©March 2009

Most physicians learn about nutrition in biochemistry and organic chemistry classes.  This prepares them well for when patients present with concern about the number of glucose molecules required for the synthesis of one molecule of palmitic acid.  Unfortunately, patients are more inclined to ask their physicians whether taking a daily multivitamin is a good idea.  A clear answer to the latter question remains obscured by the conflicting conclusions of well-intended research and by the wide variety of patients who inhabit the earth.  For the most part, advice on the subject of vitamin supplementation therefore tends to be left to the well-informed discretion of the practitioner under the banner of the “art of medicine.”  Nevertheless, there are some facts worth sharing about the ins and outs of vitamin supplements.

Certain things are required for normal health.  While humans require water, oxygen and sunlight (for the manufacture of Vitamin D), this initial list provides little to distinguish us from our house plants.

Essential nutrients are defined as substances that are required for normal body functioning, but which cannot be produced by our own bodies.  The vitamins are classic examples of essential nutrients.  As each vitamin was identified over the past 200 years, or a food product identified that was suspected of containing an essential nutrient compound, the vitamin was given a letter.  Thus, we have Vitamin A, B, C etc…  “Vitamin G” ended up being the same as Vitamin B2, also known as “riboflavin,” and “Vitamin H” turned out to be another B vitamin called “biotin.”  “Vitamin F” turned out to be certain fatty acids, and were therefore reclassified as “essential fatty acids.”  Other nutrients that were initially thought to be vitamins were found to be produced by the body, and therefore were dropped from the list.

There are sixteen minerals that are also essential nutrients, including such common friends as calcium and iron, but also some oddballs like Zinc and Molybdenum.  Nine out of the 20 traditional amino acids, the building blocks of proteins, are also recognized as essential nutrients.

It is interesting that primitive cultures learned to adjust their diets without the benefit of biochemistry classes to include the essential nutrients.  While beans are rich in many essential nutrients, they are deficient in lysine, one of the essential amino acids.  Corn, on the other hand is rich in lysine.  It was no accident that Aztec societies learned that the marriage of beans and corn provided for a healthy population.  The burrito was born.

We now know that some vitamins can protect us from certain illnesses.  In 1992 the Centers for Disease Control recommended that all women capable of becoming pregnant should take 400 micrograms of folic acid each day throughout their childbearing years to prevent a birth defect of the brain and spinal column known as a “neural tube defect.”    Since that recommendation and the fortification of cereals with folic acid, neural tube defects have declined by nearly 40%.  Vitamin D and calcium supplementation is of benefit to post-menopausal women to help prevent the loss of minerals from the bone, thereby helping to prevent osteoporosis.

On the other hand, much research into the benefits of “antioxidant” vitamins – Vitamin C, Vitamin E, and beta carotene – in preventing cancer and heart disease have come to disappointing conclusions.  No clear protective benefit was demonstrated.  A recent large study of older women taking multivitamins showed no diminished risk of cancer or cardiovascular disease.

It is possible that a subset of the general population may benefit from supplemental vitamins, while others stand to gain nothing.  For instance, while a vegetarian diet can provide a perfectly satisfactory supply of all essential nutrients, some vegetarians or vegans (who consume no products of animal origin, including milk) may do better with supplements of Vitamin D and B12.  Breast feeding mothers should take vitamin supplements.  More dark skinned populations have been found to be deficient in Vitamin D, and this may be partly due to the diminished ability of sunlight to boost Vitamin D, or due to socioeconomic factors influencing diet and nutrition.  Vitamin C may help some people who are at risk of gout.

Forty percent of the American population spends over 20 billion dollars per year on dietary supplements.  In order to know whether you might benefit from taking supplemental vitamins, it is best to discuss this with your health care provider in light of your dietary habits, medical condition, and other medications consumed.  In a world where we are constantly bombarded by marketing messages, it is worth being reminded that nutrition comes from food.  It makes little sense to take expensive capsules three times each day that are filled with processed vitamins extracted from vegetables as a supplement to a diet of coffee and doughnuts.

Now eat your broccoli.

©July 2006

Flying over a city, it is hard to avoid comparing the pattern of highways, warehouses and agriculture below to the structure of a single overgrown organism.  Freeways, like enormous vessels, feed communities with a vital flow of traffic.  A nervous system is represented by a perplexing array of power lines and cables.  Neatly groomed fields and orchards provide nourishment.  And much like a single creature, our communities enlarge only through the increased complexity and reach of these organ systems.  The globalization of the food industry is an example of just such a system.  Worldwide food production and distribution has been anticipated for over a century as an answer to disparity and hunger.  However, the question has recently been raised whether the health of industrialized countries like the United States might be better served by relying more heavily upon food that is locally grown and processed.

Arguments supporting the use of local food sources are compelling.  Alice Waters, of Chez Panisse fame, has championed the sustainable food movement, pointing out that locally produced food often has both nutritional and culinary advantages.  Following the European model, locally baked goods and locally raised produce (so called “Slow Food”) can enrich food quality as well as community relations.

The recent notion of “Food Miles” has raised awareness of the ecological and social consequences of a globalized food industry.  Examining the catch on a glacier at the local supermarket recently revealed an eclectic mix of shrimp from the Phillipines, Mexico, China and the Gulf Coast.  While one could work up quite an appetite before locating locally harvested Tuolumne County shrimp for the dinner table, one might do better to settle for local trout.

In order  to produce food products on a scale that makes international shipping a profitable venture, systems must sometimes be employed that conflict with basic health interests.  Approximately 75% of the antibiotics used in this country are utilized by the food industry to prevent disease in densely populated herds and flocks.  As a result, a growing awareness of organic and natural husbandry practices has emerged.  Some of these safer organic techniques have been employed in locally raised turkey and beef.

It is also true that marketing ploys have made detecting the implications of such claims as “fat free,” “free range,” “cholesterol free,” and “low fat” perplexing.  It is best for a consumer to ask questions if such labels are unclear.

Many communities feature a Farmers Market during those months of the year that are conducive to locally grown produce.  No better example of the benefits of locally sourced food can be given than the displays at such Farmers Markets.  The allure of the produce at the market is so compelling that some regulars find morning cosmetic rituals refreshingly irrelevant prior to visiting the stands.  Often, social interactions with neighbors and friends are as inspiring as the opportunity to shop for fresh groceries.

Taking advantage of these local resources can provide benefits both for the health of individual local residents as well as for the health of the “community organism.”

©November 2008

Perhaps our most intimate relationship with the world around us occurs in the digestive system.  While the 30-foot tube that forms our digestive tract would portray itself as an internal organ, it is no more “indoors” than is the Caldecott tunnel traveling into the Bay Area.  The interactions that take place between us and our food within our gut are really interactions with the outside world, and therefore take place under the watchful eye of our immune systems, with “Highway Patrol” carefully monitoring the complex transactions that occur.  Sometimes the immune system itself can misbehave by reacting in an abnormal way to food products, resulting in illness.  Since the conditions that result from this misbehavior occur only in specific unfortunate individuals, the illnesses that result seem somewhat mysterious and are not easy for health care providers to diagnose.  Therefore, it is helpful for each person to pay attention to the traffic traveling through their nutrient highway in order to alert care-givers to potential signs of trouble.

“Celiac disease” or “Celiac sprue” is one of these health conditions.  While a full understanding of this illness has not yet been achieved, we know that the immune system plays a roll.  Celiac sprue (or “sprue” for short) is characterized by a sensitivity to “gluten,” a protein found in wheat and wheat products.  It appears that abnormalities in the lining of the gut occur in response to an immune reaction to components of the gluten molecule.  We also know that this abnormal reaction to wheat or wheat products runs in certain families, much like other immune-mediated disorders, and occurs in approximately 5 out of 1000 people. Symptoms may include bloating, foul-smelling diarrhea, gas and weight loss, and can develop after many years of symptom-free enjoyment of wheat foods.  The solution for people with sprue is to avoid wheat products, a feat akin to avoiding a Starbucks franchise.  Nevertheless, a strict wheat-free, gluten-free diet will bring about relief from symptoms for over 80% of people with sprue.  If your health care provider recommends such a trial diet, you will receive instructions or you may be directed to a gluten-free diet on the internet.

A different category of digestive system illness that occurs at the hands of the immune system is known as “inflammatory bowel disease.”  These conditions are generally considered to be “autoimmune disorders,” in which the immune system turns traitorous and begins to attack our own organs.  Inflammatory bowel diseases, such as Crohn’s Disease and Ulcerative Colitis, are also associated with bloating, diarrhea, gas and weight loss, but in addition may be suggested by the appearance of blood in the stool.  The diagnosis is often accomplished by performing a colonoscopy or upper gastrointestinal scope procedure with a biopsy of the lining of the bowel showing damage inflicted by inflammatory cells of the gut.  As you might guess, treatment for these conditions is focused upon diminishing the intensity of the immune system activity within the bowels, with medications related to cortisone among others.

Some people with generalized allergic conditions, often with asthma or chronic skin rashes, may have food allergies that can be life threatening.  These conditions can be dramatic, often due to the consumption of unrecognized food components to which the individual is hypersensitive.  The increasing incidence of peanut allergy in school children is an example of a food allergy syndrome that has posed an increasingly costly and important challenge to schools and school health programs.  Symptoms may include swelling of the lips, wheezing, rapid heart rate and collapse.  These patients may have some indication that they have an allergic condition, such as a bracelet, and immediate treatment with medications may be life saving.

There are reasons why a person might develop intolerance to certain foods other than from a wayward immune system.  Lactose intolerance may occur in infants or adults as a result of the inability to break down lactose sugar in dairy products, resulting again in bloating, gas and diarrhea.  Monosodium glutamate (MSG) and aspartame may also be responsible for reactions, such as symptoms of headache, when consumed in significant amounts by certain people.  These reactions are not, however, due to food allergy or the immune system but rather due to direct effects of the chemicals.

The responsibility of monitoring the traffic you allow to use your food highway is yours.  That means attention to the inhabitants of your dinner plate, but also to the toilet boil before you flush.  This season of thanks is a good time to appreciate the profoundly intimate relationship we have with the food we enjoy.

©July 2008

Disease prevention is a familiar battle cry of public health.  It is better to diminish the risk of disease before an assault begins than to wait for the first skirmishes to occur.  But there are several criteria that must be met for a particular test to effectively identify risk of illness, and thereby allow an opportunity to prevent disease.  Colon and rectal (“colorectal”) cancer prevention provides an excellent opportunity to explore the characteristics of screening tests that can make a difference.

The tests recommended for colorectal cancer prevention fall into two categories.  The “fecal tests” involve testing the bowel movements each year by collecting small smears of stool on a card or in a container.  There are several “fecal occult blood tests” (FOBT) available for this which test for the presence of otherwise invisible amounts of blood in the stool.  Each should be done carefully and in accordance with recommendations provided with the test.  There are also new fecal tests available that detect certain cancer markers in the stool, but these are more expensive.

The second category of testing includes examinations of the structure of the lower bowel (the colon) and rectum, most often with a scope called a colonoscope or sigmoidoscope.  Fourteen million annual colonoscopies are performed in this country.

Each person’s health care provider will recommend the test that is most appropriate for the individual based upon factors like family history, age and overall health.  In general and in accordance with American Cancer Society recommendations, colorectal cancer screening should begin at age 50 years.

For a preventive test to be effective, the disease you wish to prevent must be worthy of attention.  It makes little sense to mount a campaign to identify people at risk of developing hiccups.  Colorectal cancer is the second leading cause of cancer death and the third most common cancer in the United States, more than justifying the effort to screen for the disease.

Even though no test is perfect, a test that is used to screen the population for risk of disease must be acceptably accurate, without over-measurement or under-measurement.  In the case of colorectal cancer, the target being measured may be blood in the bowel movement, DNA in the bowel movement or physical abnormalities in the lining of the colon or rectum, called “polyps” (small lumps attached to the lining) or “ulcers” (shallow sores).

Even if the test is accurate, it must be capable of detecting disease risk at a time when steps can be taken to cure the patient.  In some cases, a colorectal cancer test may detect polyps or growths before they are cancerous, and in other cases they may detect growths that have already turned cancerous.  To be effective, a colorectal cancer test must detect cancers or pre-cancers at a time when surgical treatment of the condition, either via a scope or by traditional surgery, is curative.

The test must be affordable.  In an era when “affordable health care” sounds ever more like an oxymoron, there is little need to explain why affordability is a vital part of any health care recommendation.  Screening tests for colorectal cancer may be completely free, such as Fecal Occult Blood Testing at the annual Tuolumne County Health Fair, or screening may run up to as much as $6000 for a colonoscopy and biopsy.  An affordable method of screening should be available for every person, and ultimately saves in health care costs to the community.

Finally, people must be willing to undertake the test.  It is difficult to motivate the public to perform tests on three separate bowel movements when they prefer to deny any personal relationship to sewage whatsoever.  However, people become increasingly compliant with annual stool tests, colonoscopy or other screening modalities as they learn the value of colorectal cancer screening and hear of friends or relatives who have benefited from early detection.

Screening rates for risk of colorectal cancer by low income households in our area steadily decreased between 2001 and 2005, while colorectal cancer screening for the general population increased by almost 10%.  These kinds of trends contribute to the disparity in health between different economic segments of our community.  At least in regards to colorectal cancer prevention, screening tests are available that are effective and affordable.  Please spread the word that this simple test is worth your time: fecal occult blood tests will be available at the Tuolumne County Health Fair in October.