Several months ago I fractured two bones in my foot. Because of this I was evaluated and found to have mild osteoporosis. Since then I have been studying osteoporosis and would like to share what I have found.
Bone is an active tissue which responds to nutrients, level of activity, hormones and drugs fairly quickly. Strong bone is essential to avoid fractures after mild or moderate trauma. Definitive diagnosis of osteoporosis is made with a DXA (formerly DEXA) scan. Bone density which is lower than normal but not osteoporotic is termed osteopenia.
As with all body tissues, bone requires a wide spectrum of nutrients including many vitamins and minerals. Most of these nutrients are in generous supply from a diet which includes vegetables, fruits, legumes, seeds, nuts and whole grains. A few critical nutrients can be lacking even in an otherwise healthy diet. These include vitamin D, vitamin B12, vitamin K2, zinc and iodine.
Calcium is the major mineral involved in bone formation and logically might be an important dietary deficiency in osteoporosis. This is not true for those who regularly eat a variety of green vegetables and/or dairy. Legumes, almonds, tofu and canned fish (Atlantic sardines best) with bones left in are also good calcium sources. Calcium supplementation has been widely studied and debated. For many years it was assumed that supplemental calcium would help people who had osteoporosis, but recent research has not confirmed this. In fact, in some studies calcium supplementation has been associated with higher rates of heart attacks and other vascular disease but not with lower rates of fracture. Current good practice is not to offer calcium supplementation, or, at most, to prescribe a small supplement such as 500 mg a day unless the patient will not eat calcium containing foods. One theory is that supplemental calcium supplies a sudden burst of calcium in the blood which increases clotting so much that blood vessels can be blocked causing a heart attack or stroke.
Another major nutrient for bone formation is vitamin D. This vitamin is critical in all body tissues but has been particularly studied in bone health because it was long ago discovered to be the major cause of rickets, a deforming bone disease that was once common in children. An enormous amount of research on vitamin D has still not resolved many questions. Experts debate the range of adequate serum levels, whether supplementation is a good idea, and, if using supplementation, what is the optimal dose. Hundreds, perhaps thousands, of researchers around the world devote much of their time to study these questions.
Current guidelines for serum vitamin D are a level between 20 and 80 ng/mL. It is generally accepted that below 20 or above 80 are potentially dangerous ranges. Studies of likelihood of dying indicate that people with a level of around 50 have the lowest chance of death. Most people who do not take supplements are healthy with levels between 20 and 80.
Vitamin D is created in the skin after exposure to sunlight and people with adequate sun exposure will not need supplementation. Darker skin pigmentation and increasing age both require more sun exposure or supplementation. Vitamin D is a fat soluble vitamin and therefore is well stored in the body: an excess can be saved for a rainy day. Unfortunately, high levels (when serum values are above 80) are also a problem so that vitamin D cannot be supplemented in very large quantities, but someone who is deficient can take large doses for a few weeks or months to replenish body stores. Tablets with up to 50,000 international units of vitamin D are commercially available. Some suggest 300 to 800 international units a day supplementation, but there is good evidence that doses up to 2000 international units a day are safe and more reliably raise serum levels to optimal. People with little sun exposure will need higher amounts of supplementation than those who are frequently in the sun. Some foods, particularly cows’ milk and soy milk, are fortified with vitamin D but the contribution of food to vitamin D levels is modest for most people. Most supplements are in the form of vitamin D3, which is what is usually recommended. The D2 form can also be used and is as effective for most people.
My experience is that many physicians are confused and poorly informed about appropriate calcium and vitamin D supplementation. I recommend not to take calcium supplements unless your physician has determined that you have a specific reason why you need extra calcium or you are unable or unwilling to eat calcium containing foods. Someone who eats mainly junk food might need 500 mg. a day. The diagnosis of osteoporosis or osteopenia alone is not an indication for calcium supplementation. I would supplement with vitamin D3, the dose dependent on how much sun exposure you have. With little or modest exposure, I suggest 2000 units a day; with good exposure 1000 units a day. Vitamin D should be taken with meals since it is absorbed much better at that time. Even better is to have your vitamin D serum levels checked. If they are in the 40 to 80 range no supplementation is necessary.
I will send future messages about other nutrients, exercise, and other issues relating to osteoporosis.

Several months ago I fractured two bones in my foot. Because of this I was evaluated and found to have mild osteoporosis. Since then I have been studying osteoporosis and would like to share what I have found.
Bone is an active tissue which responds to nutrients, level of activity, hormones and drugs fairly quickly. Strong bone is essential to avoid fractures after mild or moderate trauma. Definitive diagnosis of osteoporosis is made with a DXA (formerly DEXA) scan. Bone density which is lower than normal but not osteoporotic is termed osteopenia.
As with all body tissues, bone requires a wide spectrum of nutrients including many vitamins and minerals. Most of these nutrients are in generous supply from a diet which includes vegetables, fruits, legumes, seeds, nuts and whole grains. A few critical nutrients can be lacking even in an otherwise healthy diet. These include vitamin D, vitamin B12, vitamin K2, zinc and iodine.
Calcium is the major mineral involved in bone formation and logically might be an important dietary deficiency in osteoporosis. This is not true for those who regularly eat a variety of green vegetables and/or dairy. Legumes, almonds, tofu and canned fish (Atlantic sardines best) with bones left in are also good calcium sources. Calcium supplementation has been widely studied and debated. For many years it was assumed that supplemental calcium would help people who had osteoporosis, but recent research has not confirmed this. In fact, in some studies calcium supplementation has been associated with higher rates of heart attacks and other vascular disease but not with lower rates of fracture. Current good practice is not to offer calcium supplementation, or, at most, to prescribe a small supplement such as 500 mg a day unless the patient will not eat calcium containing foods. One theory is that supplemental calcium supplies a sudden burst of calcium in the blood which increases clotting so much that blood vessels can be blocked causing a heart attack or stroke.
Another major nutrient for bone formation is vitamin D. This vitamin is critical in all body tissues but has been particularly studied in bone health because it was long ago discovered to be the major cause of rickets, a deforming bone disease that was once common in children. An enormous amount of research on vitamin D has still not resolved many questions. Experts debate the range of adequate serum levels, whether supplementation is a good idea, and, if using supplementation, what is the optimal dose. Hundreds, perhaps thousands, of researchers around the world devote much of their time to study these questions.
Current guidelines for serum vitamin D are a level between 20 and 80 ng/mL. It is generally accepted that below 20 or above 80 are potentially dangerous ranges. Studies of likelihood of dying indicate that people with a level of around 50 have the lowest chance of death. Most people who do not take supplements are healthy with levels between 20 and 80.
Vitamin D is created in the skin after exposure to sunlight and people with adequate sun exposure will not need supplementation. Darker skin pigmentation and increasing age both require more sun exposure or supplementation. Vitamin D is a fat soluble vitamin and therefore is well stored in the body: an excess can be saved for a rainy day. Unfortunately, high levels (when serum values are above 80) are also a problem so that vitamin D cannot be supplemented in very large quantities, but someone who is deficient can take large doses for a few weeks or months to replenish body stores. Tablets with up to 50,000 international units of vitamin D are commercially available. Some suggest 300 to 800 international units a day supplementation, but there is good evidence that doses up to 2000 international units a day are safe and more reliably raise serum levels to optimal. People with little sun exposure will need higher amounts of supplementation than those who are frequently in the sun. Some foods, particularly cows’ milk and soy milk, are fortified with vitamin D but the contribution of food to vitamin D levels is modest for most people. Most supplements are in the form of vitamin D3, which is what is usually recommended. The D2 form can also be used and is as effective for most people.
My experience is that many physicians are confused and poorly informed about appropriate calcium and vitamin D supplementation. I recommend not to take calcium supplements unless your physician has determined that you have a specific reason why you need extra calcium or you are unable or unwilling to eat calcium containing foods. Someone who eats mainly junk food might need 500 mg. a day. The diagnosis of osteoporosis or osteopenia alone is not an indication for calcium supplementation. I would supplement with vitamin D3, the dose dependent on how much sun exposure you have. With little or modest exposure, I suggest 2000 units a day; with good exposure 1000 units a day. Vitamin D should be taken with meals since it is absorbed much better at that time. Even better is to have your vitamin D serum levels checked. If they are in the 40 to 80 range no supplementation is necessary.
I will send future messages about other nutrients, exercise, and other issues relating to osteoporosis.

Dr. Michael Greger has a website called NutritionFacts which I frequently reference when I send out information about diet and nutrition. Usually his excerpts are a few minutes long but today’s was over an hour and was a summary of many things he’s come across in the past year.

Gargling with tap water greatly reduces the incidence of colds and flus. (Antiseptic mouthwashes are not recommended since they kill important mouth bacteria which help digest important nutrients. Another corollary is that vigorous rinsing water in the mouth after eating is a very effective way of removing debris which leads to gum disease and caries.)

As simple an intervention as a glass of water before school improves student performance significantly. Presumably many children go to school dehydrated.

A few minutes of vigorous exercise have dramatic effects on the symptoms of ADHD and also cause a dramatic rise in measurable immune function.

Regular eating of nutritional yeast and/or mushrooms results in a more than 50% rise in antibody activity, a strong, accurate marker of immune function.

Greger reminds us that drugs for multiple sclerosis are very expensive, are largely ineffective, and have many serious complications. In contrast, treatment of early-stage multiple sclerosis with a low-fat vegan or near vegan diet allowed no progression of disease in 95% of thousands of patients over a 34-year follow-up. No drug results are remotely comparable but there’s no money in recommending diet and the big drug companies make a fortune with MS drugs that have little or no value.

Essential tremor is a Parkinson’s like disease which starts to affect many people in their 40s with 20% or more of all Americans past the age of 80 showing signs of this condition. While it is not a disease associated with premature death and severe disability like Parkinson’s, essential tremor does lead to discomfort and mild to moderate disability. This condition has been shown due to a substance which is found almost exclusively in meat and fish. Correlation of this condition with heavy meat and/or fish eaters is stronger than the correlation found between cigarette smoking and lung cancer.

Greger quotes the head of Harvard Medical School epidemiology that a vegan diet is “extreme” but it is what science shows is the best for health.

The USDA was founded and is still run to support the American business of agriculture. Somehow, they have also gotten the role of telling the American public what correct diet is. A recent USDA letter to the egg industry board told them that they could no longer indicate that eggs were safe, healthy, or nutritious in their advertising since all of these have been scientifically proven to be incorrect. This from the department in charge of supporting US agriculture business!

Recent studies with fibromyalgia have shown by far the best results are from a whole food plant based diet.

HPV is the source of most cervical and many oral cancers. Vegetarians, and especially vegans, have much lower rates of significant HPV infection. Diet somehow overcomes the persistent organisms and helps them to be eradicated. Also vegan women have been shown to have much lower rates of all female cancers including breast and ovary.

29% of American women have bacterial vaginitis which is typically identified by doctors through the sniff test (a fishy odor from the vagina.) A vegan or near vegan diet eliminates this condition.

The United States is again number one in the world. This time it’s in erectile dysfunction which has the same cause as coronary artery disease and now is generally recognized as an excellent marker for significant heart disease. 40% of American men over the age of 40 have erectile dysfunction. Again a diet of whole food vegetable products greatly reduces the incidence of this problem.

A study was done looking at weight loss in various diets. It turns out that all calories are not created equal. People who ate a vegan diet but consumed the same number of calories as those eating an omnivorous diet lost significantly more weight.

A high percentage of Americans are constipated. A recent study showed that prunes were a significantly better treatment for this than Metamucil. Needless to say vegans have virtually no constipation.

Cancer tumor growth requires the formation of new blood vessels which are supported by a hormone secreted by the cancers. Plants, vegetables and fruits, suppress the formation of this hormone.

Almost all cancers need methionine to grow. High methionine foods are chicken and fish. Moderate amounts are found in red meat and dairy. Methionine levels are low in fruits and vegetables.

Consumption of poultry and eggs is the worst for cancer development and progression. The so-called “healthy choice” is not so healthy!
Consumption of legumes were shown to be a strong predictor of longevity.

Consumption of one serving a day of cruciferous vegetables like broccoli, cauliflower, kale, collards, bok choy, arugula etc. leads to one half the chance of recurrence in breast and several other cancers.

A group of patients with estrogen negative breast cancer was evaluated. Estrogen negative breast cancer is in general worse because it does not respond to any sort of hormonal intervention. The group of these patients who had five helpings of fruits and veggies a day and a 30 minute or longer walk six days a week reduced their chance of death in the next five years from 16% to 4%. There is no anticancer intervention or drug that comes close to these results.

Berries have been shown to reverse the progression of precancerous changes in the mouth and the esophagus. In the esophagus 52% were totally cleared and 80% were significantly improved.

Dairy, eggs and meat are almost uniformly contaminated with bacteria, often pathogenic bacteria. A federal district court ruled that this was acceptable since virtually all meat and dairy products were contaminated and everybody was used to eating them.

Many bladder infections come from contaminants from animal products, the worst of which is chicken. It turns out you don’t have to even eat the chicken, just bring it into the house and prepare it. So if you are eating food from a kitchen which uses chicken you have a significant chance of exposure to many of the organisms which cause bladder infections.

http://www.medscape.com/viewarticle/841717?nlid=78588_3041&src=wnl_edit_medp_diab&uac=155521DT&spon=22
(Reuters Health) – People over age 65 who drink diet soda daily tend to expand their waistlines by much more than peers who prefer other beverages, possibly contributing to chronic illnesses that go along with excess belly fat, according to a new study.
Research in other age groups has directly associated drinking sodas that replace sugar with artificial sweeteners and increased risk of diabetes, metabolic syndrome and preterm birth, said lead author Dr. Sharon P.G. Fowler of the University of Texas Health Science Center at San Antonio.
The new study only observed people over time, and did not test whether drinking diet soda actually caused gains in abdominal fat, she cautioned. “We can’t prove causality but there is quite a consistency in observational studies,” Fowler told Reuters Health
For older people, who are already at increased risk for heart and metabolic diseases, increasing belly fat with age just adds to health risk, Fowler and her colleagues write.
To see what role diet soda might play, the study team followed people over age 65 for an average of nine years. The study started with physical examinations and questions about daily soda intake among 749 people who were over age 65 when first examined between 1992 and 1996. By 2003-2004, 375 participants were still living and had returned for three more examinations.
People who reported not drinking diet soda gained an average of 0.8 inches in waist circumference over the nine-year period compared to 1.83 inches for occasional diet soda drinkers and more than three inches for people who drank diet soda every day, according to the results online March 17 in the Journal of the American Geriatrics Society.
The authors had taken other factors like physical activity, diabetes and smoking into account.
“It cannot be explained by the calories,” said Dr. Francisco Lopez-Jimenez of the Mayo Clinic in Rochester, Minnesota, who was not involved in the study.
People who drink diet soda may be more likely to overeat in other areas, he told Reuters Health.
“The main point is for those who drink a lot of soda, diet or not, there may be a relationship with obesity,” Lopez-Jimenez said.
“I think it probably is true that for some people, if they are not being really hardcore about losing weight and getting a healthier lifestyle, if they switch over to diet soda that allows them to have an extra slice of pizza or a candy bar,” which translates to actually consuming more calories than would have been in a can of regular soda, Fowler said.
But another possibility is that there is a real causal relationship at the molecular level, which she believes is the case.
Diet sodas are very acidic, more so even than acid rain, and the acidity or the artificial sweeteners may have a direct impact on things like gut microbes, which influence how we absorb nutrients, Fowler noted.
“Calorie free does not equal consequence free,” she said.
Although it’s still unclear if diet soda actually causes dangerous changes to health, Fowler hopes that frequent users will try to wean themselves onto other beverages, like fresh brewed coffee, tea or mineral water with natural juices added.
“It’s possible to find things without sweeteners or dose the sweetener themselves,” she said.
The study doesn’t justify a recommendation to avoid soda, but it does very clearly show that drinking diet soda does not lead to weight loss, Lopez-Jimenez said.
SOURCE: http://bit.ly/18ZeLeD
J Am Geriatr Soc 2015.

Statins and Heart Disease – Do Women Differ From Men?

The link above is to a discussion of heart disease and cholesterol in women by a prominent cardiologist (a man, not Roberts) on his blog. Roberts’s books on the subject are the current bible for women. Her conclusion is that your HDL levels are very important; statins don’t help and have bad side effects (including cataracts.

Recent studies have shown that the symptoms of heart disease may differ between men and women. For example, women are less likely than men to have chest pain while suffering an acute heart attack (acute myocardial infarction). This may delay diagnosis and may partly explain why women seem to fare worse than men under these circumstances. Furthermore, the role of risk factors for heart disease may be different between the two genders. It has also been suggested that treatment with cholesterol lowering drugs, so-called statins, may be less effective for women than men, in particular in primary prevention (individuals without known cardiovascular disease.)

These important issues were recently discussed in Reykjavik, Iceland, when visited by Barbara H. Roberts MD who is a prominent expert in this field. Dr. Roberts is director of the Women’s Cardiac Center at the Miriam Hospital in Providence, R.I. and associate clinical professor of medicine at the Alpert Medical School of Brown University. She has written two hugely interesting books, How to Keep From Breaking Your Heart: What Every Woman Needs to Know About Cardiovascular Disease and The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs.

I ran across Dr. Roberts recent book on statins while visiting New York last December for a cardiovascular meeting. I became very fond of it because it is extremely well written and can easily be read both by laymen and professionals. Her discussion is objective, evidence based, and she does not jump to any conclusions. Although Dr. Roberts has a point to make, her writing is careful and unbiased. Of course, the book has a strong message which I know many of my cardiologist colleagues will not agree with.
The internet may affect our lives more than we sometimes realize. A few days after I finished reading Dr. Roberts book I mentioned it in one of my blog posts because I felt it had an important message to everyone interested in cardiovascular disease and modern-day health care. Statins are used by millions of people worldwide. Whether we like it or not, we have an obligation to look at both the positive and negative effects of this therapy.
By coincidence, Dr Roberts read my article and we became acquainted. Six months later she arrived in Reykjavik to give two talks, a public lecture on how women may reduce their risk of heart disease, and another lecture at aimed at professionals at our University Hospital on statin therapy.
Dr. Roberts gave her first talk on the evening June 18th 2013. It was attended by more than 300 people, mostly women. I was really proud by the huge interest. Thank you, Icelandic women for showing so much interest in how to improve your health and reduce the risk of heart disease. Dr. Roberts gave a fascinating overview of cardiovascular disease, risk factors, lifestyle and prevention. It was a memorable evening.
She started by addressing the anatomy of the normal heart, the coronary vessels and the blood circulation. She then discussed important symptoms and disease concepts such as angina pectoris, myocardial infarction or heart attack, congestive heart failure, and palpitations. She touched on the underlying pathology of cardiovascular disease and introduced important disease mechanisms like atherosclerosis, plaque rupture and clot formation.
Dr. Roberts then went on to describe how the symptoms of an acute heart attack may differ between men and women. Men are more likely to experience chest pain than women. Women are more likely to have nausea, back, shoulder, abdominal or neck pain than men. Women are also more likely to have no chest pain, and just shortness of breath or sometimes fatigue.
Dr. Roberts went through most of the known modifiable risk factors for heart disease like smoking, high LDL cholesterol, low HDL cholesterol, high blood pressure, diabetes, obesity, sedentary lifestyle, the metabolic syndrome and inflammation.
Dr. Roberts dedicated a part of her talk to treatment with statin drugs. Statins are frequently used to lower cholesterol and to reduce the risk of heart disease. It is her opinion that the benefits of statins have been greatly exaggerated and that their dangers have been greatly downplayed. She mentioned the most common side effects of statin therapy like muscle pain, rhabdomyolysis, cognitive dysfunction, tendon and nerve damage, diabetes, liver and kidney damage, fatigue, cataracts and congenital defects in babies exposed before birth. She summarized the results from clinical trials addressing the effects of statins in women. She underlined that no study has ever shown that treating women who do not have established vascular disease or diabetes with a cholesterol lowering medicine lowers the risk of cardiac death or cardiac events.
Dr. Roberts concluded that high levels of LDL cholesterol appear less predictive of cardiovascular risk in women than in men. In women, HDL cholesterol appears more predictive of risk than any other lipid level. She emphasized that abnormal blood cholesterol is but one of many risk factors for cardiovascular disease and that it´s not all about the LDL-cholesterol. After covering the health risks of diabetes, inflammation, obesity and the metabolic syndrome Dr. Roberts went on to talk about the influence of diets. She mentioned a few dietary fictions like “Eating foods high in cholesterol raises your cholesterol” and “Low fat diets are good for your heart“. She also mentioned a few dietary facts like “Low fat diets lower HDL cholesterol so they are NOT heart healthy. You need to eat heart healthy fats” and “You can eat your way through any cholesterol lowering medicine“. Finally she underlined the strong scientific evidence indicating that a Mediterranean type diet reduces cardiovascular risk. Dr Roberts concluded her lecture with this message:
Prevention of Heart Disease Made Easy:
• If you smoke, STOP
• If your cholesterol is high, get it down
• If your blood pressure is high, get it down
• If your blood sugar is high, get it down
• If your weight is high, get it down
• Do moderate exercise 30 minutes/day
• Eat a heart healthy diet
• Pick your parents wisely

 The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs

Dr. Barbara Roberts gave her second lecture in Reykjavik on June 19th at Landspitali University Hospital. Again she did a wonderful job with a highly informative and provocative talk. Unfortunately, only about 40 people attended, among them only a handful of cardiologists. I know doctors are busy people, but I have to admit that I would have loved to see more colleagues. Statins are the most frequently prescribed drugs by cardiologists all over the world. Many of us believe they are our most important weapon when it comes to pharmacological treatment of cardiovascular disease. So, I can understand that it may be unpleasant to hear about their presumed bluntness.
Dr. Roberts started by going through many of the advantages and disadvantages of statin therapy. She quoted Doctor Rita Redberg: “There are millions of women on a drug with no known benefit and risks that are detrimental to their lifestyle — and no one is talking about it”. She also quoted Dr. Sidney Blumenthal: “The totality of the available biologic, observational and clinical-trial evidence strongly supports the selective use of statin therapy in adults demonstrated to be at high risk for heart disease”. So, “are statins angels or devils” she asked?
Next Dr. Roberts took us through the history of the lipid hypothesis, from the work of the German pathologist, Rudolph Virchow on atherosclerosis in 1856, to the modern day clinical trials. She underscored the difference between absolute and relative risk reduction. She summarized data from clinical trials on the use of statins in secondary prevention. The result was that statins significantly reduce the number of cardiac events among individuals with cardiovascular disease, although the effect appears less pronounced among women than men. Again, she underscored the fact that clinical trials have not shown that treating women who do not have established vascular disease or diabetes with a cholesterol lowering medicine lowers the risk of cardiac death or cardiac events.
Dr. Roberts then went through all the most common side effects of statin therapy. Unfortunately this list appears to be growing, not unsurprisingly though, considering the huge number of people taking these drugs. Recently the increased risk of diabetes and cognitive dysfunction associated with statin therapy has been highlighted. Finally, she talked about possible alternatives to statin therapy. Again she underscored the positive effects of the Mediterranean diet.

Dr. Roberts final conclusions were:
The Bottom Line
We, cardiologists tend to focus on the positive effects of statins. This is completely reasonable because clinical trials have shown that these drugs are very effective under certain conditions, and they improve the prognosis of patients with cardiovascular disease. Statins may also be effective among individuals at high risk for developing cardiovascular disease, such as those with diabetes. Nobody doubts the important role of statins in patients with familial hypercholesterolemia (FH).
Sometimes it is much easier for doctors to prescribe a drug than not to do it. Furthermore, the positive effects of statins are highly emphasized by the medical community, and these drugs are generally considered well tolerated. I am much more likely to be criticized by my colleagues if I don´t put a patient on statin therapy who might benefit, than if I put someone on such therapy who will probably not benefit from it. Sometimes we forget the words of our ancestors: Primum non nocere; first do no harm.
Sooner or later we will have to face the fact that many people have side effects from statin therapy. Often, these effects are not obvious. As doctors, we have to be alert and monitor patients for such side effects.
It has been pointed out by some of my colleagues that highlighting the negative effects of statins may encourage some patients to stop taking their drugs. Obviously, if these are individuals who are benefitting from their therapy, this may cause harm. On the other hand, providing truthful unbiased information to our patients can never be ethically wrong. Indeed, such information is necessary for shared decision making. Otherwise, our patients will not be able to make a truly informed decision on whether they want a certain treatment or not.
Finally, I would like to sincerely thank Dr. Barbara Roberts for visiting Iceland and sharing her knowledge and experience. Again, I recommend everyone interested in cardiovascular disease and modern-day health care to read her book on statin drugs. It is a strong reminder of our limited knowledge of the long-term effects of drugs that are being prescribed to millions of people worldwide.

http://www.medscape.com/viewarticle/857971_4

Differentiating between celiac disease, NCGS, and other wheat-related disorders can be challenging, but it is important for appropriate management. As stated in a recent editorial, it is counterproductive to debate whether NCGS is “real”; the patients are real and are seeking care.
The current clinical approach involves ruling out celiac disease and wheat allergy, testing for additional food intolerances or gastrointestinal conditions, and providing the latest data on the benefit/unintended consequences of gluten avoidance and these evolving entities. It is also important to inform patients and their families about what is not known. It may also be effective to individualize the recommended dietary strategy by eliminating certain components of the FODMAP class, wheat products, and/or gluten sequentially.
Because there is no specific biomarker for NCGS, the diagnosis is “confirmed” by dietary elimination, followed by double-blind, placebo-controlled gluten-based re-challenges. This is a cumbersome, time-consuming, and difficult-to-access clinical approach. Even with this information at hand, the diagnosis of NCGS may remain unclear, raising the question of whether the salutary effects of gluten withdrawal are specifically attributed to the gluten-protein per se or to nongluten components such as fermentable carbohydrates and amylase-trypsin inhibitors.
Khabbani and colleagues reviewed records from 238 patients who presented for the evaluation of symptoms responsive to gluten restriction without prior exclusion of celiac disease. Of these study subjects, 42% had celiac disease and 52% had NCGS; the remainder had an indeterminate diagnosis. The majority (67%) of subjects with celiac disease presented with symptoms of malabsorption, compared with 25% of the NCGS subjects. In addition, those with celiac disease were significantly more likely to have a family history of celiac disease, personal history of autoimmune diseases, or nutrient deficiencies.
On the basis of these findings, the authors proposed a diagnostic algorithm to differentiate celiac disease from NCGS. They state that subjects with negative celiac serologies (IgA tTG or IgA/IgG DGP) ingesting a gluten-containing diet are unlikely to have celiac disease. Those with negative serology who also lack clinical evidence of malabsorption and risk factors for celiac disease are highly likely to have NCGS and may not require further testing. Those with equivocal serology should undergo HLA typing to determine the need for biopsy.
Guandalini and colleagues proposed assessment of the levels of gamma delta T-cell receptors in intraepithelial lymphocytes (which are specific for celiac disease) or detection of IgA anti-tissue transglutaminase antibody deposits in intestinal mucosa in order to more clearly exclude celiac disease in problematic cases.

Remaining Questions:
As stated by Fasano and colleagues, a better understanding of the clinical presentation of NCGS is needed, as well as its pathogenesis, epidemiology, management, and role in conditions such as IBS, chronic fatigue, and autoimmunity. There also must be agreement on the nomenclature and definition of gluten/wheat-related disorders based on proper peer-reviewed scientific information.
It is hoped that in the future, the terms NCGS, NCWS, and wheat intolerance syndrome will be replaced by well-defined nosology, that the phenotypes and mechanisms of syndromes responsive to gluten withdrawal will be better defined, and that there will be biomarkers and definitive therapy for distinct entities.

Recently I have been re-studying low carbohydrate diets spurred on by an extensive email dialogue with Dr. Richard Feinman, Prof. of Cell Biology at Downstate Medical School in Brooklyn (my alma mater), and by multiple inquiries about the Paleo diet from friends and acquaintances. Dr. Feinman is a highly-regarded scientist who has done research on metabolism in low carb diets and I have learned a lot from him. He studies and advocates a VLCKD (very low carb diet-20% of total calories from carbs with no fat restriction.) This is the diet that most lab research has been done on. It produces ketosis and ketone bodies supply much of nutritional needs of the cells rather than glucose. Dietary ketosis, as opposed to diabetic ketosis, is not harmful to the body. The source of the limited amount of carbs is optional but most advocates including Dr. Feinman eat leafy green and other non-starchy vegetables for their nutrient value and fiber.

Most low-fat and other low-carb diets recommend consumption of non-starchy vegetables and most fruits while avoiding sugars, refined grains and limiting salt. Some low carb programs suggest avoiding saturated fat as much as possible.

Vegetables and fruits can rarely supply enough calories for long-term existence in humans. Remaining calories have to come from either starches or animal products or refined vegetable oils.

Low-carb advocates suggest meat (some including Paleo want this to be low fat), fish, vegetable oils, and dairy products (Paleo excludes dairy and others say low fat dairy.)

Most low-fat advocates suggest starches.

Inside each camp there is variation with some low-carb people favoring organ meats and full fat dairy while others suggest no dairy at all. Many in the low-fat group aim at total fat consumption of 10% of calories and total protein consumption about the same. This is not the “low” fat diet of the AHA, ADA, Framingham Study, or Nurses Health Initiative Study which suggest 30% of calories from fat. But again there is variation, particularly in regard to the amount of seeds and nuts consumed. This group also advocates little or no vegetable oils except as found naturally in whole foods.

Books and articles on the subject have mainly been quite well written and sometimes very thoroughly researched. Low-carb supporters emphasize the need for insulin control as a basis for good health while low-fat advocates want to avoid almost all dietary fat especially saturated fat and cholesterol. There is excellent laboratory and clinical support for both these positions. Each of the writers from both groups tend to ignore the strong positions of the others while showing the rationale and clinical evidence for their position. I’ve not found a book or article which looks at it well from both sides. Some have termed this the war of the diets and I don’t think that term is far off based on the approaches many scientists and authors have staked.

Another group of diets looks more towards portion control while supporting high vegetable and fruit intake with avoidance of sugar, refined grains and saturated fat. Variations on this theme were the most popular with professional nutritionists as seen in the 2013 “US News and World Report” evaluation of 29 diet programs by a panel of 21 nutrition experts selected by the magazine. In this survey, most of the low-fat diet programs were in the middle of the ratings and most of the low carbohydrate programs were at the bottom with the Paleo diet tied for last. Objections to both the low-fat and low-carb diets often centered around palatability and ease of adherence to the diet with the low-carb diets also criticized as not having long-term performance experience and a danger for development of vascular disease. My observation on these rating criteria is that many, if not most, people have a serious problem with portion control and keeping track of what quantity of food is eaten while they can more readily adapt to relatively unlimited quantities of certain foods while avoiding other foods entirely. Both the low-fat and low-carb diets typically offer this approach which many people I have talked to find easier. Also, results of these moderation diets are poor in the treatment of chronic disease. They may help somewhat in prevention but effects are small compared to a true plant based whole food diet.
Two popular versions of a lower fat, higher nutrient diets do not stress portion control. The Mediterranean Diet advocates lots of fruits, vegetables and fish plus oils with less meat, dairy, refined carbs. Compared to the standard American diet (SAD) people who eat this way live longer and have better health but do not have nearly the longevity or lack of chronic disease which those who eat a whole food plant based diet enjoy. This diet is not very effective in the treatment of chronic disease. Another version of a low-fat diet is flexitarian, in which the low-fat plant based whole food diet is modified to include small amounts of fish, low fat dairy and/or meat. Several knowledgeable physicians I’ve met follow this diet as preventative but say they would eliminate all animal products for themselves or patients to treat many chronic diseases. The issue for advocates of the low-fat diet is what qualifies as a “small” amount and how reliable patients will be if allowed this flexibility. Esselstyn says that he knows he can successfully treat all his patients with coronary disease so why take a chance on a modification.

Low-carb programs have convincingly shown excellent control of weight and metabolic syndrome (MetS) including diabetes and high blood pressure. Low-fat programs have had similar results with a comparison study between the two-favoring low-carb. However, in this study in the low-fat group 24% of calories came from fat which does not come close to the guidelines suggested by the low-fat diet promoters. Low-carb diets may also induce good serum lipid profiles which suggests to some researchers that atherosclerosis would be well treated and controlled by this diet. This diet also generates low blood insulin levels together with a ketotic state both favoring less cancer development and growth. Another hormone, IGF-1, a strong promotor of cancer growth, is increased with animal, not vegetable, protein consumption. I don’t know how these changes balance out for tumor growth. I have not seen a study which treats patients with advanced coronary artery disease with a low-carb diet nor am I aware of any long-term studies in groups of patients following this program except those of contemporary indigenous groups in whom heart attacks are rare until western food choices are introduced. The few autopsy studies pre-western food in these people usually show atherosclerosis but they often die young for other reasons so that clinically relevant vascular disease and cancer rates are uncertain.

Low-fat diet programs are well documented to prevent and reverse advanced coronary artery disease and population studies of large groups following this diet show low rates of cancer and other chronic diseases especially vascular disease. This diet typically is associated with longevity and low end-of-life morbidity where there is not famine or infectious disease.
Many people have asked me about body building and diet. Most body builders and professional athletes eat large amounts of animal protein and many take protein supplements, usually but not always from animal products. I am convinced that any protein supplement, animal or vegetable is a bad idea. Isolated protein concentrates promote cancer growth according to many studies. Some world class athletes eat plant based diets and feel they perform better because of it (Venus and Serena Williams, Martina Navratilova, Arian Foster, Tony Gonzalez among others) and a few champion body builders also eat a plant based diet. However, I’m sure it is easier to build muscle bulk with animal products. A plant based diet may be as good or better for performance.
It is certain that you are very unlikely to have good health with lots of processed food, sugars, salt, and refined carbs in your diet and that if you combine a high carb with a high fat diet that you will have a poor diet likely to lead to chronic diseases. The question is; are some people better off with low carb and others with low fat. Certainly, some people strongly prefer one over the other. Is this genetic or due to degree of fat addiction or due to an individual’s body doing better on one of them? Is it cultural? Does it matter which you choose? I am confident that you will thrive on a plant based whole food diet which avoids processed oils. A few people have reported doing poorly on this diet, then feeling better switching to a low carb diet or some modification of a fully plant based diet. When physicians have evaluated the few, who don’t thrive typically they find a deficiency in vitamin B-12, an essential fatty acid, or a mineral (often zinc or iodine.) These deficiencies are easily treated. Constipation and headaches are usually a problem with low-carb diets but this is not the case with low fat (8-12%) diets. Incidence of vascular disease and cancer are certainly much lower on a low-fat diet. I don’t know what they would be on a long term low carb diet.

When Evidence Says No, but Doctors Say Yes

By Axel Pfaender

Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments.

https://www.theatlantic.com/health/archive/2017/02/when-evidence-says-no-but-doctors-say-yes/517368/

• DAVID EPSTEIN AND PROPUBLICA 

• FEB 22, 2017

John McDougall spoke about current practices in diabetes treatment, a topic I have recently studied and given presentations about. Diabetes drugs and monitoring devices are a huge business, one of the major profit sources for the medical industry. In recent years many of these products have increased dramatically in price as pharmaceutical companies try to increase profits. The strength of big pharma’s relationship to government has prevented control of unjustifiable prices in the United States.

The following is a combination of my findings and McDougall’s:

Diabetes prevention and treatment are among the greatest tragedies of modern medicine. As we have developed brilliant diagnostic tools and surgical techniques we have failed in the management of chronic diseases, especially diabetes. Diabetes is typically divided into type 1, a disease of insufficient insulin production and type 2, a disease of insulin resistance where cells cannot effectively use insulin. Recently, more people have developed a combination of the two types in which there is less than optimal insulin production plus insulin resistance, a condition sometimes referred to as type 1.5 diabetes. All types have increased blood sugar plus very high rates of premature death, many vascular diseases, cancer and dementia. This is a terrible disease.

When insulin was discovered in the early 1920’s people with type 1 diabetes were no longer doomed to early death due to high blood sugar. In that era type 2 diabetes was much less common (the western diet was not as bad as it is now) and not understood as a separate disease. A few years after insulin became available doctors were shocked that their diabetic patients were still dying prematurely just as before insulin was available- only a few years later in life. Even with glucose (blood sugar) lowering, diabetes of both types predisposes to aggressive vascular disease in large vessels (heart attacks, strokes, amputations) and small vessels (kidney failure, blindness, neuropathy.) Elliot Joslin, a famous diabetologist of the early 20th century, said that diabetic patients formerly died of too much blood sugar but now died of too much fat in the blood which caused fatal forms of vascular disease. We’ve known this for 90 years but little has been done to effectively fix the problem, and diabetics are still dying prematurely and suffering from heart attacks, strokes, amputations, kidney failure, blindness and neuropathy. The assumption that control of blood sugar with insulin and oral drugs would prevent these diabetes complications has turned out to be false. In fact, all of the drug treatments for diabetes have major side effects which often over-shadow the advantage of their blood sugar lowering. Multiple reviews have concluded that there is little advantage to intensive blood sugar monitoring and treatment. Intensive monitoring fills the patient’s life, preventing joy in day to day activities. Intensive treatment often leads to episodes of hypoglycemia (too low blood sugar) which are dangerous, even fatal.

A major multi-university study in 1970 concluded that diabetic patients would be just as well off if they had no treatment at all! Little has changed since then. Oral drugs are more sophisticated and much, much more expensive but offer little benefit.
http://www.diapedia.org/introduction-to-diabetes-mellitus/1104938831/the-university-group-diabetes-program
Since this area is such a huge, profitable business the medical industry does not acknowledge this proven fact, and most doctors are trained to give these drugs in large quantities. Type 1 diabetes will always require insulin; type 2 diabetes is curable by diet alone. Some patients with type 1.5 diabetes will require small doses of insulin even on a healthy whole food plant based diet. McDougall emphasizes that he gives no one oral diabetes drugs since, with a healthy diet, their glucose lowering effect is not necessary and they may lead to dangerous hypoglycemia and other serious side effects.

First line oral therapy is usually metformin, chosen because it has the least side effects. But multiple reviews of this drug have failed to show increased longevity and there is only questionable minimal improvement in some complication rates. Other common drugs, sulfonylureas and Avandia, have increased rates of cardiovascular disease and other serious side effects.
Avandia is still heavily marketed and prescribed in spite of a $3 billion fine for poor reporting of results, and there are over 50,000 lawsuits pending due to serious complications from this drug. https://www.drugwatch.com/avandia/lawsuit.php
You can imagine the profits made by these drugs if they are still selling one with this track record. A few new drugs are reported to offer a very small decrease in cardiovascular disease but with serious drug side effects and at great expense. Drugs are approved by the FDA and heavily prescribed if they lower blood sugar, but the problem with diabetes is premature death, terrible vascular complications, increased cancer and dementia rates which drugs do not help. Only a whole food plant based diet allows diabetics good health and longevity!

The frequency of diabetic vascular complications is much lower in those on a whole food plant based diet. Isidore Snapper, a famous physician-researcher of the mid 20th century, was chief of medicine at the Rockefeller Institute hospital in Beijing (then called Peiping.) He wrote that, none of the patients in his large diabetes clinic had any complication of the disease and concluded that their diet of rice and vegetables with little animal products or vegetable oils (they were too poor to afford these foods) protected them from the ravages of diabetes which most western civilization patients suffer. Ironically, the mainstay of their diet was white rice, a relatively low nutrient food which is frequently vilified as a cause of health issues. Vascular disease and all its sequelae are the result of too much animal product food and refined vegetable oils, not carbohydrates. Refined grains (wheat, rice) and sugars including honey and agave are unhealthy foods but do not cause diabetes or diabetic complications. If combined with animal products and refined oils they will add to the problem. Experimental animals and people fed sugar don’t become diabetic; those fed a high fat diet do.

John McDougall also spoke on “Does Sugar Feed Cancer:”

Proponents of low carb diets claim that sugar is the major culprit in the development and progression of cancer. The scientific literature contradicts this.
A review by a national study group concluded that high fat diets are the problem in cancer and that there is not good evidence that carbohydrates promote cancer. A possible mechanism is the slowing of blood flow caused by a high fat meal. (Vegetable oils like olive oil cause even more slowing than than animal product fat.) A typical American high fat meal leads to a 20% decrease in the amount of oxygen delivered to body tissues for several hours, often up until the next high fat meal. The theory that low oxygen levels promote the development and progression of cancer was proposed by the Nobel winning biologist, Otto Warburg, and later confirmed in cell cultures and experimental animals. Clinical studies have confirmed that a whole food plant based diet (which will be low fat) significantly increases longevity in people with known cancer and the American Cancer Society now states this in its patient information literature.

Kevin Hall, the lead researcher on obesity at the NIH, discussed his findings:

Drastic diets change the perception of what you need to eat and so participants in THE BIGGEST LOSER TV series all are long term failures. They revert quickly to normal eating habits and back towards previous weight. Most think they are still dieting since the effort not to eat even more is very high. Very severe calorie restriction plus heavy exercise always fails because of this reprogramming of appetite levels.

A modest number of those on true low fat or true low carb diets do succeed at long term weight control but it’s currently not possible to predict who will succeed on either. Hall mentions other issues like longevity, cardiovascular disease and cancer due to diet but doesn’t discuss them. As he points out, weight is a marker for health and is not the bottom line. Of course, this is where a whole food plant based diet shines, with overwhelming evidence that it is good at avoiding/treating many diseases regardless of the relative value of different diets for weight loss.

Ironically one of his studies was partially funded by the Taubes group to help prove the carb-insulin model of insulin secretion. Proponents of low carb diets have claimed that carbohydrates cause insulin secretion (true) and therefore lead to promotion of obesity and poor health (totally false.) In metabolic ward studies (research subjects live in the research lab where all their food intake and activity are monitored) Hall’s studies showed that a low fat diet resulted in more body fat loss than a low carb diet which led to loss of more muscle tissue, not fat- exactly the opposite of what Taubes and other low carb advocates have been claiming. It’s a devastating study for this movement since it destroys the major scientific basis of their diet. In addition to being bad for health (CV, auto-immune, cancer, overall longevity) the low carb diet is also bad for fat loss versus muscle loss. In spite of this research, none of them have retracted their dangerous advocacy of high fat and protein diets. Even worse, the popular press parrots their advice like gospel.

https://www.nih.gov/news-events/news-releases/nih-study-finds-cutting-dietary-fat-reduces-body-fat-more-cutting-carbs