Tuesday, May 31, 2011

Response to Jackie's Question about Allergy Testing- Blog #34

There are allergies and sensitivities. If you are having a classic allergic reaction (such as hives or swelling), traditional allergy scratch testing or a blood RAST or ImmunoCal test usually works well. Sensitivities and reactions are trickier because the reaction can evolve from a large number of possible causes. Each test looks for a different reaction. For example, there is a specific test for lactose intolerance but it finds no other types of reactions. The best general screening test that I sometimes use is an IgG test from MetaMetrix. It has the least number of false positives and looks for non-allergic reactions to 30 foods. It must be ordered by a practitioner.

Thursday, May 26, 2011

Blog #38 Looking for Piracetam

Recently, my oldest daughter graduated from college (wahoo) and we decided to take a trip to celebrate. I have always wanted to go to Spain and she was willing to go anywhere that had Wi-Fi service so off we went to Barcelona. Barcelona turns out to be a wonderful place to visit and I highly recommend it if this was a travel log. Nor is this a culinary treatise so I will not go on about the intricacies of rabbit stew (not a fan) or chickpeas with black sausage (absolutely delicious). Instead, it is about how even though I left the country, the nutrition detective tagged along.

At first I did not notice her as I experienced the wonders of drinking chocolate and becoming entranced by any architecture designed by Gaudi. Eusebi Gaudi is Barcelona's most famous architect and his presence in the city is impossible to miss. He designed the Sagrada Familia Cathedral using nature as his inspiration. The inside of the cathedral has a forest motif and the outside spires are shaped like stacks of fruit. So, there is something vaguely nutritious about it. There are honeycombs, spirals, plant and animal designs all piled together in an over the top mishmash. You either love or hate the result.

Detectives have curious natures (that is, they experience curiosity, they are not necessarily odd) and as I wondered around, I could not help but notice that in busy areas there are pharmacies on practically every block. You cannot fail to notice them because they have either flashing green or red crosses. And unlike our super pharmacies that carry everything from mops to narcotics, these pharmacies are very small. They have the equivalent of one CVS aisle's worth of items on display and over the counter medicines, like ibuprofen, are all behind the counter. One pharmacy might carry feminine hygiene products and the next not. Maybe that is why they need so many. They must have some type of community pharmacy group where they all agree on who can carry what. Hector's pharmacy gets the face cream but one on 10th and Cambria gets the deodorant.

I could not figure the system out so if we needed something, we just went from one to the next until we ran into it, which never took long. Then I started wondering about locating piracetam. Piracetam is a substance developed in Belgium in the 70's that is the best cognitive enhancer I know. It improves the motor planning and speed of thinking. Nobody knows exactly how it works but taking it with choline enhances its effect. There have been many variants developed since the 70’s but piracetam has a long history of use and so I think it is the most predictable. Piracetam can be found in the US, but the source tends to be China, so I tell people Nootropil (a Spanish brand) from Europe is a more reliable product. And here I was in Spain!

So one morning I walked into a tiny pharmacy three streets behind our apartment and requested in my best high school Spanish a box of Nootropil. They speak a Catalan version of Spanish in Barcelona so nobody ever seemed to understand anything I said. Either that or my Spanish is dreadful which was my daughter's explanation. The clerk looked at me blankly. After repeating several versions of my request she handed me a slip of paper and instructed me to write down the name. "Ahhhhh," she responded with understanding after reading the name. That was easy, I thought until she started shaking her head and waving her hands. I needed to try the pharmacy next door or three doors down that carried piracetam and hair spray.

Armed with my paper I made faster progress until finally at the third pharmacy, I hit pay dirt. There for a measly 3.5 Euros (less than $6), I was able to purchase a box of Nootropil in my choice of potencies (800 or 1,200 mg). When I asked in my cringe inducing Spanish if a prescription was needed, the pharmacist appeared puzzled that I asked. I had asked because piracetam inexplicably sometimes seems to require a prescription and other times does not. I have a client in Ireland who needed a prescription while one from Italy, did not. You can order it from England without a prescription but I think you need one if you are actually in England.

To further thicken the plot, getting piracetam in Spain was no harder than tracking down a nail clipper and about the same cost while getting piracetam in the US can take weeks and costs many times more. It made me realize again how little medicine is about what works and how much it is about health care politics and just how things are done in a particular place at a particular time.

Last year, I saw a child who had severe, global developmental delays. Dmitri had been getting occupational, speech and physical therapies but was making very slow progress. After creating a good nutritional base for learning, I asked his mom if she had ever thought about trying piracetam. In these complicated cases, piracetam can speed up progress by building neuroconnections across the corpus callosum to help with processing. I pointed her to some resources and information about it so she could consult with her doctor.

Several weeks later she reported her doctor advised her against using piracetam. It cannot be that good, the specialist had said, or he would know about it. He could not assure her it was safe and there was no evidence (according to the expert), that it worked. What was his alternate suggestion? There wasn’t one. She would have to learn to live with his disabilities. Dmitri’s mom was discouraged but listened to her doctor. Dmitri progressed very slowly until the summer. His mom decided to take Dmitri home to Poland and spend time with her family.

While there she made an appointment with a neurologist her family liked and asked him about piracetam. He told her Dmitri should have been put on piracetam a long time ago. Of course, it was safe and if she were there, he would have been put on it a long time ago. She started it right away and Dmitri’s speed of progress increased.

So either piracetam only works in Europe or if someone tells you they have never heard of something, you should not trust their opinion on it. The US doctor did not realize how much of what he thought he knew was colored by limited medical cultural experiences. Maybe he should travel more.

Wednesday, May 11, 2011

#35 Nutrition Fatigue and Cholesterol

Lipitor, a cholesterol lowering statin drug, is the best selling medication of all time. One year 9 billion dollar’s worth was sold in the US alone. Now it is more like 7 billion per year (source: Los Angeles Times May 4, 2011) because a bunch of copy cat drugs were rolled out to hone in on such financial largesse. (Crestor, Zetia and Zocor to mention the brand names of 3 of the 6 other statins.) The point is, there is a lot of money involved in anything having to do with statins.

All the statin drugs lower cholesterol but in slightly different ways. The key to their success is buying into the theory that lowering cholesterol reduces heart disease.
Recently my friend, Basil sent me an e-mail, “There is a small but growing school of thought that rejects the high cholesterol-heart disease hypothesis. High cholesterol may not cause CVD (cardiovascular disease),” he wrote. “They were talking about it on that silly Dr. Oz show. You should write about that.”

Okay. I will though I will disclose that my temporarily crippled assistant, Tania, has been spending a lot of time recently deepening her relationship with Dr. Oz and she describes him more as “almost cute”.

An interesting study completed in 2006 on two popular statins, Vytorin (Simvastatin) and Zetia (Ezetimibe) changed the conversation about cholesterol lowering. Both drugs successfully lowered cholesterol however, the study (sponsored by the drugs’ manufacturers Merck and Schering-Plough) found the medications did not prevent heart attacks or other life-threatening events. There was actually no benefit from taking them. (See: The New York Times, Jan 14, 2008, “Drug has no benefit in trial, makers say”.) This four year long, multicenter trial of Simvastatin and Ezetimibe in Aortic Stenosis (SEAS), found the rate of congestive heart failure, stroke and cancer actually went UP when people took these two drugs together though in people who already had symptomatic aortic stenosis, ischemic events decreased (“Intensive Lipid Lowering with Simvastatin and Ezetimibe in Aortic Stenosis,” A.B. Rossebo, et al, NEJM, 2008, 359.)

Dr. Terje R. Pedersen, chairman of the SEAS trial summarized the findings by calling the drug combination “safe and well tolerated”. (http://www.internalmedicinenews.com/specialty-focus/cardiovascular-disease/single-article-page/major-cv-events-not-decreased-with-vytorin/033eb84c9a.html). Yeah, but they do not do help prevent disease and may, in point of fact, increase one’s chance of having a stroke or heart attack. Nobody will be surprised to hear that the study was misplaced for a couple of years. There is an ongoing investigation on how that could have happened. Do not expect results any time before hell freezes over.

Confusion and debate commenced and nothing changed. Both drugs still enjoy robust sales because the important point the manufacturers want doctors to remember is that the drugs lower cholesterol. Which brings us to Basil’s point. Maybe high cholesterol levels are not the risk factor for heart disease that they are believed to be.

The quiet truth is that the big difference between Zetia and the other statin drugs is that Zetia lacks anti-inflammation properties. All it does is lower blood cholesterol levels. Most of the other statins have mild anti-inflammatory properties. Mounting evidence suggests that high inflammation not high cholesterol may be what is increasing heart attack risk. It just happens that inflammation goes down as a secondary side effect of the cholesterol lowering process.

When you think about it, lowering inflammation as the mode of action makes much more sense than lowering cholesterol. For one thing, if lowering cholesterol is so important, why have heart attack rates barely dropped even though practically everyone you know over 50 takes a statin drug? Heart attacks and heart disease statistics have changed little since the massive and pervasive use of cholesterol lowering therapies.

The cover story for the May 2011 Harvard Heart Letter announced, “Gloomy forecast on heart disease”. The article goes on to say the American Heart Association predicts heart disease will increase 17% and heart failure and stroke will go up by 25% each over the next 20 years. They recommend avoiding tobacco, exercising, maintaining an ideal weight, managing stress and eating better. These are all life style choices that lower inflammation. Only one (healthy eating) might lower cholesterol.

Of course, lowering inflammation requires lots of work on your part while taking a statin drug only gives your wallet a work-out. I predict you will not hear much about the doubts surrounding the effectiveness of statin drugs until October. Actually, you do not need a Nostradamus level of psychic ability to predict that sometime this fall there will suddenly be many reports on how researchers now know it was not the cholesterol lowering properties of Lipitor that helped the heart but its mild anti-inflammatory properties. (We actually already know this.)

Why will this hot news story break in the fall? Because Lipitor goes off patent in November and the 7 billion dollar a year cash cow is about to become hamburger. Generic drug manufacturers will be able to crank out the thing at a tenth of the cost. Seniors on restricted incomes will finally be able to save lots of money on medication but what’s this? They no longer need their statins?

That’s right. I can see the headlines now, “New anti-inflammatory drug slashes heart attack rates.” I think they should call it, Inflamator.

Sunday, May 1, 2011

#34 Nutrition Fatigue

“There was an article in the paper that women who take calcium are more likely to get heart attacks,” my loyal assistant, Tania reported to me one morning. “Should I stop taking my calcium?” she asks ominously.

“E Tu, Tania, E Tu?” I lament dramatically.

“As usual, I have no idea what you are talking about,” she snapped, uncharacteristically irritable.

I hate to say it but Tania has been a tad bit cranky lately. Her mood seemed to shift slightly last month after a freak accident and subsequent major surgery to insert a foot long titanium rod into her leg. The only good thing that seemed to come out of this horrible ordeal is that after years of failed badgering on my part, she finally started taking her supplements regularly. Now it seemed even this small benefit was in danger of being lost under the constant onslaught of negative media reports on supplements.

There is a condition called, compassion fatigue that happens to people when they are so overwhelmed by hearing horrible stories of suffering that they just cannot feel anymore. A general numbness descends. The news media has managed to create this in most of us regarding every major disaster in the last few decades with relentless, non-stop reporting of every tragic, pain ridden moment.

A similar condition happens with “health” reports regarding nutrition which I call nutrition fatigue. Much of the information is negative. Some of the more recent sound bites (insert ten exclamation points to mimic intensity of reporting) claim fish oil does not lower cholesterol, choline causes heart disease, calcium does not protect the bones and melatonin causes precocious puberty, scratch that, now it delays puberty.

No wonder everyone is confused, scared or discouraged because nothing works and the world is going to pot anyway. The solution is to take a deep breath, check into the situation more thoroughly by reading the actual research and think it through. Who has time for all that? Exactly.

I do take the time to do this because people tend to stop taking their supplements in response to these irresponsible reports and I get a lot of panic laced questions. There are so many reported health news disaster stories to pick from but let’s start with calcium because I have already gotten several questions about the study Tania mentioned. Calcium use to be an uncomplicated nutrient until sound bite reporting got to it.

You may recall the beginning of the made-up calcium debate. It involved the huge Women’s Health Initiative study published in the New England Journal of Medicine a number of years ago. The initial headlines screamed that taking calcium does not help bones!!!!!! The comprehensive study had over 36,000 women in it and the ones taking calcium did not have any less fractures than the other group, the reports trilled. Women all over the country viewed their calcium supplements with suspicion. My phone started ringing.

Upon careful review of the study, it turned out that half the women in the calcium supplement group did not actual take their calcium. They were naughty. Unfortunately, there were so many naughty women that removing their data from the study would have invalidated it, so the researcher left the non-compliant ladies in. Garbage science. The study really proved that if you do not take your supplements, they do not work. No big news item there.

In this case as the study was scrutinized, new amended reports started to surface. One from ABC News asked the question, “Does calcium help bones?” Then it answered that in a big study (the same one), women who took calcium had significantly less breaks but they had to take calcium for a long time. So, it was not a quick fix and by the way, maybe it increases kidney stone risk. I guess just saying, “yeah, it does”, would have been boring because everyone already knew that anyway.

The study Tania heard about was a new unexciting study about bone health published in the British Medical Journal. To spice it up, the results were reported with the byline, “Calcium builds bones but may weaken the heart. “ However, there was insufficient evidence in the study to prove or refute an association between taking calcium and heart disease. The researchers were not even looking for a calcium and heart disease link but after the study was done were picking through the data to see what else they could put together to report.

People taking calcium before the study started had no increase in cardiovascular incidents but in the group given calcium for their study there might have been slightly more heart incidents but the association was murky because of many other variables. No problem. Maybe someone else had found an association they could apply, after the fact, to their study. They looked through the literature for other studies to boost the possibility and start a debate.

Researchers from the Women’s Health Initiative (WHI) study weighed in that they did not find any increased cardiovascular risk in the 36,000 women in their study. The new investigators had to be looking very hard to come up with this vague association, one WHI researcher pointed out. (Of course, it is hard to say if one can trust the WHI based on what their researchers initially reported about their study.) There may be science here somewhere but it sounds more like a reality TV script for The Real Biology PhDs of Cambridge. This kind of “I wonder if”,” chitchat should be limited to conversation between researchers over a few beers on a Friday afternoon and not reported as science news.

The result of this sensationalized reporting is some people worried about heart disease, stopped taking their calcium. A larger number of people already forgot the details of the latest report but are building a sense that nutrition is confusing or there is always something wrong with supplements. While annoying and destructive, the results are mild compared to what happens when the financial stakes go up. Then the marketing people get involved and start spinning the results to be sure you take away what they want you to believe which can be very distant from the real findings.

To be continued….