American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, February 6, 2012

Minding your second favorite organ

As a preventive medicine physician who truly believes "if you don't have your health, you don't have anything," our prevailing behaviors have always been hard to fathom.

The parent who simply can't find time to cook a family dinner can, always, find time to take a kid to the ER or endocrinologist. People who can't afford mixed greens can afford diabetes test strips.

People who carefully and responsibly invest in the financial security of their retirement (although we know that's no guarantee of a good outcome!) routinely neglect altogether any investment in their health. If money can be put aside for future benefit, why can't time be "put aside"--invested in physical activity, eating well, getting enough sleep? It can be, of course, but our social norms don't encourage it, and it doesn't happen. Standard-issue, responsible modern adults carefully tend their money, and neglect their health. It's normal, and almost expected. But it's bizarre and often calamitously costly.

Many people reach retirement with the money they need, lacking the health they need to use that money for anything enjoyable. As a physician, it is excruciatingly painful to look into the imploring eyes of a retiree who has long anticipated their golden years--and has cultivated the bank account to underwrite it--now disabled by progressive diabetes, lung disease, brain disease or heart disease that need not have occurred.

And it is all too common. I have seen, and continue to see, many such patients. Patients who reach retirement age with robust good health and too few dollars come along, too, of course, but far less often. And here's the news flash: Those with health but not much money are clearly a happier group than those with money but not much health. I have met them on the intimate turf of clinical care, and they have told me so.

This is the backstory for a careful consideration of the Alzheimer's disease crisis we now face.

There has been enormous attention of late to the grim and genuinely frightening problem of Alzheimer's disease. The problem is grim by its very nature. There is little we contemplate with greater dread than the loss of our minds, our very selves. The problem is frightening at the personal level because we feel vulnerable to this increasingly common condition we don't know how to cure, and at the collective level, where estimates suggest it could cost the nation $1 trillion dollars annually by 2050. There is also the terrible burden on family members, who must face the high demands of care, compounded by the heart-wrenching loss of a loved one who is still there, yet already gone.

It is in this context that President Obama has declared a war of sorts on this scourge, calling for means of both prevention and treatment by 2025, or even 2020. There is lively debate about how realistic the goal is, although on that issue, I note that the best way to predict the future is to create it. You don't get to the moon without committing to the trip.

To create the president's future, it will be important to develop new treatments, as it is for obesity and diabetes. But as with obesity and diabetes, it will be important not to let the hunt for breakthrough treatments become the tail that wags the dog.

Alzheimer's is overwhelmingly a vascular disease, and thus overwhelmingly preventable. Estimates are less well established than for other chronic diseases, but it seems likely the risk can be trimmed by nearly 80% and perhaps eliminated entirely but for the extremely genetically vulnerable by minding our general health.

It is only fair and honest to concede that we do not have perfect defenses against Alzheimer's. And, to some extent, we are hoisted on our own petard, vulnerable to this condition of advancing age because we are better at living longer than ever before.

But the evidence is strong, if not incontrovertible, that whatever the genetic underpinnings, the epigenetics of Alzheimer's, those exposures that influence how genes behave, are of profound importance. By and large, Alzheimer's is a vascular disease. By and large, the practices that prevent cardiovascular disease, eating well, being active, avoiding tobacco, slash the risk of Alzheimer's.

Study after study after study after study that has shown an elimination of up to 80% of all chronic disease with the application of lifestyle as medicine has NOT carved out an exception for Alzheimer's. The evidence that we can alter gene expression with the power of lifestyle almost certainly pertains to Alzheimer's as it does to cancer. By minding our bodies, we can mind our minds, too. We can best mind both, by minding the short list of what matters most to health.

Available evidence suggests that controlling cardiac risk factors can lower dementia risk specifically by 50% or more.

So see a doctor at regular intervals to have your blood pressure and cholesterol monitored. High cholesterol can contribute to dementia by accelerating the development of atherosclerosis; controlling blood lipid levels with diet or medication can protect against this. High blood pressure can damage the blood supply to the brain in several ways, and is the leading risk factor for stroke. At least one European study suggests that treatment of high blood pressure all by itself can cut dementia risk in half.

While the scientific evidence linking cigarettes to dementia per se is equivocal, the link between smoking and vascular disease is clear and strong. So avoid tobacco to protect your brain by protecting the blood vessels that nourish it.

There is some evidence to support what most of us have heard about "brain foods." Fish consumption appears to protect brain function, most likely by contributing omega-3 fatty acids to the diet. An omega-3 oil supplement, one to two grams daily, is an alternative. Antioxidants in food appear to be protective as well, contributing to the reputations of blueberries, red wine and green tea.

But while an inventory of potential brain foods can be assembled, the evidence is much stronger for the importance of the overall dietary pattern. Eating well is as important to the brain as it is to the heart. Lower your risk of Alzheimer's with plenty of vegetables and fruits, whole grains, beans and lentils, olives and avocado, nuts and seeds. Limit consumption of highly-processed foods, fast foods, sugar, salt, saturated and trans fat. Physical activity, too, nurtures the health of body and mind alike.

There is some evidence that poorly controlled stress, lack of sleep and various nutrient deficiencies, vitamin E, vitamin C, and vitamins B12 and B6 in particular, may increase the risk of dementia. Controlling stress, getting adequate sleep and a balanced diet with or without supplements may all confer protection.

Finally, population studies consistently suggest that those who exercise their brains protect their minds from dementia. Crossword puzzles and Sudoku are aerobics for your brain. Just as physical activity defends the body against aging and infirmity, mental activity seems to help preserve the vitality of the brain. The Mayo Clinic and the Alzheimer's Foundation, among others, provide nice summaries of prevention strategies online.

As we mind our mind by minding our bodies, we can mind our business into the bargain. The price tag of Alzheimer's, and chronic disease in general, threatens nothing less than our national solvency. Only prevention can solve that problem. A breakthrough drug for Alzheimer's would be wonderful, but who is naive enough to think the drug would be dispensed for free? Serious chronic disease is bad financial news when we can't treat it, and still bad financial news when we can! The financial news turns to the good only with prevention. Lifestyle is not only the best medicine we have. It is the only medicine we have already available to all, at essentially no extra cost, and without a prescription.

A healthy brain needs clear arteries, a sound heart, clear lungs, fit kidneys, a robust liver. Even if your brain is your second-favorite organ, you can tend it best by looking after all the other less-favored organs on which it is co-dependent.

Altogether too many of our loved ones have Alzheimer's already; and too many more will get it. There is no question we need the government, and big Pharma, and the biomedical community at large to wage the battle of treatment on our behalf.

But prevention is the greater prize in the long run, and is largely already within our grasp. There is no need to wait for the government, or big Pharma. Take matters into your own hands. Mind your mind and mind your body with the zeal and diligence you routinely apply to minding your own business. Because, they are.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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