Doctor Pierce's Notebook

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.

Lard and Fat - Yum

Slate Magazine references the book Fat: an Appreciation of a Misunderstood Ingredient, with Recipes.   The book has won the Best Single Subject Cookbook award, as well as Cookbook of the Year, at the 2009 James Beard Awards, and is on my bedside table.  This gist of the article is that lard has gotten a bad rap. 

Lard's advantages over vegetable shortening:

1.  No trans fats to cause an immune/inflammatory response

2.  Mostly monounsaturated, and even the saturated portion will increase your HDL*

3.  Great taste and texture in cooking/baking

4.  Higher smoking point (along with coconut and palm oils), meaning less fat absorbed by whatever you're frying

Vegetable shortening's advantages over lard:

1.  Um, none that I can think of

The article outlines a method to make your own lard.  Unfortunately, unless your live near my brothers and my mom in Charlotte, NC (pork capital of the world!), it can be difficult to find pork fat in your grocery store.  I make my lard with Trader Joe's Low Sodium Bacon, following the method outlined in the article.  You can even use this TJ Lard in cooking/baking; just don't add any additional salt to your recipe.

*Remember HDL is the "good" cholesterol and you want that level to be higher

Celiac Sprue Review Article

Here is an article written by Dr. Alessio Fasano, one of the world's leading experts on Celiac Sprue, an autoimmune disease that causes poor absorption of vitamins, minerals and other nutrients in the intestines. The gist of the article is that Celiac Disease, like other autoimmune diseases, occurs in the presence of 3 factors:

1.  Exposure to an environmental factor (in this case, gluten, a protein found in many grains such as wheat, barley, rye and oats)

2.  Genetic susceptibility

3.  Having an unusually permeable intestinal wall (a "leaky gut" as Dr. Fasano calls it)

What makes gluten so special?  All proteins are made up of amino acids (20 or 22 of 'em, depending on who's counting), of which 8 are considered essential (meaning the body can't manufacture them, and must get them from the diet.)  Most protein gets broken down quickly into amino acids, but gluten contains large amounts of glutamine and proline, 2 amino acids which resist easy breakdown.  The resulting bigger chunks of protein cause an immune/inflammatory response (the gut makes a food/not food decision and says "not food").  The end result is slowly worsening absorption of vitamins, minerals and other nutrients.  If you think of the intestines as a tube with fingers projecting from the inner wall, this immune response cuts the fingers off at the first knuckle, decreasing absorption.  End result:  abdominal pain, diarrhea, anemia, potentially death (up to 35% probability according to Dr. Fasano). 

People of Celtic origin (Irish, Scottish, British, Welsh) have about a 5% likelihood of having the genetic susceptibility, but it can occur in others.  Dr. Fasano quotes a 1 in 133 chance, meaning 45 million people may be at risk.  Unfortunately, gluten may be giving us a double whammy - it may be the proximate cause of the leaky gut, also.

Speculation:  Could gluten be the inciting cause (or at least the straw-camel-back) of all allergic disorders?  Occam's Razor says at least "maybe."  It would be useful to look at the rate of autoimmune diseases in southern China before the introduction of wheat into their diet (rice does not contain gluten) versus now.

BMI Bogusity

These two  articles align with my thoughts on Body Mass Index--which is to say that BMI is not a useful measure of health.  BMI's only advantage is that it uses the data that's easiest to obtain - everbody knows their height and weight.  Unfortunately, it doesn't take weight distribution into account.  BMI numbers will tell you that your 92 year-old bottom-heavy, tiny-waisted great-grandmother  (with an HDL cholesterol of 117 and a triglyceride reading of 93)  is just as obese as your 56 year-old skinny-legged and pot-bellied aunt (HDL 33, TG 237) and that simply isn't the case.  

What really matters is not arbitrarily defined obesity but waist size corrected for frame size in men, and waist size and waist to hip ratio corrected for frame size in women.  Simply put, it's good to have a small waist for men, and a small waist and bigger hips for women.

So, I've come up with my own way of measuring risk of dying, the WARM for men (Waist to Arm Ratio Measurement) and WHARM for women (Waist to Hip to Arm Ratio Measurement.)  I'll use myself as an example.  

My waist today is 33 1/4 inches.  I measure it at its widest point around the belly button.  I take my arm measurement which is the width at the bony part of the elbow with my arm bent at a 90 degree angle.  (This is called the epicondyles.)  I use body fat calipers to make the measurement.  So that makes my WARM 33.25/2.7 = 12.3. 

For women it's more complicated.  Your Italian great-grandmother's WHARM with a waist of 32 inches, hips of 48 inches and an arm measurement of 2.5 inches would be the waist to arm ratio multiplied by the waist to hip ratio, or (32/2.5) X (32/48) = 8.5.  Your  aunt's WHARM with waist 40, hips 38, and arm 2.3 would be (40/2.3) X (40/38) = 18.3. 

If you are actively trying to improve your health, whatever fitness and nutrition program you start out on, if the number drops lower as you go, you are decreasing obesity related health risks.  If it stays the same or goes higher, then your health risks are increasing.  It is important to note that a drop in the scale won't necessarily translate into a drop in your WARM/WHARM index.  

This Japanese study shows a higher risk of mortality in the lowest quartile of BMI the underweight people, with no higher risk for "obese" BMIs.  This is probably a malnutrition/cancer/chronic disease effect.  I know, I'm citing a BMI study after I've been trashing BMI as a measure.  I will have to come up with an adjustment factor for the risk of being underweight.

Let's say we're all 5 ft 7 in tall and we all weigh 162 lbs.  That means we all have a BMI of 25.  Are we all equally at risk?  Who's gonna live the longest?  What's the ideal WARM or WHARM?  I don't know yet, but lower is probably better (up to a point.)  I'll start keeping data on patients, looking at HDL, TG, LDL, cardiac CRP, and what actual diseases such as diabetes, HTN, CAD, cancer, BPH, and other diseases effected by inflammation.

Swearing Alleviates Pain

I love this.  Now when your spouse yells at you after you drop the F-Bomb after you drop the X-Box on your foot, you can say, Dr. Pierce says it's gooood to swear.

6 Step Depression Cure without drugs

I recently saw an interview by Dr. Helen Smith of Dr. Steve Ilardi, whose team of midwestern psychologists has an old-fashioned way of preventing/treating depression - go back to the cave.:

To confront the country's growing depression epidemic, a modern phenomenon, psychologist Steve Ilardi peered backward into human history. Way back: tens of thousands of years and beyond. His research steered him there, to an examination of the hunter-gatherer way of life, to a time when humans lived in roving, close-knit bands. Back to the Stone Age. What he learned led Ilardi and his research team at the University of Kansas to propose a program to reclaim six disappearing lifestyle elements. They call it Therapeutic Lifestyle Change, intended to help modern humans deal with depressive illness. The team identified factors that are antidepressant but are compromised by contemporary culture: Exercise, omega-3 consumption, light exposure, sleep, social connectedness and anti-ruminative behavior (From healthyplace.com). I have yet to read the book, but it certainly appears to be an interesting premise. HT:  Instapundit

Caffeine Reverses Alzheimer's

Drinking 5 cups a coffee a day could reverese Alzheimer's according to a recent study.