Most American adults choose the medical care they and their family receive based on finances, availability, past experience and personal preference.

For the more educated upper middle class this is usually care predominately provided by a physician (MD or DO) and that physician’s support system such as physician assistants, nurse practitioners and other nurses. A physician associated with a medical training facility may also use students, residents and fellows.

Some choose to rely mainly on other credentialed health care providers like chiropractors (DC), naturopaths (ND), those trained in some form of oriental medicine. Some of this care is excellent.

Uncredentialed practitioners offer a wide variety of approaches and treatments. Some of this care is also excellent but there is a high probability of ending up using ineffective or dangerous remedies.

Another large group uses little or no medical provider: cost, fear and mistrust are common reasons for this.

Many try a combination of some or all of these approaches depending on past experience and an increasing reliance on the internet for information. With some caveats I believe this is the optimal way to decide on health care. Acute disease like serious trauma and major infection is almost always best treated by the physician model. Emergency rooms and walk-in clinics do an excellent job. Modern surgical orthopedic care often works wonders with joint replacements. Acute heart attacks, strokes and abdominal crises also need quick attention by a hospital.

Unless you can find a physician well trained in lifestyle medicine (there is now board certification in this specialty) you are likely to get poor care in the prevention and treatment of chronic disease. Unfortunately there is a huge amount of misinformation about chronic disease and good lifestyle, particularly diet. Indiscriminate internet searches are likely to find false or misleading advice for many reasons including financial gain for the advice giver. Many of us, including other physicians, spend a lot of effort discovering the best care for themselves and family because current medical care care options deal so poorly with chronic disease.

As I take my long morning walks with Charlie dog, the second love of my life, I often pass close to a Starbucks and see a parade of people with drinks in hand, usually some variety of a coffee extravaganza.

As a young man I started drinking coffee in company with most of my friends and physician colleagues. Cream or milk and sugar allowed me to enjoy a milkshake-like beverage, and I love milkshakes! Then living in St. Louis, I read an interview with Stan Musial, the great Cardinal baseball player, whose son was a college classmate of mine. Stan said it was okay to have milk or sugar in coffee but not both. So I tried skipping one or the other and discovered that I still enjoyed my hot morning beverage, since by now my palate had come to appreciate the coffee itself. After a while it seemed reasonable to try skipping both cream and sugar. I still liked my coffee and have drunk it that way ever since, now preferring it black. Food preferences are not usually difficult to change.

Long term tea and coffee consumption have been extensively studied. Tea has always shown significant benefits but coffee was questioned, probably due to higher caffeine content. Most recent evaluations now conclude that coffee has long term health benefits if you are not sensitive to caffeine. Darker roasted coffees are much less healthy because valuable coffee phytonutrients are destroyed with more roasting. BUT no-one even suggests that any dairy or sweetener in the coffee is healthy. In fact, dairy, but not soy milk, greatly reduces the nutritional value of coffee by binding healthy coffee chemicals with dairy protein. Take Stan the Man’s advice one step further and learn to skip both milk(except plant-based milks) and sugar in your coffee.

In past blogs I’ve commented that high fat diets have several major health consequences:

Serum cholesterol is raised leading to plaque development with subsequent arterial blockage from rupture with acute thrombosis, the usual cause of a heart attack, or narrowing due long term accumulation of cholesterol in the arterial wall.

High fat in the blood blocks normal vascular ability to dilate in response to increased demand.

Insulin is prevented from entering cells; in the long term, type 2 diabetes ensues.

A recent study by Sumei Hu and associates published in the journal Cell Metabolism looked at weight effects of 29 different diets in several strains of lab mice. Portions were not restricted nor was activity. All mice had the same weight response to different food compositions which ranged from 10-80% carbohydrates; 5-30% pure sucrose(sugar); 5-30% protein; 8-80% fat. Only very high fat diets caused the mice to overeat and become obese. Paradoxically, this did not occur when the diet was extremely high in fat (60-80%) presumably because this food was so unpalatable. High fat diets led to genetic change in brain areas evoking a happy feeling and driving too much calorie consumption, but no other dietary combination did this.

Schizophrenia is one of the most devastating and poorly understood mental illnesses. Over 50 years ago drugs like thorazine started to allow some schizophrenics to function, but at the price of sedation which made the whole world gray and uninteresting plus other series side effects. Because of this schizophrenics often stopped their medications and relapsed- the drugs were too unpleasant to tolerate.

Many hypotheses about the cause of schizophrenia have been suggested. Genetics is important, but it is certainly not the only factor, or even, perhaps, the most important one. Carefully studied patients with schizophrenia have shown that auto-immunity and inflammation can play important roles. Two severe schizophrenics were treated with minocycline, an older antibiotic most often used for acne. Both were totally cured but relapsed when the drug was discontinued. Long term, low dose minocycline allowed both to be discharged. Subsequent larger trials have confirmed benefit in many schizophrenics. Treatment with probiotics has shown a similar effect. The hypothesis is that improving the gut microbiome, thereby reducing systemic inflammation, helps brain chemistry and improves schizophrenia. Modern medicine loves chemical interventions like antipsychotic drugs, antibiotics and probiotics, usually ignoring the well documented fact that a whole food plant based diet is by far the best way to create and maintain a healthy gut microbiome and lower systemic chronic inflammation.

Richard Aiken, a psychiatrist who emphasizes lifestyle medicine, has recently written a book, Neurodietetics, which looks at the effects of diet on mental health.

Neuro-psychiatric problems are the leading cause of disability worldwide and are poorly handled compared to other medical conditions. There is no brain bypass surgery and drugs for these diseases are of limited use, often providing more harm than good.

In the United States severe mental health illness and suicide are greatly increased since 1940, correlating with diet change to less whole plant foods, more processed and fast foods, and increasing chemical pollution.

80% of depressive episodes are preceded by psychological stress with increased cortisol levels which distort brain function. These effects can be greatly dampened by an anti-inflammatory diet, one that is high fiber, low fat and filled with the nutrients only whole plant foods provide. Just two weeks of this healthy diet show big results in various parameters of mental health. A study of Geico employees who made these dietary changes has recently confirmed the power of such a diet on mood, work performance and missed work time.

Dean Ornish is well known for research into the effects of lifestyle on heart disease and prostate cancer as I have discussed in previous blogs. His approach is different than others in that it emphasizes total lifestyle, not just diet or exercise. The Ornish program includes a whole food plant based diet, appropriate moderate exercise, meditation and/or yoga, and participation in a support group.

After his research documented the effectiveness of this approach to prevent and treat chronic disease medicare began funding it several years ago. 80-90% of patients who have completed the Ornish program are still following it a year later; rates are almost as high at five years with remarkable results. In contrast, only 50% of those prescribed statins are still taking them after six months. Ornish feels this high adherence is because patients are empowered to be in charge of themselves and they feel much better. His patients have a 50% decrease in healthcare costs in the first year and up to a 400% decrease in subsequent years. Insurance companies and local communities have begun to offer and support this program.

Ornish’s observations:
Personal community, not social media, creates health and quality of life.
No difference was found in results of coronary angioplasty versus a sham procedure (except for an acute heart attack.)
Lifestyle modification of the gut microbiome is shown to effect the development of Alzheimer’s disease.
Angiogenesis, the development of new blood vessels supporting cancer progression, is effected as much by lifestyle change as by expensive drugs which have severe side effects.

Joel Kahn is an interventional cardiologist, professor at Wayne State University in Detroit who actively advocates plant based eating to prevent and treat heart disease. He has his own restaurant for patients and the public where only healthy whole plant foods are served. Kahn’s presentation consisted of a review of scientific studies supporting the importance of this diet in heart disease. They included:
Ridler’s work on hsCRP (heart sensitive C reactive protein)– CRP is the basis of a blood test measuring inflammation; hs is the fraction of CRP which best reflects the form of inflammation which effects the heart and blood vessels. Chronic inflammation is critical in the progression of dangerous atherosclerotic plaques, the kind that lead to heart attacks. hsCRP is increased greatly with obesity, mainly proportional to visceral fat, the cause of a pot belly. A meat based diet and elevated blood sugar are also associated with elevated hsCRP.
A recent study from NYU which compared a WFPB diet with the recommended American Heart Association diet showing much lower hsCRP with WFPB plus better patient compliance- it’s a tastier, more satiating diet.
Valter Longo’s research on longevity conclusions- a low calorie “Mediterranean” diet with very little meat and processed carbs, especially sugars prolongs life. Cancer promoting IGF-1 levels are very low on this diet with improvement in diabetes, multiple sclerosis and response to cancer chemotherapy.
Saturated fats and vegetable oils damage bowel lining with resultant “leaky gut” and subsequent chronic inflammation.
A long term high animal protein ketotic diet has been examined in nine published studies all of which showed much higher mortality. This is one of the worst, perhaps the worst, diets ever studied.

Monica Aggarwal is a cardiologist at the University of Florida medical center who developed rheumatoid arthritis five years ago. At the time she was in her 30’s, had just had three children in rapid succession, was working hard, sleeping little and stressed. An aggressive drug regime improved her arthritis but she was still very sick from all her medications. Although she was a lifelong vegetarian she realized lifestyle including diet was playing a role in her disease. She started yoga, got more sleep and gave up dairy which allowed her to wean her drugs. Now she is again an active cardiologist and does triathlons.

Western lifestyle has lead to an explosion of heart disease, cancer, Alzheimer’s and auto-immune conditions like rheumatoid arthritis. A genetic predisposition to disease is triggered by lifestyle choices. Diet affects the gut microbiome with resultant bowel wall damage and the development of “leaky gut.” Toxic bowel contents reach the bloodstream, cause chronic inflammation and disease is triggered, the variety depending on genetic predisposition.

Aggarwal is changing the paradigm at the University of Florida: all cardiac patients get a plant based menu; the staff cafeteria offers many healthy whole plant foods; medical students, residents and fellows all receive training in nutrition science and the importance of lifestyle in chronic disease.

Aggarwal’s rheumatoid factor, a marker for her disease, remains very high but she has been symptom free off all medications for four years.

Anthony Lim practices lifestyle medicine in Santa Rosa where he works at Kaiser, TrueNorth and the McDougall program. He observed that many patients become discouraged when they lose weight but plateau at a level above optimal. They may become frustrated and return to old eating habits since weight loss was their primary reason for diet change.

Lim suggests that allowing unlimited eating of healthy foods may fail for weight loss if caloric density is not considered since dilatation of the stomach plays a major role in satiation. Stretch receptors around the stomach signal satiety. Eating enough food to fill the stomach but limiting calories is best done by eating mainly low calorie dense foods.

He measures food groups by average calories per pound. His numbers:

                      Vegetables- 100
                       Fruit-  200
                       Whole unprocessed starches like potatoes, oatmeal-  520
                       Pasta or Legumes-  600
                       Meat- 800
                       Processed starches (even whole grain bread and whole grain cold cereals)-  1500
                       Sugars and Dried fruit-1500
                       Junk food (chips, cookies)-  2300
                       Seeds and Nuts- 2800 (very healthy but limit to 1 ounce/day if trying to lose weight)
                       Oils and Fats- 4000

His cut off for unlimited quantities is all foods at 600 or less.

Lim suggests limiting or avoiding healthy snack bars, meat substitutes and starting the meal with low calorie dense foods. His ideal dinner plate is half veggies and half legumes and healthy starches.

This week Deb and I attended the 6th annual Plant-Based Nutrition Conference in San Diego. We had also attended this conference a few years ago in San Diego but they rotate locations (next June NYC; next September San Francisco.) Attendees are mostly health care professionals learning about effects of diet on health with an emphasis on the evidence that whole food plant based eating is the key to preventing and treating most chronic diseases. This conference was a sell out with over 1000 attendees from all over the world. Our only complaint was the huge size with the personal touches being lost. Business is booming for healthy eating!

We’ve now been to dozens of conferences which look at nutrition effects on medical issues and are always delighted to meet the other attendees: some patients, some devotees of a vegan lifestyle for a variety of reasons, and medical professionals seeking to improve what they can offer patients. Deb and I agree the best part of these conferences is talking to those searching for the truth about food’s impact on health (and the planet.) This week was no exception. Our first meal was shared with a woman from Hungary who was attending a plantrician conference for the second time. She works for a health care company and is exploring what information is available to clinicians using diet in their practice. Other attendees we met included a family of dentists from Beverly Hills who encourage patients to use diet for health; a senior psychiatrist from Johns Hopkins who eats plant based himself and considers it an important part of medical care; a dermatologist from San Diego who uses plant based dietary therapy to treat some patients with great success in acne and psoriasis; a primary care physician from St. Thomas, Virgin Islands whose practice emphasizes whole food plant based diet; several nurse practitioners and physician assistants who incorporate information and advice about healthy diet in their daily work.

Subsequent posts will review specific meeting content.