Our practice Family Medicine Coeur d’Alene was formed in 1977 with the vision of providing an organized, intelligent, compassionate, and caring healthcare environment.  Here at Family Medicine Coeur d’Alene, we pride ourselves on uniting the best aspects of traditional primary care- the “town doctor”- with the current evidenced based medical care.   Our knowledgeable, caring staff takes pride in providing consistent, continuous care to you and your family- in both sickness and health. While we believe that prevention and early management is the key to long-term health, we also try to be present for our patients in crisis care. We are one of the few primary providers in the area who continue to follow our patients’ care in the hospital.  This demonstrates our commitment to continuity of care.

Primary Care Medical Home, also referred to as the Patient Centered Medical Home (PCMH), Advanced Primary Care, and the Healthcare Home, is a promising model for transforming the organization and delivery of primary care.  This model aligns with many of the long time traditions and goals of Family Medicine Coeur d’Alene, but expands on it to carry us into a new generation with electronic medical records and a transforming face of healthcare delivery in our increasingly convoluted healthcare system.

A Medical Home is not simply a place but a model of primary care that delivers more effective care that is:

- Patient-Centered

- Comprehensive

- Coordinated

- Accessible, and

- Continuously improved by a systems-based approach to quality & safety

Patient-Centered:

We hope to empower our patients to invest and participate in their own health and wellness.  This is the first goal of the new Medical Home model.  I believe we can come closer to achieving this with the help of our commitment to education, Electronic Medical Record, Patient Portal, and Team Approach.  It is our hope to always involve you in informed medical decision making and in the to empower you with knowledge by providing access in the next year to your own labs, imaging, and ‘Patient Plans’ through your own internet based ‘Electronic Patient Portal”.  We hope to have better access to both electronic and paper resources on your relevant disease processes; and guide you on measures you can take to improve their own health outcomes.

Demands for increased production, increasing paperwork and prior authorizations, and shortage in primary care providers has driven shorter visit durations, squeezing more patients into already overbooked schedules.  This can create an atmosphere with little room for your involvement in medical decision making, little time for teaching, decreased time for preventative care, and underutilization of lifestyle and dietary counseling and intervention.  It is our hope that by adopting the Medical Home model we can prevent the loss of patient centered medical care that we all value so much!

Increased economy hardships have created a need for patients to address more each visit as many are unable to afford return visits and multiple copays.  In addition, many folks are often delaying medical attention until illness is more advanced or numerous issues have piled up increasing the complexity of each visit.   We know, and have proven over and over that investing in preventative care and health maintenance is far less costly then trying to fix things after they are broken or addressing only crisis care.  Effectively managing a diabetic or congestive heart failure patient with regular visits, open communication, coordination assistance, and regular access is significantly cheaper and clearly better for the patient than the alternative.  Crisis care for uncontrolled chronic illness burdens the ER, requires prolonged hospitalizations, and increases the need for expensive invasive interventions.  We also know that patients who are actively engaged in their own health; invested with knowledge of their illness, health goals, and plan of care; and have regular and timely access to preventative and health maintenance visits—have significantly better health outcomes and prognosis (go figure!).

Comprehensive:

While every patient and physician would love to have the luxury to spend up to an hour each visit with ample time to council in disease process, preventative care, and lifestyle modification– this model is reserved currently for “boutique clinics” realistic only for those who have the financial means to pay out of pocket for such services.  This model for the general public is otherwise not attainable given the shortage of primary care physicians, nor affordable in an already strained healthcare system.  While we have strived to provide this type of comprehensive care here at FMCDA, as noted previously, it is getting harder to do under our current medical environment and reimbursement model. The goal of the Medical Home model is to utilize every individual’s strengths and skills in a coordinated team approach lead by your personal physician.  We hope to be hiring additional mid-level (PA’s and Nurse Practitioners) to staff each team (A, B, and C) to offer better access in same day appointments, and to lead group visits educating our patients in relevant preventative health topics and chronic disease management.  We intend to employ a part-time nutritionist to council and educate patients who struggle with obesity & diabetes, or patients who just want to participate in proactive preventative interventions to avoid onset of diabetes or obesity.  We intend to employ a counselor to help patients navigate and identify difficult social/life stressors and mental illness that can drastically affect ones health and resource utilization.  We intend to employ a part-time Social worker to help our children, elders, and patients in hardship identify and obtain available Community and Federal resources in our increasingly confusing Health System.  We intend to hire a Pharmacist to review interactions between medications, survey for ongoing need vs risks of medications amongst individuals with numerous medications, and to help create medi-sets for patients who struggle with remembering complex regimens that can result in health complications if taken incorrectly.   By employing a multidisciplinary coordinated team, we hope to deliver a more complete, efficient, affordable, and coordinated health care product to you, our valued patients and friends.

Coordinated:

With the help of EMR’s (Electronic Medical Record’s), a requirement to execute the Medical Home model, we now have the ability to run reports and collect data to improve health care delivery, follow through, and outcomes.  We can identify who is overdue for health maintenance, who is not meeting health goals or benchmarks, and who may benefit from an educational workshop for just a few examples.  The Medical Home model encourages reaching out and identifying patients with certain chronic illnesses or patients who are at high risk for poor health outcomes so they do not get lost in the complexity of the healthcare system.  The model encourages assigning nurse health advocates who can help coordinate needed follow up, set goals, and identify needed services for individuals at risk or in need.  A referral coordinator can help patients set up consultations but also follow up to make sure appointments are scheduled and attended.  One of the fundamental goals of a Medical Home is to better coordinate and help patients manage their health, not only overwhelm them with diagnosis, medications, and appointments with very little ability to monitor or provide the tools for patients to actually follow through.

Accessible:

While preventative medicine and chronic health management can be scheduled in advance, the Medical Home model also strives to be present for you in acute illness and crisis care.  Same day appointments, extended office hours, triage nurse available for phone calls throughout the day can allow opportunity for more accessible and timely health care direction and delivery.  This in turn can help reduce the burden and cost of Emergency room visits and delayed care that can result in poorer health outcomes and increased system wide costs.  Multi-study analysis has shown an average of 30% reduction in ER visits and 6% reduction in hospitalizations with the Medical Home model.  This reduction in crisis care management accounts for the majority of the healthcare cost saving netting 30% despite larger upfront investments and overhead required to run a true Medical Home.   In addition, remote communication with secured email, prescription refill requests, and scheduling through internet based ‘Electronic Patient Portals’ can provide more seamless health care coordination and access available even after office hours.

Continuously improved by a systems-based approach to quality & safety:

Developments in Evidence Based Medicine, and Standards of Care are under constant revision and flux.  As a physician, we must be a perpetual student and stay apprised to all the current data and best health practices and create an environment of continuous learning with timely incorporation into our practice of medicine.  The Medical Home model requires consideration of Evidence-based medicine and clinical decision-support tools to guide treatment, and to frequently assess that set goals are being met. The Medical Home also encourages a 360 degree culture of feedback, where our patients, staff, and physicians can share insights, applause, and even gripes—for we can only grow in an environment of feedback and sometimes in humility.

Obstacles that prevent Physicians from providing meaningful patient care:

Physicians are spending more abbreviated face to face time with patients to compensate for increased hours scribing, sifting through increasingly onerous paperwork burden, or contending for ‘prior-authorizations’ with insurance companies to name a few, that extend work hours far beyond when the last patient leaves the office.  Decreased reimbursements to cover increasing overhead and resulting cuts in clinic support staff; extending non-patient work hours with increasing paperwork, documentation, and red tape; and decreased ability to spend true meaningful hours spent in actual patient care is lending to primary care physician disillusion, burn out, and shortages as well as decreased patient satisfaction and outcomes.

We do believe that the Medical Home model holds the potential to improve the way primary care is delivered by: re-focusing on preventative health measures, education, chronic disease management, improved access, evidenced based practices to achieve patient centered health care.  These measures in turn have been shown to decrease system wide costs of healthcare delivery, improve both physician and patient satisfaction, and improve overall health outcomes (our most valued objective!).

by Dr. Brittany C. Burns

February 17, 2013

Flu vaccinations are in!  Call the clinic to schedule your quick ‘in and out’ nurse visit for your flu vaccination administration.  High risk individuals with Diabetes, Asthma, Emphysema, Immunosuppression, and other major chronic medical illness are especially urged to get in for their flu vaccination.  Elderly and young children are also among the populations that can become more dangerously ill from the flu, and these individuals as well as close care givers or loved ones are encouraged to get their flu vaccination.  Please call the clinic with any questions, see below information from the CDC.

Flu Vaccination

Why should people get vaccinated against the flu?

Influenza is a serious disease that can lead to hospitalization and sometimes even death. Every flu season is different, and influenza infection can affect people differently. Even healthy people can get very sick from the flu and spread it to others. Over a period of 31 seasons between 1976 and 2007, estimates of flu-associated deaths in the United States range from a low of about 3,000 to a high of about 49,000 people. During a regular flu season, about 90 percent of deaths occur in people 65 years and older. The “seasonal flu season” in the United States can begin as early as October and last as late as May.

During this time, flu viruses are circulating in the population. An annual seasonal flu vaccine (either the flu shot or the nasal-spray flu vaccine) is the best way to reduce the chances that you will get seasonal flu and lessen the chance that you will spread it to others. When more people get vaccinated against the flu, less flu can spread through that community.

How do flu vaccines work?

Flu vaccines (the flu shot and the nasal-spray flu vaccine (LAIV)) cause antibodies to develop in the body about two weeks after vaccination. These antibodies provide protection against infection with the viruses that are in the vaccine.

The seasonal flu vaccine protects against three influenza viruses that research indicates will be most common during the upcoming season. Three kinds of influenza viruses commonly circulate among people today: influenza B viruses, influenza A (H1N1) viruses, and influenza A (H3N2) viruses. Each year, one flu virus of each kind is used to produce seasonal influenza vaccine.

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What kinds of flu vaccines are available?

There are two types of vaccines:

• The “flu shot” — an inactivated vaccine (containing killed virus) that is given with a needle, usually in the arm. The flu shot is approved for use in people older than 6 months, including healthy people and people with chronic medical conditions.
  
  There are three different flu shots available:
  • a regular flu shot approved for people ages 6 months and older
  • a high-dose flu shot approved for people 65 and older, and
  • an intradermal flu shot approved for people 18 to 64 years of age.
• The nasal-spray flu vaccine — a vaccine made with live, weakened flu viruses that is given as a nasal spray (sometimes called LAIV for “Live Attenuated Influenza Vaccine”). The viruses in the nasal spray vaccine do not cause the flu. LAIV is approved for use in healthy* people 2 through 49 years of age who are not pregnant.

Seasonal flu vaccines protect against the three influenza viruses (trivalent) that research indicates will be most common during the upcoming season. The viruses in the vaccine can change each year based on international surveillance and scientists’ estimations about which types and strains of viruses will circulate in a given year. While some manufacturers are planning to produce a quadrivalent (four component) vaccine in the future, quadrivalent vaccines are not expected to be available for the 2012-2013 season.

About 2 weeks after vaccination, antibodies that provide protection against the influenza viruses in the vaccine develop in the body. Information specific to the 2012-2013 season including the flu vaccine formulation, can be found at 2012-2013 Flu Season.

Who Should Get Vaccinated This Season?

Everyone who is at least 6 months of age should get a flu vaccine this season. It’s especially important for some people to get vaccinated. Those people include the following:

• People who are at high risk of developing serious complications like pneumonia if they get sick with the flu. This includes:
  • People who have certain medical conditions including asthma, diabetes, and chronic lung disease.
  • Pregnant women.
  • People 65 years and older
• People who live with or care for others who are high risk of developing serious complications. This includes:
  • household contacts and caregivers of people with certain medical conditions including asthma, diabetes, and chronic lung disease.

A detailed list is available at Who Should Get Vaccinated Against Influenza. A complete list of health and age factors that are known to increase a person’s risk of developing serious complications from flu is available at People Who Are at High Risk of Developing Flu-Related Complications.

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Who Should Not Be Vaccinated?

There are some people who should not get a flu vaccine without first consulting a physician. These include:

• People who have a severe allergy to chicken eggs.
• People who have had a severe reaction to an influenza vaccination.
• Children younger than 6 months of age (influenza vaccine is not approved for this age group), and
• People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated.)
• People with a history of Guillain–Barré Syndrome (a severe paralytic illness, also called GBS) that occurred after receiving influenza vaccine and who are not at risk for severe illness from influenza should generally not receive vaccine. Tell your doctor if you ever had Guillain-Barré Syndrome. Your doctor will help you decide whether the vaccine is recommended for you.

When Should I Get Vaccinated?

CDC recommends that people get vaccinated against influenza as soon as flu season vaccine becomes available in their community. Influenza seasons are unpredictable, and can begin as early as October.

It takes about two weeks after vaccination for antibodies to develop in the body and provide protection against the flu.

Flu vaccine is produced by private manufacturers, so availability depends on when production is completed. If everything goes as indicated by manufacturers, shipments are likely to begin in August and continue throughout September and October until all vaccine is distributed.

Doctors and nurses are encouraged to begin vaccinating their patients as soon as flu vaccine is available in their areas, even as early as August.

]]> http://www.fmcda.com/2012/09/flu-vaccinations/feed/ 0 http://www.fmcda.com/2012/06/food-allergies-vs-intolerance/ http://www.fmcda.com/2012/06/food-allergies-vs-intolerance/#comments Wed, 06 Jun 2012 04:41:33 +0000 admin http://www.fmcda.com/?p=381 2012 Lecture Series

by Brittany C. Burns MD

May 11, 2012

Food Allergies vs. Intolerance and the Inflammation it Stirs up

Todays lecture is to review food allergies versus intolerance. A story of how some foods can stir up inflammation, which predisposes the majority of major illness such as cardiovascular disease, autoimmune disease, and cancer.  Food intolerances may also flare other underlying predispositions to common everyday ailments such as acne, irritable bowel syndrome, seasonal allergies, recurrent sinusitis, recurrent ear infections, migraines, joint pain, and fatigue.  During this lecture we will also discuss in more detail, one of the more common culprits of inflammation: wheat/gluten!

Food, while clearly satisfying and enjoyable, is more importantly our source of energy that fuels all that we do.  Our bodies are amazingly adaptable at utilizing the fuel it is given, but there are definite differences in the quality of foods, and efficiency with which our bodies function and run on these fuels.  Food in excess leads to obesity, and poor quality leads to disruption of hormonal balance, lack of essential nutrients, inflammation, and disease.   We have a wide variety of foods now readily available year around thanks to commerce and manipulation of our food sources and production- this is in some ways a luxury, but it may also be argued an evolutionary disadvantage.  To wit: in the past our ancestors had it easier to make good choices. Food sources were locally grown or caught and required energy expenditure (exercise) to acquire and seasonal variability helped to promote a constantly varied diet.  In our current culture, we have excess cheap grain crops available and access to year around availability of most produce, which is thought to play a role in increasing food allergies and intolerance.

Food Allergy vs. Intolerance

A food allergy occurs when your body’s immune system mistakenly thinks that a harmless substance (meaning whatever food you happen to be eating), such as cows’ milk or soy protein, is a threat. In response, the body creates and flags these foods with IgE antibodies releasing a cascade of inflammatory mediators and histamines. These mediators trigger allergic reactions, most commonly seen in the respiratory system or gastrointestinal tract.  Symptoms of a food allergy can range from mild to severe, and the amount of food necessary to trigger a reaction varies from person to person. Symptoms of a food allergy may include: rash or hives, nausea/vomiting, stomach pain/cramping, diarrhea, itchy skin, shortness of breath, chest pain, swelling of the airways, and anaphylaxis.  Typical food allergies include dairy, eggs, wheat, soy, peanuts, tree nuts, and fish.  An allergic reaction is typically fairly quick; within minutes to an hour, whereas intolerance may not present for hours or even days later.  The true prevalence of food allergy is only about 2% of the adult population. In children, the incidence is higher at 3-7%, although the majority of children outgrow food allergies by the time they start school.

Intolerance is typically when your digestive system has trouble processing foods that you’ve ingested. A food sensitivity or intolerance is a more generic term, comprehensive of any adverse food reaction, that can be immune-mediated or non immune-mediated. For instance, some people react to the tyramine present in cheeses. This is due to release of histamine, and is not antibody mediated.  Lactose intolerance is another common problem caused by the lack of an enzyme that enables the body to digest lactose, a sugar present in milk. These distinctions between the mechanisms of food intolerance are however of little consequence, because the symptoms are often similar and the treatment is elimination. 

Symptoms of food intolerance include: headaches, irritable bowel, abdominal pain/cramping, gas/bloating, heartburn, headaches, achy joints, fatigue, fibromyalgia, recurrent sinus/ear infections, ADHD, irritability/anxiety, and acne.  Common food intolerances include:

-Lactose: This is a sugar in cow’s milk that requires the enzyme lactase to be broken down into simple sugars for absorption in the gastrointestinal tract. Estimated to affect 10-15% Northern European, and 80-90% African American.

-Sucrose or maltose: Both are sugars requiring enzymes for digestion into simple sugars for absorption.

Histamine and tyramine: These are substances created in the fermentation process in aged cheeses, processed meats, beer, wine, vinegars, and soy sauce. They naturally occur in some foods as well.

Salicylate: This is a salt contained in some foods and is used to make aspirin.  Tartrazine: This is an artificial food color used in food.

Benzoates, butylhydroxyanisol (BHA), butylhydroxytoluene (BHT), sulfites: These are preservatives added to foods.

Monosodium glutamate (MSG): This is a naturally occurring or added flavor enhancer in foods.

Other food dyes: These are color additives used in food.

Gluten: This is a protein found in wheat, rye, barley and oats, although the role of the latter is controversial and is currently the subject of research.  We will discuss this further in the next section.

How can you tell the difference between a food allergy and intolerance? Food allergies can be triggered by even a small amount of the food and occur every time the food is consumed. People with food allergies are generally advised to avoid the offending foods completely. On the other hand, food intolerances often are dose related. People with food intolerance may not have symptoms unless they eat a large portion of the food or eat the food frequently. For example, a person with lactose intolerance may be able to drink milk in coffee or a single glass of milk, but becomes sick if he or she drinks several glasses of milk. Most food intolerances are found through trial and error to determine which food or foods cause symptoms.  Keeping a food diary to record what you eat and when you get symptoms can be helpful to locate trends.  Another way to identify problem foods is to go on an elimination diet such as the ‘Whole 30’(more info at www.whole9life.com).  This involves completely eliminating any suspect foods from your diet until you are symptom-free. You then begin to reintroduce the foods, one at a time. This can help you pinpoint which foods cause symptoms.

What is leaky gut syndrome?

When the intestinal lining becomes damaged, it can let partially digested proteins into the blood stream. The body does not recognize these foreign proteins and assumes they are invaders. It therefore sends out an immune response, attacking the protein molecules. After several exposures, the body quickly recognizes that particular food foreign and potentially dangerous and in response mounts an attack. This is how leaky gut can lead to food allergies. Leaky gut syndrome can also cause a constant state of inflammation and immune up rise that can lead to other health problems, such as arthritis, eczema, irritable bowel syndrome, and many believe fibromyalgia.

How do you get leaky gut syndrome?

Being our first line of defense against many things trying to enter our bodies, the intestinal lining is well designed. However, it is tricky business, as it is supposed to let nutrients through and shield from harmful invaders or toxic substances.  Leaky Gut Syndromes are usually provoked by exposure to substances that damage the integrity of the intestinal mucosa, disrupting the desmosomes which are the glue that bind the cells together and increasing passive absorption or leakage between cells bypassing our built in defenses.

To breach the gut defenses, it usually takes a number of different traumas over a period of time to compromise the intestinal lining to the extent that we develop a leaky gut. Bacteria, fungi, yeast, such as candida, and other parasites can all become overwhelming without checks and balances that maintain a healthy balance among symbiotic organisms and damage the lining. Many drugs can cause harm as well, such as aspirin, ibuprofen, and other pain medications. Antibiotics can cause it (though indirectly), by killing the beneficial bacteria in the gut, which leaves a blank slate and allows harmful bacteria and fungi to flourish and fill in the gaps. Anything that causes inflammation of the intestines can also damage the lining.

Compromised intestinal barrier function can also cause disease directly by increased permeability.  This stimulates a classic hypersensitivity response to foods and to components of the normal gut flora such as bacterial endotoxins, cell wall polymers, and dietary gluten. This response can cause “non-specific” activation of inflammatory pathways mediated by complement and cytokines rather than antibodies, which are much more “specific “ and more easily measured.  If you have food allergies, particularly if you developed them later in life and are allergic to more than one food, chances are you also have leaky gut syndrome. If you can heal your leaky gut then you may be able to overcome many of your allergies as well.
Grains, Gluten, and Celiac Disease

Grains were engineered to feed the masses and are relatively new foods to humans in our long history of existence (~0.4% of our existence).  Our guts thus have not had nearly as much time to evolve and fully adapt to efficient use of this fuel.  Generally speaking, if you have to heavily process a food to make it edible, than it was likely not made by nature for us to consume.  Grains have to be processed and cooked to break down their thick skins- shells built by nature to withstand the gut and passing through undigested to fertilize distant soils.  Some people appear to tolerate consumption without obvious ill effect, but many do have real consequences although albeit subtle and often disguised.

Several recent studies show gluten intolerance prevalence estimated between 30-70% in the general population.  For some people this manifests as IBS or constipation, for others achy joints or fatigue, but often, vague symptoms that people learn to live with and ignore.  Gluten intolerance or sensitivity has also been linked to autism, schizophrenia, and ADHD.

Celiac disease is an extreme adverse reaction to gluten that leads to sloughing of the gut lining and more severe symptoms.  It is estimated that currently we are only diagnosing 25% of true Celiac disease, 75% living their lives undiagnosed.  People with Celiac disease have an autoimmune reaction in the small intestine.  The complex proteins (gluten/gliadin) found in wheat, rye, and barley trigger the immune response that attacks the cells lining the small intestine causing sloughing and decreased functional surface area for nutrient absorption.  This reaction also creates inflammation and a cascade of reactions that can lead to other autoimmune disorders, osteoporosis, infertility, neurologic conditions, and cancer.  Scientist at the University of Maryland have evidence that gluten sensitivity is indeed different from celiac disease on the molecular level and in the response it elicits from the immune system.  This research demonstrates that gluten sensitivity and celiac disease are part of a spectrum of gluten disorders.  Isolating specific biomarkers in the immune response of people with gluten sensitivity could lead to diagnostic tools to help identify this condition with more objectivity.

Grain is a big business in this country: we see commercials preaching heart health, and seals of approval on packaging promoting in the minds of the public health benefits of grain. Fiber does help to reduce cholesterol, cardiovascular disease, and diseases such as diverticulosis.  The only benefit from whole grains is the fiber content.  Grains lack micro/macronutrients, minerals, antioxidants, and in fact some new evidence suggests components referred to as ‘anti-nutrients” that may leach minerals from the other foods we consume with grains. Grains are dense in empty carbohydrates and stimulate insulin and in excess can lead to diabetes an overwhelming epidemic in our society.  Grain is not nutrient dense as are vegetables that also happen to be rich in fiber and confer all the same benefits and more.  Grains are simple carbohydrates that are rapidly broken down to sugars in our blood and in turn trigger insulin secretion. Insulin exposure in excess contributes to insulin resistance, metabolic syndrome, and type II diabetes.  So even if one is not allergic or intolerant to grains, it would be wise in avoiding these relatively nutrient void and carbohydrate heavy foods.
Increasing Incidence of Food Allergies

There are many theories to explain why we are experiencing higher incidence of food allergies.  The ‘hygiene theory’ of disease, suggests that children are not exposed to enough dirt and bacteria anymore, and therefore do not build up a normal immunity to harmless substances. So when they are exposed, their immune system overreacts and they develop an allergy.  In third world countries where parasitic infections are still commonplace, allergies also interestingly appear to be less common.  This association between GI parasites and our first line of defense, our gut immunity seems to play a large role in assisting our immune function.

It also follows that the symbiotic relationship between our healthy gut flora and our gut immunity has changed as well.  Less children are breast fed, and do not inherit healthy flora and immunity from their mothers.  Children born via C-section do not pick up the healthy flora from the birth canal to populate the infants gut and these infants appear to have higher incidence of allergies, eczema, and asthma latter in life.  Children who undergo numerous courses of antibiotics also have a compromised natural flora, as it takes on average 3 months to replenish our gut flora after a course of antibiotics.  There are several theories that the lack of healthy balance between our gut and natural flora may weaken our gut defenses and cause sensitization.

The lack of seasonality of local produce, with constant availability of foods that in the past where only available for limited seasons, also has been proposed to contribute to increased food sensitization.  We are also now becoming more knowledgeable and aware of food allergies, thus more are recognized whereas in the past many likely went undiagnosed.
Inflammation

Inflammation is the primary outcome and consequence of food allergies and intolerance.  Aside from the symptoms that affect our quality of life, it is the inflammation that takes the silent long-term toll on our health.  Much of Western illness is fuelled not only by inflammation but also a sedentary lifestyle, and hormonal imbalance. Hormones are held in delicate balance and are influenced intimately by our lifestyles—by diet, stress, activity level, weight, and sleep.  Our diets in turn influence our weight, cholesterol, inflammation, and hormonal balance.  These factors are all intertwined and imposing to varying degrees depending on our genetic foundation.  If you can afford to choose the more nutrient dense and quality food option, it will be an investment that will pay back in dividends with improved health outcomes in your future.

A review of food Allergies versus Intolerance. A story of how some foods can stir up inflammation, which predisposes the majority of major illness such as Cardiovascular disease, Autoimmune disease, and Cancer.  Food intolerances may also flare other underlying predispositions to common everyday ailments such as Acne, Irritable Bowel Syndrome, Seasonal Allergies, recurrent Sinusitis, recurrent Ear infections, Migraines, Joint pain, and Fatigue.  During this lecture we will also discuss in more detail, one of the more common culprits of inflammation-Wheat/Gluten!

Date: May 11, 2012 @ 6:30 PM.

Location: CrossFit CDA (corner of 4rth & Coeur d’Alene Ave).  Patients of FMCDA welcome to attend!

Speaker: Dr. Brittany Burns

Crossfit Coeur d’Alene has formed a team for the Coeur d’Alene Relay For Life event that will take place from June 1st through the night and into June 2nd.  All interested FMCDA patients have been invited to joint Crossfit CDA team to help raise money for this very important cause.

You can visit our team page by using the following link:http://main.acsevents.org/site/TR?pg=team&fr_id=37852&team_id=1116774

You can donate to the team for the cause via this website even if you can’t join the team for the relay.  You can also sign up as a team member to help with the 24 hour team walk.

Crossfit CDA will also be hosting a Relay for Life ‘Throwdown’ (work-out) at the gym Saturday May 12th at 8am. To participate, the buy-in is $20/person. The workout will be programmed for teams of 4. You can either form your own team and come up with a theme and outfits, or show up and get assigned a team that day.  Non Crossfit CDA members are welcome!

The more the merrier, so make sure to bring friends and family. There will be prizes for the winning team as well as prizes for the most creative team theme! So bring your crazy!

‘Genotype vs Phenotype’

(Lecture #3 in 2012 series)

Brittany C. Burns MD

March 29/2012

7:30 PM

CrossFit CDA

The genotype is the genetic makeup of an individual.  It is a map for all our proteins that build our organs, tissues, hormones, receptors, neurotransmitters, etc.  There are two alleles for any given gene.  You inherit one allele from each parent via random selection.  Dominant alleles will guarantee inheritance of that trait, while recessive alleles can remain hidden until 2 alleles are inherited together to display the trait.  An example of this is the human CFTR gene, which encodes a protein that transports chloride ions across cell membranes, can be dominant (A) as the normal version of the gene, or recessive (a) as a mutated version of the gene. Individuals receiving two recessive alleles will be diagnosed with the disease of Cystic Fibrosis.

Genetic mutations that appear to predispose illness in certain situations can also have once provided protection in certain environments.  A good example of this is with Sickle Cell disease.  Carriers of the recessive sickle cell trait have a natural protection against malaria, however the unfortunate individual who receive 2 alleles of sickle cell trait will demonstrate the debilitating disease of sickle cell.  In the environment where malaria was more lethal than the 25% born with sickle cell disease, it provided the people who inherited this trait an advantage and thus multiplied.  Now this trait, in our current environment, only conveys disease.  Both your inherited genotype and non-hereditary environmental variation contribute to the phenotype of an individual.  The phenotype is how you display your genetic potential.  This concept is most impressively demonstrated with identical twins that have been separated early in life, and ultimately display very different phenotypes despite their identical genotypes.  We all have the potential for disease, some more so than others depending on your genotype.  It is important to realize that most disease is not hardwired like the examples of sickle cell or cystic fibrosis above, but rather confer a predisposition that may or may not be expressed depending on life exposures.

Many genes that may now predispose disease once conveyed a protective element in certain settings.

This phenomenon can be applied to much of illness and novel adaptation, however, often in subtle variances.  We see clustering of genetic variance depending on peoples heritage, such as Cystic fibrosis trait is more prevalent in Caucasians with European decent and Sickle Cell in African Americans from certain regions in Africa with high prevalence of Malaria.  Likewise, we see people of certain heritage with increased prevalence and predisposition to Obesity and Diabetes.  There is this idea of the “thrifty gene hypothesis”, where people of more recent ‘hunter and gatherer’ background carry a genetic makeup that once allowed them to hold and store calories during times of feast so that they survive and thrive more readily during times of famine.  Now, in this age where food is readily available 24/7 and does not require energy expenditure to acquire, these same genes predispose Obesity and the expression of disease in the form of Diabetes.

We see this genetic portfolio predisposing obesity and diabetes prevalent among, for instance, the Native Americans and Samoan people.  Their genetics do not guarantee manifestation of disease, but rather predispose disease in our current environment with sedentary lifestyles and diet rich in carbohydrates such as grains and sugar.  An individual with this predisposition must work in some ways harder to maintain healthy body weights to avoid the vicious cycle of hyperinsulinemia, weight gain, and insulin resistance that leads to type 2 Diabetes.  These same people tend to thrive on the Paleo diet that is far lower in refined grains, sugars, and simple carbohydrates, which their Ancestors were not accustomed nor exposed to.

Agriculture – including the growing of grain crops, like wheat and barley, has only been practiced for around ten thousand years, a relatively short time compared to how long humans have been eating other foods (e.g. digestion-friendly meat, fish, vegetables and fruits) – 2.5 million years.  Our bodies have not evolved as fast as our ability to produce Modern Foods. In fact our capacity to grow grain crops like wheat, corn and rye has far outstripped our digestive systems’ development. That is, we do not yet have all the necessary biological equipment to process these proteins (gluten) effectively without consequences of varying degrees of inflammation in most and disease in many.  Inflammation, remember, is the ignition or fuel of most disease and illness.  Without inflammation, cholesterol does not stick and form plaque in our arteries predisposing to stroke and heart disease.  Without inflammation, our immune system is less inclined to turn on itself and exhibit autoimmune disease.  Without inflammation, cancer is much less prevalent.  Inflammation ages us and ails us.  While we cannot avoid all inflammation, like stress in our lives, we frequently do have power and choice over much of our practices that contribute to inflammation.

Much of western illness is fuelled not only by inflammation but also sedentary lifestyle, and hormonal imbalance.  Hormones are held in delicate balance and are influenced intimately by our lifestyles—by diet, stress, activity level, weight, and sleep.  Our diets in turn influence our weight, cholesterol, inflammation, and hormonal balance.  These factors are all intertwined and imposing to varying degrees depending on our genetic foundation.  Some individuals may have to work very hard to increase their metabolic rate and maintain healthy body weight, while other run hot and have troubles keeping the weight on.  Much of this is driven by your genetic make-up, but it does not mean that you cannot achieve a healthy body weight; it just means you may have to work harder and be more vigilant to achieve it!

Both your inherited genotype and non-hereditary environmental variation contribute to your phenotype or how you express your genetic potential.  While we cannot control the genes we are dealt, we can to some degree control how they are expressed by the choices we are able to make in our lifestyle.  It is true that are bodies are amazing and adaptive and can utilize a wide variety of fuels, but it is also true that there are superior fuels that humans are more adapted to utilize more cleanly without the byproducts of disease that accumulate over time.  In the past Natural Selection would sift out those who demonstrated disease that in turn made them less fit in their given environment.  Current medical aid and social subsidies may be argued to blunt the affects of Natural Selection, thus carrying forward genes that predispose disease.  We must therefore, learn to manipulate our environments so that we do not express these diseases and we can learn to do so by building knowledge of what promotes disease processes.

We cannot expect our genotype to adapt over our lifetime.  We still must try to live true to the fuels that our bodies are most adept at processing cleanly.  This remains to be: adequate sleep, routine exercise, play, a wholesome low inflammatory diet, avoiding smoking and excess alcohol, and minimizing life stressors.  Make sure to keep vigor in your life with exercise, play, and healthy relations, as these factors are the most potent influences in my experience to success of longevity with grace and quality.  Remember, it is not only about living a long life, it is more importantly about the quality of life and maintaining independence of mind and body into your later years.  We all are dealt a hand from a genetic “deck of cards”- how you play that hand is up to you! I encourage you all to empower yourself with knowledge and to be insightful on health and habits that may help you live longer healthier lives with the genes you’ve got!

“Phenotype versus Genotype”

A conversation of the genetics we are gifted with and how we choose to express them through our choices and lifestyle. A review of how our lifestyles predispose much of western disease.  A sub-focus on healthy body weight and image and metabolic set points we inherit.

“Not as simple as avoiding eggs and red meat”

Lecture #2: February 23, 2012

Prepared by Dr. Brittany Burns

High cholesterol is a serious health problem that affects about fifty million Americans.  Hyperlipidemia refers to increased levels of lipids (fats) in the blood, including cholesterol and triglycerides.  Why do we care about Hyperlipidemia?  Although hyperlipidemia does not cause you to feel bad, it can significantly increase your risk for stroke and in developing coronary heart disease, latter in life.  People with coronary disease develop thickened or hardened arteries in the heart muscle. This can cause chest pain, a heart attack, or both.  It is for these reasons that screening for hyperlipidemia and appropriate treatment is highly recommended.

A lot of people don’t take the risks of high cholesterol very seriously. After all, one out of six people have high cholesterol. A staggering 50% of Americans have levels above the suggested limit. Could something so common really be a serious health risk?  Unfortunately, yes. Cholesterol is a direct contributor to cardiovascular disease, which can lead to strokes and heart attacks.  The World Health Organization estimates that almost 20% of all strokes and over 50% of all heart attacks can be linked to high cholesterol.  However, it is also important to realize that high cholesterol all by itself does not cause coronary artery disease all by itself, it contributes to a cascade of things that leads to coronary artery disease.  Genetics, diet, smoking, hypertension, diabetes, weight, inflammation, activity level and more are also contributing factors that predispose coronary heart disease.  The more factors you can control for, the less likely you are to suffer from coronary artery disease in the future.

How does Cholesterol lead to disease?

Everyone has cholesterol in his or her blood. But if your levels of the bad forms of cholesterol are too high, the excess can accumulate on the walls of your arteries with other substances to form plaque, which can narrow and clog the artery like a drain. It can also lead to arteriosclerosis, or hardening of the arteries, which turns the normally flexible tissue into more brittle.

Plaques can form anywhere. If they form in the carotid artery in the neck, it’s carotid artery disease. When they form in the coronary arteries — which supply the heart muscle with blood — it’s called coronary artery disease. Like any organ, the heart needs a good supply of blood to work. If it doesn’t get that blood, you could get angina, which causes a squeezing pain in the chest and other symptoms.

There are other risks associated with high cholesterol.  If these plaques break open, they can form a clot. If a clot lodges in an artery and completely chokes off the blood supply, the cells don’t get the nutrients and oxygen they need and die.  If a clot gets to the brain and blocks blood flow, it can cause a stroke. If a clot lodges in the coronary arteries, it can cause a heart attack.  It can accumulate in the liver and cause Fatty Liver Disease, or trigger Pancreatitis.  Recent studies also have even shown an association with increased severity of post-menopausal hot flashes and high cholesterol.

High cholesterol risks are usually not immediate. The damage accumulates over years and decades — high cholesterol in your 20s and 30s can take its toll in your 50s and 60s. Because the effects take time, many people don’t feel a real urgency in addressing it, as there are no immediate symptoms.  This lack of immediate consequence contributes to many people ignoring treatment or lifestyle changes necessary to address this problem.

Having high cholesterol may not hurt you today or tomorrow, but if you ignore it now, it can greatly impact your quality of life in the future.

Cholesterol Isn’t All Bad

While too much of certain kinds of cholesterol can be harmful, just the right amount of it does a lot of important work in the body.  In recent years, cholesterol and fat intake has gotten such a bad rap that most people don’t know the good it does.

Cholesterol performs three main functions:

1. It helps make the outer coating of cells.
2. It makes up the bile acids that work to digest food in the intestine.
3. It allows the body to make Vitamin D and hormones, like estrogen in women and testosterone in men.

Without cholesterol, none of these functions would take place, and without these functions, we wouldn’t exist.  Cholesterol is so important to the body that we make it ourselves—Mother Nature doesn’t leave it up to humans to get whatever they need from diet alone. So even if you ate a completely cholesterol-free diet, your body would make the approximately 1,000 mg it needs to function properly.

What is Cholesterol?

Cholesterol is a type of fat, or lipid. If you held cholesterol in your hand, you would describe a waxy substance that resembles whitish-yellow candle scrapings. Cholesterol is absorbed in the gut, and then flows through the body via your bloodstream, but this is not a simple process. Because lipids are oil-based and blood is water-based, they don’t mix. If cholesterol were dumped directly into your bloodstream, it would congeal into dysfunctional globs. To get around this problem, the body packages cholesterol and other fats into small protein-covered particles called lipoproteins that do mix easily with blood. The proteins used are known as apolipoproteins.

The fat in these particles is made up of cholesterol and triglycerides and a third material called phospholipid, which helps make the whole particle stick together. Triglycerides are a particular type of fat that have three fatty acids attached to an alcohol called glycerol—hence the name. They compose about 90 percent of the fat in the food you eat. The body needs triglycerides for energy, but as with cholesterol, too much is bad for the arteries and the heart.

Where does Cholesterol come from?

Your body makes cholesterol.  Your blood cholesterol level is determined by the sum of how much cholesterol your body makes and how much you take in from food, minus how much your body uses up or excretes. High cholesterol can result from a problem in any of the variables in that equation—your body may produce more cholesterol than it needs due to a genetic predisposition, you may be getting too much from your diet, or you may not excrete cholesterol in your bile efficiently. The fact that Americans have higher blood cholesterol levels than citizens of the Far East or Africa could be due to differences in genetic factors, but most evidence suggests that our higher cholesterol levels are largely a product of our diet.

For most people—especially those with high cholesterol—the liver and other cells aren’t the body’s only sources of cholesterol. Our society’s typical high saturated fat diet also packs a powerful cholesterol punch. How can cholesterol from a hamburger and French fries eventually make its way to your heart’s arteries? As you eat food with cholesterol, your intestines go through a complex process of breaking down fat molecules and building them into new molecules that the body can use.

FIGURE 1.2 How Food Becomes Cholesterol

Lipoproteins

The two main types of lipoproteins important in a discussion on heart disease are low-density lipoproteins (LDL) and high-density lipoproteins (HDL). Though the names sound the same, these two particles are as different as night and day. The differences stem from their densities, which are a reflection of the ratio of protein to lipid; particles with more fat and less protein have a lower density than their high-protein, low-fat counterparts. There are countless other lipoproteins, some of which we are just beginning to understand, but in order to get a basic understanding of how cholesterol affects your body and how the food you eat affects your cholesterol levels, LDL and HDL are the ones to start with.

Low-Density Lipoproteins (LDL)

The LDL cholesterol (sometimes called “bad cholesterol”) is a more accurate predictor of coronary disease than total cholesterol.  In the average person, 60 to 70 percent of cholesterol is carried in LDL particles. LDL particles act as ferries, taking cholesterol to the parts of the body that need it at any given time. Unfortunately, if you have too much LDL in the bloodstream, it deposits the cholesterol into the arteries, which can cause blockages and lead to heart attacks. That’s why people refer to LDL as the “bad” cholesterol. The good news is that most people can decrease their LDL if they address the kinds and quantities of fats they are consuming and adopt healthier lifestyles.

LDL targets differ, depending on your underlying risk of heart disease.  Most people should aim for an LDL level below 130.  If you have other risk factors for heart disease, your target LDL may be below 100.  If you are at very high risk of heart disease, you may need to aim for an LDL level below 70.  In general, the lower your LDL cholesterol level is the better.

Other Risk Factors for Cardiovascular Disease:

In addition to high bad cholesterol, there are a number of other factors that increase the risk of coronary disease and its complications.

Adult Treatment Panel III or ATP III has summarized the current recommendations for the management of high cholesterol.  ATP III guidelines are based upon epidemiologic observations that showed a graded relationship between the total cholesterol concentration and coronary risk.  They are influenced by the absence or presence of preexisting CHD.  A meta-analysis of 38 trials found that for every 10 percent reduction in serum cholesterol, CHD mortality was reduced by 15% and total mortality risk by 11%.  The ATP III risk assessment tool is based on the LDL fraction and are influenced by coexistence of CHD or equivalents and cardiac risk factors.

The following are coronary disease-risk equivalents:

• Symptomatic carotid artery disease such as stroke or transient ischemia attack.
• Peripheral arterial disease: claudication
• Diabetes Mellitus, type 1 and 2
• Abdominal aortic aneurysm

Major CHD risk factors other than LDL include:

• Cigarette smoking
• Hypertension: blood pressure ≥140/90 or use of blood pressure medication
• Low HDL-cholesterol: <40 in men, <50  in women
• Family history of coronary disease at a young age in a first degree relative (parents and siblings). In males: first degree relatives <55 years; in females: relative  <65 years
• Age: Increasing risk of coronary disease with increasing age (Men >45, Women >55)

HDL >60 counts as a “negative” risk: its presence removes one risk factor from the total count.

Other factors that increase the risk of coronary disease include:

• Obesity: Central Obesity or “apple” body type greater than “pear” body type
• Stress: elevated cortisol and adrenalin levels
• Sedentary Lifestyle or physical inactivity
• Impaired fasting glucose
• Inflammation: Diseases that causes chronic inflammation such as Celiac and Rheumatoid arthritis is linked to increased CAD.  C-reactive therapy can be used as a marker.
• Gender: Men have a higher risk of coronary disease than women at every age

If you have a CHD equivalent, or two or more CHD risk factors other than LDL, the 10-year risk of CHD is assessed using the ATP III modification of the Framingham risk tables available as online calculators @: hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof.  Risk not necessary in people without CHD who have 0 to 1 risk factors as their 10-year risk of CHD is <10%.

The last step in risk assessment is to determine the risk category that establishes the LDL goal, when to initiate therapeutic lifestyle changes, and when to consider drug therapy.

• Low CV risk (0-1 risk factors):
  • Lifestyle treatment for LDL >140
  • Rx Medication for LDL >190
  • Moderate CV risk (2+ risk factors and Framingham Score <20%):
    • If CRP low, lifestyle treatment for LDL >130, Rx med for LDL >160
    • If CRP high, lifestyle treatment for LDL >100, Rx med for LDL >130
    • High CV risk (CHD or risk Equivalent or Framingham Score >20%):
      • Lifestyle treatment for LDL >80, Rx med for LDL >100
      • Very High CV risk (Cardiovascular event—Heart attack or stenting):
        • Lifestyle treatment for LDL >70, Rx med for LDL >80

Typically, I recommend always pursuing diet and lifestyle changes first, but this does depend on the motivation of the individual to follow through with these changes and the level of risk for that individual.  We will not get into the details of Rx cholesterol medications this lecture, as all of you merely being present for this lecture show motivation that I encourage you to in turn apply to healthy choices.  When lifestyle and dietary changes fail to alter your cholesterol levels below satisfactory goals based on your individual risks, I would encourage you to discuss Rx options with your Primary Care Physician.  It can take 3-12 months depending on the individual circumstances for diet and lifestyle changes to take affect on your lipid panel.  I would encourage close monitoring of your progress.

High-Density Lipoproteins (HDL)

HDL is basically the opposite of LDL. Instead of having a lot of fat, HDL has a lot of protein. Instead of ferrying cholesterol around the body, HDL acts as a vacuum cleaner sucking up as much excess cholesterol as it can. It picks up extra cholesterol from the cells and tissues and takes it back to the liver, which takes the cholesterol out of the particle and either uses it to make bile or recycles it. This action is thought to explain why high levels of HDL are associated with low risk for heart disease. HDL also contains antioxidant molecules that may prevent LDL from being changed into a lipoprotein that is even more likely to cause heart disease.  HDL also has been shown to protect against inflammation.

Lifestyle changes affect HDL levels—exercise can increase, while obesity and smoking lower. As for diet, in general, the high-fat diets have a tendency to raise HDL as well as LDL, while low-fat diets tend to lower. However, by carefully choosing the right foods, you can eat a diet that lowers LDL while raising HDL.

HDL targets are >40 for men, and >50 for women.  HDL above 60 confers extra cardiovascular protection.  HDL above 75 has been associated with ‘Longevity Syndrome’ in average living 5 (men) and 7 (women) years longer, and relative freedom from coronary heart disease!  If you have HDL cholesterol greater than 60, I suggest ignoring your ‘Total Cholesterol’ number and instead calculating your ‘Non-HDL Cholesterol’, or your ‘HDL-Total Cholesterol Ratio’ (as explained below in the next section).  When your HDL is high, it provides protective value, yet inflates your ‘Total Cholesterol’ thus giving an inaccurate picture of your true risks, whereas these modified calculations take the HDL benefits into consideration and provide more accurate representation.

LIPID and CARE trials found that for a 10 mg/dL  in HDL, the event rate decreased by 29% in those with LDL <125 compared to 10% in those with LDL cholesterol >125.  So just because your LDL cholesterol is well controlled does not mean you can ignore your HDL!

High triglyceride levels, physical inactivity, being overweight, obese, smoking, high sugar carbohydrate intakes, type two diabetes, inflammatory conditions, some medications as well as genetic factors can contribute to low HDL cholesterol levels.

Total cholesterol

A high total cholesterol level can increase your risk of coronary disease. However, decisions about when to treat high cholesterol are usually based upon the level of LDL or HDL cholesterol, rather than the level of total cholesterol.

• A total cholesterol level of less than 200 mg/dL (5.17 mmol/L) is normal.
• A total cholesterol level of 200 to 239 mg/dL (5.17 to 6.18 mmol/L) is borderline high.
• A total cholesterol level greater than or equal to 240 mg/dL (6.21 mmol/L) is high.

The total cholesterol, in my opinion is for many a poor representation of your overall cardiovascular risks as it includes your HDL (good cholesterol).  Individuals who have low HDL are at high risk for CV, but will deflate their total cholesterol number making it look not as high.  Same is true for individuals with high HDL, this number inflates the total cholesterol but is known to be cardio protective!  For these reasons, I encourage you to look past this number and look at the breakdown components of your cholesterol.  Other approaches that give a more accurate representation include your total to HDL ratio and your Non-HDL cholesterol.

Total to HDL cholesterol ratio: This has been suggested to have a greater predictive value than the serum total cholesterol or LDL cholesterol level for future artery plaque formation potential.  The number is obtained by dividing the total cholesterol value by the value of the HDL cholesterol. (High ratios indicate higher risks of heart attacks low ratios indicate lower risk).

High total cholesterol and low HDL cholesterol increases the ratio, and is undesirable. Conversely, high HDL cholesterol and low total cholesterol lowers the ratio, and is desirable. An average ratio would be about 4.5. Ideally we want to be better than average if we can. Thus the best ratio would be 2 or 3, or less than 4.

• Among men, a ratio of 6.4 or more identified a group at 2-14% greater risk than predicted by total cholesterol or LDL.
• Among women, a ratio of 5.6 or more identified a group at 25-45% greater risk than predicted by total cholesterol or LDL.

Non-HDL cholesterol: Defined as the difference between the total cholesterol and HDL.  It is helpful to know your non-HDL cholesterol because your level of non-HDL may predict your risk of cardiovascular disease even better than your LDL “bad” cholesterol. That’s because your non-HDL number tells you all the bad cholesterol circulating in your blood – not just your LDL cholesterol but your VLDL cholesterol levels as well. Both LDL and VLDL particles are artery-clogging “bad” lipids. When you subtract the “good” cholesterol (HDL) from your total cholesterol, you are left with all the “bad” cholesterol.

The goal for non-HDL cholesterol in this circumstance is a concentration that is no more than 30 mg/dL higher than that for LDL.  Other goals are that the non-HDL be no more than 120 for prevention and no more than 100 for regression, or reversal, of atherosclerotic lesions in those with established coronary artery disease or those at very high risk, such as diabetics or those with evidence of severely clogged arteries, including people who have had a heart attack or have angina or claudication (difficulty/pain in walking due to insufficient blood supply to the legs and feet).  For individuals with Triglycerides that are so high that LDL cannot be measured directly the Non-HDL cholesterol can be used to risk stratify.

Triglycerides

High triglyceride levels are also associated with an increased risk of coronary disease. High TG’s generally mean lower HDL and are frequently associated with diabetes, insulin resistance, obesity, high blood pressure, smoking, and genetic disorders.  Triglyceride levels are divided as follows:

• Normal – less than 150 mg/dL (1.69 mmol/L)
• Borderline high – 150 to 199 mg/dL (1.69 to 2.25 mmol/L)
• High – 200 to 499 mg/dL (2.25 to 5.63 mmol/L)
• Very high – greater than 500 mg/dL (5.65 mmol/L)

Treatment for elevated triglycerides is usually centered on decreasing insulin desensitization by cutting down sugars (Ex: deserts, sweets, juice, pastries, soda) and simple carbohydrates (bread, pasta, cereal, crackers, pastries, potato, rice) in the diet.  Niacin supplementation also can be particularly affective for reduction in Triglycerides.

When should you have your Cholesterol checked?

Many expert groups have guidelines for cholesterol screening. The guidelines differ in their recommendations about when to start screening, frequency of testing, and when to stop.

• Lipid screening should start earlier for those who have increased risks.  These include individuals with diabetes, hypertension, overweight, or with a family history of heart disease.  Some suggest starting a screening panel in mid 30’s, others in mid 20’s.
• The American Academy of Pediatrics (AAP) recently endorsed recommendations that call for checking LDL (bad) cholesterol levels in all kids between the ages of 9 and 11.
• Lipid screening should definitely start at age 45 for both men and women, most agree here.
• Screening should include total cholesterol, LDL, triglycerides, and HDL-cholesterol levels and are measured most accurately after fasting 12 hours.
• The optimal time interval between screenings is uncertain; reasonable options include every five years, with a shorter interval for those with high cardiovascular risk or elevated lipid levels and longer intervals for low-risk individuals with low or normal levels.
• There is no recommendation to stop screening at a particular age.
• Screening may be appropriate in older people who have never been screened, although screening a second or third time is less important in older people because lipid levels are less likely to increase after age 65.

High Cholesterol Treatment

Lipid levels can be lowered with lifestyle changes, medications, or a combination of these approaches. In certain cases, a clinician will recommend a trial of lifestyle changes before recommending a medication.

Lifestyle changes — All patients with high LDL or Triglyceride cholesterol should try to make some changes in their day-to-day habits, by addressing their diet, losing weight (if overweight or obese), decreasing stress, avoiding inflammation, adequate sleep, smoking cessation, and exercise. Refer to first lecture on “Wellness—back to the basics” for further details.

Nutritional supplements—If you’re worried about your cholesterol and have already started exercising and eating healthier foods, you might wonder if adding a cholesterol-lowering supplement to your diet can help reduce your numbers.  Below is a summary of common supplements to combat high cholesterol, some with good evidence to support their use and others with limited to no conclusive evidence.

Omega 3 fatty acids (fish oil) — These essential fatty acids have a favorable effect on cholesterol. Supplement sources include fish oil capsules, flaxseed and flax seed oil. Omega-3 fatty acids decrease the rate at which the liver produces LDL cholesterol and triglycerides. They have an anti-inflammatory effect in the body, decrease the growth of plaque in the arteries, and aid in thinning blood.  I recommend eating at least two servings of fish a week. The highest levels of omega-3 fatty acids are in: Mackerel, Lake trout, Herring, Sardines, Albacore tuna, Salmon, and Halibut.  You should bake or grill the fish to avoid adding unhealthy fats. If you don’t like fish, you can also get small amounts of omega-3 fatty acids from foods like ground flaxseed or canola oil.  You can take an omega-3 or fish oil supplement to get some of the same benefits 1200-2000mg, but you won’t get other nutrients in fish, like selenium.

Olive oil– Olive oil contains a potent mix of antioxidants that can lower your “bad” (LDL) cholesterol but leave your “good” (HDL) cholesterol untouched.  The FDA recommends using about 2 T (23 grams) of olive oil a day in place of other fats in your diet to get its heart-healthy benefits. To add olive oil to your diet, you can saute vegetables in it, add it to a marinade, or mix it with vinegar as a salad dressing. You can also use olive oil as a substitute for butter when basting meat or as a dip for bread. Olive oil is high in calories, so don’t over do it. The cholesterol-lowering effects of olive oil are even greater if you choose extra-virgin olive oil, meaning the oil is less processed and contains more heart-healthy antioxidants. But keep in mind that “light” olive oils are usually more processed than extra-virgin or virgin olive oils and are lighter in color, not fat or calories.

Soy protein — Soy protein contains isoflavones, which mimic the action of estrogen. A diet high in soy protein can slightly lower levels of total cholesterol, LDL cholesterol, and triglycerides, and raise levels of HDL cholesterol. However, normal protein should not be replaced with soy protein or isoflavone supplements in an effort to lower cholesterol levels.  Soy foods and food products (eg, tofu, soy butter, edamame, some soy burgers, etc.) are likely to have beneficial effects on lipids and cardiovascular health because they are low in saturated fats and high in unsaturated fats.  No more than 25g daily is necessary.  The controversial effects of exogenous estrogen ingestion, however in many peoples opinion, tends to make me recommend against using soy as a tool to lower cholesterol.

Garlic — A large trial showed that garlic is not effective in lowering cholesterol. In this study, participants with an elevated LDL took one of several types of garlic extract (raw, powdered, aged) or a placebo (inactive pill) six days per week for six months. At the end of the study, the LDL levels were not improved in the garlic group compared to the group that took the placebo. While garlic has been shown to help with high blood pressure and hold other health benefits, garlic does not appear to be affective in lowering cholesterol.

Plant Stanols and Sterols — Plant stanols and sterols may act by blocking the absorption of cholesterol in the intestine. They are naturally found in some fruits, vegetables, vegetable oils, nuts, seeds, and legumes. They are also available in commercially prepared products such as margarine (Promise Active™ and Benecol®), orange juice (Minute Maid Premium Heart Wise®), rice milk (Rice Dream Heart Wise™), as well as dietary supplements (Benecol SoftGels® and Cholest-Off®).   You don’t need more than 2g daily.  Despite lowering cholesterol levels, there are no studies demonstrating a reduced risk of coronary heart disease in people who consume supplemental plant stanols and sterols. There is some evidence that these supplements might actually increase risk.

Soluble fiber—Soluble fiber helps to reduce LDL cholesterol.  Two servings per day or 5-10g or more a day should be sufficient. Good sources of soluble fiber include oats and oat bran, barley, almost any kind of bean, apples, pears, prunes, eggplant, and okra.  Aim for 10 grams of soluble fiber per day.  Eating 1 1/2 cups of cooked oatmeal provides 6 grams of fiber.

Vitamin D– In a recent journal of “Circulation”, the researching team reports that vitamin D regulates signaling pathways linked both to uptake and to clearance of cholesterol in macrophages.  The process that leads to LDL oxidation that in turn stimulates atherosclerosis becomes accelerated when a person is deficient in vitamin D.  Thus supplementing with vitamin D to maintain adequate levels (30-150, goal >50) is recommended.  The FDA recommends 800 IU daily, this may be enough for Florida or San Diego however in the Northwest I recommend 2000 IU daily to maintain adequate levels.

Artichoke Extract—Inconclusive evidence exists, however claims of LDL and total cholesterol lowering have been suggested.

Green Tea– Has been shown to make mild shifts in lowering LDL and is also known to have other health benefits from the tannins that are rich in antioxidants including appetite suppression.

Walnuts, almonds, and other nuts– Walnuts, almonds and other nuts can reduce blood cholesterol. Rich in polyunsaturated fatty acids, walnuts also help keep blood vessels healthy.  According to the FDA, eating a handful (1.5 ounces, or 42.5 grams) a day of most nuts, such as almonds, hazelnuts, pecans, pine nuts, pistachio nuts and walnuts, may reduce your risk of heart disease. Just make sure the nuts you eat aren’t salted or coated with sugar.  All nuts are high in calories, so a handful will do.

Red Yeast Rice—There is evidence that red yeast rice can help lower your LDL cholesterol. However, the FDA has warned that red yeast rice products could contain a naturally occurring form of the prescription medication known as lovastatin. Lovastatin in the red yeast rice products in question is potentially dangerous because there’s no way for you to know what level or quality of lovastatin might be in red yeast rice, and liver enzymes should me monitored while taking this supplement.

Red yeast rice is the product of yeast ( Monascus purpureus ) grown on rice, and is served as a dietary staple in some Asian countries. The use of red yeast rice in China was first documented in the Tang Dynasty in 800 A.D. A detailed description of its manufacture is found in the ancient Chinese pharmacopoeia, Ben Cao Gang Mu-Dan Shi Bu Yi, published during the Ming Dynasty (1368-1644). In this text, red yeast rice is proposed to be a mild aid for gastric problems (indigestion, diarrhea), blood circulation, and spleen and stomach health.

Niacin—Shown to help increase HDL and decrease Triglycerides.  In fact Niacin is so affective that prescription versions have been made to use in lipid lowering treatment.  The OTC supplements are not FDA regulated, and thus do have varying bioavailability and dosing depending on the brand.  A common burden of Niacin that causes many to discontinue its use is flushing.  Flushing is not an allergic reaction, but rather vasodilation of the peripheral arteries.  Taking an aspirin or high fiber snack 20-30 min prior to taking the Niacin can help to reduce flushing.  Typically it is a bit of a hump to get over, but once your body becomes accustomed to it the side effects of flushing resolves.  I recommend starting at 500mg and gradually titrating the dose as tolerated up to 2000mg a day.  Non-flush forms typically have decreased efficacy in cholesterol lowering, but can be tried if regular Niacin can not be tolerated.

Medications — There are many medications available to help lower elevated levels of LDL cholesterol and triglycerides, but only a few for increasing HDL cholesterol. Each category of medication targets a specific lipid and varies in how it works, how effective it is, and how much it costs. Your healthcare provider will recommend a medication or combination of medications based on blood lipid levels and other individual factors.

If risks are high, medications may be suggested to be started immediately always in coordination with lifestyle and diet modifications.  If risks are low to moderate, conservative approaches and trials with supplements, diet, and lifestyle should be considered first for those who are motivated and proactive.  For some, despite best efforts and clean diets and lifestyle, medications are still necessary.

Statins — Statins are the most powerful drugs for lowering LDL cholesterol and are the most effective drug for prevention of coronary heart disease, heart attack, stroke, and death. Statins include lovastatin, pravastatin, simvastatin, fluvastatin, atorvastatin, and rosuvastatin. These medications decrease the body’s synthesis of cholesterol and can reduce LDL levels by as much as 20 to 60 percent. In addition, statins can lower triglycerides and slightly raise HDL cholesterol levels.

Ezetimibe — Ezetimibe (Zetia®) impairs the body’s ability to absorb cholesterol from food as well as cholesterol that the body produces internally. It lowers LDL levels when used alone. It has relatively few side effects when used alone. However, there are no studies that demonstrate better outcomes in patients who take ezetimibe, either alone or in combination with other cholesterol-lowering medications. Further study is needed before ezetimibe is recommended as a first-line treatment. This is why this medication is reserved only for individuals who can not tolerate Statin therapy.

Bile acid sequestrants — The bile acid sequestrants include cholestyramine, colestipol, and colesevelam. These medications bind (combine with) bile acids in the intestine, reducing the amount of cholesterol absorbed from foods.  Bile acid sequestrants may be recommended to treat mild to moderately elevated LDL cholesterol levels. However, side effects can be bothersome and limiting, and may include nausea, bloating, cramping, and liver injury. Taking psyllium (a fiber supplement, such as Metamucil®) can sometimes reduce the dose required and the side effects.

Bile acid sequestrants can interact with some medications, including as digoxin (Lanoxin®) and warfarin (Coumadin®), and with the absorption of fat-soluble vitamins (including vitamins A, D, K, and E). Taking these medications at different times of day can solve these problems in some cases.

Nicotinic acid (Niacin) — Nicotinic acid is a vitamin that is available in immediate-release, sustained-release, and extended-release formulations. Nicotinic acid may be recommended for people with elevated cholesterol levels and some types of familial hyperlipidemia.

• Side effects — Nicotinic acid has several possible side effects, including flushing (when the face or body turns red and becomes warm), itching, nausea, and numbness and tingling. This is not an allergic reaction, rather it causes the vessels in the skin to dilate and a rush of blood to the surface of the skin.  This medication can also be hard on the liver; patients who use it require regular monitoring of liver function, and those with liver disease should avoid this medication. For those with gout, Niacin should be avoided as it can increase uric acid levels.

Taking nicotinic acid with fiber rich food and taking aspirin (325 to 650 mg) 30 minutes before can decrease the side effects. Side effects often improve after 7 to 10 days.

Fibrates — Fibrate medications (gemfibrozil, fenofibrate and fenofibric acid) can lower triglyceride levels and raise HDL cholesterol levels .  Fibrates have been associated with muscle toxicity (causing muscle pain or weakness), especially when used by people with kidney insufficiency or when used in combination with a statin medication. Fenofibrate/fenofibric acid (Tricor®, Triglide®, Trilipex®) are less likely to interact with statins than gemfibrozil, and are safer in people who must use both medications.

Diets

Low fat diet vs Paleo diet

Which diet is the best diet for high cholesterol?  Historically, low fat diets have been recommended for both elevated cholesterol and heart disease.  However, more recently we are realizing that it is not as simple as avoiding eggs and red meat.  In large trials comparing different diets, results several very different diets are all somewhat similar.  This is a story of no clear winners when discussing cholesterol lowering alone.  Extremely low fat diets, vegetarian, low carbohydrate diets such as the Atkins, and diets rich in good fats such as the Mediterranean diet all finish similarly with cholesterol comparisons.

So what is the best diet?  What have we learned from each of the diets that have been studied in depth?  Here is a summary of what I have read, and my take:  We know that decreasing saturated and bad fats help to lower cholesterol from AHA (American Heart Association) recommended low fat diets.  But when these diets were compared to a diet focusing on getting known cholesterol-reducing foods such as nuts, soluble fiber, olive oil the latter was more affective at cholesterol lowering (several studies showing ~3% vs ~13% reduction).  Diets such as the Mediterranean diet or Portfolio diet rich in olive oil and nuts helps to reduce cholesterol due to increased healthy fats and Omega 3 content.  Low carbohydrate diets such as the Atkins diet, help reduce cholesterol by reducing insulin secretion and metabolic syndrome.  Vegetarian diets rich in fruits, vegetables, and Soy help reduce cholesterol due to its high soluble fiber and soy content.  We also know that high inflammation with many chronic illnesses increases cortisol and affects cholesterol processing.  Likewise, processed and foods exposed to high heat cooking (fried) denatures proteins and fats that increases bad cholesterol and plaque build up.

So lets put this all together…… A diet rich in nutrient dense foods and soluble fiber such as fruits and vegetables; low in commonly pro-inflammatory foods such as wheat and dairy; low in simple carbohydrates such as sugars and refined grains; high in healthy fats and Omega 3’s (nuts, grass fed and wild red meat, olive oil, cage free eggs); low in preservatives, high heat degradation, and processing—what does this sound like?  Sounds awfully familiar, and very similar to Paleo!  Unfortunately large controlled studies have not yet been done, but Paleo is gaining momentum.  We hope to have statistics and good evidence based medicine in the near future so that this way of life can be better excepted within the medical community and mainstream public.

We must also consider the importance of how our diets affect our hormonal access, gut, energy levels, nutritional content, and inflammation.  For many, the Paleo diet can achieve not only cholesterol lowering but also overall health benefits of all the above.  Every individual is different, and our diets should reflect this.  There is not a one size fits all.  Some may do fine with whole grains or dairy without inflammatory or gut issues, but many don’t.  Some can eat endless eggs, bacon, and trans-fats found in store bought cookies and processed foods without consequences on their cholesterol, and others who have a genetic predisposition to high cholesterol may have to dial these foods rich in saturated fats down.

Avoid fried high temperature cooked and heavily processed foods

With all the focus on LDL cholesterol, a lesser known form of cholesterol called oxycholesterol may pose the biggest heart health threat, says Chinese scientist.  Scientist from the Chinese University of Hong Kong identified fried and processed food as the main sources of Oxycholesterol in the diet.  Their work demonstrated that oxycholesterol boosts total cholesterol levels and promotes atherosclerosis more than non-oxidized cholesterol.  “Foods of animal origins contain cholesterol, which is stable at room temperature. However, it is susceptible to oxidation during heating, particularly, long frying and high temperature.”  Oxycholesterol is also produced from oxidized oils, particularly the trans-fatty acids and partially-hydrogenated vegetable oils.

Sticking with Treatment

Sometimes healthy lifestyle choices, including supplements and other cholesterol-lowering products, aren’t enough. If your doctor prescribes medication to reduce your cholesterol, take it as directed while you continue to focus on a healthy lifestyle. As always, if you decide to take an herbal supplement, be sure to tell your doctor. The herbal supplement you take may interact with other medications you take.

The treatment of high cholesterol and/or triglycerides is a lifelong process. Although medications can rapidly lower your levels, it often takes 6 to 12 months before the effects of lifestyle modifications are noticeable. Once you have an effective treatment plan and you begin to see results, it is important to stick with the plan. Stopping treatment usually allows lipid levels to rise again.

“Wellness- Back to the Basics…..”

By Brittany Burns MD

01.11.12

Health is an interplay between many variables including sleep, nutrition, exercise, stress, relations, ‘play’, genetics, and even a bit of random luck.  There are things that are within our realm of control, and others that are unfortunately out of our control.  Controlling for the variables that we do have power over, will optimize your chances for a healthy life less riddled with disease and illness.

The medical world has an overwhelming amount of knowledge and ways to manipulate or suppress disease and illness. For many people it is easier to take a pill to address disease or compensate for unhealthy lifestyle, but a pill is still riskier and far inferior to ‘getting back to the basics’. Unfortunately, much of medicine is focused on fixing and controlling disease rather than preventing disease. I propose that we switch our mindset and focus on avoiding and preventing illness. Linking yourself in with a good Primary Care Provider (PCP) who focuses on preventative medicine is highly recommended. Regular annual physical exams and lab evaluation for screening and preventative advice helps to catch disease early when often it can still be reversed or cured.  Ultimately your PCP, labs, and knowledge are tools that you can choose to use and empower you to make healthy life choices. Making good choices, and following through with them can be the most challenging to incorporate in your lives, yet by far the most rewarding and powerful!  Physicians, medicines, and supplements don’t make you healthy, it is ultimately your choices that determine the healthiest version of you!

Empowering you with knowledge of healthy practices, basic fundamental understanding of disease, and wellness is the goal of this lecture series.  So today we ‘get back to the basics’….

Sleep…

Everyone differs on how much sleep is necessary to achieve adequate rest.  Teenagers typically require 8-11 hours of sleep, and tend to have a second wind in the evening often keeping them up later and a tendency to sleep in in the mornings.  Adults require between 6-9 hours of sleep.  Variables that affect how much sleep is needed include: individual variability, activity level, stress levels, and sleep efficiency.

Individual Variability:  The best way to find your ideal amount of sleep is to tune in to how you are feeling.  Do you feel rested in the morning or are you pealing yourself out of bed and hitting snooze several times?  Do you have reasonable energy during the day or feeling lack luster consistently?  Some of us honestly do well on 6 hours, and others need those 9 hours.  Oversleeping is actually detrimental and can change neurochemical hormones that lead to daytime grogginess, and predispose decreased spirits or depression.  Making up for the lack of sleep previous days with oversleeping is never as efficient or affective as aiming for better consistency.

Activity level: The more you demand from your body the more sleep is required and vital to maintaining the equilibrium of wellness.  Ramping up activity level usually requires more sleep for recovery, and that sleep is typically deeper and more efficient.  Once activity level is stabilized you will typically return to your baseline sleep requirements. Additionally, exercise also combats stress and decreases the adrenergic state of higher stress hormones, however be mindful that ‘overtraining’ can have the reverse affect.  Exercise, both mental and physical, is an excellent sleep aid and preferable to medications.  Exercise, in a addition to improving sleep, also is powerful in combating daytime fatigue, raising metabolic rate, and improving general energy levels.

Stress level:  Stress often leads to higher base line adrenalin levels, which interferes with the sleeping state.  It affects the ability to fall asleep, sleep efficiency, and often causes frequent waking with sometimes more difficulty falling back to sleep.  Racing thoughts and worries is a common hindrance to falling asleep.  Diaphragmatic breathing, and wind down activities can help to relax the mind and combat these stressors when triggered.  Working towards minimizing the culprit stressors, when able, clearly is the most ideal.

Sleep efficiency:  People who seem to require longer amounts of sleep to feel fully rested may be suffering from poor sleep efficiency.  High adrenalin levels from stress and anxiety, Neuro-hormonal shifts such as decreased serotonin levels in depression, sleep apnea, alcohol, caffeine, and lack of good ‘sleep hygiene’ are among the most common causes of decreased sleep efficiency.

Good ‘sleep hygiene’ refers to behaviors that help reinforce our natural Circadian Rhythm controlled within the brain.  This “Circadian Rhythm” and flux of hormones such as Melatonin that coordinate and reinforce sleep can be disrupted by many behaviors including: noise pollution, light exposure, and inconsistent sleep timing.

• Falling asleep and sleeping with ambient noise such as TV, computers, and music distracts from your natural ‘wind down’ and ability to self soothe and fall asleep without aid.  Just as an infant should be taught to self soothe and fall asleep without aid of feeding or codling, you too will be better served and sleep more efficiently if you learn this valuable tool.
• Leaving lights on or not having adequate window treatments to block out light (unless you are part of the few that are able to follow the rise and fall of the suns natural light) disrupts the Circadian axis.  If a nightlight is necessary, red light appears to be the least disruptive.
• Inconsistent sleep hours and significant variability in your bedtime negates a lot of our natural built in tools that reinforce sleepiness and sleep efficiency, it renders the Circadian Rhythm useless and confused.  I realize that consistency is not always possible for everyone due to jobs that require shift work and other circumstances, but when you can control for this, a set ‘bed time’ is helpful.

Top health reasons to strive for adequate sleep duration and good sleep efficiency include:

Memory: Your mind is surprisingly busy while you snooze. During sleep you can strengthen memories or “practice” skills learned while you were awake (it’s a process called consolidation).  “If you are trying to learn something, whether it’s physical or mental, you learn it to a certain point with practice,” says Dr. Rapoport, who is an associate professor at NYU Langone Medical Center. “But something happens while you sleep that makes you learn it better.”

Lifespan: Too much or too little sleep is associated with a shorter lifespan — although it’s not clear if it’s a cause or effect.  In a 2010 study of women ages 50 to 79, more deaths occurred in women who got less than five hours or more than six and a half hours of sleep per night.
Quality of Life: Research indicates that people who get less than 6 hours of sleep have higher blood levels of inflammatory proteins than those who get more sleep. Inflammation is linked to heart disease, stroke, diabetes, arthritis, and premature aging.  A 2010 study found that C-reactive protein was higher in people who got six or fewer hours of sleep, which is associated with heart attack risk.  Sleep deprivation also triggers stress hormones such as cortisol that also contribute heart and many other diseases.

Improved Performance athletics: A Stanford University study found that college football players who tried to sleep at least 10 hours a night for seven to eight weeks improved their average sprint time and had less daytime fatigue and more stamina. The results of this study reflect previous findings seen in tennis players and swimmers.

Creativity: Your brain appears to reorganize and restructure memories, and researchers at Harvard University and Boston College found that people seem to strengthen the emotional components of a memory during sleep, which may help spur the creative process.

Grades and Job performance: Numerous studies attesting to this have been performed.

Reaction time and judgment: Sleep deprivation has been compared to levels of alcohol intoxication in studies performed on sleep deprived medical residents, which drove reform of work hours in recent years.  Sleep deprivation has been shown to greatly slow reaction speed and increase risks of motor vehicle accidents.

Weight loss: Researchers at the University of Chicago found that dieters who were well rested lost more fat than those who were sleep deprived, who lost more muscle mass.   Dieters in the study also felt hungrier when they got less sleep.  Sleep and metabolism are controlled in the same parts of the brain.  When you are sleepy, certain hormones spill into your blood that also help to drive appetite.

Improved Spirits:  Lack of sleep predisposes to depression and anxiety.  Sleeplessness leaves our fuses short and lends to emotional irritability.  We tend to overreact emotionally when sleep deprived with temper or tears.

Nutrition…

This is a huge subject that I cannot possibly do complete justice to in the time we have in this first lecture.   We will be addressing more details on the specifics of nutrition throughout the lecture series, but today I want to point out the overwhelming importance and emphasis on good nutrition.  There is a lot of truth to the saying: “We are what we eat”.

Food, while clearly satisfying and enjoyable, is more importantly our source of energy that fuels all that we do.  Our bodies are amazingly adaptable to utilizing the fuel it is given, but there are definite differences in the quality of foods and efficiency of which our bodies function without disease.  We have such a variety of foods readily available year around thanks to commerce and manipulation of our food sources and production.  This is a luxury, and in some ways an evolutionary disadvantage.  In the past our ancestors in some ways had it easier to make good choices with whole home grown unaltered foods, involved preparation, limitation of food availability, and seasonal variability that helped in avoiding over indulging and eating for pleasure only.  In our current culture we have access to a wide array of tastes from differing ethnic past times, year around availability of most produce, easy access, and fast foods requiring minimum preparation all lending to the ease of over consumption.  We must be mindful of this, and actively strive to make good choices and practice restraint in our culture of excess.

Enjoy, yes! But please don’t forget that the quality of food that you choose to consume drives and fuels your health.  Excess leads to obesity, and poor quality leads to disruption of hormonal balance, lack of essential nutrients, and disease.   There is a limit to the quantity that should be consumed, so what we do consume should be nutritionally loaded with minerals, micro/macro nutrients, antioxidants, and essential nutritional building blocks like protein.  You get the most ‘bang for your buck’ with whole foods including: fruits, vegetables, nuts, and meat.

Grain is a big business in this country. We see commercials preaching heart health, and seals of approval on packaging promoting in the minds of the public health benefits of grain. Fiber does help to reduce cholesterol, cardiovascular disease, and diseases such as diverticulosis.  From all that I can gather the only benefit from grains is the fiber content.  Grains lack micro/macronutrients, minerals, antioxidants, and in fact some new evidence suggests components referred to as ‘anti-nutrients” that may leach minerals from the other foods we consume with grains. Grains are dense in carbohydrates, and in my opinion, empty carbohydrates that stimulate insulin and in excess can lead to diabetes an overwhelming epidemic in our society.  Grain is not nearly as nutrient dense as vegetables that also happen to be rich in fiber and confer all the same benefits and more.  Why not choose the more nutrient dense option?

The less altered and preserved your foods are, frequently the healthier they tend to be.  We cannot yet fully understand or recognize the impact of all the additives placed in our foods, but are now accumulating data that many are pro-carcinogenic and alter our delicate hormonal circuits.  Foods that are raised as they are accustomed by nature are more nutrient dense, and have healthier ratios of nutritional components.  A mass produced apple today in the grocery store, has in some research shown to contain only 1/4^th of the micronutrients and antioxidants an apple once contained prior to the 1950’s.  Red meat is not all created equally– grass fed and wild red meat contains a fraction of the saturated fats that grain fed beef contains and is much higher in Omega 3 content.  While I understand it is sometimes difficult and expensive to eat all organic and entirely clean, I encourage you to do so as much as you are able.

Daily Vitamin Supplements

While we try to mimic nature in mass processing and packaging components in supplements and capsules, they do not compare to what nature provides in more balanced doses in whole foods.  We do not yet fully understand all the intricacy of these nutritional components to fully extract and package them, although we certainly try to make these short cuts.  If you eat a balanced, nutrient dense diet you will get far more than what is contained and afforded in a daily multivitamin.

Vitamin D Supplementation

In the Northwest we do tend to lack adequate Vitamin D production.  Vitamin D is made and processed in the skin from the sun.  It is hard to get enough Vitamin D from diet alone—vitamin D rich foods include many fish, organ meat, and fortified dairy products.  We have known for some time now that Vitamin D is essential in bone health and incorporating Calcium into our bones.  We, more recently, are understanding that Vitamin D is functioning more like a hormone and is integral in many crucial functions.  In the immediate sense Vitamin D helps with energy levels, decreased spirits such as the ‘winter blues’, muscle and skeletal aches, and immune augmentation.  In the long term low Vitamin D levels have been linked to increased risks of osteoporosis, MS, kidney stones, heart disease, diabetes, and cancers such as breast and colon.

FDA recommends 800-1000 IU’s daily, which may be sufficient for San Diego or Florida but not here in the Northwest.  Normal Vitamin D levels are 30-150, with my goal of getting above 50.  I recommend a minimum of 2000 IU daily, and for those that have low Vitamin D levels on low side of normal range (30-50), recommend 4000 IU daily.  If falling below normal limits, Rx doses of Vitamin D may be necessary to build adequate stores before transitioning to daily OTC supplementation.

Omega 3 Supplementation

Fish, wild caught meat, free range eggs, nuts, and natural oils such coconut and olive contain good quantities of Omega 3’s.  In the past our ancestors consumed a great deal more Omega 3’s than we do in our current diets.  In cultures observed today who consume higher Omega 3’s we see less consequences of many Western illness, most notably Cardiovascular disease.  Omega 3’s act as a natural anti-inflammatory, and thus is helpful for our joints and those that suffer from joint disease or arthritis.  Inflammation also plays a large role in cardiovascular disease, causing sticky arteries and contributing to the cascade of events that promote plaque build up in the arteries.  A recent large controlled study showed a 20% reduction in heart attacks and strokes in individuals who supplemented daily with Omega 3’s likely at least in part due to its anti-inflammatory affects.

I typically recommend 2000mg Omega 3 daily.  In some cases when dealing with greater inflammation, higher doses may be recommended.

Cholesterol

This is another large topic that we have a whole lecture dedicated to in March 2012.  Briefly cholesterol is a mixture of both genetics and lifestyle.  There are some who do everything right and still have high cholesterol, and likewise those who make very poor choices and have perfect cholesterol—that is genetics.  Most of us fall in the gray shades between where we may have some predisposition to elevated cholesterol, but good lifestyle choices can significantly impact cholesterol numbers.

It is best to look at the breakdown of your cholesterol numbers.  I am not a big fan of the “Total Cholesterol” number as it sometimes tends to not convey the full picture.  Rather, I encourage you to look at the breakdown components: HDL, LDL, and Triglycerides.

* HDL:  The good cholesterol, the higher the number the more cardio-protective.

– Exercise and conservative amounts of wine can help elevate the HDL.

– Supplementing with Niacin can also help elevate HDL.

* LDL:  bad cholesterol that can predispose plaque build up if elevated.

– Healthy diet low in saturated fats (Examples: cheese, fried foods, grain fed red meat)

– Omega 3 Supplementation can help lower  LDL.

* TG’s:  A bad cholesterol that also contributes to increased cardiovascular disease.

– Healthy diet low in sugar and carbohydrates (in particular grains) helps keep this low.

– Niacin Supplementation can help lower TG’s, if elevated.

Exercise….

“Exercise is the closest thing we’ll ever get to the miracle pill that everyone is

seeking.  It brings weight loss, appetite control, improved mood and self-esteem,

an energy kick and longer life by decreasing the risk of heart disease,

diabetes, stroke, osteoporosis, and chronic disabilities.”

(Holly Atkinson, MD, Editor, Health News, May 27, 1997)

Little we have in medicine is more powerful or versatile as regular exercise.  Recent studies have shown that exercise reform in individuals with stable Coronary Artery Disease is equal if not better than coronary stenting.  In a large longitudinal study of 50,000 people comparing the impact of Fitness, Obesity, Hypertension, Smoking, Elevated Cholesterol, and Diabetes—Fitness was the strongest predictor of avoidable death.  Exercise need not be the same for everyone.  In a large Nurse Health study, merely upgrading from 0 hours to 1 hour of exercise a week decreased heart risks in half.  Some strive to be competitive athletes, and other just to be healthy and maintain base level of fitness.  Everyone can gain from any level of exercise, but your goals may differ and drive the duration, frequency, and intensity.  Rate of return on exercise duration greater than 30min diminishes.  Exercising with greater intensity appears to be equal to that of longer duration and lower intensity.  Prioritizing time for activity and exercise may be the single most effective health intervention.

Benefits of exercise:

-        Decrease Depression 30-50%

-        Decrease anxiety 48%

-        Decrease Diabetes progression 58%

-        Decrease Alzheimer’s 50%

-        Decrease Hip fractures in Postmenopausal women by 41%

-        Decrease pain from Arthritis 47%

-        Decrease Hypertension 36% when walking daily for >30 min

-        Improve Fatigue and sleep quality

-        Increase Libido

-        Maintaining independence and function in our elder years

Stress….

Stress is the physical, mental, or emotional tension experienced in reaction to an event.  Stress is typically experienced when we perceive demands exceeding our resources.  Physiologically we deal with stress by tapping into the ‘Fight of Flight” mechanism weather it is appropriate for the situation or not.  This is also known as the ‘Sympathetic’ response, versus the ‘Parasympathetic’ response or the restful state.  Hormones such as adrenalin are released to help drive the ‘flight response”.  Heart rate and blood pressure increases to deliver more oxygen and sugars to important muscles.  Sweating increases to cool these muscles.  Blood is diverted away from the skin to keep at the core first in line for vital organ use and to reduce blood loss if injured in the periphery.  Attention is focused on the threat.  This circuit is meant for survival if a lion were chasing at your back, however in stress our bodies are tripped over into this state inappropriately even with no real active threat.  The extreme version of this is known as a ‘Panic Attack’.   Stress effects multiple facets of the human situation, including:  cognitive, emotional, behavioral, physical, and social.

Effects of chronic stress includes:

—  Increased vulnerability to the common cold and decreased immune function

—  Slower wound healing and poor DNA repair

—  High blood pressure and high cholesterol

—  Heart disease

—  Weight gain (central fat storage) due to increased cortisol levels

—  Poor control of blood sugar among diabetics

—  Poor health behaviors to cope or compensate for stress (e.g., diet, smoking, no exercise)

—  Shortened telomeres and telomerase activity which leads to advanced aging

—  Hair loss due to hormonal imbalance

—  Decreased memory and concentration leading to increased errors and poor work performance

—  Increased irritability with higher adrenalin levels affecting interpersonal relations

—  Decreased sleep efficiency with more difficulty falling and staying asleep

Recognize symptoms of stress, including:

Physical:

-        Indigestion, IBS, Constipation, Diarrhea, Stomach ulcers

-        Headaches

-        Backaches, neck stiffness and muscular tension or spasms

-        Sleeping difficulty and daytime fatigue

-        Appetite changes with under or over eating

-        Decreased libido and sexual function

Behavioral:

-        Withdrawal: neglecting responsibilities and social isolation

-        Acting out: with drugs, alcohol in excess, smoking, gambling, spending spree, promiscuity

-        Work infractions: tardiness, poor hygiene or appearance, accident prone

-        Disorganization: forgetfulness, decreased concentration, decreased ability to multitask

Emotional:

-        Hostility, Anger, Resentment

-        Low self esteem, feelings of worthlessness, insecurity, apathy

-        Irritability, defensive, argumentative, restless

-        Overcompensation, denial, suspicious or paranoid

Tools to help ‘flip the switch’ from Sympathetic to Parasympathetic or restful state include diaphragmatic breathing, progressive muscle relaxation, and meditation.  Diaphragmatic breathing taps into the phrenic nerve in the diaphragm and helps to slow breathing.  Progressive muscle relaxation helps to release tension and refocus the mind.  Meditation uses imagery to clear the clutter and thoughts that overwhelm and keep the ‘fight or flight’ response cycling.  Exercise, one of the best anxiolytics, helps to run the adrenalin levels down, calm the nerves, and improve sleep quality.  Addressing stressors that are within your control even if it means life changes is important to consider, yet sometimes admittedly difficult.  We all will experience stressors in our lives that are outside our control, but controlling for other variables like getting adequate sleep, ‘play’, good nutrition, and rallying support around you can help your ability to cope better in these situations.

Relations…

“…my father told me of a careflul observer, who certainly had heart-disease and died from it, and who positively stated that his pulse was habitually irregular to an extreme degree; yet to his great disappointment it invariably became regular as soon as my father entered the room.” -Charles Darwin

Scientist have long noted an association between social relationships and health.  More socially isolated or less socially integrated individuals are less healthy, psychologically and physically, and more likely to die.  Humans are very social creatures, and when isolated, can frequently lead to depression and changes in hormonal balances that in turn predispose disease, in particular cardiovascular disease.

Marriage was one of the first non-biological factors identified as improving life expectancy.  A large study performed in the 1970’s showed significant data varifying this relation of social support and health outcome.  The explanation that has been proposed is that married people tend to take fewer risks with their health and have better mental and emotional health. Marriage also provides more social and material support.

Humor shared amongst family and friends is infectious. The sound of roaring laughter is far more contagious than any cough, sniffle, or sneeze. When laughter is shared, it binds people together and increases happiness and intimacy. In addition to amusement, laughter also triggers healthy physical changes in the body. Humor and laughter strengthen your immune system, boost your energy, diminish pain, and protect you from the damaging effects of stress.

The take home message:  Surround yourself with friends and family.  Communicate, laugh, commiserate, and when times get tough lean on a shoulder for support.

Play…

Children do this well.  Humans are by nature playful beings, and to stifle that can cause much angst and melancholy.  Often as we grow up, our busy lives with jobs, family, life obligations consume our time and we forget to prioritize ‘play’.  The obligations that appear to consume our time are often self imposed.  I propose that you prioritize and if need be schedule in time for ‘play’ that is all your own.   ‘Play’, is essential for the mind and soul and important to help lessen the chances for depression and anxiety, which in turn tax the body through hormonal changes.  ‘Play’, is different for everyone—it may be a hobby, sport (CrossFit!), dancing, recreation, or tradition.  What ever it is for you, ‘play’ is essential to be healthy both mind and body.

Genetics…

Genetics is what we are gifted from our parents.  How we choose to express our genetic potential depends on the choices we make in our lives.  Just because your father died of heart disease, does not mean that you are doomed to have the same fate, rather it should light a fire underneath you to decrease your risks as much as possible through good choices.  Many of our parents and grandparents lived very different lives without fully knowing the impacts of their lifestyle choices.  Many may have smoked and ate poor diets that together with their genetic predispositions lead to poor outcomes and disease.  We are lucky to be armed with more information to guide and empower those who are motivated to avoid those vices that weaken the links in our genetic chain.  I encourage you to open your eyes and follow the basics that we know to be true, not to follow the masses that ignore these very essential life skills and are content to take another pill and become another static.

Our next lecture will be focusing on this interplay of “Phenotype” how are genes actually express themselves based on life exposures, versus “Genotype” the detailed under-wiring that predisposes us to many of our strengths and weaknesses, but are no way ‘hard-wired’.

Upcoming lectures, exact dates and times to be posted:

FEBRUARY 2012

“Phenotype versus Genotype”

A conversation of the genetics we are gifted with and how we choose to express them through our choices and lifestyle. A sub-focus on Weight and Metabolic set points, Cholesterol, and Western disease such as Diabetes.

MARCH 2012

“Cholesterol–not as simple as avoiding eggs and red meat”

Cholesterol, like most things is a mix of genetics and lifestyle.  An in depth discussion of how our bodies produce and process cholesterol, differences between good and bad cholesterol, and how they affect our bodies.

APRIL 2012

“Is Wheat as evil as the Guys make it out to be?”

A review of food Allergies versus Intolerance. A story of how some foods can stir up inflammation, which predisposes the majority of illness such as Irritable bowel disease, Cardiovascular disease, Autoimmune disease, and Cancer.

MAY 2012

“What makes us Fat?”

Weight loss is not as simple as Calories in and Calories out.  Genetics, metabolic set point, and hormonal interplay often have a powerful impact on weight.  Will also discuss how to determine your ‘ideal body weight’ and how that may differ from your ‘healthy body weight’.

JUNE 2012

“How Exercise and Flexibility keeps you Younger”

Breaking the vicious cycle.  As we age are muscles and ligaments strap down tighter making us more prone for injury.  With injuries we tend to hold still, stalling our recovery and playing into the vicious cycle leading to more sedentary lifestyles.  We will review the literature and known effects of exercise on Alzheimer’s, longevity, and living independently into your 90’s.

FREE TO ALL CFCd’A ATHLETES, others welcome at a $5 facility fee!

Our practice was formed in 1977 with the vision of providing an organized, intelligent, compassionate, and caring healthcare environment.  Here at Family Medicine Coeur d’Alene, we pride ourselves on uniting the best aspects of traditional primary care- the “town doctor”- with the cutting edge of today’s leading healthcare.   Our knowledgeable, caring staff takes pride in providing consistent, continuous care to you and your family- in both sickness and health. While we believe that prevention and early management is the key to long term health, we are also present for our patients for crisis care. We are one of the few primary providers in the area who continue to follow our patients care in the hospital.  This demonstrates our commitment to continuity of care.  Come experience what it is like to have a medical partner truly invested in your long term wellness!

Our board-certified physicians will focus on comprehensive preventative care and education to all well patients, while using our broad medical knowledge and current techniques to diagnose and treat illness.

As family physicians, we are health advocates trained to care for and guide our patients through an increasingly complex health care environment.  We provide care to all stages of life- birth to end of life, and all points in between.  We treat the whole person, and encourage our patients to actively participate in their own health and well being.