Wednesday, March 31, 2010

What are we busy about?

“It is not enough to be busy; so are the ants. The question is: what are we busy about?”
 ~Henry David Thoreau

That is a good question, what ARE we busy about?!

Today is one of those days where almost every minute of my day is scheduled.

5:05 wake up. Make coffee, make lunch, write emails, read news/blogs. Practice (in by 6:25, out by 8:25). Home for quick shower and breakfast. On bike by 8:45. Clinic all day (scarfed down lunch of PB&J, fruit salad from fruit cart, and avocado mmm). Biostats class 4-7pm (here now… hungry again, multi-tasking, catching up on emails). Birthday taco dinner (Happy birthday, Caitlin!!) then Fanfarlo concert.

The more hectic the day, the more I need morning practice... it helps keep my mind un-busy even if my body isn't.

Tuesday, March 30, 2010

Mind-body hygiene

This month’s Yoga Journal has a nice article about Sat Bir Khalsa, a researcher and assistant professor of medicine at Harvard Medical School who has dedicated his career to researching yoga. I like how he talks about yoga as mind-body hygiene:

“I think of this as hygiene. We have dental hygiene, which is a well-accepted part of American culture. Schools teach it, doctors recommend it, parents reinforce it. Imagine if people didn’t routinely brush their teeth. That would be unheard of in this country! But what about mind-body hygiene? We have nothing for that.”

Monday, March 29, 2010

Prescriptions for the planet

I liked this week’s New England Journal of Medicine opinion piece about climate change and why medical professionals should care (the rise of infectious diseases being one reason).

The author, Emily Shuman, says, “I believe that it is also our responsibility as members of the health care community to do our part" and help reduce greenhouse gas emissions.

Yes! It’s not enough for the medical community to react to the rise in infectious diseases as a result of climate change, but also to prevent this from happening in the first place.

So what can medical providers do? The article references the EPA’s website with recommendations. Surprisingly, this site has no mention of eating less meat or more locally grown foods. I found this WikiHow site much more useful. It includes the following:
  • Eat locally
  • Bike more
  • Grow your own food 
  • Eat low on the food chain (vegetarian or vegan): “a vegan diet contributes 1.5 fewer tons of CO2 or CO2 equivalents to the atmosphere each year than the average North American diet" 
Seems like these are recommendations physicians should be giving… not only are they good for climate change, but they are also good for our health.

Sunday, March 28, 2010

Horse chow & food for thought

“Here are some factors for health and a long life which we have put into practice: positive, optimistic thinking; a good conscience; outdoor exercise and deep breathing; no smoking; no alcohol or drugs, including coffee and tea; a simple diet – vegetarian, sugar-free, salt-free, low in calories and fat and 55% raw. These will vitalize the life span. Avoid medicines, doctors, hospitals.”
~The Nearings, from Loving and Leaving the Good Life

In honor of our book club meeting today, we tried out the Nearing's horse chow (which they ate every morning). Simply mix together:
  • 4 cups oats
  • 1 juice of a lemon
  • 1 cup raisins
  • dash of sea salt
  • olive oil to moisten
Horse chow. It grows on you :)

Some more food for thought from this book…  

Have less, be more philosophy:
“It’s what you are, not what you have on that is important in life… I regard being and doing as the essential ingredients of life; merely living and having can be an obstruction and burden. It’s not what we have but what we do with what we have that constitutes the real value of life.”  

“One of the horrors of civilization. Direct experience is what we need; that’s what we’re here to get: experiential education, not through television, where we’re physically separated from doing. It separates the individual from reality; encourages passivity; implants deleterious images directly into the unconscious; dulls awareness; gives the illusion of experience; has a hypnotic addictive quality which is totally dangerous and obnoxious.”  

“One day a week, usually Sunday, we gave our digestive system (and whoever cooked) a rest, by eliminating our already light breakfast and lunch and fasting during the day. Having no scheduled activity except perhaps a walk or a swim, or putting up a bit of stone wall, we took the day easy. These fasting days were ended in the evening by the fire with a supper of popcorn, carrot juice or cider.”

Scott’s reaction to a doctor who told him to take vitamin B12 and get routine medical tests:
“If I did this I would be trying to prolong my life under medical supervision for the rest of my life. Thank you, but I would rather die much earlier than follow such a course… My formula is to stay well and live as long as I can, in moderate health and vigor. If I cannot stay well by a normal diet and temperate living, the sooner I did, the better for me and the society of which I am a member.”

Why be vegetarian:
“For every possible reason, but primarily ethical. George Bernard Shaw always answered the same question by another: ‘How can you justify the disgusting habit of consuming animal carcasses?’ We know of no valid reason for eating flesh. The rotting carcasses are full of diseases and poisons. Raw fruits and vegetables and nuts are vital and clean if organically grown. A vegetarian diet is simpler, more economical, and kinder.”

Friday, March 26, 2010

Research update: Month 5

We were awarded the grant and got IRB approval... so now we can really move forward with our study. This means it’s time for some self-experimentation!

So today, we drew our own blood to practice our telomere/telomerase measurement technique. Success! Our lymphocytes are currently sitting in a -80 degree freezer.

Being in the lab today was such a different experience from my pre-med lab classes in college (which I dreaded). Drawing the blood, seeing it separate into the three distinct layers (plasma, lymphocytes, red blood cells), calculating the number of my cells lying at the bottom of the test tube (which was 15 million!)… we were doing the practice behind all the theory. I’m sure it will get boring (as everything usually does), but right now I love it… and I can’t wait for our results.

“The irony is that science has served only to show how small human knowledge is…. and the scientists, no matter how much they investigate nature, no matter how far they research, they only come to realize in the end how perfect and mysterious nature really is. To believe that by research and invention humanity can create something better than nature is an illusion. I think that people are struggling for no other reason than to come to know what you might call the fact incomprehensibility of nature.”

~Masanobu Fukuoka (The One Straw Revolution)

Wednesday, March 24, 2010

Mysore-style medicine

Mysore-style yoga is self-practice of Ashtanga yoga. Each student individually learns the poses and practices them every day. In Philadelphia and in cities all across the globe, Ashtangis meet every morning for this practice (and many more practice in the privacy of their own homes).
Mysore-style yoga means that:
  • Each student practices at the pace that works for him or her.
  • The practice room is silent except for the words exchanged between teacher and student.
  • The teacher is educated in the theory behind the practice.
  • The teacher watches each student closely, provides guidance, and gives adjustments to each student.
  • A community is created based on the shared values of health and commitment, and the shared experiences of struggle and progress.
What if our medical system were to provide preventive medical care using the mysore-style paradigm?
  • Where patients commit to a “self-practice” of health and prevention.
  • Where doctors help teach, guide, and “adjust” each patient.
  • Where the community supports, encourages, and strengthens each individual’s self-practice.
  • Where physicians work together with patients to create health, rather than react to disease. 
Mysore-style medicine is good in theory (the 1%). How might it work in practice?

I think Dean Ornish's lifestyle program (where patients commit to a low-fat vegetarian diet, exercise, and stress reduction) is one successful example.

Tuesday, March 23, 2010

The most daring thing

"What should young people do with their lives today? 
Many things, obviously. 
But the most daring thing is to create stable communities 
in which the terrible disease of loneliness can be cured." 

~Kurt Vonnegut, Jr.

Monday, March 22, 2010

Health Reform: Prevention, Wellness, & Primary Care

"Of all the forms of inequality, injustice in health care is the most shocking and inhumane."
~Martin Luther King, Jr
Health care reform passed in the House last night, and if all goes well will become final this week. Representative James E. Clyburn of South Carolina said, “This is the Civil Rights Act of the 21st century.”

With this reform, 32 million previously uninsured people will now be insured, health insurers will be unable to deny or drop coverage to the sick, small businesses will receive tax credits for buying employees’ health insurance, and the Medicare “doughnut hole” will be closed.

In addition to all of that, there are many exciting preventive/ wellness/ primary care changes worth highlighting.

The bill will:
  • Establish a “Community-based Collaborative Care Network Program” for health care providers to create integrated health care services for low-income, uninsured, and underinsured populations.
  • Establish “The National Prevention, Health Promotion and Public Health Council” to coordinate prevention, wellness, and public health interventions.
  • Create a Medicare demonstration program called “Independence at Home” to provide primary care services in patients’ homes, allowing health professionals to share in savings from reduced hospitalizations, reduced health services, and improved health outcomes.
  • Establish a grant program to support evidence-based and community-based prevention and wellness services that increase prevention, reduce chronic disease rates, and address health disparities.
  • Provide free evidence-based preventive services (i.e. no cost-sharing).
  • Provide grants for small employers to develop “wellness programs,” and establish pilot programs to financially reward employees for participating in these wellness programs.
  • Require chain restaurants and vending machines to disclose nutritional content of each item sold. 
  • Increase residency-training positions, prioritizing primary care and general surgery in areas with low physician-to-population ratios.
  • Increase flexibility in laws regarding residency payment in order to promote training in outpatient settings.
  • Ensure availability of residency programs in rural and underserved areas. 
  • Increase workforce supply of health professionals by providing scholarships and loans for primary care training, providing grants to providers in medically undeserved areas, recruiting providers to rural areas, creating loan repayment programs, training residents in preventive medicine and public health.
  • Support the development of training programs that focus on the primary care models of medical homes, team management of chronic diseases, and the integration of physical and mental services.
  • Increase funding for community health centers. 
  • Establish new programs for school-based health centers.

Sunday, March 21, 2010

Farming & Medicine

The first seeds are planted for our garden (beets, mixed greens, and cilantro) and I’ve been reading The One-Straw Revolution by Masanobu Fukuoka. This book is opening my mind to the world of farming. Most surprising though, is how this little book about farming is also about my world of medicine.

An excerpt from my reading today that parallels many of my thoughts on modern medicine and medical research:
Before researchers become researchers they should become philosophers. They should consider what the human goal is, what it is that humanity should create. Doctors should first determine at the fundamental level what it is that human beings depend on for life.

In applying my theories to farming, I have been experimenting in growing my crops in various ways, always with the idea of developing a method close to nature. I have done this by whittling away unnecessary agricultural practice.

Modern scientific agriculture, on the other hand, has no such vision. Research wanders about aimlessly, each researcher seeing just one part of the infinite array of natural factors which affect harvest yields. Furthermore, these natural factors change from place to place and from year to year…

Modern research divides nature into tiny pieces and conducts tests that conform neither with natural law nor with practical experiences. The results are arranged for the convenience of research, not according to the needs of the farmer. To think that these conclusions can be put to use with invariable success in the farmer’s field is a big mistake…

Even if you can explain how metabolism affects the productivity of the top leaf when the average temperature is eighty-four degrees (Fahrenheit), there are places where the temperature is not eight-four degrees. And if the temperature is eighty-four degrees in Ehime this year, next year it may only be seventy-five degrees. To say that simply stepping up metabolism will increase starch formation and produce a large harvest is a mistake. The geography and topography of the land, the condition of the soil, its structure, texture, and drainage, exposure to sunlight, insect relationships, the variety of seed used, the method of cultivation – truly an infinite variety of factors – must all be considered. A scientific testing method which takes all relevant factors into account is an impossibility.

Saturday, March 20, 2010

Loving spring

“It's spring fever. That is what the name of it is. And when you've got it, you want - oh, you don't quite know what it is you do want, but it just fairly makes your heart ache, you want it so!
~Mark Twain

I love this quote and it perfectly fits how I feel today on this warm Saturday spring morning. A taste of new projects and ideas... a feeling that things are slowly sprouting.

Hopes for the day: run by the river, farmer’s market, coffee in the park with an old friend, seed shopping (for the hoped-for garden on our balcony!), paper writing, book reading (The One-Straw Revolution)...

Thursday, March 18, 2010

Match day!

Today is “match day!” Congratulations to all of my classmates!

This is the day 4th year medical students open the envelope that tells them where they will be doing their residency… it’s an exciting (and anxiety-filled) day.  (Because of my research, I’ll be doing this a year from now).

Out of the ~150 graduating students this year, I counted 7 doing family medicine or primary care internal medicine. That’s only 4.6% of the class!!

With all the talk about health reform and the need for primary care physicians, I can’t believe how few of my classmates are going into primary care! And I mean, actually going into primary care… because most going into the traditional primary care fields (internal medicine, pediatrics) plan on doing a fellowship (i.e. in cardiology, infectious disease, pulmonary, renal, oncology/hematology, etc), and will become specialists.

Of course, specialists play an important role in medical care. But at the same time, the world really needs more well-trained, comprehensive, and forward-thinking primary care physicians.

Part of the reason more people don’t go into primary care might be the prejudice that exists against it. I am always prepared for the occasional negative reaction when I tell people about my plans to do family medicine, such as:

“Why? They are inferior to specialists and have to constantly defer to them….They earn little money… Their knowledge of medicine is an inch deep and a mile wide…. They are viewed disrespectfully by doctors who specialize.”

These reactions certainly feed insecurity about my career choice, but they also motivate me even more…. primary care docs need to prove these people wrong!

Wednesday, March 17, 2010

Lessons from da Vinci

“Iron rusts from disuse; water loses its purity from stagnation ... even so does inaction sap the vigor of the mind.”
~Leonardo da Vinci
Some of my favorite factoids about this man:
  • A vegetarian
  • Bought caged birds just to release them
  • Did daily aerobics and stretching exercises (yoga?!)
  • Kept journals of lists, ideas, drawings
Here is Wikihow’s (love this!) summary of the steps to think more like Leonardo da Vinci:
  1. Be curious: ask questions, cultivate an open mind
  2. Test knowledge: experience, question, learn from mistakes
  3. Refine senses: enhance sight, draw, practice mindfulness
  4. Embrace uncertainty and mystery: practice the Socratic method – ask questions rather than give answers
  5. Balance art and science, combine logic and imagination
  6. Cultivate fitness and poise: physical fitness, body awareness, ambidexterity*
  7. Recognize interconnection of all things: “systems thinking”
*Ambidexterity! This is one I can start practicing… left hand for teeth brushing, unlocking my bike, eating, etc.

Tuesday, March 16, 2010

Aversion to relaxing

Hard practice today… sore, slow, my mind in other places.

I blamed it on the recent cold rainy weather and my poor sleep. “Tomorrow will be better,” my teacher said.

I rushed through the finishing postures – barely a shoulder stand, a few breaths in headstand, and a quick savasana (the final rest).

Afterwards my teacher came up to me, “You have to take a longer savasana… It’s all related.” The difficult practice, the not sleeping, the rushing through the finishing postures.

“You have an aversion to relaxing,” he said.

“I have an aversion to relaxing?” Yes.

He is right. This is something I can be blind to, something I need to work on.

What I think is most important about this: his observation is something my primary care doctor (if I had one) would never have noticed this about me. It is only in my daily practice with him that he sees my habits and tendencies… allowing him to identify and correct them.

Monday, March 15, 2010

Obesity: A symptom of poverty

This NY times article on the Obesity-Hunger Paradox is worth the read (thanks to Rob for sending my way!).

The article quotes Joel Berg, executive director of the New York City Coalition Against Hunger, who says: “Hunger and obesity are often flip sides to the same malnutrition coin… Hunger is certainly almost an exclusive symptom of poverty. And extra obesity is one of the symptoms of poverty.”

Many poor neighborhoods simply do not have access to fresh fruits and vegetables. People are not starving, but they are “food insecure.” If the only food available/affordable is fried foods, doughnuts, etc, then that is obviously what people are going to eat.

This is a ripe area for some creative and innovative thinking, and New York City has come up with some good ideas. One solution is “Health Bucks,” where the city encourages the use of food stamps at farmers’ markets by giving an extra $2 for each $5 spent there. Other solutions include getting fresh fruit and vegetable carts into poor neighborhoods, and providing tax credits for grocery stores that move to these areas.

In my view, research on healthy food is useless if people aren’t able to apply it to their lives. It seems that before anything else, we need to figure out how to get basic, nutritious, health-full foods to neighborhoods that need them the most.

Sunday, March 14, 2010

Gems from Geeta

Today I went back to Geeta Iyengar’s book, Yoga: A Gem For Women.

Geeta was a very sick child. After almost dying from a kidney infection, her father (BKS Iyengar) told her: “From tomorrow onwards no more medicines. Either you practice Yoga or get prepared to die.” So, she began practicing yoga.

Here are some gems from her book...

On woman today:
“She now has to do the double work of having to meet financial pressures and maintaining harmony in the family. It is necessary for her to keep perfect health and harmony to withstand the stresses and strains of life. Yoga is capable of giving this needed relief if she devotes a little of her time daily to its practice.”
On motherhood:
“Motherhood is woman’s ordained duty. This is not merely a physical state, but a divine state. In giving birth new responsibilities begin for her and she has to prove herself. Motherhood adorns her with the sacred qualities of love, sacrifice, faith, tolerance, goodwill, and hard work. This is her highest religion – her svadharma. These qualities are ingrained deep into her nature… For all this, woman has to pay a high price physically and psychologically in her role of mother, wife, sister, and friend. Stabilization of the physical and mental states is achieved by asanas and pranayama. Her salvation lies in practicing them.”
On health:
“Without health there is no strength. Strength is preserved only when health is maintained. Health of the body means both physical and mental well-being. It is a sign of a peaceful state of the body and the mind when one is able to follow ethical codes, maintain moral standards, and fulfill social obligations… as the Upanisad says: “The Self is not realized by a weakling.

Saturday, March 13, 2010

Nature does not hurry

Rainy Saturday: a trip to the farmers market, hours spent reading a book, and a (much needed) day of rest from practice. After a week of constant rushing and busyness, I long for days like this. But then why do I find myself missing the hurry and structure of to-do lists?!

I like this quote by Lao Tzu and want to remind myself of it more often: “Nature does not hurry, yet everything is accomplished.”

Friday, March 12, 2010

Up to our generation

Throughout this class on cancer over the past two weeks, I’ve been paying special attention to the role of diet in both the cause and treatment of various cancers. The take away points are:

1) The food we eat impacts virtually every part and process in our body: inflammation, immune function, metabolism, oxidative damage, and more.


2) There is not enough funding for studies on diet (or other lifestyle changes). The big money goes towards drug development.

One researcher said that his generation has largely failed in this area, and “It will be up to your generation to introduce some of these dietary changes.”

Yoga stops trafficking

Check out this one-day global yoga event to raise awareness about human trafficking in India (this Saturday)!

108 sun salutations, led by Odanadi children in Mysore.

(anyone know of an event in the Philadelphia area?!)

Thursday, March 11, 2010

Guest Blogger, Rob Shulman: Eating local and in-season

One habit I wanted to develop in 2010 was to eat more local and in-season food, but I have found this especially challenging during the winter here. I met Rob through the Philadelphia ashtanga yoga community. I love how he writes about the beauty and benefits of eating this way (especially in the winter), and how it goes hand in hand with our practice of yoga.

Guest blogger, Rob Shulman:  
Eating local and in-season

I have followed the local and in-season concept since the '90s during my first vegan/veggie sojourn (this time I have returned to that diet as a result of my yoga practice and it feels so much better).

My body loves welcoming each new item according to the season and I enjoy knowing I can connect that food with a local farmer. Eating locally forces you to become resourceful to find new ways to enjoy the veggies and fruits you may slowly tire of over the winter. I love all the squashes and apples our region in particular offers, and find new ways every day to enjoy them in my kitchen. I may start canning, which only adds to the arsenal of good food to extend through the Winter, a time that seems to be the most trying for people to maintain the local food strategy. Winter is indeed a time of dormancy, but also can be a time for creative exploration.

Eating local and in-season has another wonderful benefit. Just like our bodies become more accustomed to the cycle of the moon and nature because of our beautiful yoga practice (i.e., how we rest on moon days), our digestive system and thus mind become that much more active and open by eating locally. Our body really awakens with the arrival of Spring and its fresh greens and then rejoices with the arrival of Summer with its broad selection of fruits. And when our body has had its fill of Summer fun, it welcomes the cooler climate and comforting foods that arrive in the Fall (my favorite season).

I think eating in this way also makes you appreciate the wonderful gift of living in the Northeast, with its four true seasons. And it is certainly complementary to our yoga practice and all that it encourages us to achieve.

~Rob Schulman

Wednesday, March 10, 2010

And for prevention?

Patient-doctor interaction of the day:

Patient (just finished chemotherapy treatment): What can I do for prevention?

Doctor: Nothing. The only thing I can tell you is to have moderate alcohol intake. There is some evidence for that.

No word on exercise and nothing on diet.

The thing is, he's a great doctor and his patients absolutely love him. I just think this reflects how doctors are being trained these days... trained to think about treating a disease rather than creating health.

Tuesday, March 9, 2010

The price of innovation

I love this quote by Scott Nearing:

“The majority will always be for caution, hesitation, and the status quo – always against creation and innovation. The innovator – he who leaves the beaten track – must therefore always be a minortarian – always be an object of opposition, scorn, hatred. It is part of the price he must pay for the ecstasy that accompanies creative thinking and acting.”

~Scott Nearing (From Loving and Leaving the Good Life by Helen Nearing)

***Want to talk more about this book? Join us Sunday March 28 for our Philly book club's first meeting! A book list for future meetings is to the right...  please send your suggestions for others!***

Monday, March 8, 2010

Diet matters

This study shows an association between diet and ovarian cancer survival. About 1 in 71 women will be diagnosed with ovarian cancer. It is the 5th most common cancer and 5th leading cause of death in American women. Unfortunately, ovarian cancer is usually diagnosed at late stages… and so it often has a poor prognosis.

This study analyzed the diet of 341 women before their diagnosis of ovarian cancer, and looked at their cancer survival rates.

They found that patients who ate yellow and cruciferous vegetables prior to their diagnosis had significantly longer survival times, while those who ate meat and drank milk had significantly shorter survival times.
Survival curves for vegetables (left) and yellow vegetables (right). Longer survival with more vegetables, and specifically more yellow vegetables.
Survival curves for meat (left) and milk (right). Longer survival with less meat and less dairy.

It is important to note that this study looked only at dietary habits before the diagnosis of cancer, so tells us nothing about the effects of a dietary change on cancer outcomes (this would be a good question for future studies).

The dairy finding is especially interesting to me. Potential explanations the researchers suggest include: 1) molecules in milk (such as galactose) are directly toxic to the ovaries, and 2) hormones given to cattle for growth (which humans ingest along with the milk) can lead to cancerous growths.

The explanation for meat’s role in lowering cancer survival rates include the following: 1) fat and cholesterol present in meat, 2) hormonal substances given to cattle, 3) carcinogens generated during the processing and preparation of meats, and 4) high iron content of red meat (iron causes oxidative stress leading to DNA damage).

This study provides data for what may seem intuitive to many: that the food we eat before any diagnosis of cancer will influence our ability to survive it.

Sunday, March 7, 2010

Sets of 54?!

I’m working on fluidity in my backbends/drop-backs – cutting out the extra breaths and the purposeful distractions.

The other day after finishing my usual 3-5 drop-backs and ready to move on, my teacher looked at me and said: “Do sets of 54.”

Haha, umm, sets of 54?! He must be joking! I laughed (along with everyone else who overheard).

But maybe he wasn’t joking? Iyengar did 108 drop-backs in row – that’s two sets of 54 (and if you watch videos of him, he makes them look effortless).

Saturday, March 6, 2010

Time to think

Yesterday, I overheard part of a conversation between two scientists. One said to the other:

“You’ve got to make time to think.”

You’ve got to protect whole afternoons. You need chunks of time. That time and space is essential for creativity and moving forward with ideas.

One thing I love about the research world is that thinking, brainstorming, and hypothesizing are prioritized. If only there were more of this in the clinical world!

Unfortunately, it seems that too often clinicians (including attendings, residents, interns, and medical students) are busy, overworked, and sleep deprived… leaving little time (or motivation) for thinking.

Friday, March 5, 2010

Guest Blogger, Michael Boucher: "Applying research to practice"

Applying research to practice
Michael Boucher

The headline of the study was simple and clear: healthier diets linked to better mood and less depression.

But what does that actually mean?

In writing about this article, I want to talk about a larger issue: how do doctors continue to learn medicine?

As a soon-to-be doctor, I realize I don't know the best way to learn and use new knowledge and information. How do I balance my learning between:

1) textbooks (the established knowledge, and the party line)

2) professors (real-life knowledge with a heavy dose of personal idiosyncrasy)

3) industry-sponsored medical education programs (easy access, cutting edge research, but often heavily biased)


4) research journals (the "highest and most pure" form of knowledge acquisition, but with hundreds of new articles every month, how am I to consistently and reliably learn this exponentially-growing body of knowledge).

So, with these questions in mind, I read the abstract.

The take-home point of this article is the following: middle-aged Australian women who ate a "healthy" diet had lower rates of depression and anxiety compared to those women who ate a "unhealthy" diet. To quote the article:
"After adjustments for age, socioeconomic status, education, and health behaviors, a "traditional" dietary pattern characterized by vegetables, fruit, meat, fish, and whole grains was associated with lower odds for major depression or dysthymia and for anxiety disorders. A "western" diet of processed or fried foods, refined grains, sugary products, and beer was associated with a higher [rates of depressive symptoms]."
However, as the authors point out in science-speak: “These results demonstrate an association between habitual diet quality and the high-prevalence mental disorders, although reverse causality and confounding cannot be ruled out as explanations."

In other words, we don't know if better diets cause better moods, or if better moods cause better diets, or if some third unknown variable causes both better moods and better diets.

This is a well-known problem in science and medicine: It is "easy" to design a study that finds correlations between two variables. It is “very hard and expensive" to design to study that proves causation. We would need a "prospective, randomized controlled" study that does the following:

Takes a group of depressed people. Randomly split them into two groups. One group gets psychiatric treatment and continues to eat their normal diet. Another group gets psych treatment PLUS a healthy diet. Control for as many variables as you can think of, and see if one group becomes less depressed than another.

Simple in theory, incredibly hard in practice.

So how does that affect me?

If I were a researcher, I would say: Okay, lets try to design that prospective randomized study.

But I am not a researcher. I am a consumer of medical research. So when I read this, I get conflicted:

My instinct says: of course better diets would help with depression. That just makes sense.

My logical mind says: I cannot let the results of this study affect my clinical practice. It would be wrong to use these results in the way I treat patients, because I don't know if it is true. In fact, it may even be harmful. While it seems to hard to believe, a perfect example of "jumping to conclusions" is the selenium / prostate cancer study. For several years, higher selenium levels were correlated with lower rates of prostate cancer. But, when they randomized men to either selenium supplements or nothing, they found, surprisingly, that higher rates of selenium supplementation actually resulted in HIGHER likelihood of prostate cancer. In other words, even though the correlations suggested that selenium was good, when we actually did a randomized controlled study, we discovered that it was actually bad.

With this is mind, I think it is very important to think critically about how medical doctors consume medical information. Studies of correlation abound in medicine research articles. But I believe that if we let these studies influence our practice, we are doing a disservice to our patients. As a thought experiment: Imagine a drug company publishes a study that showed that people who took their drug also happened to be healthier. Would you start prescribing this drug? No! You would demand a randomized control study. So why shouldn't we hold nutrition and "alternative therapy" research to the same scientific standard? Yes, it is hard to do these studies, but if we want to be fair to our patients, we need to be honest with how we consume the research.

Finally, to those potential readers who are not in medical school. I want to reassure you that there are resources for doctors to help keep up with the literature. Non-profit, non-industry organizations like The Cochrane Database and Essential Evidence spend significant time and energy combing through the medical research and publishing the meaningful, scientifically accurate and clinically relevant research for medical professions. Furthermore, I can use the vast research universe not as a book I need to read from beginning to end, but as a database that I can access and evaluate when I have a clinical question. I have a decent understanding of how to evaluate the research. I just need to be consistent in how I choose to consume this information.

I am curious if you think like me, that it is wrong to apply the results of correlational studies like this to your clinical practice?  

Mike is a 4th year medical student going into psychiatry.

Thursday, March 4, 2010

People want a pill

I'm taking a fascinating class this week about cancer and emerging therapies. Today we had a lecture on COX1 and COX2 inhibitors (enzymes which are blocked by aspirin, ibuprofen, and other non-steroidal anti-inflammatory drugs - NSAIDs).

Brief summary: Inflammation in the body can promote cancerous growth. Conversely, decreasing inflammation is protective against cancer.

This does not mean we should simply take anti-inflammatory drugs (NSAIDs) as cancer prophylaxis, because these have side effects (as all medications do).

After the lecture, I asked the speaker how diet affects inflammation levels in the body. He said: 1) there is evidence that increasing omega 3 fatty acids decreases inflammation, 2) people in Japan and India (where there is lower meat intake) have lower rates of colon cancer (which then increases when they switch to a western diet), and 3) body fat acts as an inflammatory substance.

Then he said:

“But people want a pill. They don’t want to have to change their lifestyle.”

I'm wondering if that's really true – do people really want a pill? It’s easy to use that as an excuse for expensive drug studies, but I also think that people (especially doctors) aren’t educated enough about the power of diet and lifestyle change.

Wednesday, March 3, 2010

Eat meat?

Doctor-patient interaction I witnessed today...

Patient (two years out from breast cancer diagnosis): 
What do you think about eating meat?


If I had to give up meat, I’d kill myself. I don’t think there’s any evidence that eating meat is detrimental.

Tuesday, March 2, 2010

The doctor of the future

“The doctor of the future will give no medicine, but will interest his patients in the care of the human body, in diet, and in the cause and prevention of disease.”

~Thomas Edison

Monday, March 1, 2010

Research year update: Month 4

"All you need in this life is ignorance and confidence; 
then success is sure."  
~Mark Twain

The further along I get in this research study, the more I realize how hard it is going to be.

We’re moving into the phase of less creative questioning, less theorizing, and more logistics. How are we actually going to carry out our ideas?

Two challenges I’m struggling with:

1) Human beings are complicated.

Small sample sizes and human complexities make clinical studies “noisy”... and difficult to identify trends and associations. Answering our research question would be much more straightforward in genetically identical mice.

2) Recruitment is hard.

How do we get patients to enroll in studies? This is what I've been thinking about:
  • The study question has to be understandable and appealing so people want to be involved.
  • The time commitment must be minimal – everyone is busy.
  • Offer compensation – money is always appreciated.
  • Work with physicians who will encourage their patients to enroll – much better to come from your doctor rather than a stranger in the waiting room.
  • The recruiter should be genuinely excited about the study and share that with the patient. 

"Genius is one per cent inspiration and ninety-nine per cent perspiration. Accordingly, a 'genius' is often merely a talented person who has done all of his or her homework."
~Thomas Edison

I need to remember that as with anything - research, doctoring, yoga, habits, relationships, love - it’s 99% practice, 1% theory