Doctor Pierce's Notebook

meet dr. pierce

 

Dr. Jim Pierce is an Internal Medicine physician with a special interest in obesity and obesity related diseases.  Fifteen years ago, he began researching the relationship of high-carbohydrate, low-fat diets to obesity and "Syndrome X" and has been slowly developing a nutritional philosophy that is designed for our bodies living within a culture of abundance.  Dr. Pierce believes that obesity and its related diseases--type II diabetes, heart disease, cancer--are part of the "blessing of abundance," and that we have not yet caught up with how to live with such prosperity.  

Dr. Pierce loves food, he loves wine, and he loves cooking, and he wants to share with his patients how to live and enjoy nutrition not as simply a means to live but as a way of enjoying life to the fullest. 

His nutritional protocol is designed to cleanse and restore a body in crisis to a more natural state of metabolism, after which we can begin to re-learn how to eat and enjoy food in all its natural flavor and abundance. 

Clinical Experience of a Diet Designed to Reduce Aging

Clinical Experience of a Diet Designed to Reduce Aging

Nutrition is funny--it is probably the single most important factor in our health, yet it is one of the least studied or understood in medical circles.

Everyone thinks she's an expert on food--reading blogs and even premiere news outlets on nutrition are filled with misinformation and snarky, ignorant sniping against concepts that are either willfully misrepresented or simply misunderstood. (I recently read a blog post attacking Dr. Atkins that reported that his diet included fat marbled steak and an ice cream sundae every night. Had the writer even READ a sentence of Dr. Atkins' books?)

But the clinical evidence in favor of high-fat, adequate protein, low-carbohydrate nutritional plans keeps pouring in.

This study shows that the nutritional approach we favor reduces markers associated with aging and age related disease--independent of caloric intake. Which is another one of my mantras: calories are nearly meaningless.

In this study, body weight, serum leptin, insulin, fasting glucose, triglyceride, and free T3 significantly decreased as well as the triglyceride/high density lipoprotein ratios.

Carbs against Cardio: More Evidence that Refined Carbohydrates, not Fats, Threaten the Heart: Scientific American

via www.scientificamerican.com

More evidence that carbohydrates are the culprit in the obesity and heart disease epidemics.

It's not simply that reducing fat and increasing carbohydrates doesn't help, it actually has a negative effect.

Dr. Oz's Report on Diet and Genes

via www.doctoroz.com

Dr. Oz recently did a show on genetics and weight loss--nutrigenomics, which was a combination of really good information and some not so good information.

There is something to the idea that your genetic make-up has a lot to do with what kind of diet you will respond to and how. While isolating the particular genes that identify which diet is best for you is somewhat new, the general hypothesis has been around for awhile in the form of both anthropological and ethnographic nutrition. Which is to say: we've often looked at our human ancestors in general, and our specific ancestors and their places of origin in order to determine what diets suit which people best.

This is the foundation for the paleolithic diet--eat only what the cave men ate, nuts, berries, leafy greens, and meat--and for the real food movement, which basically says, if it has a food label, you shouldn't eat it.

The nutrigenomic idea is slightly misleading--the report suggests you have a gene that tells us exactly what you should eat.  This is not exactly the case.  You have genes that tell us what sort of disease processes and metabolic tendencies that you've inherited.  What diet that means you should have is, at best, a hypothesis, (what I like to call a SWAG, a scientific, wild-ass guess) much of it based on faulty premises, like the idea that low-fat dieting has a positive effect on stroke and heart-attack, or the idea of a calorie and its relationship to nutrition and obesity. 

For that is the most potentially misleading part of Dr. Oz's report: the idea that the bottom-line is "calories in, calories out"--the laws of thermodynamics tell us that this is not the case. It takes more energy to process a protein "calorie" than a carbohydrate "calorie". I use calorie in quotes, because even the concept of a calorie is rather bizarre and very flawed.

Quality of calories matter more than quantity, and it seems that all calories are not created equal.

It's not just calories in, calories out.  Not by a long shot. 

Low-fat diet vs. Low-Carb: Which Makes You Hungry?

From Edward Lear's The Book of Nonsense

Ghrelin, A New Gastrointestinal Endocrine Peptide that Stimulates Insulin Secretion: Enteric Distribution, Ontogeny, Influence of Endocrine, and Dietary Manipulations -- Lee et al. 143 (1): 185 -- Endocrinology

One of the popular claims of the low-carb diet craze is that there is no hunger. For a long time people accepted that hunger was just a part of weight reduction--it turns out that it may only be a part of weight reduction that involves inadequate fat and protein.

Ghrelin, one of the hormones involved in regulation of appetite, is decreased by a high-fat diet, and increased in the presence of a low-protein diet. Furthermore, intravenous gherlin stimulates insulin secretion.

All of which supports the popular claim that low-carbohydrate eating actually suppresses your appetite. Or rather than suppressing it, it likely returns your appetite to its natural state.

Who Gets to Define Low-Carbohydrate Diets?

OBJECTIVE Low-fat hypocaloric diets reduce insulin resistance and prevent type 2 diabetes in those at risk. Low-carbohydrate, high-fat diets are advocated as an alternative, but reciprocal increases in dietary fat may have detrimental effects on insulin resistance and offset the benefits of weight reduction.

via diabetes.diabetesjournals.org

So hold on--what's this? Low carb diets might have DETRIMENTAL EFFECTS on insulin resistance? Let's take a closer look.

Look at this sample menu below.  You'll see that in the "low-carbohydrate" they have included, bread, white potatoes, bread crumbs, carrots.  All foods that provoke insulin response.  So what they've determined is that "calories in and calories out" works no matter what the quality of those calories are. Both diets reduced overall body mass and both diets resulted in increased insulin sensitivity.   

This is not a low-carbohydrate diet in any sense of the term as it is understood clinically.  Furthermore, it is a pro-inflammatory diet as it includes gluten, white potatoes, and high-glycemic vegetables.  

Their conclusion that the insignificant findings on arterial health may become significant is speculative--and even more to the point, the pro-inflammatory effects of fat are only present in the presence of carbohydrates.  While including pro-inflammatory foods like gluten, white potatoes, and carrots, you've tested nothing but the pro-inflammatory effects of those foods. 

What is going on?  When will they test a truly low-carbohydrate anti-inflammatory diet without reservation? 

TABLE 1

Sample menus for a typical day on each intervention diet

Meal	Low-carbohydrate diet (7.7 MJ)	Low-fat diet (7.6 MJ)
Breakfast	Scrambled eggs (40 g); bacon rasher, fat trimmed, grilled (20 g); hash brown, grilled (45 g)	Cornflakes (40 g), bran-based cereal (7 g), semiskimmed milk (200 g), pineapple juice (250 g)
Lunch	Wholemeal bread (72 g), cooked ham (30 g), mayonnaise (25 g)	Wholemeal bread (72 g); cooked ham (60 g); mayonnaise, reduced calorie (13 g); cheddar cheese, reduced fat (20 g)
Dinner	Potatoes, in skins, boiled (145 g); chicken breast in crumbs, baked (140 g); peas, boiled (95 g); carrots, boiled (70 g); gravy instant granules (4 g)	Potatoes, in skins, boiled (260 g); chicken breast in crumbs, baked (120 g); peas, boiled (50 g); gravy instant granules (5 g);
Additional foods	Peanuts, roasted and salted (40 g); Brazil nuts (30 g); butter (21 g); cheddar cheese (44 g);	Chocolate mousse, low fat (55 g); apple (153 g); jaffa cake (13 g); cola (150 g); chewy cereal bar (23 g); fruit yogurt, low fat (150 g); white bread, toasted (27g); strawberry jam (10 g); semiskimmed milk (300 g)

More Evidence That "BMI" is useless

Primary author Dr. Eric Braverman compared the BMI data -- a calculation that uses height and weight to determine amount of body fat -- to results on the study participants using Dual Energy X-ray Absorptiometry scans -- a direct measure of percentage body fat.

via www.upi.com

Our clients know that we consider the BMI charts useless--and here's more evidence that this is so. Using Dual Energy X-ray Absorptiometry scans to provide a direct measurement of body fat percentage, Dr. Eric Braverman tested the current criteria for diagnosing obesity used in American medicine and the World Health Organization for gathering obesity statistics.

We weren't surprised to discover that not only is the BMI chart (using height and weight to determine body fat) inaccurate, it is leading to massive under-diagnosis of obesity.

This is why we rely on our own formula for determining your body fat percentage, using abdominal circumference (your waist measurement) as our primary data point in determining the health of our patients.

The fact is, as with many things in the body, it's about ratios and relationships. It's about a ratio of fat to lean tissue, and it is very much about where your fat is concentrated. The key point here being, not that gaining abdominal fat makes you unhealthy but: when you are unhealthy you will have excess abdominal fat.

Here's where it gets to be a cycle: that fat layer, caused by disturbances in the health of the body, creates further disturbances in the body which lead to more fat storage. It's a feed back loop between the fat layer (I call it "the fat parasite") and the body that our protocol is designed to disrupt, to make returning to a state of health--and staying there--more likely than with other approaches.

This is one of the key points in our protocol. A loss on the scale isn't necessarily a good measure of your increased health and fitness. In fact, it is quite possible to lose weight on the scale and be worse off, if that loss is lean tissue loss, while your adipose tissue stays the same or even increases.

Our protocol is designed to preserve lean mass and to target adipose tissue (fat) and this is why it stands out from other weight-loss methods.

It's interesting to note that the inaccuracy of BMI also works in reverse. It doesn't distinguish between healthy, lean tissue and body fat. So a healthy athletic individual (say a professional athlete) often qualifies as obese, when their abdominal circumference tells us otherwise.

So Braverman's ultimate conclusion--that the global obesity epidemic might be much bigger than the 300 million obese reported by the WHO--doesn't necessarily follow, though he may be correct. But the central point remains: BMI is a useless measure of health and fitness and should be placed in the round file of medical history once and for all.

Can a High-Fat Diet Beat Cancer? - TIME

via www.time.com

University of Wurzburg has recently tried to treat terminal cancer patients on a high fat, carb-free diet and observed some interesting results.

The theory is: cancer cells grow by metabolizing sugars, if the sugars are removed from the diet the cancer may stop growing or even shrink.

It wasn't a true clinical trial--but the results were interesting enough to generate a true clinical trial.

Two problems affected this preliminary study: one, was that only patients for whom all traditional therapies had failed were allowed into the study, so the group was already very bad off. Four patients died in the first week of the study.

Two, was that a handful of patients weren't willing to give up sweets and dropped out of the study.

However, five patients stayed alive and their condition stabilized or improved.

Based on this and previous studies on pediatric cancer patients and mice, the results provide a robust recommendation for a full-scale clinical study on low to no carb eating and treating cancer.

My Current Recommendations For Swine Flu (H1N1) and Seasonal Flu

These are the CDC's current Swine Flu Vaccination recommendations (updated 28 Aug 09): 

CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended that certain groups of the population receive the 2009 H1N1 vaccine when it first becomes available. These target groups include pregnant women, people who live with or care for children younger than 6 months of age, healthcare and emergency medical services personnel, persons between the ages of 6 months and 24 years old, and people ages of 25 through 64 years of age who are at higher risk for 2009 H1N1 because of chronic health disorders or compromised immune systems.

We do not expect that there will be a shortage of 2009 H1N1 vaccine, but availability and demand can be unpredictable. There is some possibility that initially the vaccine will be available in limited quantities. In this setting, the committee recommended that the following groups receive the vaccine before others: pregnant women, people who live with or care for children younger than 6 months of age, health care and emergency medical services personnel with direct patient contact, children 6 months through 4 years of age, and children 5 through 18 years of age who have chronic medical conditions.

My personal recommendations are based upon the following factors:

1.  CDC recommendations

2.  My general philosophical belief in the beneficence of vaccination for major communicable diseases

3.  My general bias against new medical treatments (i.e. less than one year's worth of data from widespread use in the general population) except in deadly diseases such as advanced AIDS - think recalls of cars in the first year of almost any new or redesigned Detroit auto model 

4.  The similarity of this Flu strain to that of the 1976-77, 1957, and 1918-19 strains, and the potential of full or partial immunity for those people old enough to have been exposed in any or all of those years

5.  The increased incidence of Guillain-Barre Syndrome (GBS), a potentially fatal autoimmune disease that causes paralysis, associated with the 1976 H1N1 vaccine (as a consequence the vaccine was withdrawn from use) (nb link to UK article below)

6.  The susceptibility of this year's H1N1 strain to Oseltamivir (Tamiflu) and presumably to Zanamivir (Relenza) (although laboratory resistance has been seen, this has not yet manifested as human resistance (nb link to promedmail below)

7.  The resistance of last year's seasonal influenza strain to Tamiflu, but susceptibility to Relenza (along with Amantadine and Rimantidine, 2 older flu meds that are not considered effective against influenza A

8.  This year's upcoming seasonal flu vaccine, the 2009--10 trivalent vaccine, contains the virus strains A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Brisbane 60/2008-like antigens.

9.  Most seasonal influenza A (H1N1) virus strains tested from the United States and other countries are now resistant to oseltamivir (Tamiflu) (per the CDC)

10. The unproven theory that dietary gluten (a protein found in grains such as wheat, rye, barley and oats) may be a contributing factor in the rise in autoimmune diseases in western cultures 

11.  Both Relenza and LAIV (one of the two seasonal flu vaccine options, the other being the TIV flu shot) are nasal sprays and should not be used by those with asthma or reactive airway disease, nor should pregnant women receive LAIV

12.  My prediction based on past seasonal flu resistance patterns is that we'll be seeing a drift (small change from past years' strains) rather than a shift (major strain change), and thus I think the seasonal flu vaccine will be very effective (around 80-85%)

Given all of the above considerations, here are my recommendations regarding seasonal flu and swine flu (H1N1):

A.  Follow the CDC guidelines for the seasonal flu (nb CDC link below) - get vaccinated and take your usual seasonal flu precautions

B.  Ask your doctor if there is a "Flu Entrance" to the office/clinic/ER to decrease exposures

C.  Sign up at cdc.gov for weekly email updates on swine flu, but remember that no government in human history has ever run a website, economy or healthcare system in a timely, efficient fashion.  The government can't keep you healthy or safe -it's your responsibility

D.  Viz. C. above, a Washington State biosurveillance firm warned the CDC about the current swine flu outbreak in Mexico 18 days before the World Health Organization (WHO) alert was issued.   You will get better real-time info from private sites such as google.org/flutrends

E.  Re: swine flu vaccination, the risk/benefit ratio is not so easy.  If you have only one of the risk factors mentioned by the CDC at the top of this post, I wouldn't recommend vaccination this year.  But if you are a 20-something healthcare worker with asthma or an autoimmune disease (i.e. 3 risk factors), get vaccinated

F.  If you are either exposed to or exhibit Flu-Like-Symptoms (FLS) which include fever >101 degrees, headache, dry cough, joint or muscle aches like you've been run over by a truck, do the following:

1.  If it's not during standard seasonal flu season (i.e. Dec-Mar with the peak usually beginning in mid-late Jan), assume it's swine flu and ask your doctor for Relenza (non-asthmatics only) or Tamiflu.  Remember, treatment is only useful if your symptoms are < 48 hours old - get treated quickly.  After 48 hours of symptoms, don't go to your doctor's office - it's either supportive care at home (fluids, naproxen or ibuprofen and tylenol),  or go to the ER if you're really sick

2.  If it's during flu season, it could be either swine or seasonal flu.  Ask your doctor for Relenza (non-asthmatics only) and either Amantidine or Rimantidine (as an optional boost against last year's Tamiflu-resistant seasonal influenza B).  If you are asthmatic, ask for Tamiflu for swine flu protection and either Amantidine or Rimantidine for Seasonal influenza B protection

G.  Pregnant women:  get the TIV (seasonal flu shot), not the LAIV (flu-mist nasal vaccine).  Follow the E. recommendation above.

H.  Children:.  I'm not a pediatrician - follow the recommendations of the CDC and your pediatrician

I.  Whether or not you have Celiac Sprue, start eating a gluten-free diet now.  Your immune system will thank you for it.

What will I personally be doing?  I'll get the seasonal flu shot as soon as it's available, but I will not get the swine flu vaccine this year, as I have only one CDC risk factor.  I will be wearing a mask while seeing patients during outbreaks to prevent transmission of subclinical flu (i.e. early infection before symptoms show).  I'll recommend the same for my wife.  For my 11 month old daughter, 2 seasonal flu shots and no swine flu shot.  For my 27 month old daughter, 1 seasonal flu shot (she got 2 last year per the CDC recommendations) and no swine flu shot

Worst case scenario: 

1.  Relenza- and Tamiflu-resistant swine flu emerges

2.  Relenza-resistant seasonal flu emerges

3.  Seasonal flu shifts instead of drifts, with ineffective seasonal flu vaccine

Result:  300-500,000 US deaths (i.e. 10 times worse than an average flu season)

Likelihood:  5%

More likely:  50-100,000 deaths (i.e. 1.5 - 3 times worse than average)

I will update this as the situation changes

http://www.dailymail.co.uk/news/article-1206807/Swine-flu-jab-link-killer-nerve-disease-Leaked-letter-reveals-concern-neurologists-25-deaths-America.html

http://www.promedmail.org/pls/otn/f?p=2400:1001:53103::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,78631

http://www.cdc.gov/flu/protect/keyfacts.htm

Depression Is Good

This article comes at the question of "Why Depression?" from a slightly different angle than did Dr. Steve Ilardi.  The premise here is that depression must create an evolutionary advantage, or else depressive tendencies would have been bred out. 

The working theory is that a depressive episode allows for rumination, or obsessing about a particular complex problem, which then allows the depressive to break that complex problem into its component parts.  These parts would then be potentially solvable. 

Maybe shamans were depressives who used mind-altering substances  to enhance their monomaniacal ruminations and solve the grateful clan's problems.

Or maybe the theory is flawed; maybe depression is like Huntingdon's Disease and doesn't fully manifest its evolutionary non-viability until after individual fecundity ends.

Interesting article.

Alcohol Cuts Alzheimer's Risk

http://www.eurekalert.org/pub_releases/2009-07/wfub-rma071309.php

Regular moderate alcohol intake has cognitive benefits in older adults:

Researchers found that individuals who had no cognitive impairment at the start of the study and drank eight to 14 alcoholic beverages per week, or one to two per day, experienced an average 37 percent reduction in risk of developing dementia compared to individuals who did not drink at all and were classified as abstainers. The type of alcohol consumed did not matter.

Cool.  Have an Irish Coffee on me.