly because it’s treatment involves invasive biopsies, radiation, difficult surgery and toxic medicines. The prostate is in crowded real estate, with many delicate nerves, blood vessels and other structures surrounding it. Complications from surgery and radiation can lead to erectile dysfunction, incontinence, and pain. These side effects can devastate patients’ quality of life and rarely, lead to death. If the cancer would never cause symptoms, it seems silly to treat it and risk these terrible unintended consequences.

Unfortunately, it is not so simple. Some prostate cancers are more aggressive than others, and many men have fantastic outcomes after receiving treatment. The golfer Arnold Palmer was back on the green 2 months after his prostate was removed. Many men owe their lives to the PSA test. It’s easy to say only 3% of men in our population die from this disease. It is much harder to swallow that your father, brother, or husband died form this disease when a simple blood test could have found it before it was too late. Despite all of the evidence, there is this nagging gut feeling that throwing this test to the curb seems wrong. So what should doctors and patients make of this quagmire?

First of all, more research is needed. There is likely a role for the PSA test in high-risk individuals, those with symptoms and an abnormality found on physical exam. Also, looking at the PSA in context, for example, how fast it rose from the previous measurement (the PSA velocity) or examining conditions that could have raised the PSA, could also be used to help improve the test. Studies looking at these techniques or others could lead to effective screening techniques. But what about right now?

We have to balance the risks and benefits with the information we have. Ultimately, it is a personal decision you should make with your doctor’s guidance.

Be well,

Dr. Bruce Feinberg

The controversy surrounding breast cancer screening relates to the concept that a screening tool must be both sensitive and specific. Numerous observations challenge the specificity and sensitivity of breast cancer screenings in younger women. First, the density of the breast tissue of a young woman decreases the sensitivity of both the mammogram and the exam. Also, exams in young, menstruating women are notoriously unreliable because so many changes in the breast are not specific to cancer. Finally, the chance of breast cancer in a 40-year-old woman is very low, just 1 in 1,000, leading to a very low index of suspicion.

Combined, these issues lead to problems ranging from early cancers being neither visualized nor suspected to non-cancerous changes creating misleading findings leading to unnecessary biopsies and anguish. It is true that newer and better methods are needed to screen young, high-risk women.

However, there seems to be little downside to knowing your body through self-exam, undergoing an annual physical with breast exam, and undergoing age-appropriate mammography.

It seems not a month goes by without a major news story about a scientific study calling into question the value of breast exams and mammograms. The elaborate and often complex scientific studies are reduced to 30-second sound bites that give the impression that women might as well just roll the dice when it comes to early detection of breast cancer.

Although I appreciate the science and recognize the need to scrutinize both the cost and value of all medical interventions, I remain steadfast in my support of early detection by the best-proven means available, which today is manual breast examination and mammography.

Have you been following the screening controversies in recent news? What do you think?

Be Well,

Dr. Bruce Feinberg

Part I

Imagine if we could prevent cancer the way vaccination has eradicated polio and smallpox.

In the absence of a definitive prevention strategy, medical science’s best efforts have been applied to finding the disease early enough so that it is curable.

The logic is simple: Cancer evolves from a pre-cancerous state to a noninvasive state to an invasive state. The greater the number of cancer cells, the greater the risk of mutation to an invasive state. The greater the number of invasive cells, the greater the risk of those invading cells escaping into the circulation. The greater the number of cells in the circulation, the greater the likelihood that some cells will anchor and nest in the blood vessels of another ­organ, creating metastases (spread). The greater the probability of metastases, the lower the probability of cure.

Following this logic, the key to success in cancer management is to find cancer before it is invasive, or if invasive, as soon as possible before it metastasizes. Unfortunately, some cancer screening tests that attempt to find the cancer early, before it produces symptoms and when it is curable, have had mixed success. Unlike the unquestioned success of the pap smear in allowing the early detection and cure of cervical cancer and colonoscopy for colon cancer, other tests like PSA (prostate specific antigen) testing for prostate cancer, mammogram screenings for breast cancer, and chest imaging for lung cancers remain controversial.

The controversy surrounding prostate, breast, and lung cancer screening relates to the concept that a screening tool must be both Sensitive and Specific.  A sensitive test clearly distinguishes diseased from normal structures so there are no false negative results, if disease is there it will be detected.  A specific test means that any abnormality detected is the disease we’re looking for and not something else so there are no false positive results.

Numerous observations challenge the specificity and sensitivity of prostate, breast, and lung cancer screenings.  Furthermore, even when the test is sensitive and specific it must be proven to save lives.  In the coming weeks I’ll explain why each of these cancer screenings: prostate breast and lung each remain controversial. We’ll be talking more about sensitivity and specificity, false positives and false negatives, and clinical validity and clinical utility.

What has been your experience with cancer screening?

Be Well,

Dr. Bruce Feinberg

I was walking out of the gym with my friend when he saw someone he knew and interrupted our conversation.  He called over to a woman across the room and said: “our vitamix arrived yesterday.” She responded,“you’ll love it.  You’ll feel so much better after you detox!”

“Detox?” I interjected, “Detox from what?”  My friend spoke next telling this woman that I was a doctor, goading her into the debate.  She wisely said, “I know about you doctors and I also know how much better I feel since I started detoxing – you have your opinion and I have mine”

Despite my friend’s displeasure, there was mutual agreement to end the debate, each party assured there was no convincing the other.

On the drive home I was seething with frustration.  As a scientist by training my world is structured by an understanding that information can be categorized as fact, theory, or opinion.  Two plus two is a fact.  Evolution is a theory, so complex that near impossible to prove as fact, but supported by tens of thousands of scientific observations.  Opinion is merely a deeply held belief.

Detoxing the colon or blood may have at one time been an opinion and later a theory but with the scientific tools available today it can easily be tested to determine if it is a fact; and if disproved not only would it not be a fact but then it can no longer be a theory, and certainly not an opinion.  Two plus two equals five is just factually wrong – you can’t have a theory that says it may be correct, and you can’t have an opinion that it is correct because the fact is indisputable.

Getting back to the detox story.  If one is to detox then there must be a toxin present that is going to be removed by the purported intervention.  If the toxin is present then it should be measurable.  In order to make such a claim as being detoxed a simple scientific experiment can be designed to measure the toxin(s) before and after the intervention to prove that they have been removed.  This isn’t rocket science, nor is it trying to take evolution from theory to fact. This is as straightforward as high school chemistry lab.

My frustration with the detox debate and so many health care topics like it in our contemporary culture is the abandonment of science and the willingness to accept as truth assertions that can be easily tested.  When and why did we become so gullible? It’s as if we’re buying snake oil again.

Clearly I feel very strongly about this, what about you?  Leave a comment, and let me know.

Be Well,

Dr. Bruce Feinberg

Being a good parent starts with keeping the kids safe. You have to be thoughtful and vigilant, especially with toddlers, to keep curious children free from dangers around the house. Storing knives and toxic cleaning products and other household chemicals out of reach and in locked cabinets is clearly important to prevent direct injury. Other, indirect causes of injury to children include repetitive exposures to toxins in the environment such as allergens, and secondhand smoke. Secondhand smoke in particular has gotten lots of attention for its deleterious effects on the health of children. Recent research has lead many pediatricians to warn against an indirect exposure that can stunt the intellectual growth of children under age two… TV.

The American Academy of Pediatrics has advised against exposing children under the age of two to ANY television since 1999, due to research that shows children under the age of two who watch TV have stunted language development and poor attention spans. Instead, the Academy recommended independent play and interaction with parents and siblings.

Disturbingly, there are more and more videos and television produced for children two and under. Many of these products state that they are educational. These claims are unfounded – “educational” media has never been shown to help children under two learn. More interactive, unstructured play facilitates children’s language to develop normally. Unstructured playtime is the oldest and best way for babies to become smart, well adjusted kids.

The American Academy of Pediatrics re-released these guidelines, along with some new additions because so few people got the message ten years ago. One of the new additions is the recommendation against watching television around your kids. Believe it or not, there is evidence for so called a ”second hand television” effect. Studies have shown that parents talk to their kids less when the TV is on. Child development specialists have long known that there is a correlation between the amount of time a parent talks to their baby and their language development.  Even if what’s on is not for them, babies and toddlers will glance at the TV 3 times per minute on average, even if it is across the room. That’s a serious distraction for a developing mind. While an association cannot prove a cause and effect relationship, it certainly does give a concerned parent good reason to limit screen time.

So if you have a child two or under in the house and you want to click on the TV and relax with your baby near by, maybe reconsider. Parents did the same with cigarettes for decades and unintentionally did harm. We all could use a bit more activity and less screen time in our lives. We as adults are supposed to get less than two hours a day of TV a day, while in reality the average American gets around twice that.

Try going for a walk, reading a book or even catch up with a friend with your baby in arm. That’s best for both you and the baby!

Be well,

Dr. Bruce Feinberg

This is the second of two parts about the USDA’s attempt to guide the American diet and the famous, but now defunct grap

Lost in the Ruins

In 2005, the USDA revamped the food pyramid, trying to emphasize portion control, healthy carbohydrates, healthy fat and exercise. In the process of all of the changes, it was no longer easy to understand.

The thickness of the vertical stripes were supposed to represent how much of each food group one should eat. The graphic made no intuitive sense, there was no clear servings per day. The person climbing the side was supposed to represent exercise but he was more of a distraction that added to the confusion. While the web site and literature that accompanied the new pyramid were full of useful dietary guidelines based on good research, they were complicated and hard to understand. The simple graphic made little to no sense, so Children and people with lower levels of education and income could not gain anything from these guidelines, and they are the two groups of people most affected by obesity and most need these resources. This pyramid was almost immediately criticized and lasted for 5 short years. After such a failure, the idea of a food pyramid was abandoned. The USDA dietary guidelines are now represented by a plate schematic showing how much of your plate should be filled with a particular food group.

Have we found out way out of the Ruins?

This new design may be the best yet, but it still leaves something to be desired. There is so much information about what foods are healthy and which are not, but the information is often unclear and conflicting. Foods marketed as healthy are often low calorie junk food. Not all foods within each food group are the same, and too much food – regardless of how healthy – is not good for you.
Having a healthy diet in modern times is complex. It may be impossible to have a simple graphic explain it all. Education about what foods are healthy may be the best first step. There is lots of good information on the Harvard School of Public Health and MyPlate.gov web sites for personal education. Despite all of the iterations of dietary guidelines, the message no refined sugar, no refined grains and no more processed food is key to eating in a healthy way. Schools should teach nutrition and cooking classes from an early age to understand what our bodies do with the food we eat and understand why some foods are healthy. Giving kids the skills they need to prepare healthy foods allows them to feel empowered to control their diet and prevent obesity. We have been stuck in the ruins of the food pyramid for some time now. We have an idea of the way out, but it will be a long path. I hope we can find the effort it takes to get ourselves out of these ruins, and into the sunshine.

Be well,
Dr. Bruce Feinberg

This is the first of two parts about the USDA’s attempt to guide the American diet and the famous, but now defunct graphic.

Building the Pyramid

The American diet is famously terrible. The obesity epidemic, which has been gaining momentum for years, has impressive reach; more than a third of all people in this country are now obese. The reasons for this epidemic are complicated and multi-factorial, and it has no easy solutions. One misguided public health awareness campaign trying to tackle the obesity epidemic serves as an example of how the best intentions can lead to unforeseen consequences.

The USDA has been trying to guide the eating habits of the United States population since the end of the 19th century. Early on it was recognized that the guidelines had to be simple to understand and remember. For most of the 20th century these guidelines were distributed in schools and were very simple. From the post war years to 1992 there were only 4 food groups (Fruits and vegetables, dairy, meat and cereals) and not much guidance on how much one should eat. In the early 90′s, the USDA decided to update these recommendations with a new, easy to understand way to display it. If it were simple, any one could follow its directions and improve their diet. Thus, the food pyramid was made.

The Pyramid’s Shadow

This influential graphic was ubiquitous. It could be found on the sides of cereal boxes, the walls of school cafeterias and classrooms through out the 90′s and early last decade. It said how much of each of the 6 different food groups you should eat. This guideline was visually appealing and easy to implement. People knew the food pyramid and followed it.

While the pyramid had the best intentions, the simplicity of the graphic was misleading; you could follow the pyramid and still eat unhealthily. For example, 6-11 servings of many of the foods shown on the bottom layer (such as spaghetti, white bread and other non-whole wheat starches) is too much. Excess carbohydrate consumption is associated with the development of diabetes and obesity. The pyramid made no distinction between a whole grain slice of bread and a piece of white bread. There is a huge difference in how your body deals with whole grains versus refined, white bread products. Further more, one of the carbohydrates most implicated in the obesity epidemic, the potato, is included as a vegetable! Sure it grows on a plant but it is one of the largest sources of carbohydrates for Americans and should be included in the carbohydrate food group. Unfortunately the graphic represented what the average American actually ate, not how much they should eat.

The Pyramid Crumbles

As obesity rates continued unabated, the old food pyramid began drawing more and more criticism for its short falls. The USDA realized that something had to change. Critics agreed that the pyramid was based on out-of-date evidence. Research shows that a diet heavy in fruits and vegetables is best. Fat, which was villain-ized on the old pyramid, is actually good in appropriate quantities if it comes from plant and fish oils. The food pyramid had to be revamped to include more fruits and vegetables, less carbohydrates and including other lifestyle factors such as exercise and portion control.

The USDA had to come out and say that most Americans ate poorly and were getting fat. They were hesitant, just as you would be hesitant to tell your wife she looked fat in that old dress she pulled from the back of the closet. The cold hard reality is that Americans needed to exercise more, eat fewer calories and get rid of the processed sugars, grains and foods and the USDA knew that Americans wouldn’t be happy.
Check in soon to read how the USDA tried to lead us out of the ruins of the food pyramid. You will have to decide for yourself how lost we are.

Be well,

Dr. Bruce Feinberg

Snake oil is a term that has come to mean a medical treatment that is a scam. This term was coined to describe the goods sold by traveling drifters posing as doctors, chemist or healers in the late 19th century. These hoaxsters would peddle their patent medicines – which were expensive placebos or highly alcoholic tinctures. Sometimes, real snake oil (Chinese water snake oil brought over from Chinese railroad workers) was sold as a treatment for aches and pains, but the fake ointments, elixirs and salves and other patent medicines were far more rampant in the United States.

In 1906, the Food and Drugs Act was passed and medications needed to undergo more rigorous testing before they were sold. Although these patent medicines have been in decline for more than a century, we may have discounted the healing effects of literal snake oils too soon.

Pythons are gigantic snakes, often reaching twenty-five feet in length. They can eat prey that are larger than themselves, and when they do, the fat and oils in their blood increases to astronomical levels and their organs drastically increase in size and how much work they do. Amazingly, the organs return to their normal size after a few weeks, no worse for wear. Researchers studying how this occurs have found that the cells in python’s hearts increase in size, not number, to accomplish this amazing and rapid growth.

The process of cells increasing size, leading to growth is called hypertrophy, and human hearts undergo hypertrophy in two major ways: One is when an athlete trains his or her heart to be stronger, an example of healthy hypertrophy. By contrast, when humans have high blood pressure, the heart hypertrophies in order to deal with the increased strain. This unhealthy hypertrophy leads to growth of the heart where it eventually cannot pump blood effectively, leading to heart failure. When snakes gorge themselves they experience the healthy kind of hypertrophy and that has caught some medical scientists eyes.

In a long shot experiment, these scientists injected the plasma (blood without any cells) of feasting pythons into pythons that were starving. To their surprise, the starving snakes organs underwent hypertrophy just as if they had been feasting. After that, they injected the feasting snake’s plasma into mice and their hearts underwent healthy hypertrophy, just like the snakes. Upon further analysis, they discovered that only a precise mix of three fatty acids, the main components of python snake oil, lead to these changes. They are now studying how these changes occur and hopefully what they find could lead to a potential treatment to the unhealthy hypertrophy that failing hearts experience.

Surprisingly there are some possible health benefits from snake oil beyond the hypertrophy python experience. As it turns out, Chinese water snake oil, the type classically known as snake oil actually has the highest levels of Omega-3 fatty acids of any animal. There is some evidence that oils with lots of omega-3 fatty acids have anti-inflammatory properties.

There’s a chance those Chinese rail workers were on to something good that was distorted and slandered by greedy American conmen. Perhaps someday snake oil will overcome its bad reputation, but unfortunately for now, it will remain synonymous with greed, quackery and deception.

Be well,

Dr. Bruce Feinberg

Source
http://www.nytimes.com/2011/11/01/health/python-digestion-study-holds-promise-for-human-heart-health.html?pagewanted=2&_r=1&ref=health