Wednesday, October 17, 2012

Light At Night and Disease

You don't hear much about light pollution. And when you do, it's usually a story about wildlife or greenhouse gases or stargazing. That's about to change.

Recent research has drawn a connection between dim light exposure at night and depression. The investigators found that light, comparable to the levels of light pollution surrounding cities, not only triggered depression in animal models but also increased specific inflammatory molecules in the hippocampus, a part of the brain involved in mood disorders. When the inflammatory molecules were blocked, the depression lifted.

We have known for some time that inflammation is associated with many diseases. In fact, it seems as if it is an essential condition for most of them. A Who's Who of inflammatory illnesses would number over 100 and include Alzheimer's, atherosclerosis, arthritis, Parkinson's, cancer and mood disorders. The connection with mood disorders was first appreciated when depression was found to be more prevalent in those with inflammatory disorders than in the general population.

So the medical community has targeted anything that causes chronic inflammation as something to nip in the bud. The big players here have been stress, Western diet (high in fat and processed foods), and sedentary lifestyle. Now we may have to add light at night (LAN).

This shouldn't come as a complete surprise. We evolved in an environment that alternated between light and dark. Over tens of thousands of years, this was an environmental constant. In this setting, our cells developed a kind of clock that is organized on a daily (circadian) pattern. Disrupt that rhythm and the trouble begins.

In the 100 years that widespread use of electric bulbs has become the norm, our genome has not adapted. Genetic change does not occur that rapidly. We are still wired for darkness at night, and artificial light disrupts our circadian rhythms. A growing body of research suggests that artificial light at night increases the risk for a variety of diseases including obesity and certain cancers.

If you think about some of the most common symptoms of depression, this story makes more sense. Circadian cycles, sleep, hunger-satiety, and memory are typically altered in depression. People with depression describe difficulty sleeping or excessive sleep. They often relate that their "clock is off." They complain of a loss of appetite or an inability to stop eating. Depression's capacity to impair memory is so profound that depressives have been misdiagnosed as suffering from dementia, a memory disorder.

The brain centers that control these functions (hunger-satiety, circadian cycles-sleep, memory) are located in the hypothalamus. Bingo! That's the part of the brain adversely affected by light at night, according to the recent research.

Over the past century there has been a dramatic increase in the incidence of depression, sleep disorders and obesity. This new data suggest that at least part of this increase could be due to the ever-growing exposure to light at night.

Imagine if we were to discover that light plays a major role in the obesity epidemic. I can see the headline now: "My Nightlight Made Me Fat."

So how might you respond to these findings?

Does your bedroom look like a NASA control room when you turn off the lights? Does your phone, TV, cable, computer, fax, printer, smoke alarm, etc. emit light? Do your curtains eliminate all light from outside?

For once, we may want to be in the dark.

Change Is Easier Than You Think: Thinking's The Problem

We all want to change something. Most of us have tried and had either fleeting success or chalked up a failure. Why is it so hard?

The way we think about change is the problem. In this arena (unlike most), we think too much. We usually think our way to keeping things exactly as they are.

There's always a good reason we do the things we set out to change. On some level, these things -- whether food or drink or drugs -- work. They may cause all sorts of problems, but there's a reason we keep doing them, and it's not laziness or lack of willpower. They soothe us in some fundamental way, no matter how transiently.

Our mind has devised this maladaptive solution and has hijacked our better sense in an attempt to protect us. It is dedicated to preventing the loss of this behavior and made anxious by even the idea of such change. For this reason, most thinking about change has been sabotaged from within.

Change is about doing, not thinking.

There are three big mistakes people make that doom their attempts from the get-go. Avoid these and you're off to a great start.

Mistake #1: It's not something you want to change, it's someone else's agenda.

This may prove more complicated than it seems. Let me give you an example.

Harry's wife wants him to lose weight. His doctor has informed him that he's developing a pre-diabetic condition that puts him at risk for all sorts of bad things. Harry believes that enjoying life means eating and drinking to your heart's content. To curb these appetites is to create a life not worth living.

In this setting, it's highly unlikely that Harry will change. However, let's say Harry really loves his wife and that she is terrified of losing him. He wants to "be there" for her. He wants to feel like a good husband. He is distressed that he is the cause of her anxiety. It is more powerful to see himself as a good partner than to enjoy the pleasures of a glutton. Now, change has become his agenda.

Mistake #2: The change you want to make is not a behavior.

Let's stick with Harry. So Harry decides that what he really needs to do is lose weight (fine) and therefore defines weight as his thing to change (not fine).

The choice of what we're going to change is the most important factor for success. It must be a simple behavior, not a broad goal. Hopefully the chosen behavior will move you toward a broad goal.

If weight-loss is desired and diet the approach, then an example of an appropriate change would be to eliminate bread. This can be done on a day-by-day basis. The goal each day is to have no bread that day. This sits much more comfortably in our minds than the resolution that we will never again have bread.

Another essential component here is the ease with which we can measure success. You go without bread today, you succeeded. Success is not months or years down the road when you tip the scales at some magical number. And there is nothing like this one-day accomplishment to make something feel controllable. Success breeds success.

Mistake #3: You will adopt the change behavior most of the time.

Choice is the enemy. Good old Harry figures, "hey, I've been eating a ton of bread every day, if I don't eat bread most days, it will be a big step in the right direction."

As soon as the option to eat bread sometimes is on the table (so to speak), you'll fail. Every time you sit down to eat, you will play the "do I eat bread this time" game. It's as if you decide to wrestle with the decision to change this behavior several times a day. There will always be a rationale for why it's ok to eat bread "this" time. And you will feel worse after allowing yourself to do it. Such feelings make you feel weak and erode confidence that you have the power to change.

100 percent is easier than 90 percent

I know this sounds upside down, but it's not. No matter what you're trying to eliminate -- bread, gluten, TV, alcohol, pot -- I believe you will succeed much more of the time when it's all or nothing.

I'd say "good luck," but it's not about luck. It's about making it really small, getting out of your own way, and creating some successes.

Saturday, September 22, 2012

Why You Can't Sleep Through The Night

More than 30 percent of adult Americans, about 60 million people, complain of difficulty sleeping. For about a quarter of these individuals, treatment begins with medication. This tells us two things. Sleep is a big problem and a big business.
So how does one of the most basic biological functions become so disordered? After all, what could be more natural than sleep?
The first thing you notice when digging into what we know about sleep is how little we understand. The function of sleep, a state that occupies one-third of our lives, remains unclear. Why is sleep necessary for our survival? Why do we dream?
Sure, we have made some connections by observing what happens to people who are sleep-deprived or perform shift work. Clearly, physical and cognitive function take a hit. Medical interns working on the night shift are twice as likely as others to misinterpret hospital test records that could endanger their patients.[1] The Exxon Valdez oil spill and the Three Mile Island and Chernobyl nuclear power plant accidents were attributed in part to the consequences of compromised night shift workers. We know memory and learning are impaired. Protein synthesis that produces the building blocks needed for cell growth and repair is markedly diminished.[2] But theses are crude observations, not understanding.
The second thing you realize, and this boggles the mind, is that almost everything we do know about human sleep has been learned in the last 50 years. Unfortunately, like the first beliefs in any discipline, many of the early theories about our sleep were wrong.
Until recently, humans were thought to be different from all other animals in having sleep that is consolidated into one continuous nocturnal episode. This notion of uniquely human sleep held sway until the early 1990s when Thomas Wehr, a sleep researcher at NIMH inadvertently stumbled on something that changed everything, or should have.[3]
Wehr selected healthy untroubled sleepers who were accustomed to 16-17 hour days and seven to eight hours of sleep, a routine that many of us live by or envy because we get less sleep. He exposed them to 10 hours of light and 14 hours of dark per day and watched what happened to their sleep. This ratio of light to dark (10:14) mimics the natural light of a typical winter day in a temperate climate. Initially, they slept for 11 hours per night, suggesting a chronic sleep deficit, and then settled into an average of 8.9 hours each night. By the fourth week Wehr saw something that wasn't supposed to happen in humans. They all developed a sleep pattern characterized by two sleep sessions. Subjects tended to lie awake for one to two hours and then fall quickly asleep. After about four hours of solid sleep, they would awaken and spend one to two hours in a state of quiet wakefulness before a second four-hour sleep period.
This bimodal sleep has been observed in many other animals. One such creature turns out to be pre-industrial man. Only recently have anthropologists and historians scrutinized the sleep of other cultures, earlier centuries and prehistoric humans. In the remarkably informative At Day's Close, Night in Times Past, Roger Ekirch unveils nocturnal life in the pre-industrial west.[4]
Drawing from a broad range of sources he found a trove of evidence documenting our history of bimodal sleep. Until the late 1700s, and the widespread use of artificial light, people retired to bed soon after sun down and entered what was called "first sleep." They would awaken three or four hours later and enjoy a couple hours of quiet. During this time they often prayed, chatted about dreams and had sex. A French physician described this time between sleeps as a particularly good opportunity for sexual intimacy when couples "do it better" and have "more enjoyment." The middle night interactions seem to have been essential for social cohesion.
This was followed by "second sleep" that again lasted three to four hours and ended with sunrise. In fact, a study of contemporary cultures across the globe reveals a wide spectrum of sleep habits.[5] Some anthropologists now speak of three sleep cultures: monophasic cultures (the West, where one consolidated sleep period dominates), siesta cultures (where one afternoon nap is added in the afternoon, the word siesta meaning the sixth hour) and polyphasic cultures (China, Japan, India where multiple naps throughout the day of varying lengths are the norm).
Researchers have replicated and expanded on Wehr's work. Several studies have taken subjects to deep underground bunkers free of any artificial light in order to observe our internal clock's rhythm. Again, they observe this biphasic pattern. Subjects sleep in two four-hour solid blocks separated by a couple hours of meditative quiet during which there is a remarkable surge of prolactin, unseen in modern humans. The participants report feeling so awake during the day that it is as if they experience true wakefulness for the first time.
So we find ourselves in a somewhat perverse situation. We have not evolved to naturally drift rapidly into one continuous nocturnal snooze. But according to the medical community and the pharmaceutical industry, if we don't do this, we suffer from a sleep disorder that merits medicating. However, if you ask any sleep expert how some people seem to fall asleep quickly and sleep continuously for seven or eight hours they'll say that such a sleep pattern is characteristic of chronic sleep deprivation.
We evolved in an environment of alternating light and darkness and developed internal clocks to manage in such conditions. Every known organism with two or more cells has an internal clock.[11] In this regard, we are not unique. It is our use of artificial light to extend our day and defy our natural rhythms that distinguishes humans. We have just begun to understand the consequences of this Promethean sin.
Sleep deprivation has been linked to obesity, hypertension, insulin resistance, cardiac disease, and compromised immune function.[6][7][8][9] In the same way that food products/supplements are replacing normal eating with dire health effects, sleep continues to be condensed by the 24/7 culture. The recent rapid growth of a new category of medications that promote wakefulness makes one wonder if sleep will soon be optional or ultimately obsolete.[1]
So what can you do?
The constraints of work schedules and family responsibilities make radical changes in sleep-wake timing difficult. Here are some guidelines:
1. Abandon the idea of going to bed for six to eight hours of sleep at night (unless this works for you).
2. Get a feel for what your sleep cycle looks like. If you wake up before you need to, get up. This is probably a natural cycle end. You will make up for lost nighttime sleep with a nap(s).
3. Napping Guidelines:
  • Timing: Afternoon (3-5 p.m.) -- proven to provide more sleep efficiency, more slow-wave sleep, and less time to fall asleep.[12]
  • Duration: Optimally 10-20 minutes. People experience greater cognitive impairment due to sluggishness after a nap of 30 or more minutes than that due to sleep deprivation.
  • The full benefits of naps comes with habitual napping. Stick with it!
4. If possible, when you feel like reaching for that afternoon caffeine fix, take a nap.

[1] Veasey S et al. Sleep Loss and Fatigue in Residency Training JAMA, Sept 4, 2002 Vol 288, No.9
[2] Sleep: A Comprehensive Handbook, edited by T. Lee-Chiong 2006 John Wiley & Sons p904
[3] Wehr T et al. In short photoperiods, human sleep is biphasic Journal of sleep research 1992 (2) 103-107
[4] Ekirch AR, At Day's Close, Nights In Times Past 2005 WW Norton & Co, Inc.

[5] C.M. Worthman and M. Melby. Toward a comparative developmental ecology of human sleep. 2002, In: Adolescent Sleep Patterns: Biological, Social, and Psychological Influences, M.A. Carskadon, ed. New York: Cambridge University Press, pp. 69-117.
[6] Ackermann K et al. Diurnal rhythms in blood cell populations and the effect of acute sleep deprivation in healthy young men. SLEEP 2012;35(7):933-940.
[7] Spiegel K et al. Sleep loss: a novel risk factor for insulin resistance and type 2 diabetes Journal of Applied Physiology Nov 2005 vol 99 2008-2019
[8] Knutson KL et al. The metabolic consequences of sleep deprivation. Sleep Medicine Reviews vol 11, Iss 3, 163-178 June 2007
[9] Gottlieb DJ et al. Association of usual sleep duration with hypertension. The Sleep Heart Study. Sleep vol 29, No 8, 2006
[10] Boutrel B et al. What keeps us awake: the neuropharmacology of stimulants and wakefulness-promoting medications. Sleep, vol. 27, No. 6, 2004
[11] Ko CH et al. Molecular components of mammalian circadian clock. Human Molecular Genetics 2006 15 (suppl 2) R271-R277
[12] Brooks A; Lack L. A brief afternoon nap following nocturnal sleep restriction: which nap duration is most recuperative? SLEEP 2006; 29(6):831-840.

Monday, September 10, 2012

What We're Talking About When We're Talking About Cleansing

The 1981 Raymond Carver short story collection "What We're Talking About When We're Talking About Love" masterfully showed us that everyone has a different conception of love. At the end of the eponymous story Carver seems to suggest that while we may struggle to put into words what love is, it's worth the effort, even if we fail.

I think a similar effort should be made with the contemporary practice of "cleansing", a term used here to cover a broad spectrum of behaviors (from colonics to detox diets/drinks) defined by an attempt at purification or elimination of undesirable material from our bodies.

Why make such an exploration?

A Google search on "health cleanses" draws 4 million 430 thousand entries. Clearly this is on a lot of people's minds. And the mind is my focus. The cleansing phenomenon is driven by a perception of self as dirty. Dirt, like love, means different things to different people.

The etymology of dirt (the dirt on dirt, so to speak) is telling. In Olde English "dritan" was a verb meaning to defecate. Middle English coined the noun "drit" for excrement. Over the years the i and the r swopped places giving us "dirt". So it's not a stretch to see where the idea that if there's a place in us that needs cleaning, it must be that final pathway of our feces, the colon.

Our bodies turn food into feces. But we take in more than food. We take in ideas and experiences that are also "metabolized" in the sense that they are broken down and mined for useful material that we store in our memory and use in a variety of ways. They may be nourishing in that they provide a sense of wellbeing or the belief that we're a good person. Alternatively, some ideas and experiences give us mental indigestion. They tamper with our sense of our selves as decent. They make us feel dirty.

We all carry around an idea of what we should be. The distance (in our own estimation) between this ideal and where we actually live, defines how we feel about our self. Traditionally such self-evaluation was based largely on how we felt we were measuring up in our relationships as a spouse or son or mother or neighbor or citizen or religious community member.

Because the distance between our ideal self and actual self is so often a painfully large expanse littered with regret, every culture has had its way of addressing the feelings of being guilty, dirty, impure. We want to "come clean", to start over. Confession, prayer, fasts, sweathouses, service, and yes, now, colonics, all fit into this category.

So how did we get here?

The traditional roles mentioned remain powerful. But a new metric for assessing how we measure up has taken root. Now the moral meter appears to be our bodies, our diet and exercise. What do you weigh? How much red meat? Did you really have pizza last night? How often are you exercising? What is your cholesterol? How many cocktails? Are you flossing? Did you get your annual checkup or colonoscopy (not colonic!) or mammogram or Pap smear?

Don't get me wrong. We should take care of ourselves. But obsessing about our bodies will not replace the cleansing feelings that come from caring for others.

Our culture is attempting to substitute diets and detoxs for self-exploration and the hard plodding work of accepting what can't change and trying to change what can, for the better. As Raymond Carver said about love, it's worth the effort, even if we fail.

Monday, September 3, 2012

Let’s Talk Dirty: The Trouble with Cleanses, Colonics and Wipes

Cleanliness may be next to godliness, but it also may do us in.  A growing body of data suggests that a wide range of ills, from allergies and asthma to inflammatory bowel disease, may be the consequence of our fetish for clean.

A quick look at the shelves of pharmacies and supermarkets speaks volumes to the priorities of a culture. The aisles of cleaning products continue to metastasize claiming more space and new frontiers. The territory in need of a good scrub now ranges from our garage to our gut, from our teeth to our toilet. Whether it’s the surface of our kitchen counter or the surface of our face, cleaner is not just better but safer.

A kind of homeland security mentality has invaded the cosmos of clean. The axis of evil here is bacteria and all bacteria are bad. But nothing could be further from the truth. We can’t live without bacteria. The bottom line: we are part bacteria.

Our bowels are a perfect example.  There are way more bacterial cells living in our gut than the total number of our own cells in our entire body. We are, so to speak, colonized. These gut microbes turn out to be incredibly important. Anyone who has been on antibiotics, which kill many of these bacteria, can attest to the stomach misery caused by upsetting the balance of these little lodgers. Growing evidence suggests that a reduced diversity of these bugs is with inflammatory bowel disease, metabolic syndrome (prediabetes) and obesity. So why would you want to “clean” a colon?

Decreased exposure to the bacterial world has been cited as a cause of the explosion in childhood allergic conditions. For instance the rate of peanut allergies in children more than tripled between 1997 and 2008. Children living in urban centers are twice as likely to have peanut and shellfish allergies compared to kids in rural areas. 5.9 million children in the US under the age of 18 (1 in 13) have a potentially life-threatening food allergy. An allergic reaction to food sends an American to the ER every 3 minutes.

When a species develops an allergy to its food, that species is in trouble.

The explanatory theory for this phenomenon is called the Hygiene Hypothesis. Without the exposure to bacteria that we experienced historically and that our bodies evolved to cohabitate with, our immune systems go haywire. We develop hyperactive immune reactions to all sorts of things, i.e. we develop allergies and autoimmune disorders.

So how did we get here?

Let’s start with the new improved soaps, the antibacterial soaps. Studies have demonstrated that they provide no greater protection from contamination. In fact, they appear to be associated with an increased frequency of fevers, and upper respiratory tract symptoms. Apparently, these agents are non-specific killers. They knock out both the invading pathogenic bacteria that cause illness and the friendly “flora” or usual bacterial tenants. The problem here is that our bacterial flora actually provide protection from many invading bacterial bad guys, preventing them from finding a niche in our bodies.   

Don’t get me wrong. Hand washing is good. Just do it with regular soap.  Interestingly, good old-fashioned soap does not seem to kill off the non-pathogenic bacterial flora and is therefore ironically more effective in preventing contamination.

Another pervasive culprit is the “wipe”. What a great name, with its double-barreled implication of total elimination of the enemy (“wipe out”) and ease of victory (with a mere “wipe down”).

The “magic bullet” in antibacterial wipes is some form of the antibiotic called Triclosan. And it seems to be everywhere. Surfaces in food-processing plants, chopping boards, and refrigerator shelves are impregnated with this titan of the microbial battle. But in any confrontation between humans and bacteria we win pyrrhic victories only.

The bacteria have seen our ante and raised the bet. Not only have bacteria developed a resistance to Triclosan, there are now strains that eat it. As you might imagine, all this Triclosan finds its way into our waste grounds, sewers and water supply. In these fertile domains, the bacterial number has not diminished. In fact there has been an increase in the bacterial populations that are resistant to prescription antibiotics.

Any story of this kind would be incomplete without mentioning the bonfire of resistant bacteria steadily stoked by the misuse of antibiotics. This includes prescribing them for every sniffle (most of which are viral and therefore unaffected by antibiotics) and their pervasive use in the animals we consume. 75% of all antibiotics are used in the service of promoting growth in livestock.

Let me close with a plea for a dirtier world, a relinquishing of the desire for a squeaky clean colon. We are not dirty. We may feel dirty, but we do not need cleansing. There is a difference between guilt and contamination. It can be difficult not to fall prey to the idea of a Spring Cleaning of our bodies, a return to some innocent beginning.

We know the hard work of how to clean up our lives.  Attempting to sterilize the environment or our bodies won't do it. 

And when it comes to dangerous bacteria, we must cultivate the good bacterial part of us to survive them. Diversity is a good thing in man and microbe.

Tuesday, August 7, 2012

Gun Mathematics

James Holmes went to the movies and shot 142 people. Wade Page entered a Sikh temple and gunned down 9 citizens. 31,513 people were killed by firearms in 2010 in the United States. (1) It remains remarkably easy to obtain firearms in most states.

One man, Richard Reid, boarded flight 63 from Paris to Miami on December 22, 2001 with plastic explosives in his shoe. The fuse failed to ignite. Reid is serving a life sentence in a supermax prison that houses the most dangerous prisoners in the federal system. All airline passengers since Reid’s attempt must remove their shoes so they can be scanned for bombs.  

How do we make sense of the different responses?
To put the question another way, how do we compare the association of shoes with bombs vs. the association of firearms with mortality? What would the equivalent of the new transportation safety regulations be for guns?

Is this simply a matter of the relative impotence of the shoe lobby compared to the gun lobby?

A brief review of the statistics lends some clarity to this uniquely American situation.

Firearms are one of the top 10 causes of death in the US. (1) In a 2003 World Health Organization study, the US was compared to 20 other high-income countries (Australia, Austria, Canada, Czech Republic, Finland, France, Germany, Hungary, Iceland, Japan, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Slovenia, Spain, Sweden, Scotland, and the United Kingdom). The US population at that time was 290.8 million and the combined population of the other countries was 563.5 million. There were 29,791 firearm deaths in the US that year and a total of 7,653 firearm deaths in the other 20 countries. (2)

We Americans are not more violent. But American violence is often lethal violence. And there is one reason for this fact; access to guns. We humans are an emotional lot, prone to impulsive behavior. Most violence is impulsive and the consequences limited by what’s at hand.

Another set of statistics helps frame a rational approach to gun legislation. Firearm deaths fall into three categories, suicides, homicides, and accidents. Most people are unaware of the fact that suicides represent the largest category, followed by homicides. (1)

It is fair to say that the majority of individuals who commit suicide are mentally ill or temporarily out of their minds. Most suicide deaths are accomplished with firearms. Between 2003 and 2007, an average of 46 Americans committed suicide with guns each day. (3)

Studies attempting to explain why some regions have higher suicide rates repeatedly find a strong significant positive association between gun ownership and rates of suicide. (4) Simply put, states with more guns have more suicides.

Public health concerns legitimately include gun control.

Similarly, preventable accidents fall under the purview of public health. Many fatal firearm accidents occur in children. In the U.S., children between the ages of 5 and 14 are 11 times more likely to be killed accidentally by a gun compared with the same aged children in other developed countries. (5) If we can perfect the child-proof medicine bottle, we should be able to protect children from guns.

It took one shoe to change the way Americans travel.
What will it take to change our way with guns?  


1.     U.S. Department of Health and Human Services, CDC, National Center for Health Statistics, National Vital Statistics Reports Jan 11 2012 Vol.60, 4
2.     Richardson EG, Hemenway D, J Trauma 2011 Jan; 70 (1):283-43
3.     Hemenway D. Amer J Lifestyle Med 2011 5:502
4.     Miller M, Lippman S, Azrael D, Hemenway D. Household firearm ownership and rates of suicide across the 50 U.S. states J Trauma. 2007;62:1029-1035
5.     Richardson EG, Hemenway D. Homicide, suicide, and unintentional firearm fatality: comparing the United States with other high-income countries, 2003 J Trauma. Doi: 10.1097/TA.


Friday, August 3, 2012

The New Elixir - A Cup of Joe

The world’s most widely used pick-me-up reduces your risk of neurodegeneration, depression, cancer and cardiovascular disease, and that’s just the beginning of the story.  Yes, I’m talking about that legal, over-the-counter beverage now available every other block. You know, brain juice, brew, liquid energy, morning mud, rocket fuel, wakey juice.

It may even be an ingredient in that fountain of youth we’re still searching for. According to a recent study in the New England Journal of Medicine, coffee lowered all-cause mortality by over 10% after 13 years of follow-up. (1)

Before I summarize the remarkable medicinal properties this plant-based beverage has recently been shown to possess, let me flag the potential negative effects. They are few in number and undoubtedly the positive dwarfs the negative. However if you happen to suffer from one of these conditions, you might want to consult your doctor before changing your coffee consumption.

Coffee can increase blood pressure and intraocular pressure (a potential concern if you have glaucoma), make the anxious more anxious, and worsen tremors and insomnia. (2) There, that’s it. Makes you wonder why it’s gotten such bad press in the past.

While it is true that caffeine transiently increases blood pressure, it appears that when consumed in  coffee, the increase is small and offset by protective effects. For instance, coffee beans are rich in antioxidants that decrease LDL and markers of inflammation (3-8). Inflammation occurs early in the development of cardiovascular disease and is most commonly triggered by a sedentary lifestyle, stress, and processed foods.

Overall coffee appears remarkably heart friendly. It has been shown to substantially decrease the risk for coronary heart disease (4) and as little as 2 cups per day decreases the risk of heart failure. (9)

Recent research has demonstrated coffee’s capacity to protect the brain as well. Investigators found that 1-6 cups per day reduce the risk for stroke by 17% (3) A well designed Swedish study followed female coffee drinkers for an average of 10 years and found a 22%-25% reduction on stroke risk. (11)

Well that’s great you say, but can it help me loose weight? Yes, indeed. By decreasing glucose absorption, coffee can facilitate weight loss, especially when combined with other measures. (15) It also improves glucose metabolism and insulin sensitivity, thereby decreasing one’s risk for Type 2 Diabetes. (12-14)

Coffee also appears to provide protection from a number of cancers through its antimutagenic and antioxidant effects. (16,18) Studies suggest different quantities are necessary to affect different cancers; prostate cancer – 6 cups/day (17), estrogen receptor-negative breast cancer - > 5 cups/day (21), endometrial cancer - > 4 cups/day (16)

When it comes to protecting your brain, studies have shown coffee to be a potent agent. Recent investigation demonstrated a protective effect in subjects with mild cognitive impairment, a condition that usually progresses to dementia. Those who consumed 3-5 cups of coffee per day attained blood caffeine levels of > 1200 ng/ml showed no progression of their condition during the 2 to 4 years of follow-up. (22)

Coffee drinkers also appear to be at lower risk for Parkinson’s disease. Recent research presented at annual meeting of the American Academy of Neurology demonstrated that as little as 3 cups of coffee per day may block the formation of Lewy bodies, an early diagnostic sign of the development of Parkinson disease. (23)

The other remarkable brain benefit relates to mood.
Just last year researchers found that women who consumed 2 to 3 cups of coffee per day lowered their risk for depression by 15% compared to women who drank less than 1 cup per week. And more coffee afforded more protection. Those drinking 4 or more cups per day lowered their risk by 20%. (24) The investigators speculated that this antidepressant effect stemmed from coffee’s antioxidant and anti-inflammatory qualities. (25-27)

If all that isn’t a sufficiently broad spectrum to convince you that coffee might be the most exciting “new” gun in medicine’s armamentarium, the list goes on.

What type of pathology remains? “Can it fight infection?” you ask. Yes, and not just any wimpy intruder. Coffee has also proven itself a potent force against one of the scariest bacteria, methicillin-resistant Staphylococcus aureus, known as MRSA. The mechanism of this effect remains a mystery. However, subjects reduced the likelihood of having MRSA in their nasal airways by almost 50% by drinking coffee regularly, regardless of quantity. (28)

So bottoms up.

For once a simple pleasure is the perfect prescription.

1. Freedman ND, Park Y, Abnet CC, et al. Association of coffee drinking with total and cause-specific mortality. N Engl J Med. 2012;366:1891-1904
2. Pasquale L. Program and abstracts of the American Glaucoma Society 22nd Annual Meeting; March 1-4, 2012; New York, New York. Abstracts 23 and 83.
3. Larsson SC, Orsini N. Coffee consumption and risk of stroke: a dose-response meta-analysis of prospective studies. Am J Epidemiol. 2011;174:993-1001.
4. Wu JN, Ho SC, Zhou C, et al. Coffee consumption and risk of coronary heart diseases: a meta-analysis of 21 prospective cohort studies. Int J Cardiol. 2009;137:216-225.
5. Natella F, Nardini M, Belelli F, et al. Coffee drinking induces incorporation of phenolic acids into LDL and increases the resistance of LDL to ex vivo oxidation in humans. Am J Clin Nutr. 2007;86:604-609.
6. Gómez-Ruiz JA, Leake DS, Ames JM. In vitro antioxidant activity of coffee compounds and their metabolites. J Agric Food Chem. 2007;55:6962-6969.
7. Nardini M, D'Aquino M, Tomassi G, et al. Inhibition of human low-density lipoprotein oxidation by caffeic acid and other hydroxycinnamic acid derivatives.  Radic Biol Med. 1995;19:541-552.
8. Montagnana M, Favaloro EJ, Lippi G. Coffee intake and cardiovascular disease: virtue does not take center stage. Semin Thromb Hemost. 2012;38:164-177.
9. Mostofsky E, Rice MS, Levitan EB, Mittleman MA. Habitual coffee consumption and risk of heart failure: a dose response meta-analysis. Circ Heart Fail. 2012;DOI:10.1161/CIRCHEARTFAILURE.112.967299.
10. Larsson SC, Orsini N. Coffee consumption and risk of stroke: a dose-response meta-analysis of prospective studies. Am J Epidemiol. 2011;174:993-1001.
11. Larsson SC, Virtamo J, Wolk A. Coffee consumption and risk of stroke in women. Stroke. 2011;42:908-912.
12. Huxley R, Lee CM, Barzi F, et al. Coffee, decaffeinated coffee, and tea consumption in relation to incident type 2 diabetes mellitus: a systematic review with meta-analysis. Arch Intern Med. 2009;169:2053-2063.
13. Sartorelli DS, Fagherazzi G, Balkau B, et al. Differential effects of coffee on the risk of type 2 diabetes according to meal consumption in a French cohort of women: the E3N/EPIC cohort study. Am J Clin Nutr. 2010;91:1002-112.
14. Floegel A, Pischon T, Bermann MM, et al. Coffee consumption and risk of chronic disease in the European Prospective Investigation into Cancer and Nutrition (EPIC)–Germany study. Am J Clin Nutr. 2012;95:901-908
15. Vinson JA, Burnham B, Nagendran MV, et al. Randomized double-blind placebo-controlled crossover study to evaluate the efficacy and safety of a green coffee bean extract in overweight subjects. Program and abstracts of the 243rd American Chemical Society National Meeting and Exposition; March 25-29, 2012; San Diego, California. Abstract 92.
16. Je Y, Hankison SE, Tworoger SS, et al. A prospective cohort study of coffee consumption and risk of endometrial cancer over a 26-year follow-up. Cancer Epidemiol Biomarkers Prev. 2011;20:1-9.
17. Wilson KM, Kasperzyk JL, Rider JR, et al. Coffee consumption and prostate cancer risk and progression in the Health Professionals Follow-up Study. J Natl Cancer Inst. 2011;8;103:876-884.
18. Turati F, Galeone C, La Vecchia C, et al. Coffee and cancers of the upper digestive and respiratory tracts: meta-analyses of observational studies. Ann Oncol. 2011;22:536-544.
19. Galeone C, Tavani A, Pelucchi C, et al. Coffee and tea intake and risk of head and neck cancer: pooled analysis in the international head and neck cancer epidemiology consortium. Cancer Epidemiol Biomarkers Prev. 2010;19:1723-1736.
20. Song F, Qureshi AA, Han J. Increased caffeine intake is associated with reduced risk of Basal cell carcinoma of the skin. Cancer Res. 2012;72:3282-3289.
21. Li J, Seibold P, Chang-Claude J, et al. Coffee consumption modifies risk of estrogen-receptor negative breast cancer. Breast Cancer Res. 2011;13:R49.
22. Cao C, Loewenstein DA, Lin X, et al. High blood caffeine levels in MCI linked to lack of progression to dementia. J Alzheimer Dis.           2012;30:559-572.
23. Ross W, Duda J, Abbott R, et al. Association of coffee caffeine consumption with brain Lewy pathology in the Honolulu-Asia Aging Study. Program and abstracts of the 64th Annual Meeting of the American Academy of Neurology; April 21-28, 2012; New Orleans, Louisiana. Abstract #S42.005.
24. Lucas M, Mirzaei F, Pan A, et al. Coffee, caffeine, and risk of depression among women. Arch Intern Med. 2011;171:1571-1578.
25. Pasco JA, Nicholson GC, Williams LJ, et al. Association of high-sensitivity C-reactive protein with de novo major depression. Br J Psychiatry. 2010;197:372-377.
26. Ng F, Berk M, Dean O, Bush AI. Oxidative stress in psychiatric disorders: evidence base and therapeutic implications. Int J Neuropsychopharmacol. 2008;11:851-876.
27. O'Connor A. Coffee drinking linked to less depression in women. New York Times. February 13, 2012. Accessed January 11, 2012.
28. Matheson EM, Mainous AG, Everett CJ, King DE. Tea and coffee consumption and MRSA nasal carriage. Ann Fam Med. 2011;9:299-304.

Friday, June 29, 2012

Run For Your Life, But Not Too Far

Once again, we have a story of "the dose makes the poison." In the fitness world many believe that if running 5 miles is good for you, running 10 might double the benefit. Apparently not.

A recent study presented at the American College of Sports Medicine's annual meeting suggests that shorter distances (less than 20 miles per week) provide a greater mortality benefit. (1) While this is an unexpected finding, the more shocking news is that with increasing distance the reduction in mortality doesn't just level off but actually but reverses.

Dr. Duck-chul Lee led the research, a part of the Aerobics Center Longitudinal Study (ACLS) which includes 52,000 men and women in a retrospective analysis. Subjects entered the study free of cardiovascular disease, EKG abnormalities, diabetes and cancer. They were followed for 15 years.
Running was associated with a 19% lower risk of all-cause mortality compared with individuals who did not run.

Interestingly, how fast you run is important too. Subjects who ran 6 and 7 miles per hour had a significant (21% and 27%) lower risk of all-cause mortality. Those running faster (8 or more miles per hour) had a nonsignificant decrease in risk of all-cause mortality.

The most robust decrease in risk of death was seen in subjects who ran between 10 and 15 miles per week.

How often you run also makes a difference. The benefits of running were lost in those running more than 5 days per week.

While it is possible that some unmeasured variables might have contributed to these findings, the investigators corrected for other known factors such as age, gender, smoking status, blood pressure, and cholesterol levels.

The ACLS study coincides with the publication of a review paper in the Mayo Clinic Proceedings on the possible causes of heart damage seen in participants of long-distance endurance events (marathons, Ironman, long-distance cycling).(2) The review suggests that such activities may cause fibrosis of the heart muscle that can lead to arrhythmias and coronary artery calcification and hardening.

The bottom line is less is more. This data should not be a reason not to run. A regimen of up to 20 miles a week in 2 to 5 sessions at a pace below 8 miles per hour looks best.

So, run for your life, not too far, too fast, too often.  


1. Lee DC, Pate RR, Lavie CJ, et al. Running and all-cause mortality risk--is more better? American College of Sports Medicine 2012 Annual Meeting; June 2, 2012; San Francisco, CA. Presentation 3471.
2. O'Keefe JH, Patil HR, Lavie CJ, et al. Potential adverse cardiovascular effects from excessive endurance exercise. Mayo Clin Proc 2012; 87:587-595.

Men, Aging and Bone Loss

Osteoporosis, a weakening of bone that increases the risk for fracture, is usually thought of as a postmenopausal woman's problem. However, about 20% of the 44 million Americans who have osteoporosis or low bone mineral density are men.(1) And men fare less well with this potentially painful and debilitating condition.

30% - 40% of osteoporosis related fractures occur in men.(2) In those cases involving hip fracture, men have a mortality rate two to three times greater than women.(3,4,5) Because this represents a significant public health issue the Endocrine Society recently released a review of the topic with updated practice guidelines.

All adult men should have osteoporosis on their radar as one of the chronic conditions to monitor and take steps to prevent. Here is a brief overview of this condition and summary of the Endocrine Society's recommendations.

The increased risk of fracture due to osteoporosis occurs approximately 10 years later in men than women. Race, ethnicity, location and lifestyle all contribute to one's risk. North American and Northern European men have the highest rates of fracture due to osteoporosis, while Blacks and Asians have the lowest. (6)  Interestingly, the female to male ratio among Caucasians is about 3-4:1 whereas it is around 1:1 in Asians.(7) Smoking, sedentary lifestyle, and excessive alcohol consumption significantly increase risk.

Hormone levels play an important role. There is no question that the anabolic effects of testosterone are beneficial. But relatively recent investigation has demonstrated that estrogen is at least as important in men for healthy bone maintenance.(8)


Who is at risk and should be evaluated?
All men over 70 years of age and 50-69 year olds with a history of delayed puberty, hypogonadism, hyperparathyroidism, hyperthyroidism, chronic obstructive pulmonary disease, glucocorticoid or GnRH agonists, alcohol abuse or smoking.

Lifestyle recommendations include reduced alcohol intake for those men who consume three or more units of alcohol per day. Smoking cessation should also be a priority. They suggest weight-bearing activities for 30-40 minutes per session, three to four times per week. If vitamin D levels prove to be low (<30ng/ml) supplementation is encouraged targeting a blood 25(OH)D level of at least 30ng/ml. Men at risk for osteoporosis should consume 1000-1200 mg of calcium daily. Ideally this should come from dietary sources rather than supplements. A recent study suggests that calcium supplements may increase the risk for heart attack in women. This association has not been observed in men.

These interventions, in conjunction with a variety of medications when necessary, can prevent the progression of osteoporosis, a condition which need not compromise the quality of life.

(1) Burge R et al. 2007 Incidence and economic burden of osteoporosis-related fractures in the United States. J Bone Miner Res 22:465-475
(2) Bliue D et al. 2009 Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 301:513-521
(3) Frosen L et al. 1999 Survival after hip fracture: short- and long-term excess mortality according to age and gender. Osteoporos Int 10:73-78
(4) Haentjens P et al. 2010 Meta-analysis: excess mortality after hip fracture among older women and men. Ann Int Med 152:380-390
(5) Holt G et al. 2008 Gender differences in epidemiology and outcome after hip fracture: evidence from the Scottish Hip Fracture Audit. J Bone Joint Surg 90B:480-483
(6) Maggi S et al. 1991 Incidence of hip fractures in the elderly: a cross-national analysis. Osteoporos Int 1:232-241
(7) Kanis JA et al. 2002 International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res 17:1237-1244
(8) Gennari L et al. 2008 Estrogen land fracture risk in men. J Bone Miner Res 23:1548-1551
(9) Watts NB et al. June 2012 Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endo Metab: 97(6):1802-1822

Friday, April 27, 2012

Against All Odds


     I was going to call this piece “A Plea For Math Literacy” but thought few titles could better guarantee no one would read it. For most of us, math is our first academic experience of being plain wrong. An incorrect answer in math is never “interesting” the way a response in English or even History class might be. No math teacher ever admiringly uttered the phrase, “Now that’s an different perspective.” I’ll never forget the math teacher who called my answer “not even wrong”. No one likes being wrong, but we turn our backs on math at a cost.

     Math literacy may seem to mix two different systems, the world of numbers and the world of words. Traditionally literacy related to the ability to read and write. But it has grown to encompass the capacity to understand all forms of communication including body language, imagery, or any symbol system relevant to a particular culture.

     We live in a culture where the art of estimation is essential if we hope to understand the wide range of magnitudes and time frames that are tossed around in every day discourse. Whether considering the national debt or your mortgage rate, the population of China or the daily loss of brain cells, an earthquake of 4 or 6 on the Richter scale, the date of the Industrial Revolution or the origin of the universe, you’re lost without some basic math smarts that provide a sense of proportion. 

      Now more than ever, we are flooded with data that could inform our decisions. This is particularly true when it comes to our health. Doctors no longer dictate treatments. In the age of “informed consent” we are presented with the odds of this procedure or medication having “x” benefits and “y” risks. We are expected to make our own decision. (And the complexity of patient decision-making will increase dramatically as the human genome is deciphered.) Yet we rarely use the pertinent data when we make our choices.

     Why do we play the odds rather than calculate them?

     On a fundamental level we seem hard-wired for bad decision-making. We like to presume that we have control over what happens to us. We believe that if we stick to a plan the desired result should occur. If we take "good" care of ourselves (or if we are "good") we will grow old and prosper. But any 10 year high school reunion demolishes these naive assumptions.

     Daily life provides shedloads of examples of just how bad we are at understanding the odds; the popularity of the lottery, casinos, junk food, and cigarettes. Like disagreeable information of any kind, when we don't like the odds we remove them from consciousness. And when we fail to bury disturbing odds we unwittingly seek data that will bind our anxiety. The newspaper we read, the TV shows we follow, the people with whom we socialize, are all chosen to confirm our view of the world, that we're doing the right thing, that we know, that we are secure.

     We are masterful at avoiding the discordant experience of learning something that contradicts our beliefs. And we are equally disturbed when others respond to new information and change their stance. In politics it's pejoratively labeled flip-flopping, a career ender.

     Certainty is seductive. But the reality is that we live in a sea of uncertainty. And yet we are raised (and raise our children) to believe the opposite. Can this change? I think so. While the complexity of the kaleidoscopic forces that drive our choices is overwhelming, there are things we can do in order to encourage better decision-making. And math may be one of the most powerful antidotes to emotionally-based judgements.

     Here's a short list of ideas that could be applied at any stage of development, from kindergarten to think tanks.

     Encourage suspicion of experts and the accepted verities.

     Explore who profits from one set of data versus another.

     Introduce children to probability calculation early in a real-world accessible form using something they find interesting like a favorite player's batting average, or the chances of winning at tic-tac-toe, or the relative risk of getting a filling with and without brushing your teeth.

     Most importantly, we must attempt to get more comfortable with the messy business of ambiguity, complexity and not knowing. If we could delay even briefly that reflexive leap to embrace social or intellectual ready-made conceptions, it could have enormous impact. Like fast-food, these packaged ideas allow some immediate soothing, but provide nothing that nourishes.  In the end they make us sick because in adopting beliefs that are not our own we blind ourselves to what we really think and feel. And without such knowledge, making the right choice is against all odds.

Saturday, April 21, 2012

Balancing Acts

     The concept of balance is considered a fundamental quality for the good life. We believe that only a balanced approach can provide the reasonable stance, whether we’re talking about eating, religion, work, sleep, sex or money. Our language reflects this view through such expressions as “an unbalanced individual”,  “a chemical imbalance”, “a balanced economy”.  The unbalanced desire of addiction has spawned every conceivable form from chocoholic to workaholic or shopaholic. And yet for all the lip service balance receives as the prudent path, we worship excess.

     Should we aspire to balanced lives? Certainly not when it comes to love. The very expression “falling in love” speaks to the need for a loss of balance. It is hard to imagine what balanced love looks like, if it looks like love at all.  Don’t we want to believe we would die for someone or some thing? Can we say what amount of love or grief or belief is excessive?

     The notion of balance implies an awareness of what is too little and what is too much. But one can only identify excess by knowing what is enough, something we struggle with (“enough is enough” is as close as we’ve come). We seem much better at identifying excess in others, and we are mesmerized by it.  The righteous indignation and moral superiority that comes with labeling someone else’s excess is made all the more pleasurable for its reassurance. It implicitly suggests that we know our limits, how much is enough and appropriate, that we are in control of our desires.

   We all have some form of excess that feeds our favorite rant, drug addicts, alcoholics, suicide bombers, narcissists, fat people, anorexics, CEO salaries, celebrity orgies, serial killers, faith, atheism.  But the one we find most outrageous or offensive or unreasonable or fascinating, tells us something important.  Show me which excess you can’t abide and I’ll show you who you are.

     How can we understand our relationship with excess? How do we continue to believe that more money or cars or shoes or food or sex will make us happy? Why are we the only animal that can be made ill by our appetites?

     It is precisely because money or cars or shoes or food or sex is not quite what we want that we find ourselves thinking that perhaps more would be satisfying. When we have too much, it is because we have too little of what we need.


Saturday, April 7, 2012

Sitting Ducks


          “Those who think they have not time for bodily exercise will sooner or later have to find time for illness.”
                    Edward Stanley, Earl of Derby 1873

     We continue to deny this idea despite more than a century of data. In the latest contribution to this argument, an Australian group put another nail in the coffin of the couch potato. They demonstrated that the amount of time we spend sitting correlates with all-cause mortality. For those who haven’t been living under a rock, this is not news. However, what puts this study on the map is the finding that the negative effect of prolonged sitting was not significantly reversed by physical activity.

     The fact that modern humans spend so little time out of a chair has given birth to a vital new field, sedentary behavior research. Investigation has revealed that the adverse consequences of prolonged sitting (surely this will become a familiar acronym in the literature – PS, so let’s coin it now) stem from a web of causes including; reduced metabolic function, increased triglycerides and decreased HDL-cholesterol (the good one), decreased insulin sensitivity, and impaired carbohydrate metabolism. These are the usual suspects in any discussion of cardiovascular disease, diabetes or obesity.

     But now the data suggests two important things. First, it seems that physical activity and sedentary behavior act independently through different mechanisms. This would explain why the damage of PS (sitting for 10 hours a day) is not undone by 30 minutes of daily exercise. Secondly, they have found that normal weight is not protective against the  ravishes of PS and in no way means you’re healthy.

     The pioneering work on this issue was done in the early 1950’s by a British researcher, Jeremiah Morris, the man responsible for connecting physical exertion and health. In seeking to determine whether there was an association between the type of work people do and heart disease, he stumbled upon groundbreaking data. Morris combed through the health records of 31,000 bus drivers and conductors in London. The conductors had significantly less heart disease than the drivers. The only variable that consistently distinguished one group from the other was activity level.

     So if this link was appreciated more than 50 years ago, why has so little been done, allowing heart disease to remain the number one killer? The answer is simple. Medicine addresses disease not health. Until you are sick, the medical system has had nothing to offer. We’ve gotten better at treating heart disease but have just begun to seriously consider preventing it. Until people stop thinking about health in terms of doctors and medicines, things will not change. 

     The “progress” afforded by the Industrial Revolution has provided a natural experiment demonstrating the catastrophic effects of sedentary life. If one considers our genetic wiring, perfected over hundreds of thousands of generations, this all makes perfect sense. We were made to move. And our genome has not adapted to this relatively new lifestyle. It turns out we need more than exercise.

      So don’t just sit there. Get up and get well.