Common Sense Eating

My acerbic Irish grandmother would take a look at our modern obsessions with nutrition, light up a Camel, and ask what good comes of all the worrying. She’d have a point. After fifty years of expert advice on diet, what do we have? The fattest society on earth, an epidemic of diabetes, and the first generation that will not meet, let alone exceed, the life expectancy of their parents.

We live in bodies exquisitely suited to life forty-thousand years ago. The sweetest things on the planet were some sparse berries. The only drink was water. No one fattened up wild game with corn. Getting food required considerable expenditure of energy, and who would waste energy chasing more food than they needed? But just in case extra food came along, the body was equipped with a highly efficient means of squirreling away the excess as fat, to cover inevitable times of short supply. Lights went out when the sun went down, and everyone rested up for the next day’s pursuit of food.

These old-fashioned bodies are now awash in too much food that is too easy to obtain, and in manufactured food full of unnatural, but edible chemicals. We are also awash in advice, calorie counts, carbohydrate grams and recommended daily allowances. Looking at the results, our grandparents might guess that the average man is more in need of common sense than tables, charts, diets and recommended daily allowances. So here are some common sense suggestions about how to navigate the modern world of food.

Shop the perimeter of the grocery store

Everything your body needs is out there. Don’t skip any of the departments, spend the most time and money on fruits and vegetables, go for color, avoid sugar, and remember that there are vitamin and micronutrients in dairy products, meats and fish that are scarce elsewhere. Egg whites are one of nature’s best proteins. The closer food is to its actual source, and the less the processing, the better its nutritional value.

In the middle aisles, stick to a list

There is nothing in this part of the store that you need for survival, but there are cooking essentials like olive oil and spices, convenient staples like canned tuna and tomatoes, and whole-grain, high fiber cereals. Look for packages with the fewest ingredients. Remember – “natural flavors” often come from manufacturing plants on the New Jersey turnpike, soy protein is a very unnatural derivative of the manufacture of soybean oil, vegetable oils that go rancid are not good for you, and oils derived by cold pressing are closer to their original sources than those that are refined like petroleum.

Opt for fresh food over manufactured food whenever possible

The addition of high fructose corn syrup and preservatives to almost every packaged food gives us cheap, long-lasting and attractive products, but think of these foods as emergency rations. If you built your home with poor materials and filled your car with unsuitable fuel, they might hold up for awhile, but over time they would suffer premature failure. Fresh and frozen foods that haven’t strayed too far from their original sources are the materials and fuel your body is built to handle.

Think regular meals with smaller amounts and balanced composition

We are designed to need a balanced mixture of food every 4-6 hours (while awake). Your hand is a rough guide to amount and mix of food for each meal. You need protein, carbohydrate and fat and you don’t need to read labels to know if you are getting them all. Protein comes from living things that were able to move around on their own, and necessary fat comes along with protein. Beans are the only exception and their protein comes by virtue of bacteria which transport nitrogen into the roots of bean plants and which do move around. Carbohydrates come from stationary living things. The carbohydrate portion of a meal should cover the palm of the hand. The protein component fits in the area from the base of the thumb to the big central crease. The fat that you need comes along with your protein source, in the olive or coconut oil needed for cooking, and in any milk you drink.For perspective on old fashioned eating, consider a sample meal in a California museum that is a replica of a hotel of the Gold Rush era. Dinner consists of a hard roll, an apple, and a few clams and some leafy greens floating in a thin broth – fuel enough for the people who did the hard labor of building this country.

Make the time to prepare food and eat in a nice setting, with good conversation

Get back to the way your body is designed to eat, the way people have eaten for thousands of years, and you’ll save time by being healthier and more energetic and not having to read diet articles. And lighten up – a small amount of ice cream or pie or chocolate now and then is fine. Amount is the key.

Choose water

If you are thirsty, you need water. If you want liquid to help wash down food, pick water. If you want water to taste like something else, choose a liquid that lacks high fructose corn syrup and has some nutritional value: fresh, pulpy juices with their vitamins and fiber, or milk, with its protein, minerals and vitamins. Coffee and tea? Fine. No one has ever been able to pin much bad on either one, in moderation. Ditto for wine, in even more moderation.

Avoid fake food

Artificial sweeteners – a real boon for diabetics – are unnecessary chemicals for everyone else. There is no evidence that artificial sweeteners promote weight loss. They may even lead to weight gain. Not worth it for the mere 12 calories in a teaspoon of sugar. And margarine? Even ants won’t eat that (but they do like butter).

We are where we are after over half a century of harping on fat and cholesterol. Common sense tells us they can’t be the only problems. Common sense is what we need – along with a diet, sleep and physical activity suitable for life 40,000 years ago.

Posted by medical plaintalk

Physician turned medical writer.

Mind-Body Medicine

If the mind, that rules the body, ever so far forgets itself as to trample on its slave, the slave is never generous enough to forgive the injury, but will rise and smite the oppressor. Henry Wadsworth Longfellow

In the 1600s, philosopher René Descartes gave the world the concept of mind-body dualism. The body was composed of physical substance, visible, weighable and measurable. The mind was something else. Over the next three centuries, as scientists deconstructed the body to discover its secrets, the mind reclaimed its place as an inseparable part of the body. (Soul is another matter, not open to scientific inquiry.) Some rudimentary examples of the mind-body connection are the blush of embarrassment, the adrenaline rush following a near miss accident or the receipt of bad news, and the cotton mouth that accompanies emotional distress. The mind perceives and the body reacts. The mind decides and the body acts. Not only are mind and body inseparable, but most often the body responds to a vast subconscious system rather than to the aware part of the mind known as consciousness.

The powerful subconscious mind

In Sigmund Freud’s (1856-1939) introductory rendering, the unconscious mind was a cauldron of seething resentments that gave rise to neurotic behaviors and bad dreams. Modern research softened this view and today the unconscious mind seems more like an executive secretary who relieves the boss of routine work. It sorts through incoming information, keeps track of the environment and runs the motor system that operates the body, all with such subtlety that much of the time you, the boss, think you are in charge. But if you have an electrode placed in your brain recording the action of the nerve cells that put your arm in motion, the recording will show activation of those cells before you are consciously aware of your decision to reach for that candy bar. Before you “know” it, the choice has been made in your subconscious mind. But this doesn’t mean we are automatons – after all, you can still decide not to eat the candy.

The neuropeptide network: connection of mind to body

The subconscious mind may have even more power than we suspect. The same chemicals that transmit information in the brain are found in virtually every organ of the body. This neuropeptide network, discovered around 1980, bridges the gap between the brain and the body, making a psycho(mind)somatic(body) connection. Since the time of Freud, the word psychosomatic has a bad reputation, often synonymous with “hysterical” or “without physical cause.” All symptoms, however, are technically psychosomatic because they arise in the body and are perceived in the mind. The discovery of the chemical interplay between brain and other body organs forces us to consider whether the flow of information goes the other way too. Can the mind cause diseases to happen? Can it help heal disease?

Placebo effect

Eastern medical practices have always regarded the body/mind as one entity. Since the 1950s, Western medicine has acknowledged the mind’s influence over the body by taking into account the placebo effect in studies of new treatments. The placebo effect is the relief that happens when a patient believes he has received a real treatment, despite the treatment being a sham. The phenomenon may reflect the power of belief or it may reflect the fact that many disease processes get better on their own – the only way to tell is to add a third, no-treatment group to each study. The fact that the placebo effect occurs in more than 30% of patients in many studies demonstrates the mind’s significant role in disease and health.

Conventional medicine takes a look at the alternatives

Western medicine’s gradual acceptance the mind/body connection culminated in the establishment of a National Center for Complementary and Alternative Medicine (NCCAM) within the National Institute of Health (http://nccam.nih.gov/) in 1991. The center conducts controlled studies on subjects such as the effect of regular meditation on chronic pain, anxiety, high blood pressure, cholesterol, health care use, substance abuse, post-traumatic stress syndrome in Vietnam veterans. It offers objective descriptions of Eastern medical theories which for which science has no proof. Part of the NCCAM’s mission is also to educate the public to become discerning customers within the vast alternative care and wellness industries that capitalize on the tantalizing possibility that good health may be a byproduct the “right” frame of mind.

The alternative and the conventional medical industries operate side-by-side, sometimes, but not always complementing each other. Conventional medicine is increasingly fragmented, with care delivered on an organ by organ basis. The whole person and his mind- body relationship can get lost in the process; unwanted side effects occur, and sometimes treatments hurt more than they help. But conventional methods save many lives and provide much needed comfort. Alternative practices that teach wellness via mind-body wholeness also do much good, mostly in preventing disease by emphasizing the back- to- basics factors: nutrition, sleep, exercise, relaxation, relationships and environment. Importantly, most of them do no harm except if they keep patients from seeking conventional help when necessary.

The importance of habits

In this century, the commercial spotlight is trained on the role of the mind in sickness and in health, which may obscure an important fact: most of the mind’s effects on health are subconscious, embedded in long years of mental and physical habits and not amenable to conscious adjustment over short periods of time. The right thinking and attitudes will help only insofar as they can work their way into the subconscious underpinnings of the mind by the diligent practice that leads to habit formation. Whether the mind-body practices are called meditation, yoga, Tai-chi, guided imagery, art and music therapy, biofeedback or acupuncture, they should be undertaken as long term projects requiring persistence, just like all those other low-tech habits that promote good health. The mind may be the body’s master, but it cannot change the laws of nature that govern all biologic systems. There are no quick and easy fixes.

Interesting Reading

Blink: The Power of Thinking Without Thinking, Malcolm Gladwell, Little Brown, Boston, 2005

Anatomy of an Illness as Perceived by the Patient, Norman Cousins and Rene Dubos, W.W. Norton & Co., NY, 1979.

Posted by medical plaintalk

Physician turned medical writer.

The Opiate Epidemic: Why Now?

In the 1970s, doctors in inner city hospital saw many patients suffering complications of heroin use, but outside those communities there was no talk in the media about an epidemic of opiate abuse. Now, four decades later, the state of Kentucky is suing Purdue Pharma for the devastating effects of its opiate drug OxyContin on its citizens, the Governor of Vermont devoted his 2015 State of the union address to the problems of prescription opiate and heroin abuse in his state, and a California doctor was recently convicted of second degree murder in the narcotic overdose deaths of three patients. And these just a few of the news stories related to our current “opiate epidemic.” Is this a new problem, and if so, how did we get here?

What are opiates?

Opiates are psychoactive substances that have been used for over 5000 years. They are derived from the poppy plant and ingested, smoked or injected to produce relaxation, pleasant euphoria and mild hallucinations. Medically speaking, they also alleviate pain, coughing and diarrhea. Opium, the general name for poppy plant extracts, is a complex mix of substances which include the alkaloid chemicals morphine and codeine. Morphine was isolated and named in Germany in 1805. Though very effective as a pain remedy, morphine was, by the end of the Civil War, termed a “hydra headed monster” that was “wrecking lives and home.” In a search for a non-addictive opiate, an English pharmacist created heroin in in 1874. Synthetic offshoots like Vicodin, Percodan and Percocet followed in the 20th century, and OxyContin debuted in the mid-1990s.

Dependence and addiction

Opiates alter the brain’s structure and chemistry. Normally, the brain produces “endogenous opioids” in response to activities that are pleasant and rewarding. In response to opiate drugs, the brain promptly lowers its own opioid production. If the drug supply is interrupted, the lack of internal production of opioids causes withdrawal symptoms – agitation, nervousness, high blood pressure, pain, nausea, vomiting and seizures. Opiate use has produced dependence on an external source. Its severity depends on dose and length of time opiate drugs have been used. When the next dose preoccupies thinking and drug seeking interferes with routine life, causing medical and social ills, dependence has become addiction.

Withdrawal symptoms are relieved by taking more opiate drugs, but over time the dose required to keep withdrawal symptoms at bay increases. This is called tolerance. At the same time, however, the opiate dose that causes respiratory depression does not change and one of the side effects of progressively larger doses of opiates is respiratory depression – failure to breathe. Respiratory depression is the usual mechanism for death in someone who has overdosed on an opiate drug.

The road to heroin addiction

Since 1999, opiate overdose deaths have quadrupled in this country. Prescriptions for opiates have skyrocketed, as has heroin use. The US accounts for eighty percent of the opiates consumed in the world and an estimated 2.1 million Americans have opioid related substance abuse problems. Medically speaking, though, this is not an epidemic and it is not a new problem. The reasons for the hyperbolic use of epidemic language in the media are sociologic. We have entered a new era in which the pattern of use of heroin has changed dramatically, moving out of the lower socioeconomic strata into smaller cities, towns and wealthy suburbs and into the lives of children. In this story, the medical profession and pharmaceutical industry have played roles as large as those of innovative drug dealers from a small town in Mexico.

In the modern history of the poppy plant derivatives, heroin was a street drug and heroin users were typically found in decaying inner cities. The other opiates remained under the control of physicians, who were constrained in their prescription writing by the fact that these drugs fell under federal controlled substance laws. Use was restricted even in terminally ill cancer patients because of fear of addiction, a view that changed only after the advent of the hospice movement in the 1970s.

By the 1980s, buoyed by the good feelings of providing relief for cancer pain, doctors who dealt with other forms of chronic pain – typically orthopedic in nature, but also nerve pain and headaches – began to change their views about the use of narcotics. A short letter in the prestigious New England Journal of Medicine in 1976 stated that a review of hospitalized patients who had received opiates showed no evidence of significant risk of later addiction to the drugs. Though it was nothing of the kind, this letter was later described as a “landmark study” and used to support the view that, when used to treat pain, opiates did not cause addiction.

By the 1990s powerful opiates were flowing into the community in large quantities for routine treatment ankle sprains and dental work. In hospitals, pain became the “fifth vital sign,” measured subjectively by the patient on a 1-10 scale, and used in hospital satisfaction surveys used for quality control. Opiates flowed much more freely because patient satisfaction surveys counted for insurance reimbursement and discharge medications often included narcotic prescriptions.

OxyContin appears

While medical prescribing practices were changing, Purdue Pharma developed OxyContin. Heavily marketed as a product that could not cause addiction because the patented timed release would prevent the initial high and euphoria associated with the conventionally produced pills, the drug came in large doses. But people seeking a high soon learned to crush the continuous release pills. OxyContin quickly became a popular street drug, sold by the people who were getting prescriptions for the myriad pains that bring people to doctors’ offices. Pill mills popped up where drug seekers could find unethical doctors willing to write prescriptions with no requirements other than money.

Heroin is cheaper than OxyContin

Heroin requires no doctor’s prescription, is far cheaper than stolen OxyContin sold on the streets, and satisfies the dependence, tolerance and addictions of people who have slipped into those traps with prescription drugs. Heroin overdoses are claiming teenagers in wealthy suburbs of Midwestern cities and in New England – because heroin has arrived there with young men who deliver small amounts directly to customers who contact them by phone. These dealers are salaried non-users, they provide reliable quality heroin, and they disappear back into Mexico after short term stays.

Rethinking

Solutions will have to come from objective study of the results of loosening the standards of prescribing addictive and mind-altering drugs for self-limited problems that can be adequately treated with lesser drugs. And while the care of the terminally ill and some patients with severe nerve pain may require opiates, there have been no controlled studies on risk vs benefit for the treatment of other chronic pain problems, ones which may benefit more from a comprehensive approach combining lifestyle changes, exercise and counselling such as had been provided in pain clinics in the past. Last but not least, doctors and patients could all benefit from a widespread educational campaign about signs of increasing tolerance to and dependence on brain altering drugs.

Posted by medical plaintalk

Physician turned medical writer.

Risky Business

pharmaceutical
From Gk. pharmakeutikos, from pharmakeus “preparer of drugs, poisoner,” from pharmakon “medicine, drug, poison, charm, spell, enchantment.”

As the ancient Greeks saw it, drugs, poisons, spells and enchantments were all in the same family. Over the centuries, science separated useful treatments from the occult relatives, but injected and ingested chemicals have always retained a mystical ability to inspire faith and hope. Because we now live in a world of non-stop, sophisticated, and ubiquitous marketing of drugs to healthy people, faith and hope have to be tempered by some healthy skepticism about the products being pushed by the new shamans.

Seeking expanded markets for drugs

Drugs companies do much superb work and save lives of people who are desperately ill. Without them, our children would die of simple infections and surgery would be, at best, unsafe and very painful. But beyond the pharmaceutical laboratories stretch marketing departments, an enormous sales force, and corporate board rooms that seek expanded markets. Television, magazine and newspaper ads show sincere, dedicated researchers seeking cures for debilitating diseases, but the primary goal of advertising is to convince doctors to prescribe the company’s drugs. Direct advertising to consumers enlists the general public in the task.

The project is wildly successful. In 1993, around the time marketing drugs directly to consumers became legal, patients filled 2 billion prescriptions for medications. By 2003, after a population increase of only thirteen per cent, the prescription rate was up 70 per cent to 3.4 billion, or 11.8 prescriptions medications a year for every man, woman and child in the country.

Expanding disease definitions expands markets

Dig into the pharmaceutical company culture and you will find policies that push expansion of disease definitions to include more and more people who are not actually sick. Drug marketing highlights selected risk factors for future illness, and converts them into “diseases” in their own right, to be measured by tests and managed by drugs. Examples? Cholesterol levels and bone density measurements. High cholesterol and osteoporosis are not diseases since they do not impair functioning and cause no symptoms. Among many other factors, they are simply correlated with illnesses that appear later – heart attacks and fractured bones.

Other risk factors such as inactivity and poor diet – the ones unresponsive to drug magic – fade in importance as marketers seek to convince potential customers that the risk factor that responds to drugs is the primary cause of a potential illness. Scratch the surface of “awareness campaigns” and you are very likely to find drug companies behind them, ready with easily packaged solutions for the problems they’ve brought to your attention.

Keep track of the ads you see, and you’ll notice other “illnesses:” depression, anxiety, pain, sexual “dysfunction,” gas, bloating and other non-specific stomach ailments. Some people suffer significant medical problems in these arenas, but the marketing is aimed at the far larger numbers who have minor and temporary complaints that fix themselves, or can be fixed by facing problems and adjusting lifestyles. The blossoming Type II diabetes epidemic is a great new opportunity for pharmaceutical marketing of drugs – the focus will be on controlling blood sugar rather than on the weight control, diet and exercise needed to prevent the disease.

The molding of the therapeutic mindset by the drug industry

Most doctors report that they are not influenced by marketing, even if they attend industry-sponsored seminars and meetings set in luxurious vacation spots, or meet with drug company representatives who dispense free samples. But there is a much more insidious and effective corporate influence on physicians: the molding of the therapeutic mindset by continuing education. The pharmaceutical industry recruits influential physicians in respected academic institutions to oversee the studies that get new drugs through an arduous approval process. Results are reported in prestigious medical journals, under the authorship of highly respected investigators. Nothing but pure scientific interest appears to motivate the research.

But pharmaceutical sponsorship produces gray areas: reports are very often written by drug company employees who extract results from data provided by the researchers; negative results sometimes escape reporting; statistics have a way of making very modest results look impressive, especially to consumers reading the simplified translations drug companies provide as press releases.

Doctors rely on a constant stream of reports of advances by medical researchers to chart the best course of treatment for their patients. Like consumers, they need good information untainted by commerce. Professional journals now require publication of their author’s affiliations with pharmaceutical companies along with any articles involving the company’s products. This is a step toward much needed transparency. Other steps have to come from the audience. More than ever we need to be educated and to be aware of fear tactics and manipulation.

Statistics color perceptions

A good, educational starting point is a rudimentary understanding of statistics, because the benefits of drugs must outweigh their risks to justify treatment of any condition. The use of “relative” numbers to inflate trivial differences in risks and benefits is psychologically misleading and happens all the time. Reporting something as a 33% or 50 % improvement in risk may only mean the difference between one and two or three cases in the 100 people studied over however many years the study ran.
Vast numbers of people, including children, take daily medicines that target behaviors and moods, or single risk factors for a disease. Based on short term studies, the drugs appear safe. But there are no long term studies yet to guide us in this new era of perpetual drug use aimed at optimizing behavior and preventing disease.

Be wary; ask what statistics really mean, and pay attention to drug-free ways of preventing disease and modifying behavior.

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Posted by medical plaintalk

Physician turned medical writer.

Gout and Girth: A Sweet Relationship?

At Hampton Court, one of King Henry VIII’s sixteenth century palaces outside London, tour guides regale visitors with tales of Henry’s obesity and the miseries he suffered during flare-ups of gout – exquisitely painful episodes of arthritis that come from the buildup of uric acid crystals in joints. Gout was known as “the king’s disease,” because it afflicted wealthy people who could afford the meats and sea foods that trigger uric acid crystal formation. The guides also point out the “confectionary,” a corner room near the kitchen wing, and describe the sugar-rotted royal teeth produced by the then scarce sweetener. The guides do not link Henry’s gout to the royal sweets, but perhaps they should. Sugar is composed of equal parts glucose and fructose, and scientists are now beginning to link increased fructose intake not only to obesity and type II diabetes, but also to increased uric acid in the blood – a risk factor for gout.

What is uric acid

Some uric acid in the blood is normal, because every cell in the body makes uric acid out of purines, chemical compounds that come from the regular breakdown of DNA and RNA as cells recycle themselves. Purines also come from many foods, but are particularly concentrated in red meat, organ meats like liver, many fish and shellfish, and yeasty beverages like beer and red wine. Uric acid in the blood is not bad – it serves as a powerful antioxidant. However, in some genetically susceptible people, uric acid levels become too high because they make too much, or because their kidneys don’t excrete enough into the urine.

When uric acid crystallizes

Abnormally high uric acid levels in the blood, a condition called hyperuricemia, can be present for 10-20 years without any symptoms. But just as minerals crystallize out of water in caves and form stalagmites and stalactites, uric acid can crystallize out of fluids in the body, forming microscopic deposits in tissues, especially kidneys, joints, tendon sheaths and skin. The painful part comes with the inflammation that ensues when the body attempts to eliminate the crystals. The classic case of gout, also known as podagra, begins suddenly with exquisitely painful, bright red swelling in the joint space between the foot and the big toe. Symptoms last from days to weeks.

The swelling comes from inflammatory fluid in the joint space. Diagnosis of gout depends on withdrawing some of this fluid through a needle and examining it under a microscope, where the uric acid crystals show up as pointy spicules which bend light waves in an identifiable way. Fluid withdrawal can also relieve some of the pain, but the mainstays of treatment during acute attacks are anti-inflammatory drugs such as Indocin, ice and or heat, and plenty of water. Prevention of attacks depends on efforts to lower uric acid levels, by diet, weight loss and use of medications that block uric acid production or increase its elimination in the urine.

Fructose is a building block for uric acid

For centuries, dietary advice about gout has revolved around foods high in protein. But as numbers of gout cases climbed steadily over the last forty years and average uric acid levels in people without gout also increased, a correlation with increased sugar consumption began to emerge. Scientists are now studying the relationship of sugar intake to uric acid and gout and also attempting to tie uric acid to hypertension, obesity and heart disease.

Sugar consumption was once rare to non-existent. Table sugar, a mixture of the two simple sugars sucrose and fructose, came only from sugar cane, which originally grew only tropical regions. Sugar’s spread around the world followed trade routes, and accelerated markedly after the discovery of the beet as a sugar source in the 18^th C. But the most dramatic rise in sugar consumption followed the invention of high fructose corn syrup (HFCS) in the 1970s. From work done so far, it appears that sugar’s fructose is a bigger culprit than its glucose in aggravating the metabolic syndrome (obesity, high blood pressure, heart disease and diabetes). And the metabolism of fructose actually produces uric acid.

When the glucose/fructose mix of sugar enters the body, glucose is transported directly into cells for use, but fructose requires processing. This requires energy, provided by ATP (adenosine triphosphate), and ATP breakdown produces uric acid. Eating fructose regularly also makes fructose easier to metabolize because it “induces,” or makes the body produce specific enzymes required to break it down. For someone prone to overproducing uric acid, or someone whose kidneys excrete it inefficiently, a diet chronically high in fructose may not only provide the building blocks for uric acid, but also speed its production.

Cutting fructose may help – and will do no harm

Cutting purine-rich foods down in a diet helps many susceptible people remain gout free. There is no data yet on the effectiveness of limiting fructose intake on gout or hyperuricemia, but such a diet can do no harm. Limiting fructose sources to whole fruits would dramatically lower total fructose intake for most people. Fructose is the major sugar in fruits, but it is combined with fiber and vital nutrients and present in much lesser quantities than in sugar-sweetened beverages, soft drinks, baked goods and many processed foods. Even ketchup contains HFCS.

When dietary modification is not enough to keep people gout free, drugs that block uric acid production or increase its elimination help. Ideally, uric acid levels should be in the range of 3-6 mg/dl. Diet is important not only for those who have suffered acute gout attacks, but also for those who have high uric acid levels without any symptoms. Hyperuricemia warrants a good look at the amount of dietary fructose.

Henry VIII’s confectionary was a clue to the relationship of girth to gout. As uric acid research progresses, blood tests for uric acid will probably become routine, because high levels often precede the development of high blood pressure and Type II diabetes, even in people not susceptible to gout.

Other Gout Facts

Many diuretics in common use raise uric acid levels and can trigger gout, especially the thiazide group.

Gout attacks commonly follow trauma or surgery because tissue breakdown produces purines.

Cancer treatments may also raise uric acid levels as tumor cells break down.

Uric acid levels increase in women after menopause and women rarely suffer from gout before then.

Uric acid levels in men rise at the time of puberty.

Posted by medical plaintalk

Physician turned medical writer.

Sickle Cell Anemia: Side Effect of the Battle with Malaria

One of the milestones in the history of molecular biology and genetic diseases occurred in 1949, when Lines Pauling ( 1901-1994; 1953 Nobel Prize in Chemistry) discovered that sickle cell anemia, an inherited blood disorder, was caused by a single change in the structure of a single protein in hemoglobin, the complex molecule which carries oxygen in everyone’s red blood cells. For the first time, a hereditary disease was shown to be the result of a miniscule change in DNA that leads cells to make slightly different proteins. In sickle cell anemia, the tiny substitution in the hemoglobin protein changes the way the molecule shapes itself three-dimensionally and this change causes all of the misery and illness associated with sickle cell anemia (also known as sickle cell disease).

Hemoglobin fails to stack and fold itself normally

Hemoglobin molecules carry oxygen from the lungs to the rest of the body, and pick up carbon dioxide to be expelled on the next pass through the lungs. Hemoglobin molecules are stacked neatly inside red blood cells which, under a microscope, look like plump, oval discs, flattened in their mid-sections. To hold and release oxygen and carbon dioxide, the hemoglobin molecules change their shapes, folding and unfolding in response to changes in the acidity of the blood. In sickle cell disease, hemoglobin does not stack neatly or fold correctly, and it distorts the shape of the red blood cells, damaging their membranes. Instead of flattened ovals, red blood cells containing sickle cell hemoglobin assume odd and spiky shapes which are reminiscent of sickles.

Abnormally shaped red blood cells cause trouble

Distorted, sickled red blood cells are shorter-lived than normal red blood cells, causing anemia , or low red blood cell counts, with symptoms of fatigue, weakness and shortness of breath. The abnormally shaped cells also get stuck in small blood vessels of many organs, causing pain and organ damage, and symptoms like strokes, abdominal pain, joint pain and swelling. Episodes of pain and other symptoms are called sickle cell crises, last for about a week, and often require hospitalization and narcotics. The spleen can become severely damaged and non-functional in patients with sickle cell disease. The spleen is an important part of the immune system and, without it, sickle cell patients can be subject to life threatening infections. They require prophylactic antibiotics and careful attention to immunizations. Sickle cell crises are triggered by stress, dehydration, infections and illness and the damage they cause can shorten life. Modern diagnosis and treatment have raised life expectancy of sickle cell patients to over age fifty, an improvement of almost a decade compared to the past. Some babies with sickle cell disease have been successfully treated with bone marrow transplants.

A common genetic trait

In certain parts of the world, 10-40% of the population carry one copy of the mutated gene that codes for the abnormal hemoglobin of sickle cell anemia. Those carriers are said to have sickle cell trait, and they do not suffer from sickle cell disease, which appears only if two copies of the gene are present. But since children get half their genes from each parent, if two carriers of the sickle cell trait get together and have children, the odds are that 25% of their children will be born with two copies of the gene and have sickle cell disease, 25% will have normal hemoglobin, and fifty percent will carry a single copy of the gene, without symptoms. These are the same odds that are associated with other recessive traits, such as blue eyes or red hair, that require two copies of a given gene for expression of the trait carried by the gene.

The trait has an upside – in malaria infections

Why would a genetic trait be so common when it can lead to a disease that causes illness and premature death? The geography associated with sickle cell trait provides one answer. Sickle cell trait is common in groups of people who come from the belt of the earth around the equator where malaria is or was at one time endemic: sub-Saharan Africa, India, the Mediterranean and Arabian Gulf countries, and Central and South America. What is the relationship between malaria and sickle cell trait? The malaria parasite lives in red blood cells, which are full of hemoglobin. The parasite feeds on hemoglobin as a necessary part of its lifecycle. But something about the hemoglobin produced by the abnormal gene makes carriers of the sickle cell trait less likely to succumb to malaria in infancy and less subject to severe malarial symptoms at older ages. The sickle cell trait thus confers a survival advantage on people from malarial regions of the earth, and it has persisted in the population despite the disadvantage it produces when a child inherits two copies of the sickle cell gene. Paradoxically, two copies of the gene do not protect against malarial symptoms because the infection triggers sickle cell crises.

Sickle cell disease affects as many as one in 400-500 of African Americans in the United States, and about 1 in 36,000 Hispanic Americans. About 90,000-100,000 people in the US have the disease. The sickle cell trait is present in one out of every 12 African Americans and one of every 100 Hispanic Americans. In France sickle cell disease is now the leading genetic disease because of emigration from Africa and the Caribbean. Over a long period of time, as these populations live and reproduce in regions where malaria is not a significant threat, the trait may disappear since it will no longer be conferring a survival advantage. In the meantime, researchers hope to better understand how sickle cell hemoglobin tames the malaria parasite and to use the knowledge in the battle against this ancient disease.

Posted by medical plaintalk

Physician turned medical writer.

Pain in the Neck: More than a Metaphor

The cervical spine is a slender stack of fragile bones that balances the 15-17 lb. skull atop the body. Each bone has a round thick body and an arch of thinner bone projecting from its backside. The knobs of bone you feel in your own spine are just the tips of each bony arch, called the spinous processes. A wide array of ligaments, tendons and muscles hold the vertebrae together, and thirty-seven separate joints allow the head to move through a wide range of finely calibrated movements. Arthritic changes accumulate in most necks over the years, particularly in the lower regions where most movement takes place. In scans of people over 50, almost all will show some degree of wear and tear change in the lower vertebrae.

Aging changes in bones neck bones and ligaments

Wear and tear takes form of thickening of bony edges of the vertebrae and degeneration of the discs between them. These changes may put pressure on the nerves that exit from the spinal cord through bony canals between the stacked vertebrae, and occasionally on the spinal cord itself, which travels through a canal formed by the centers of the stacked arches. The ligaments that line this canal also thicken with age and create ridges inside the canal that press on the spinal cord. Degenerative changes contribute to episodic neck pain, and sometimes to more severe symptoms that require medical attention.

Why the neck hurts

The neck is second only to the low back pain as a common source of pain. Most neck pain is benign and episodic, coming from muscles, tendons, ligaments and joints. Painful episodes usually occur after some unaccustomed activity, such as painting a ceiling or suddenly twisting or bending the neck, or after sustaining a neck position for an unusual amount of time – for example, over a long drive. Even an unaccustomed head position occasioned by wearing new bifocals can trigger a bout of stiff neck.

Other symptoms

Neck pain requires medical attention when it persists or is associated with neurological symptoms in the arms or legs. Sensory symptoms like numbness or tingling in fingers and arms are quite common when underlying degenerative changes are present in the neck. While they may indicate pressure on nerve roots, sensory symptoms also occur when neck pain is simply a reflection of tight muscles and ligaments. The same nerve fibers that carry pain sensations also carry sensory messages and pain seems to have a kind of spillover effect into other sensory pathways. That same spillover effect also can also cause a wide variety of sensory and pain symptoms in the head. Headaches, pain in the back of the head, and even eye pain can be attributed to some neck problems.

Red flag symtoms: weakness and bladder control problems

Neurological symptoms indicating trouble in the motor nerves or in the spinal cord, in the setting of neck pain and degenerative changes, often indicate a more serious degree of trouble. Weakness in arm or hand muscles may mean that motor nerve roots are being squeezed as they exit the spinal column. Weakness, fatigue and stiffness in the legs, and new trouble with bladder control are symptoms of pressure on the spinal cord. Sensory problems usually recover when the painful cause is successfully treated, but motor nerves and the spinal cord are more fragile and less reliably improve even after surgical decompression. When motor problems are part of the picture, medical attention should be sought sooner rather than later.

Diagnosis

Careful history and physical examination are crucial to the proper diagnosis. Diagnosis of a painful, stiff neck begins with taking a history. Most people do this before they ever see a doctor. What did I do yesterday? Did I sleep sitting up on a plane? In a strange bed? What movement makes this worse? What makes it better? Do I have any other funny symptoms? Most people also do the right thing by avoiding maneuvers that cause pain, applying either heat or ice, and even trying a soft cervical collar, which does not really immobilize the neck, but gives the head a temporary place to rest. Most often the neck improves and no medical attention is required.

Medical attention, when sought, should begin with a very detailed history, not only of the current episode, but of past problems, and other medical problems which might cause or complicate neck problems. Important facts include history of trauma, rheumatoid arthritis, cancer, vascular disease, infections and past radiation treatment. Evaluation then moves to a physical examination, not only of the neck, but a general physical exam and a neurological exam. Imaging studies, electrical evaluation of nerves and muscles, and blood work follow under some circumstances. These include symptoms persisting more than 6 weeks, severe symptoms involving a single joint, presence of fever and weight loss, suspected fracture or dislocation, associated neurological symptoms or findings, and failure of simple treatments over a course of 4-6 weeks.

Treatment

Conservative measures are effective for treating common types of neck pain, especially if carried out conscientiously. Massage, hot or cold applications, topical pain relieving and muscle relaxing creams and intermittent use of aspirin or non-steroidal anti-inflammatory agents are all helpful but they are play a only a supporting role. The major goal is to correct posture, not only of the neck, but of the whole spine, by strengthening and stretching of the muscles that support the spine and those that suspend and move the shoulders. An effective exercise program, under supervision of a qualified physical therapist, involves the entire spine, as well as legs and arms. In addition, supporting the neck’s normal curve in sleep with a good cervical pillow is crucial.

When conservative measures fail, more invasive means of treatment such as injections of anti-inflammatory and analgesic drugs are often added. Surgical treatment of neck pain problems is reserved for situations in which a nerve root or the spinal cord must be decompressed, or ones in which pain is so severe and unremitting that fusing the bones to decrease movement of the neck is considered the only option. In comparison to the number of people with neck pain at some point in their lives, surgically treated neck complaints are actually few and far between. Considering how much the neck moves, how much wear and tear it sustains and how little protection it has, this is a remarkable measure of its resilience.

Posted by medical plaintalk

Physician turned medical writer.

Vitamins: Is Nature’s Magic Enough?

When I was a medical intern I watched my supervising resident perform an immediate and visible cure and in that moment understood the appeal of vitamins to our pill-loving culture. We were laboring over an old gentlemen brought to the emergency room from Boston’s Commons – a park that was home to many people whose diets came largely from brown-bagged liquor bottles. Our patient was agitated and confused. Try as we might we could not get his eyes to move in any direction. My resident disappeared and returned with a tiny syringe filled with a Vitamin B1, also known as thiamine. He injected the liquid into the patient’s vein and, as if he’d waved a wand, our patient’s eye movements returned and he calmed down. Here was a miracle drug, and it was something nature made for us.

Vitamin deficiency

The magic of our patient’s recovery was a clear example of the function of vitamins. In minute amounts, they act as facilitators of chemical reactions necessary for energy production and cellular maintenance of all kinds. Our patient had a textbook case of vitamin deficiency, the result of a very bad diet or failure to absorb vitamins from the stomach and small intestine, or both. Alcoholism is the most common setting, but vitamin deficiencies occur with other severe gastrointestinal problems and in the malnutrition associated famine or devastating illness like cancer and AIDS. Sometimes medical treatment itself is the perpetrator, in the form of anticancer drugs or bypass surgery for morbid obesity.

Vital nutrients

For thousands of years, people have understood that certain foods contain substances vital to human life. The ancient Egyptians recognized that night blindness was cured by eating liver. In the 1700s, seagoing men found that lime juice prevented scurvy – the aches, skin rashes and loss of teeth from painful gum disease that occurred when men attempted to live for months without fresh food. When the nature of food’s magic yielded to chemical analysis, scientists found complex molecules with many active forms that acted as co-factors or triggers in energy-producing chemical reactions in all cells of the body. They were also involved in cell maintenance and reproduction.

Naming the magic

Chemists named the indispensible compounds vitamins (vita: root word for life; amine: a chemical group containing nitrogen, which early studies suggested all vitamins contained) and tagged them with letters as well as chemical names (see list below). Vitamins F – K eventually became part of the large Vitamin B complex group, and some vitamins were downgraded to “vital nutrients.” Synthetic vitamins appeared on store shelves, joining age-old remedies like cod liver oil, yeast and wheat germ. But even in our times, the best source of vitamins remains the whole foods in which nature embeds them with other factors that we may not yet recognize as important.

Water soluble vitamins

The B vitamins and Vitamin C dissolve in water. They aren’t stored in the body and can be lost or inactivated by cooking. These water-soluble vitamins find their way to their target cells, get used, recycled a bit, and then find their way out of the body in the urine. They need to be eaten on a daily basis. You cannot overdose on B vitamins in food, but very high doses of B vitamin pills can damage the nerves.

Fat soluble vitamins

Fat-soluble vitamins (A, D, E and K) accumulate in liver and fat tissue, ready to be used when necessary, but damaging if too much is stored. Some Arctic explorers died of brain swelling from consuming polar bear liver, very high in Vitamin A. Too many carrots (source of carotenes, or pre-Vitamin A) cause yellow skin. Too much Vitamin D raises blood calcium levels, producing weakness, lethargy and kidney stones. Vitamin K can interfere with Coumadin, a medicine used to prevent blood clotting, so patients are cautioned to eat only small amounts of very flavorful greens like Kale and collards.

If you are not alcoholic or malnourished from serious illness, if you live in a western countries where vitamin fortification (enrichment) of common foods is the routine, if you eat well-balanced meals drawing fresh food from plant and animal sources, if you are meeting your energy needs and not trying to lose weight by restricting calories, and if you get enough sun exposure, you do not need any vitamin pills. Vitamins are best absorbed from real food.

Vitamin supplements?

In our current eating culture, however, a couple of vitamins do warrant concern. Folate (Vitamin B9) consumption, vital to cell replacement, is inadequate when fruits and vegetables are not chosen or hard to come by. Vitamin D deficiency, which became rare when fortification of milk began, is again on the rise, producing rickets (malformed bones) in children, weakened bones in adults, and weakened immune systems in all age groups. Cholesterol phobia makes people avoid good Vitamin D sources like whole milk and egg yolks. Sun exposure of head and arms for just 15 minutes 2 or 3 times a week makes enough Vitamin D in skin to our needs, but effective sunscreens and lack of outdoor activity have put serious dents in sun exposure.

What about Vitamin C, the wonder vitamin? Most plants and animals make it. We do not. Linus Pauling, Nobel prize-winning chemist, speculated that our intake should be much higher than the small amount required to prevent scurvy. Apes, who’ve also lost the ability to make Vitamin C, consume 10 -20 times as much as we do. Goats, who make Vitamin C in huge quantities, make even more when stressed. Does Vitamin C help prevent colds, strengthen our connective tissue, and get used up faster in times of physical stress? Maybe. We just don’t know. But in the meantime, large doses, up to several thousand milligrams per day, appear to do no harm. (Smokers do need extra C.)

Take advice with a grain of salt

What are we to think of all the articles we see extolling the virtues of this vitamin or that in preventing this disease or that? Be wary of these words: suggests, indicates, may be, could prevent. If any of the putative effects were as clear as our emergency room patient’s revival, or the salvaging of sailors’ gums and teeth, or the cure of the Egyptians’ night vision, we would not be using tentative words. Keep your focus on a fresh food diet that excludes no food group, and on the physical activity that enables you to eat enough food to get everything you need without getting fat. Take Vitamin C if you want to, and add a multivitamin from a reputable company if you are dieting or restricting your diet in any way, or don’t like vegetables and fruit.

Major Vitamins and Some Food Sources

Vitamin name	Chemical name	(RDA) Recommended daily allowance (male, age 19–70)	Animal Source	Plant Source
Vitamin A	(retinol, retinoids and carotenoids)	900 µg (micrograms)	Beef and chicken liver* Whole milk, eggs, cheese	Carrots, spinach, yellow vegetables and fruits
Vitamin B1	Thiamine	1.2 mg (milligrams)	Pork*, lean meats, fish	Brewer’s yeast, wheat germ, whole grains Enriched grains, legumes, nuts
Vitamin B	Riboflavin	1.3 mg	Eggs, lean meats, milk	Brewer’s yeast*, cereals, nuts, leafy greens
Vitamin B₃	Niacin	16.0 mg	Lean meats, poultry, fish, eggs	Beets, Brewer’s yeast*, peanuts, other nuts, sunflower seeds, green leafy vegetables, coffee, tea
Vitamin B₅	Pantothenic acid	5.0 mg	Calf’s liver*, eggs, yogurt	Brewer’s yeast*, whole grains,sunflower seeds, mushrooms, squash, cauliflower, broccoli
Vitamin B₆	Pyridoxine	1.3-1.7 mg	Liver, egg yolks, poultry, fish	Wheat germ, whole grains, peanuts, walnuts, bananas, avocados
Vitamin B₇	Biotin	30.0 µg	Eggs yolk, liver	Brewer’s yeast, wheat bran cauliflower, avocado
Vitamin B₉	Folic acid	400 µg	Beef liver*, egg yolk	Fortified cereals*, leafy green vegetables, citrus fruits
Vitamin B12	Cyanocobalamin	2.4 µg	Meat, eggs, dairy products, shellfish, salmon	Fortified plant milks and cereals only. No natural plant sources.
Vitamin C	Ascorbic acid	90.0 mg		Citrus fruits*, tomatoes, berries, green and red peppers, broccoli, spinach
Vitamin D	Ergocalciferol and Cholecalciferol	5.0 µg-10 µg	Dairy products, salmon, tuna	Fortified cereals
Vitamin E	Tocopherol and Tocotrienol	15.0 mg		Wheat germ oil, almonds, hazelnuts,sunflower seeds and oil, safflower oil
Vitamin K	Naphthquinone	120 µg		Broccoli, Kale, Swiss chard, soybean oil, canola oil, olive oil

*excellent source

Posted by medical plaintalk

Physician turned medical writer.

Alzheimer’s Disease: A Power Failure?

Like Willy Sutton, the bank robber famed for his explanation of why he robbed banks (because that’s where the money is), Alzheimer’s disease researchers have aimed most of their efforts at the well-known, visible pathology of the disease, the collections of debris scattered among the dying cells in the brains of patients suffering from the dementing illness. Made of a protein known called beta-amyloid, these plaques are the cause of the progressive death of brain cells and consequent loss of mental function – or so it has been thought. Research focus on amyloid plaques has been disappointing, though, yielding neither effective treatments nor preventive strategies. Moreover, the dramatic rise in the incidence of Alzheimer’s disease (AD), from 2% of people over age 85 in 1960 to 50% in 2000 indicates that something else is in play, something other than bad genetic luck that supposedly causes beta-amyloid to accumulate and nerve cells to die.

Energy production in the brain

As attention has turned to other potential causes of AD, older research findings seemingly unrelated to AD have assumed new importance, particularly discoveries related to brain energy metabolism. The preferred fuel for the brain is glucose. Until the 1980s, researchers thought that the brain, unlike other organs, did not need use the hormone insulin to allow glucose to enter its cells. But in the 1970s insulin receptors were discovered in brain cells and insulin was found in the spinal fluid, implying that the brain did indeed use the hormone. Because progressive resistance to insulin and difficulty getting glucose into cells to provide energy are the hallmarks of type 2 diabetes, and because the rise in AD incidence paralleled rising rates of type 2 diabetes in the last few decades, researchers began to wonder if AD might be rooted in insulin resistance and impaired energy production in brain cells. Insulin resistance in the brain might also explain the results of glucose metabolism studies in the brains of people at high genetic risk for AD, showing as much as 25% decrease in the use of glucose in areas concerned with memory and learning – long before any symptoms suggestive of AD have appeared.

Insulin resistance

By 2005, the idea that insulin resistance in the brain plays a significant role in the development of AD gained traction. Since not all type 2 diabetics get AD and not all AD patients have type 2 diabetes, insulin resistance cannot be the sole cause of AD. But a high blood insulin level is one of the two biggest risk factors for the disease. The other is a genetic factor – the gene for the E4 version of a protein called apolipoprotein B (apoB). Like insulin, apoB’s function is moving the building blocks for energy production into place in the various cells of the body. ApoB is like a delivery vehicle, packed with fats and cholesterol which are necessary for building the cellular machinery in the brain and providing fatty fuel for use when glucose is unavailable.

The tie between glucose, insulin and amyloid

Does impairment of glucose metabolism in the brain have any relationship to the classic pathological components of the disease – the amyloid plaques littering the brain, the destruction of nerve cell architecture, and the non-specific inflammatory changes? There are tantalizing clues. In the brain amyloid protein is a normal waste product. What is not normal is its accumulation in clumps around nerve cells. Beta-amyloid is usually broken down by an enzyme called IDE, insulin destroying enzyme. IDE breaks down insulin much more readily than it does amyloid proteins and when insulin is present in high amounts, the amyloid waits longer to be cleaned up and precipitates out of solution, forming clumps. Uncleared amyloid also prevents insulin from attaching to nerve cells to let more glucose in, depriving them of fuel.

Competition for IDE may not explain beta-amyloid accumulation completely, but it is a link between insulin, glucose metabolism and AD. In addition, high levels of glucose in all parts of the body prompt the development of abnormal collections of proteins/glucose combinations called advanced glycation products which trigger inflammatory damage to tissues in all organs. The brain is no exception.

A link between poor sleep and AD?

Sleep is another subject beginning to gain attention in the prevention and treatment of AD. Lack of good sleep contributes to the development of the metabolic syndrome, including type 2 diabetes, though disruption of normal hormonal rhythms. In normal people and in people with sleep apnea, sleep deprivation produces measurable impairments in working memory, thinking speed, attention, vigilance, and higher cognitive functions – the same functions affected by dementing illnesses such as AD.

Reasons for optimism

Do changing theories about AD have any practical consequences? Indeed. First, there is more reason for optimism about the future. If AD rates have risen because of changing dietary habits and lifestyles, we can change them again. The factors known to produce the metabolic syndrome are weight gain, lack of exercise and poor diet. Regular exercise is recognized as a deterrent to the development of AD. Some people are beginning to feel that the low fat dietary recommendations must also be changed since they have resulted in diets high in processed foods and carbohydrates, and low in foods with high amounts of antioxidants which counter inflammation. Fat metabolism, abnormal in the metabolic syndrome, is also important in the brain, which contains 25% of the body’s cholesterol. It needs sufficient healthy fats in the diet for normal function.

The second practical implication of the changing view of AD is the application of known drug treatments for type 2 diabetes, both for attempted prevention and for treatment of AD. Clinical studies in AD patients are already under way, using medications that improve insulin resistance. Intranasal insulin has also been tried. It is delivered directly into the brain, without fear of lowering body glucose levels and has shown some promise in improving AD symptoms. These approaches are entirely new and evidence of shifting focus in research. If Willy Sutton were an AD researcher he would be changing his targets.

Terminal Lucidity and Lucid Intervals

Caregivers of Alzheimer’s patients have long reported episodes of the patient returning briefly to “themselves,” for periods of hours to days. Some dramatic cases of such returns have been reported in the terminal phases of life. All of these cases have fallen into the “we don’t know why that happens” category of clinical observations. The concept of brain cells failing to function because of lack of energy is one that fits the appearance of lucid intervals better than a theory of the disease that implicates cellular destruction alone as the underlying cause of symptoms.

Arch Gerontol Geriatr. 2012 Jul-Aug;55(1):138-42. doi: 10.1016/j.archger.2011.06.031. Epub 2011 Jul 20. Terminal lucidity: a review and a case collection.

Nahm M¹, Greyson B, Kelly EW, Haraldsson E.

Posted by medical plaintalk

Physician turned medical writer.

Vitamin D: A Developing Story

Ten years ago, it is unlikely that vitamin D was on your list of things to worry about. Now you probably know someone who is vitamin D – deficient and taking a vitamin pill every day – or at least during the winter months when the sun is low in the sky. Finding a magazine or newspaper that hasn’t published stories warning about deficiencies in the “sun vitamin” is difficult. What happened? Do we have a new problem, or have we just learned more about an old one?

The magic ingredient in cod liver oil

The old part of the Vitamin D story is about a childhood disease called rickets and an adult version of rickets called osteomalacia. Both afflictions became common when urbanization crowded people into the sooty cities of northern Europe in the 1700s. Affected children had bowed legs, malformed chests and teeth, weak muscles and easily fractured bones. In adults, whose bones had stopped growing, the symptoms were bone pain, fractures, and muscle weakness. Though folklore from coastal cities had long described cod liver oil as a remedy for these problems and for other rheumatic complaints, it wasn’t until the early 20^th C that scientists discovered that the magic ingredient in cod liver oil was one of the newly described vitamins- special compounds the body can’t make but needs to get in small amounts from specific foods. Vitamin D was the fourth one named, after Vitamins A, B, and C.

Further research demonstrated that Vitamin D is present in many animal fats, and is necessary for the transport of calcium from the intestine into the blood. The rampant rickets and osteomalacia of the early industrial revolution years seemed accounted for by poor diet, but the concentration of these problems in northern climates prompted more questions. The answers started a new chapter in the story of Vitamin D—its relationship to the sun and its reclassification as a hormone rather than a vitamin.

Vitamin D is actually a hormone, not a vitamin

Vitamin D, as demonstrated by an elegant series of experiments in the 1920s, can be made by the body, in the skin —as long as the skin is exposed to sufficient sunlight. By the time of this discovery though, the vitamin label was too well established to be removed. What started out being known as the bone vitamin became the sunshine vitamin, and more research into its biochemistry placed the “vitamin” firmly in the camp of the hormones, which are made in the body’s glands and and which act on many different and distant parts of the body to signal changes in cellular functions. Chemically , Vitamin D most resembles steroid hormones such as testosterone and cortisol and estradiol.

The discovery of Vitamin D receptors

Vitamin D research took its next leap when hormones were discovered to have receptors in the tissues where they were active. Sure enough, Vitamin D had receptors too, in virtually all tissues. By the 1990s researchers were busy trying to find out why. They observed that vitamin D suppressed the growth of cancer cells – at least in the laboratory. Statistical studies showed lower cardiac death rates in the people with the highest vitamin D levels. The bone vitamin suddenly had many possible functions.

In the last decade thousands of studies have attempted to relate hosts of medical problems to vitamin D deficiency, including autism, depression, dementia and other neurodegenerative diseases, many varieties of musculoskeletal pain and arthritis, and autoimmune diseases like multiple sclerosis. So far, most of the research implies that vitamin D exerts its effects in a variety of tissues over the long term, altering the way genes are expressed rather than acting rapidly and directly as it does in intestinal transport of calcium.

Deciding who is deficient in D

Nevertheless, the race is on to see whether or not vitamin D might help many of the ailments that plague us. The first step is trying to decide who is deficient. Measurements of vitamin D, which is a general term applied to a number of different forms of the vitamin, were not standardized until 2006. There is still sometimes contentious debate about which form of the vitamin to measure and what constitutes a normal level. The general consensus is that vitamin D3 (1-hydroxycholecalciferol) is the best measure of the body’s stores of vitamin D. The range of normal values of vitamin D3 comes from studies of healthy Hawaiian surfers, who rarely have levels below 30 nanograms (ng)/ml and rarely above 60 ng/ml. Different laboratories sometimes cite different values, but generally a value in the 20-30 range or lower indicates deficiency.

Requirements change with age

Requirements for vitamin D vary and change over life. As people age, skin produces less. Darker skinned people make less vitamin D. The recommended dose of vitamin D supplements is 200 IU/day (5 micrograms), 400 IU after age fifty, and 600 IU after age 70. Research enthusiasts suggest more. Sun exposure is by far the most efficient route to adequate vitamin D. Twenty minutes of face and arm exposure produces as much as 10,000 IU vitamin D, which is stored efficiently for weeks. Most supplements are made from the skin of animals or derived from plants chemicals exposed to UV light. (Plant derived vitamin D is known as vitamin D2.)

Rickets makes a comeback

Are we more in need of vitamin D now than previously? In the past, we looked for vitamin D deficiency only in obvious cases of bone disease and kidney failure (the kidney converts vitamin D3 to its most active form). But now, with the best of intentions, we may have created another version of the sunlight deficient, dietary-restricted cities where rickets once thrived. We assiduously shun fat, meat, dairy products and eggs to avoid cardiac disease. We apply sunscreen liberally to avoid skin cancer. Rickets is on the rise, there are more pediatric bone fractures than in there were a few decades ago, and general arthritic complaints abound. And we now suspect vitamin D may be required for basic cell functions in all organs.

What to do?

A little unprotected sun exposure every few days, and judicious intake of eggs, milk, fatty fish – even a little cod liver oil now and then – are reasonable tactics to increase the body’s Vitamin D production . Or you could ask your doctor to check a vitamin D blood level and consider taking a supplement if the level is low, especially if you spend the winter above the latitudes of Boston and the California/Oregon border.

Food Sources of Vitamin D

(From NIH Office of Dietary Supplements)

IU %RDA

Cod liver oil*, 1 tablespoon 1,360 340

Salmon (sockeye), cooked, 3 ounces 794 199

Mackerel, cooked, 3 ounces 388 97

Tuna fish, canned in water, drained, 3 ounces 154 39

Milk, vitamin D-fortified, 1 cup 115-124 29-31

Yogurt, fortified, 6 ounces 80 20

Margarine, fortified, 1 tablespoon 60 15

Sardines, canned in oil, drained, 2 sardines 46 12

Beef liver, 3.5 ounces 46 12

Fortified ready-to-eat cereal, 0.75-1 cup 40 10

Egg, 1 whole (vitamin D is in yolk) 25 6

*The problem with cod liver oil as a source is that Vitamin A tags along and Vitamin A can be toxic in high doses, producing brain swelling. Check the source information and composition.

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Physician turned medical writer.

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Chemical name

(RDA) Recommended daily allowance (male, age 19–70)

Animal Source

Plant Source

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(RDA) Recommended daily allowance
(male, age 19–70)