Tuesday, May 29, 2012

Integrative Medicine Part IV - Preventive Aging

Does old age necessarily mean declining health and cognition or can one age gracefully with a high quality of life?  

This was another topic discussed at the recent Health and Wellness conference organized by the University of Maryland Center for Integrative Medicine.  Steven Gambert, MD, Professor of Medicine and Surgery and Director of Geriatric Medicine at the University of Maryland Medical Center described preventive aging. Here are my notes from his talk with some personal observations added in. 

America has a rapidly aging population. In 1900 only 4% were over age 65 and 1% over 75 years. By 1950, it was 8% and 2.6% respectively and by 2000 it was 13% and 5% with these expected to grow to 21% and 8% by 2030. In absolute numbers, there are now about 12 million over the age of 80; a doubling since 1957. Older people run the full gamut from the very healthy, to those with a few health issues, to those with multiple problems to the very frail. Frail individuals (see my earlier post of frailty) have a high risk for poor outcomes of any illness, slower recovery and heightened mortality. So the agenda, of course, is to stay as healthy as possible throughout your later years.

Can you do anything to prevent illness? Can you embark on a “preventive aging program?” The answer is definitively “yes” and it is never too late to get started. But just like saving up for retirement, it’s best to begin at an early age so that the value can compound through the years.  

The first major element of the preventive aging program is to prevent an acceleration of the normal aging process. Most physiologic functions begin a slow but steady decline beginning at about age 30 to 35. This includes our bone density, kidney and lung function and cognitive skills. Some decline is inevitable but the process can be slowed. There are four basic steps.  

In no particular order the first step is to avoid environmental risk. It is never too late to stop smoking and so reduce the risk of lung cancer and other cancers but also to slow the decline of general lung function. Noise is an environmental hazard. Hearing declines with age and noise rapidly accelerates that decline. Loud music and loud restaurants are best avoided despite our current cultural attractions to both.  

The second step is proper nutrition. Eating foods with a wide mix of vitamins and minerals, high quality protein in sufficient quantity, good oils and fats and lots of fiber is of critical importance. Vitamin and mineral supplements are still valuable but they should be just that – supplements – not the prime source.  

The third step is exercise. Our muscles were meant to be used and we need to do just that. A regular regimen of moderate aerobic exercise such as walking for 30 minutes each day can’t be beat. Add to that some weight bearing exercise (probably at a gym or similar facility) three times each week to maintain and build strength. And remember to do both range of motion such as simple stretching or adding in yoga and balance exercises regularly.  

The fourth and very critical step to prevent acceleration of normal aging is to exercise your brain. Do some activities that challenge your mind – Sudoku or chess does that; watching TV definitely does not!  

Following these four steps can dramatically slow the aging process but you next need to prevent age prevalent diseases. Here again the best time to do this begins when you are young. The leading causes of death in the elderly are heart disease, cancer and stroke – no surprise here. Each of these are largely but not entirely preventable by attending to our lifestyles. Unfortunately most Americans eat a non-nutritious diet and too much of it, don’t get enough exercise, are chronically stressed and 20% smoke. The result is a population which is obese, with high blood pressure, an actual developing epidemic of diabetes and over time a high incidence of heart disease, cancer and stroke. So it behooves us to address our lifestyles beginning at whatever age we may be today and following though over the years.  

In addition older people should be sure that their immunizations are up-to-date such as annual influenza in addition to the pneumonia vaccine and shingles vaccine but also the less commonly paid attention ones such as tetanus and diphtheria. And as already suggested, avoid high noise environments, eat a good diet, get regular exercise and use your brain regularly.  

Part of healthy living includes adequate sleep. It’s simply not true that older people need less sleep. It is true that older people don’t sleep as well or as soundly and may need naps.  

Stress reduction (see a later post in this series for more information) in this hectic world is equally important. Seek ways to reduce this burden with tools such as meditation, mindfulness training, yoga, etc. Exercise can in itself be a great way to reduce stress and may have an impact on our own endogenous neurotransmitters to alleviate stress. 

Finally healthy aging also requires social contact. A good social life is actually critical to healthy aging. It will “add life to your years.”  

Aging gracefully is discussed in more detail in the last chapter of my book The Future of Health Care Delivery – Why It Must Change and How It Will Affect You. 

So it is possible to age gracefully with good health. Starting the process when you’re young makes it all that much more effective. But it is never too late to get started. It’s possible to just die of “old age” rather than one of the common chronic illnesses that are today’s plagues.  

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp

Sunday, May 20, 2012

Integrative Medicine Part III - Humanism In Medical Care

Have you ever thought that the doctor wasn’t listening to you? Didn’t seem to understand what was important to you? Was talking in medical speak but not in a language you could understand? That he or she gave bad news to you and left you hanging as to what to do next? Unfortunately, these are all too common.  

Medical advances such as new drugs, imaging devices, operating room technology and others are coming rapidly and greatly expanding what can be done for patients. But concurrently it also seems to many that medicine is so technologically focused that the age old art of humanism has become a legend. What the doctor needs to remember is that you are a human with the needs of a human; the doctor needs humanism. 

The University of Maryland Center for Integrative Medicine hosted a “Health and Wellness Conference” recently to celebrate the Center’s 20th anniversary. One plenary session was given by Thomas Scalea, MD, professor and director of the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center in Baltimore. The Shock Trauma Center is arguably the best trauma center in the country if not the world. It admits only those 3-5% of trauma patients with the most extensive injury yet survival consistently exceeds 95-97%. Credit this to the State’s emergency transportation system and the Shock Trauma Center’s exquisite teamwork, the well trained staff and the best of technology. As Dr. Scalea noted, the Shock Trauma Center is perhaps the zenith of technologic prowess.  

But, he reminded the audience that the patient also needs the provider to be humanistic. He gave some examples. Here are some that I remember from his talk, sprinkled occasionally with my own thoughts.

When you enter the room, sit down and talk with your patient. Be at their eye level, not an imposing figure hovering over the bed. 

Speak to the patient in clear English; not in medical speak. Medical speak is for your convenience and is a way of obfuscating but not communicating.  

Expect to repeat what you say tomorrow and again the next day again; your patient needs to hear it repeatedly. Don’t be annoyed they forgot it all by tomorrow morning.   

If you have bad news to deliver hold the patient’s hand. Touch has a lot of power. I would add here, when you must give bad news, be clear. The patient has already guessed his situation so don’t try to avoid the truth and be sure to then immediately explain what you propose as next steps. As a medical oncologist, I learned that this was absolutely essential. Don’t let this part wait for another day. Your patient needs to hear it right now so they can begin to focus not just on the bad news but on the hope of a new treatment or whatever plans you propose for the future, even if that means hospice. 

When you visit your patient don’t just talk, listen. Listen hard and long. Dr. Scalea described a trainee getting behind him and looking across his shoulder at the patient. When Dr. Scalea asked why he took that position, the resident responded that he wanted to see what Dr. Scalea saw. “I’m not looking, I’m listening” was the answer. Of course, “listening” also includes observing the patient’s body language including facial movements. 

Be sure what you tell the patient or family is clear. It needs to be in direct every day speech. He told of going to tell a mother that her son had died. The resident who had been working with him asked if he could be the one to deliver the bad news. “Sure, I’ll just sit to the side.” The resident used a lot of words about how injured her son had been, how they had tried to save him in the operating room, etc. and then  stood up to leave. “Wait,” said Dr. Scalea. He went over, sat down, and holding her two hands said, “Do you realize that your son has died?” She had not. It is critical to be clear. 

He described a scene at a famous hospital. The world renowned doctor and his retinue came into the patient’s room. He explained to the man that he needed a heart valve replacement. The patient thanked him and said he needed to talk to his doctor before agreeing to the surgery. The expert was clearly annoyed that his word was not sufficient. “What is your doctor’s name?”  “Dr. Hamilton.” “What is his phone number?” “I don’t know.” “Well how can I call him?” the physician sort of growled. “Well he’s right here in the room – right over there.” He was the third year medical student, the only one on the team that until now had taken the time to really talk to the patient. The expert and his retinue left. The student remained behind. The surgery was soon scheduled for the next day.  

Finally I would add that being a doctor is a privilege. We are given that privilege as a result of our medical school and residency training and our willingness to put patient care above everything else. It is a special privilege. We need to always remember that it is a privilege given to us by the patient – each and every time we have an encounter. It is a privilege that the patient can chose to retract. 

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp . There is more about the delivery of health care in my new book The Future of Health Care Delivery-Why It Must Change and How It Will Affect You.

Monday, May 14, 2012

Integrative Medicine Part II -- Health Care of the Future

Is it possible that health care can become more effective, more personalized, more attuned to real health and wellness in a manner that truly benefits you the customer?  

At the recent health and wellness conference celebrating the 20th anniversary of the University of Maryland Center for Integrative Medicine there was a panel discussion moderated by Center director Brian Berman, MD on the topic of health care of the future. Here are some excerpts from the comments made by Dr. Delia Chiaramonte, Dr. Jeff Bland and myself.  

The first question was what are the problems with the health care system today? Here are some of the responses:

There is excellent research and innovation along with superb providers in this country. But the delivery system is dysfunctional and to date America has tolerated this dysfunction. It’s a medical care not a health care system. The emphasis is strongly on disease management and not disease prevention or health promotion. American medical care is very expensive, about $8,000 per capita and yet outcomes are not what they could or should be. For example, America does not have the lowest infant mortality rate nor the longest life span. Other developed countries beat us on both counts. Medical care of acute illness is generally quite good in the United States but chronic diseases – of which there are more and more occurring – are not well cared for. The system is provider oriented rather than patient oriented and the patient is not the real customer.  

There is a shortage of primary care physicians and this is getting worse every year. Only 30% of American physicians are primary care physicians compared to about 70% in most other developed countries. Those still in primary care practice have inadequate understanding of the causes and prevention of chronic diseases. And too few appreciate the importance of care coordination nor the full range of non-pharmacologic options for care.  

The second question was what can patients do to get the best possible health care? Among the responses, here are a few:

Since today the patient is largely not the customer of the doctor, a good place to start is to change that paradigm. A high deductible health policy means that the patient will now be paying the primary care physician directly for care and thus this changes the professional-client relationship to a more normal occurrence. The physician will now become more attentive, allocate more time, offer more preventive care and will coordinate the care of chronic illnesses.  

Individuals also need to take more responsibility for their health and wellness directly. Attention to nutrition, exercise, stress and tobacco are key first steps. Work place wellness programs can materially assist. They can offer a health care premium deduction in return for engaging in added educational programs to improve lifestyles. 

Social networking can have an increasingly beneficial effect. Lifestyle changes are easier to accomplish in a peer group setting. Usually we think of this as a physical group setting but it can also be done through the use of social media. Groups help give a positive reinforcement for behavior change.  

Social networking through sites such as Facebook, Twitter or You Tube or others can be used to leverage the medical care delivery system to become more patient centered, more effective at the coordination of chronic illness, more attuned to prevention and responsive to true integrated medicine.

Everyone should have a primary care physician, one well schooled in the most current evidence-based care approaches yet who is attuned to the full gamut of integrative medical approaches such as chiropractic, nutrition, personal training, massage therapy, and acupuncture. You need to be sure that your primary care physician will spend the time needed to deal with health and wellness and not just disease. You may well need to pay your primary care physician directly rather than buy insurance but the primary care physician will then be financially able to offer you the time you really need and deserve.  

The third question was what will the health care provider of the future be like and how will integrative medicine contribute to health care in the future?

This question was addressed in an earlier post; go to this link.     

You deserve superb integrative health care but to get it you will need to take some action to obtain it. Call it a balancing of rights with responsibilites. It may cost you dreictly rather than via insurance but you may well find that the return on investment is well worth it. You can find much more discussion of this topic in The Future of Health Care Delivery – Why It Must Change and How It Will Affect You. 

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp

Friday, May 11, 2012

Integrative Medicine - Part I

Can integrative medicine add value to standard western practices? Some would say absolutely not; others point to new scientific evidence that demonstrates the value of specific modalities in specific situations.  

Health care is complex, expensive and often depersonalizing. It shouldn’t be. At the University of Maryland Center for Integrative Medicine, the staff focuses on evaluating and involving complementary medicine into traditional western or “scientific” medicine. Founded in 1991 by Brian Berman, M.D., a family medicine trained physician, he had learned the certain alternative approaches could complement the usual diagnostic and therapeutic methods that he had been taught in his medical school education and training. He found that his patients’ experiences were enriched by treating the whole person rather than depending on a technology-focused practice. A grateful and forward looking patient offered him a grant to begin the Center with the proviso that it embrace and study evidence-based science along with education and collaborative patient care to create a comprehensive humanistic approach to patient care.  

Since its founding 20 years ago the Center has been awarded over $30 million in NIH grants and has been named as a center of excellence for research. From this work have come over 340 high quality peer-reviewed scientific articles published in the best medical journals. These have been in areas such as acupuncture, herbal remedies and mind-body therapies focusing on arthritis, pain depression, cancer, trauma and inflammation. The center employs a staff for clinical care that includes family medicine and other physician specialists along with licensed acupuncturists, massage therapists, nutritionists and many other disciplines. 

As just one research example, acupuncture was studied in a double blind fashion to determine if the addition of acupuncture to best standard treatment improved the lot of those with knee osteoarthritis. Those who got acupuncture, when compared to those that got sham acupuncture, has less pain, used fewer pain medications and had greater range of motion. 

At the “Health and Wellness Conference” a few weeks ago to celebrate the 20th anniversary of the founding of Center, Delia Chiaramonte, MD described what an integrative approach to a medical dilemma might look like. She described a medical student who had suffered from severe headaches for many years that were limiting his quality of life and his effectiveness as a student. His physician had identified them as cluster headaches and had tried various standard medications without success. A frustrating situation. 

He was then evaluated differently using an integrative approach. It involved a lot of probing about his headaches, his lifestyle including diet and activity, his stresses and his school work. Like almost all medical students, he studied hard. He said he stayed up until about 3:00am, but in part this was because he couldn’t fall asleep any earlier. His diet included a lot of doughnuts and a lot of other high carbohydrate items plus about 12 cups of caffeinated coffee each day. He had no time for exercise. He sat - hunched over - in front of his computer for many hours each day, and his posture showed it.
His headaches fit the description of “cluster” headaches, often with a sense of an ice pick sticking into his right eye - near unbearable pain. The standard medical texts suggest use of ergotamine tartrate for cluster headaches and also note its potential side effects. There is no mention of other modalities or adjustments to lifestyle issues. But cluster headaches can be amplified by stress, worsened by sleep deprivation and the stabbing could well have been posture related. 

So instead of recommending medications, his integrative medicine “prescription” included the following: he was to see a nutritionist to devise a more healthy diet. He was to work with a personal trainer to establish an exercise program - one that could be done anywhere without impacting on his studies. He was to visit a chiropractor to release his sternocleidomastoid muscles and other neck muscles back to their normal length. In addition he was to have no caffeine after noon and he was to get to bed by 11:00pm each night.  

Given the pain and debility of his headaches, he was more than willing to give this prescription a try. It worked. The headaches disappeared, he felt generally better, he was no longer drowsy in class and he began to truly enjoy medical school.  And he was off all medications. 

This is the power of integrative medicine. It used a holistic approach and brought to bear many different disciplines including nutritional medicine, exercise physiology, stress management, chiropractic and family medicine. I wrote about this extensively in The Future of Medicine – Megatrends in Healthcare . 

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp

Saturday, May 5, 2012

Your Genes Need Not Be Your Fate: Nutrigenomics To The Rescue

Genomics Part 4 -- Medical Megatrends 

Are you concerned about a family history of heart disease? Or cancer? Worried that you genes will be your fate? We know that good dietary habits are generally good for us but can foods affect our genes? The new science of nutrigenomics suggests that they can. 

Nutrigenomics is about using what you eat to change your gene expression (meaning how your genes function) to optimize your health.  

Nutrigenomics is the science of how bioactive chemicals in foods and supplements alter the molecular expression and/or structure of an individual’s genetic makeup. It is apparent that one size does not fit all when it comes to nutrition. We have become aware of the limitations of population-wide advice such as the food guide pyramid. Second generation approaches have proliferated with pyramids tailored for children, the elderly, ethnic groups, vegetarians, etc. Although these attempts are steps in the right direction, they do not take full advantage of the breakthroughs in biomedical science. Fortuitously, this realization has come at a time of great expansion of knowledge with the genomics/informatics revolution. 

Nutrigenomics is a young science and built around the revolution in genomics. As such, the science is still evolving. The excitement about nutrigenomics comes from a growing awareness of the potential for modifications of food or diet to support health and reduce the risk of obesity and many deadly chronic diseases.  

Nutrigenomics will become a critical part of the entire “personalized medicine” concept that is revolutionizing medical practice as discussed in detail in The Future of Medicine – Megatrends in Healthcare. Personalized (or “custom tailored”) nutrigenomics medicine is an approach that means it is possible to have a direct impact on long term health and longevity by very specific dietary manipulations. Nutrition will no longer be “one size fits all.” 

Nutrigenomics offers hope to those who know they have a strong family history of heart disease, cancer, diabetes, obesity, and most likely many other diseases as well. At the same time it takes away the excuse of “everyone in my family is overweight so I am too.” One no longer needs to be fatalistic in this regard and hope may lie at the end of a fork.  

Nutrigenomics is not a phenomenon, a fad, or a technique to use in a vacuum. It is best as part of a total approach to lifestyle management. 

It is increasingly apparent that various foods directly affect critical genes – turning them off or on as the case may be – and thereby directly impacting the development of atherosclerosis, diabetes, many cancers and obesity, among others. The foods that we consume play a role in how genes that affect our health are expressed, or “turned on” and “turned off”.  

For example, we know that broccoli is good for us because it is one of the most nutrient dense foods that we can consume. One of the reasons that consuming broccoli may enhance our health is that many of the nutrients in broccoli have been shown to turn on genes that protect from disease and turn off genes that increase the risk of disease. For example, a nutrient in broccoli called sulforaphane has been shown to turn off genes that cause many forms of cancer. The omega-3 fatty acids found in salmon, grass-fed beef, walnuts, flax seeds, and fish oils appear to turn on genes that protect against heart disease and its risk factors. These are just a few examples of how eating a nutrient dense diet can improve health by turning on genes that protect from disease and turning off genes that cause disease.  

It is important to realize that processing foods removes or destroys phytonutrients. Hence, processed foods contain less or no phytonutrients, and this lack of phytonutrients along with chemicals that directly affect our cells’ genes explains, in part, why overconsumption of processed and ultraprocessed foods contributes to chronic disease. 

See the Future of Medicine – Megatrends in Healthcare for a fuller discussion of the implications of genomics. And watch for new developments in this fast moving new science. 

Remember, nutrigenomics has made it clear that your genes need not be your fate! Just because you have a family history of a certain disease does not mean that you are also destined to become a victim.

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).