i’m back! (for a bit)

Dear All,

Sorry I’ve been missing for a while — third year medical school was a whirlwind, and then I took a research year off where I started working on starting a non-profit and other activities.   Hope you had a wonderful Thanksgiving and to hope writing to you soon!  I’ve been slow about getting back to your questions — I am very sorry about that.  Please e-mail me at unitedstatesmedicalstudent@gmail.com for any pressing questions.  Thank you!  Jeff

a “new” take on eggs — they’re not bad!

 Today, we had an AWESOME patient management class on syncope, loss of consciousness, with these wonderful clinical vignettes, which I hope to share with you soon.  But for this post, I wanted to make a quick note on eggs, because some of my friends are afraid of eating egg yolks, worrying that by doing so, they will boost their cholesterol levels, and give themselves heart disease.

So the good news: eggs, including egg yolks, in moderation (which is defined as 1 a day or 7 eggs/week) are safe and healthy and you don’t have to be scared of them:

http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/eggs/

 

 

The other important thing to clear up is that, often in health news, you hear about being careful with your cholesterol, HDL, LDL levels — “too high” of LDL, and that’s bad.   

 

It’s then easy then to assume that “eating” cholesterol is bad for you.

 

But there’s surprisingly little evidence to support that assumption.  In fact, it appears that there is no link between eating lots of cholesterol, and giving you heart disease.

 

That is what I concluded after I read a review article written by Harvard professors Frank Hu, Joanne Manson, Walter Willet, who are respected principal investigators of large-scale studies on nutrition, preventive medicine, such as the Women’s Health Initiative, and the Nurses Health Study.  I highlighted some of the passages in that article if you were more interested (for the full article, click here Fat, eggs and heart disease):

 

In controlled metabolic studies conducted in humans, dietary cholesterol raises levels of total and LDL cholesterol in blood, but the effects are relatively small compared with saturated and trans fatty acids, and individuals vary widely in their responses. A significant positive association between dietary cholesterol and CHD was found in some epidemiologic studies, but not in others. In a pooled analysis of four studies [5–7,11], the relative risk of CHD was 1.30 (1.10 –1.50) for a difference of 200 mg/1000 kcal in dietary cholesterol [124]. But this analysis included only those studies with positive findings. The Nurses’ Health Study found a weak and nonsignificant positive association between dietary cholesterol and risk of CHD (relative risk for each increase of 200 mg/1000 kcal 5 1.12, 95% confidence interval 0.91–1.40).

Surprisingly, there is little direct evidence linking higher egg consumption and increased risk of CHD…The null association between egg consumption and risk of CHD observed in these studies may be somewhat surprising, considering the widespread belief that eggs are a major cause of heart disease. One egg contains about 200 mg cholesterol, but also appreciable amounts of protein, unsaturated fats, folate, B vitamins and minerals. It is conceivable that the small adverse effect caused by cholesterol is counterbalanced by potential beneficial effects of other nutrients.

These findings do not suggest that one should go back to the traditional high cholesterol Western diet. Instead, they suggest that among healthy men and women, moderate egg consumption can be part of a nutritious and balanced diet. Because eggs are excellent and relatively inexpensive sources of essential amino acids and certain vitamins, they can substitute for other animal products such as red meat. These results also illustrate the danger of judging health effects of a food by single nutrients or components contained in the food.

 

More fish, fish oil, omega 3

Dear All,

Many of you have heard that Tim Russert, a beloved journalist and moderator of Meet the Press, died of sudden cardiac death a few days ago.  When I listened to the interview with Tim Russert’s doctor, I was concerned and worried that he didn’t get a chance to hear about fish oil.  The reason why was because I know from personal experience at clinics and at the hospital, that patients are not often told that fish oil is an absolutely critlcal part of treatment strategy.   And when I heard Mr. Russert passed away, I felt very guilty for not stepping it up and letting more people — you — know of the life-saving effects of taking fish oil everyday.  I know these statements may sound over-the-top, but as you will see in the articles I point out, the data is strong, and the scientific evidence is there to support what I just said.  This is a topic I should have talked about long ago — as soon as I had learned about it, I should have started blogging and started youtubing about it.

You may wonder, Jeff is fish oil really that important?  After all, now that I am a third-year medical student, I’ve gotten a chance to experience the oncology floors at the hospital, urgent care, and family clinics.  I realize how little I do know — it’s a humbling experience — and the interns and residents are truly my role models.  My classmates and I greatly admire many of the doctors in the hospital, and there’s even a bit of hero-worship involved, especially when you see an intern tackling so many cases, from doing lumbar punctures to rescuing patients who can’t breathe — all on 0 hours of sleep, having stayed up for more than 28 hours — while smiling and being patient and compassionate 24/7.

So given how much I do not know, and of all the things I’ve seen and learned, many of which are more dramatic than fish, you may ask, incredulously, “do you really have to tell us about fish oil?”

I respect your skepticism, but I hope you hear me out.  Everything I’ve read seems to point that fish oil, is at least as critical as statins and other drugs in preventing sudden cardiac death and death.  In 2005, JAMA’s Archives of Internal Medicine published a systematic review comparing statins head to head with fish oil.  The review found that statins reduced risk of overall mortality by 13%, whereas fish oil reduced risk of death by 23%.   (You can read the article here: http://archinte.ama-assn.org/cgi/content/full/165/7/725)  There are many other studies showing that fish oil saves lives.  Here’s a link to another study published in Lancet, 1999, showing that fish oil reduces risk of death by 15% and risk of sudden cardiac death (which is what Tim Russert passed away from), by 45%.  (You can read about it here: http://www.ncbi.nlm.nih.gov/pubmed/10465168).  Even the American Heart Association recommends that for patients who have coronary heart disease, they should take 1g of EPA and DHA if you have heart disease: http://www.americanheart.org/presenter.jhtml?identifier=4632

After reading these studes, your next question may be, “well Jeff, if so many people are saying you should take fish oil, why are you rehashing the party line?” 

Again, that is a legitimate question, and to that, I can only sadly say, that in my experience, too many patients do not get prescribed fish oil as part of their treatment plan.  For some reason, it’s considered an optional thing to do.  “Nice, but not necessary.”  It’s also not covered by insurance, and so for patients who cannot afford additional financial burden, they do not get access to this life-saving intervention.

                                                                  —

I wish I could be sharing with you some high-tech discovery that would demonstrate a thorough understanding of complex medical problems.  That would impress not just you, but also the interns and the attendings.  In the hospital, the doctors have their codes of respect: if you know how to read supraventricular tachyarrhythmias in EKGs, you’re cool.  If you know how to treat flash pulmonary edema, you’re cool.  If you know how to handle worrisome V-tach’s — you’re cool.

What’s not cool, is fish or fish oil.   It’s not chique — not exactly the kind of topic that wows my interns and my attendings.    But when I heard about Tim Russert’s sudden cardiac death, I felt compelled to stay on this topic and share with you more information about fish oil.  I hope you can share with many of your family members this information, especially the review that I mentioned above showing that fish oil beats out statins: http://archinte.ama-assn.org/cgi/content/full/165/7/725. 

(Lastly, I just want you to know that all the sources I cite in this article are from trustworthy, prestigious institutions or journals.  JAMA Archives of Internal Medicine, Lancet, American Heart Association)

 

 

 

 

What fish and what fish oil should I eat?

Dear All, 

Again, apologies for taking so long to update the blog.  Right now, we’re in the midst of finals week, preparing for dermatology, rheumatology, orthopedics, respiratory and cardiovascular pathophysiology.  It’s going to be a fun week of studying in the snow!  (There’s a snow storm in Boston right now).   

Going back to the fish story and omega-3’s — apparently it’s a lot more complicated than what I originally anticipated.  There are two extreme views on fish.  One side, argued by many nutrition professors, is that fish is really good because of the omega-3’s, and the more you eat, the better for your heart and brain, and the better you feel, so eat your fish at every meal! (Okay, that’s a bit of an exaggeration, but you get the gist).  Another side, argued by environmentally-oriented scientists, and a few nutrition professors like Marion Nestle, is that fish is for the most part, a dangerous food.  Big fish are loaded with mercury and all farmed fish—big and small—are loaded with PCBs and dioxin.  So unless you can buy fresh wild coho salmon that costs 15 dollars per pound at Whole Foods, or unless you live in Alaska – you should pretty much just forget about seafood.   

Huge fights have erupted between both sides – nasty language thrown about back and forth, words that you thought would only be in political campaigns.  One side has said that telling people fish is dangerous is equivalent to causing the premature deaths of hundreds of thousands of people.  The other side retorted by saying that these “scurrilous attacks” don’t help anybody and that instead of blaming the fish truth-tellers, the real problem is the industrial polluter who poisons our earth. 

There have even been serious conflict of interest issues, with the tuna and fish industry influencing researchers and FDA fish safety policy.  I was surprised to read about this (Marion Nestle talks about this in-depth in her book, What to Eat) but in hindsight, I guess I shouldn’t have been… 

It’s a tough story to figure out because both sides have written several articles published in top medical and science journals arguing that fish is good and that fish is bad.  I took about 15 hours trying my best to sort through the data.  What I concluded is that, somewhere in the middle of both extremes is where the answer lies: fish is truly a healthy, “power” food, if you eat the right kinds of fish, and the right amounts.    So how much should I eat?  When, and what should I eat?  What kind of fish oil supplements are the safest?  To answer some of those questions, I made two handouts (Fish and Fish oil Recommendations, Fish recommendations part II), with references, that hopefully will help guide your shopping in the future.   

Happy Eating!

Jeff

Strategies to Prevent and Treat Vitamin D Deficiency

Hi Everyone!   

Wow very sorry for not writing in such a long time.  It’s been a little difficult these days as second-year medical school has been much busier than I thought it would be.  I wanted to post up this table from Dr. Michael Holick’s New England Journal of Medicine review article (N Engl J Med 2007;357:266-81) on Vitamin D defiency and how to prevent it.   Basically, many many people we care about — 1 billion worldwide, have vitamin D deficiency.  It’s very sad, because not having enough vitamin D can contribute to many diseases — like osteoporosis, and even common cancers, autoimmune disease, infectious disease and heart disease.  Please if you get a chance, read the Holick article (http://www.uvadvantage.org/portals/0/pdf/NEJournalofMedicine.pdf).  And check out the following table, which is from that article, which can help you make some of your decisions together with your doctor.

Best wishes!

Jeff

Follow up to Omega-3’s

Hi All!

This is a quick note, so, poorly written, but I’ve been looking up the safety of fish,and I think the take home message seems to be that lots of fish are unsafe — unfortunately.Marion Nestle’s book, What To Eat, talks about this in detail.  She reports that a studycame out in Science (2004) which looked at the PCB levels of 700 samples of salmon from all over the world.  

Salmon is typically known as one of the safest fish out there, and one of the mostnutritious.  Unfortunately, this report found that these salmon all were contaminatedwith unsafe levels of PCBs.  Only salmon from Chile and Washington State were deemedacceptable.  Fish from everywhere else?  The study found those other salmon simply had unacceptable levels of PCBs.   

Moral of the story?  It seems like this would be an argument whyone would want to use fish oil supplements — from a good brand which has taken outall the dioxins, PCBs and methylmercury.   Only five brands — omegabrite,nordic naturals, olay, vitamin shoppe and coromega have allowed themselves to be independentlytested for dioxins, PCBs and methylmercury (source: www.consumerlabs.com).These are just drafts of thoughts, so more on this later — but I wanted to just let you all about this sooner, as opposed to later.

Best,

Jeff 

Fish Oil Saves Babies

 Dear All, 

If I had to pick one nutrient to tell you about, I’d probably start with fish oil and omega-3 fatty acids: get yourself a good bottle, or eat some flaxseeds, or wild deep sea fish!  Now.

But before I go on, you should know that I’m heavily biased.  Right now, I’m in a pediatric surgery lab at the Children’s Hospital of Boston, and the team here has seen firsthand how fish oil can save babies with short gut.  Plus, Dr. Bruce Bistrian, an esteemed professor of medicine and clinical nutrition, has been very kind to take about three hours explaining to me how fish oil works biochemically.  So, I guess you could expect that I’d be excited about fish oil.   But I am also aware that when people get excited, they can get incredibly carried away, like some authors of “superfoods” or “miraculous detox” books that you bump into at a bookstore. 

That said,  special things do happen, and I wanted to tell you a short story about it.  But I hope I don’t get carried away, and I hope can be objective…  

Prior to 2005, children with short gut, or more formally, “short bowel syndrome,” had a very difficult life.  Many of them couldn’t eat because their guts were too short, due to birth defects or injury.   Because their intestines weren’t functioning, nutrients had to be given intravenously through a process called “parenteral nutrition.”  Everyday, the children had to live with needles stuck into their veins in order to receive liquidized food formula – it was highly unpleasant.

The hope was that, while on parenteral nutrition, the babies’ guts could get healthy enough to start absorbing food.   Ever so often, however, the gut just never recovered, at which point the baby would have to rely on parenteral nutrition for an indefinite period of time.

When that happens, the outlook immediately dims.  Patients on long-term parenteral nutrition often develop serious liver problems that lead to death from liver failure.  The only option at that point would be a liver transplant.  It’s an option, but not a cure, and waiting on the transplantation list can be excruciating for parents.  If the babies did not get the transplant, they would die; this was the conventional wisdom for decades. 

But when 2005 came around, a medical team here in Boston with an inclination for fish decided they were going to give babies none other than…fish oil.  You might be wondering, where in the world did they get that idea?  And if it’s such a great idea, why did it take so long to figure out?  The team did previously test the idea on mouse models, which showed promise.  But perhaps more importantly, when faced with an emergency, you find new avenues of inspiration? 

I’m not sure what was the catalyst, but what I do know was that the fish oil worked.  Once the medical team started pumping omega-3 fatty acids into the babies’ veins, their livers started to heal — so much so that even extremely ill patients who were waiting for liver transplantations no longer needed transplants! 

All of the above that I said is true, and, at least for me, it’s exciting to learn about.  But I did want to take a step back and point out that more research needs to be done — randomized controlled trials, larger studies.  And I think it’s important to point out that patients with short gut — even if they are on fish oil and are doing much better than anyone could ever expect — still have to fight courageously.  Their families still have to be very supportive, and sadly, some patients, regardless of their omega-3 fatty acid status, will pass away from other health complications related to their short gut problems.  

Nevertheless, things are encouraging.  It’s not often that you’ll find a serious article, published in a serious medical journal, begin with the word “reversal” when describing the effectiveness of a treatment.  Typically, treatments don’t “reverse” disease.  They “ameliorate,” or “improve outcomes.”  Editors are usually careful to save lofty words for only the most dramatic encounters.   In this case, when it came time to submit the report of fish oil for publication, this was the title: “reversal of parenteral nutrition–associated liver disease.” 

And without any changes, the editors accepted it.

Youtube Video on Omega-3 and Fatty Acids

For more on Omega-3 fatty acids, fish oil, and how it can be really good for you, please watch:

References for Blog Entry Titled, “Fish Oil Saves Babies with Short Gut”

References 

Alwayn IP, Gura K, Nose V, et al. Omega-3 fatty acid supplementation prevents hepatic steatosis in a murine model of nonalcoholic fatty liver disease. Pediatr Res. 2005;57:445–452 

Gura KM, Duggan CP, Collier SB, Jennings RW, Folkman J, Bistrian BR and Puder M. “Reversal of Parenteral Nutrition–Associated Liver Disease in Two Infants With Short Bowel Syndrome Using Parenteral Fish Oil: Implications for Future Management.” Pediatrics 2006;118;197-201 

Hey I’m Back!

Dear All,

 I’ve decided to try to blog “like crazy”.  So some of my posts will be more serious, and others just notes.  Perhaps many will be unfinished thoughts — others, actual pieces (well, attempts at pieces).  Anyhow, I’m going to start a section called, Youtube Summary, which will have a little more written description of what I’m talking about on Youtube.  The other sections will be “medical school” and “health news.”  I hope you enjoy!  We’ll see how this goes after four years 🙂

Jeff