Which Lifestyle Choice in China Will Kill You First?

Happy Elderly Seniors Couple Biking

If the tooth fairy gave you 10,000 RMB every year in China that you could only spend on your health, what would you buy? Would you get an air purifier? How about a gym membership; an organic delivery service; a daily massage — what would you choose? Perhaps it’s best to rephrase the question, “what gives my health the most bang for the buck?” In order to answer that, one needs to know which lifestyle choices are harmless fun and which are unhealthy.

Air Pollution : A Lifestyle Choice? 

Many in China, both local and foreign, would instinctively say that air pollution is their greatest threat to health, but is it really? Let’s make a slight intellectual leap and say that exposure to air pollution is a lifestyle choice; in other words, a modifiable risk factor. I know that breathing is of course involuntary, but most of my readers do have a choice whether or not to live here in China. If you accept this admittedly disturbing assumption, you can then compare this always dreaded “risk factor” to much more mundane risks we all encounter — such as obesity, smoking, lack of exercise, poor diet and other lifestyle choices.

We can clarify lifestyle choices even further into what the American Heart Association calls the four ideal health behaviors:

  • not smoking
  • not being overweight (body-mass index (BMI) <25 kg/m 2)
  • physical activity at goal levels (>150 minutes a week of moderate exercise)
  • diet that includes three or more servings of fruits and vegetables daily.

The AHA also lists three ideal health factors, including total cholesterol <200 mg/dL, systolic blood pressure <120 mm Hg and diastolic blood pressure <80 mm Hg, and fasting plasma glucose levels <100 mg/dL.

How many of these seven metrics do you pass? Don’t feel too guilty, as only 1 percent of the AHA’s test group of 7,622 persons passed all seven. But here’s the clincher: compared with individuals who didn’t meet any of these seven measures, those with five or more had a 78% lower risk of all-cause mortality and an 88% lower risk of death from diseases of the circulatory system. That’s impressive, no? But it’s much more interesting to find out exactly which of these ideal goals is most efficiently beneficial. Plus, how do they compare to air pollution?

Yoga Near Lighthouse

It’s All About The Relative Risks

I’m a data junkie, and I find hard numbers very comforting in the midst of my hectic “medicine is art” family medicine clinic. My favorite tool to compare health outcomes is the relative risk; this compares the ratio of a disease’s prevalence from a health exposure as compared to non-exposure. It’s simple division: divide numerator (exposure) by denominator (no exposure) and you have your ratio, your “RR”. Any RR over 1 signifies a positive risk, and under 1 is a “negative” risk, i.e. a benefit. Let’s use air pollution and smoking as initial examples. As I mentioned in my controversial post earlier this year, a day in Beijing is comparable to smoking 1/6 of a cigarette, which for many of my readers was scandalously low, almost heretical to their predisposed belief systems.  Sorry, true believers, but you can crunch the numbers yourself from Dr C Arden Pope’s sudy. From this study, we can calculate relative risks of lung cancer for air pollution, smoking and secondhand smoke:

  • Air pollution (from American Cancer Society and Harvard Six Cities studies): 1.14-1.21 relative risk
  • Air pollution in Beijing: 1.49 RR
  • Secondhand smoke victims: 1.21-1.28 RR
  • Smoking 3 cigarettes a day: 5.6 RR
  • Smoking half a pack a day: 7.7 RR
  • Smoking a pack a day: 12.2 RR
  • Smoking two packs a day: 19.8 RR

As the numbers show, “light” smoking of only 3 a day is far more deadly than living with Beijing’s air pollution. Since writing that article last winter, I’ve achieved a certain catharsis on this issue, and my personal obsession with air pollution has mellowed from debilitating to professionally curious. I’m now more concerned with the much less glamorous lifestyle choices that bedevil all developing societies, all eagerly latching onto the “Western” lifestyle and quickly picking up both the best and the worst of such lifestyle.

I’m particularly worried about obesity, the great pandemic of our times and an astonishingly pervasive crisis in my homeland, the USA. When I make my annual visit home on Boston’s south shore, I’m truly shocked just how large are the average American adult and child. Having spent six years outside of America, I can peer back with increasing impassivity and state that Americans simply don’t realize the true state of this public health disaster. One of my all-time favorite public health graphs, taken from data from a 1999 NEJM review article, shows the relative risks of increasing weight on coronary heart disease, diabetes, high blood pressure and kidney stones.

Right now, more than half of Americans are technically overweight, with a Body Mass Index (BMI) of 25, the threshold crossing from “normal” to “overweight”. This BMI of 25, now the new normal in the US, increases your lifetime risk of diabetes sixfold, and your risk of high blood pressure doubles. And that’s only at the mildly overweight group; the 35% of Americans who are technically obese, with a BMI over 30, have at least a forty-fold increased risk of getting diabetes. Obesity also raises your risk of cancers; in one study of obesity and cancers, the relative risk of death was 1.52-1.62 in the heaviest group (BMI over 40).

Shanghai Skyline in thick Fog

My 10,000 RMB Each Year Goes To…

When we discuss the global burden of disease, there isn’t anything very different anymore about China compared to most other countries. Chinese people are already dying from the same chronic diseases as the developed countries, and people here need to follow the same common sense lifestyle precautions as anybody else does.

I meet many patients who spend extraordinary amounts on imported air purifiers, whose markup is so sinfully exorbitant the distributors should be publicly flogged. But a great many of these patients are mildly overweight, or “walk” for exercise, or have only a couple servings of vegetables a day. I hope some of these same people can realize that they’re focusing their energies and their money on the wrong issue. Same goes for kids; if parents are fighting over Blueair versus IQAir for the nursery, but their child is already at 99% weight, then their pediatrician needs to have a serious discussion with them about prioritizing. And heaven forbid if you’re even a “light” smoker; please just sell the damn air purifier, return your gym membership, and go pick up a prescription of varenicline!

As for me, with my 10,000 RMB annual play money? I’m already maxed out on those pricey imported air purifiers at home, although the replacement filter cost certainly adds up (again at extortionary markups). And I’m a bit self-satisfied that I pass all three of the AHA’s ideal health factors. As for their ideal behaviors, I don’t smoke, so I’m down to the weight and exercise issue — the banes of our modern civilization. My BMI hovers at 24-25 but my waistline is starting to strain a bit at my perennial size 33 waist. Perhaps I can blame Beijing’s hard water for the pants shrinking in the wash? No, I must admit that I am slowly losing the weight battle, as are most fortysomething men. I also am skilled at hypocrisy, preaching eloquently to my patients about needing their 150 minutes a week of moderate exercise yet equally poor at following my own wise words.

So this year, I’ve locked up my wonderfully fun electric bike and now pedal to the hospital most days, even now, during Beijing’s biting winter. My exercise is now part of daily life and not a “chore” like trudging guiltily to the gym. As for getting the weight down, I’ve started to make my own morning coffee so I won’t be tempted by a Starbucks muffin to go with their Christmas toffee latte (hold the whipped cream).

My health risks are relatively small (knock on wood) so my goals are fairly modest — and very inexpensive as well. I’m way under my 10k RMB stipend, so I’ll use the rest of that money for the creature comforts you can get only in China: two hour massages; three hour KTV sessions; all-day soaks in Beijing’s local hot springs. It’s those little things in China, those cumulative and inexpensive perks, that truly soothe the soul. In China, as anywhere else, mental health is just as crucial as physical health.

 


This article was originally published in 2014 on my sister blog, myhealthbeijing.com. A Chinese version of this article was published in my New York Times Chinese health column.

What Really, Truly, Definitely Works To Lose Weight?

In my sixteen years of family medicine, I think the most frustrating disease I treat is obesity. It’s frustrating because as a doctor I feel great compassion for these patients, trying so hard to lose weight, and yet I feel almost shameful that as a primary care physician I can’t offer much in terms of medicines to help. And now that I’m back in the USA after ten years in China, I’m very concerned that America’s struggle is even worse, with more than two thirds overweight or obese. So now, driven to seriously tackle this epidemic, I’ve scoured the literature for the most up-to-date, evidence-based advice on losing weight. Please feel free to print and share this.

Surgery

Let me jump right in to perhaps the most controversial point: I think that many, many more people should consider weight loss surgery. It literally is the most effective way not only to permanently cause weight loss, but it also literally can put diabetes in remission, lower your overall death rates, and lower your heart disease risks. A huge percentage of people can stop taking diabetes medicines after surgery. Don’t believe me? Feel free to read up on it, including a 2015 meta-analysis from JAMA, and the Cochrane library review from 2014. There are three major options:

  • Sleeve gastrectomy: This involves stapling off much of the stomach, leaving around 25% of the stomach. Average weight loss is 56%. This is now the most popular of the three.
  • Roux-en-Y gastric bypass: This is the most radical surgery, with the most complications, but also the most effective, with a weight loss up to 67%
  • Adjustable gastric banding: This involves putting a flexible silicone band around the top of the stomach, which essentially limits intake of food and makes you feel full with less food. The average weight loss for this is 44%, less than the other surgeries, and is now less commonly done.

Of course there are risks to these surgeries, and weight loss is disappointing for many afterwards. But in general, this is a far, far better option than the usual lifestyle struggles leading to maybe 10-20% loss at the most, with many gaining the weight back, and still having diabetes and other diseases. In fact, a recent 5-year study comparing weight loss surgery to lifestyle interventions showed a clear winner in the surgery group, with far more people losing much more weight, as well as putting diseases like diabetes in remission — totally stopping insulin injections and diabetes pills.

I seriously hope many people, especially in the high-risk categories, make an appointment with your local bariatric surgery teams and just talk with them, to discuss your options. If you’re in my Swedish system here in the Seattle area, you can sign up for their weight loss seminar (phone 206-215-2090, email swedishwls@swedish.org) and hear them out.

In terms of who should consider bariatric surgery, the current recommendations are:

  • Everyone — and I mean everyone — with a BMI (Body Mass Index) over 40, even without any other medical conditions, should consider bariatric surgery.
  • Anyone with a BMI 30-40 with diseases such as diabetes, high blood pressure, high cholesterol, sleep apnea, or severe arthritis, can also greatly benefit. Insurance companies usually would cover it if your BMI is over 35.

Do you know your BMI? A BMI over 25 is overweight, over 30 is obese. Here’s a calculator:

[bmi_calculator]

 

Prescription Medicines

My second main point, and perhaps even more controversial among physicians, is that prescription medicines can also help with weight loss. There now are four prescriptions and one OTC supplement which actually are FDA approved for weight loss, and these expanding choices are encouraging for us family physicians on the front lines. Most work by decreasing your hunger urges. All have side effects, of course, and weight loss varies from 7-12% on average, and people often regain the weight after stopping. But since even a 5% reduction in weight loss can greatly help reduce risks for diabetes, heart disease and arthritis, I think these are definitely worth considering, and I’m using more and more of these in my practice. I strongly suggest interested people (and doctors) read the 2016 meta-analysis in JAMA, comparing all five. Here’s my summary:

  • The medicine phentermine/topiramate (Qsymia) is the most effective at weight loss, losing an average of 8.8 kg over a year, with side effects in the middle of the pack. This is currently my first choice for many. But one side effect is severe: birth defects, so all younger women have to take birth control and get monthly pregnancy tests while on this.
  • The combo medicine naltrexone/bupropion (Contrave) was less effective than Qsymia, with an average 5.0 kg weight loss, and more side effects — and also some debate about its safety with heart disease.
  • The OTC medicine orlistat (Xenical/Alli) is the least effective (2.6 kg weight loss), but has relatively fewer severe side effects (stomach issues), and also is the only one available without a prescription. You take it with each meal, and it decreases fat absorption.
  • The diabetes medicine Liraglutide (Saxenda) is second most effective for weight loss (5.3 kg), but has the most side effects. But it’s certainly a great option for those who have type 2 diabetes.
  • Lorcaserin (Belviq) has the least side effects but was second to last in effectiveness (3.2 kg weight loss).

Who’s a candidate for these prescription medicines? The FDA says that anyone with a BMI over 30, regardless of any illnesses, and also those with BMI 27-20 with risks (the usual ones mentioned above) could benefit from trying these medicines, at least for three months to see if you can get to 5% weight loss. If you do, great! Keep going! Hopefully your insurance will cover the cost (many do not). (NOTE TO DOCTORS: it’s much cheaper to order the combination medicines Contrave and Qsymia separately, as two prescriptions).

Besides these medicines, I should also mention metformin. This common prescription medicine for type 2 diabetes also has the great side effect of weight loss, and while the overall loss is less than 5% in the studies, and thus is not FDA-approved for weight loss, it’s still a fantastic first choice for pre-diabetic people who are overweight. The famous Diabetes Prevention Program showed how even after ten years, the overweight group who took metformin 850 mg twice a day had an impressive 18% reduction in developing diabetes. (That’s impressive, but not nearly as impressive as the 34% risk reduction in the group that stuck to lifestyle changes: weight loss of 7%, 150 minutes a week of exercise, and diets focused on fewer calories and less fat.)

Diets

And now we finally arrive at the third controversial issue: diets. There’s so much overwhelming confusion out there, but I like to simplify it a lot by saying that it’s not so much what you eat, but how much you eat. In other words, calorie restriction is key. If you want to lose a pound a week, you need to eliminate 500 calories each day. This is basic biochemistry. (check out your specific needs using my weight loss calculator at the top right of this article). If you can do this daily calorie restriction, especially by decreasing simple carbs, great! Keep going!

But there’s an interesting newer option you may have heard about, called intermittent energy restriction (IER; the 5:2 diet). This has been trendy since 2013, with a BBC documentarybest selling book, and a British study showing how a twice a week regimen of cutting your calories (especially carbs) had similar or better results for insulin resistance and body fat than the group that followed daily calorie restriction. When we fast, even if only for 12-16 hours (nothing between dinner and lunch the next day), insulin resistance improves and fat starts to get reabsorbed. A recent review of all IER studies showed that the evidence for IER is promising — but still premature to fully endorse, with much more to learn about which pattern is most ideal, as well as long-term effects. Also, people who aren’t overweight and are trying this actually have a lot more side effects than benefits.

Otherwise, in terms of “diet”, it’s just overwhelming out there for people searching for the “right one”. An excellent review article this year does detail quite convincing evidence that a low-carb high-fat Atkins-style diet not only reduces the hunger urge, but also has clear benefits in insulin resistance, cardiac markers, and weight loss. The DASH diet really does help to lower blood pressure and weight, and the Mediterranean diet also seems to help with heart disease and some weight loss.

But again, the main issue for all of this diet talk is to focus not on food categories, but food quantity. It’s simple biochemistry: you have to have less energy intake to lose weight. Or you could increase energy output, which leads us to:

Exercise

For decades, the usual doctor spiel is to get 150 minutes a week of moderate exercise. But that hasn’t really translated into any meaningful changes nationally, has it? So here’s where another trendy (uh oh) regimen is gaining popularity, mostly because the growing research is impressive. It’s called High Intensity Interval Training (HIIT), and it basically means you go all out for 30-60 seconds on any activity, getting to maximum exertion, then take a few seconds break, then do another all-out effort, etc etc. You do this 15 minutes tops, twice a week only (typically). Check out an example in the image below from a New York Times article about a 7-minute workout, which I also blogged about in my New York Times column in China. This HIIT routine is great because it requires zero fancy equipment, and you can do it absolutely anywhere. Click here to access the online workout app.

The 7 Minute Workout. Source: New York Times

Supplements, Diets and Herbals:

This topic is actually less controversial for me, mostly because there’s an easy answer: most of those supplements have almost no hard evidence that they work well. I’m not confident enough about recommending any of the trendy ones, and that includes CLA, chromium, 5-HTP, and garcinia. I’m sure many of you are already taking some of these. You’re welcome to read the evidence, including some excellent supplement reviews by the Natural Medicines Database (paid);  The Encyclopedia of Natural & Alternative Treatments (free); The Cochrane Library; and The National Center for Complementary and Integrative Health (NCCIH).

Personally I’d much rather have my patients focus not on supplements but on calorie restriction. I’d also rather give them one of the prescription medicines above, which all have more evidence than any supplement.

If you must choose a supplement, at least you could try that OTC Orlistat with meals. And you could also consider soluble fiber such as blond psyllium. Used especially for constipation, it also helps lower cholesterol, control diabetes a tiny bit, and also help a bit with weight loss. You’d take it with food, and it absorbs fat from that meal. In fact, it’s now recommended that Orlistat users also take blond psyllium with each dose of Orlistat, as it prevents some of those unfortunate gastric effects.

Yogurt is also one of my favorite recommendations, not just for the way the probiotics help our microbiome and immune system, but also because the literature shows that yogurt helps to manage weight loss and waist circumference. I actually prefer higher fat than the low fat versions, and adding fresh fruit to non-sweetened yogurt is a great way to start your day. Add a pack of instant oatmeal, microwaved with soy milk, and you’ve got a healthy and filling breakfast.

Stand Up!

Did you know that sitting all day at work literally is harmful to your health? Recent data, including this 2015 meta-analysis of sedentary lifestyles, shows that the more you sit, the higher your risks for heart disease, obesity, diabetes and overall death rates. I just ordered a standing desk for my office! Here are more tips on how not to be a couch potato.

Use Smaller Plates

Americans definitely have suffered “portion distortion” over decades, as sizes for all types of food creep up and up. Remember how soda machines used to carry 12 ounce cans, and now all have 20 ounce bottles? How about a small popcorn at the movies? If we can’t control these external factors, at least at home we can control portion size, and one interesting step is to replace all of your usual large dinner plates with smaller plates, like the appetizer or salad plates. Recent studies, including the 2016 meta-analysis, do show that when people switch to smaller plates, they actually eat less. How easy is that?

Keeping It Off

It’s actually not super hard to lose weight — it’s keeping it off that’s the problem for most. Unfortunately, that’s a totally normal problem because our “hunger hormones” ghrelin and leptin reset to a new balance when we gain weight, and when we lose that weight, that hormone imbalance doesn’t reset well to the lower weight, and it thinks “I’m starving!” and compels you to eat more. Some tips to control this include healthy carbs, fiber, yogurt and protein (and not a high fat diet). Also, getting a good night’s sleep literally helps to reset those hunger hormones (that’s one reason why people with sleep apnea are at risk for gaining weight).

And for those who are in the higher obese categories with BMI over 35 or 40, gastric bypass surgery actually can permanently improve some of that hunger urge. How? Removing the top of the stomach in these surgeries removes the stomach tissues that secrete grehlin; less grehlin = less hunger signals = less eating = weight loss. That’s another important reason why I urge people to consider weight loss surgery.

My Bottom Line

After writing this article, I personally feel much more empowered as a doctor to help my patients lose weight. There are a lot more options than I had realized, and I’m definitely giving all of my overweight patients this article, and I look forward to working closely with my patients to help them lose weight in a healthy and permanent way. And hopefully I’ve helped you, as well!

Good luck!

A 7 Minute Workout That Really Works

“Maximum Results With Minimal Investment”. It sounds like a shady late night infomercial, but it’s actually the subtitle of a recentreview article from the American College of Sports Medicine’s Health & Fitness Journal. Titled High Intensity Circuit Training Using Body Weight, it made worldwide headlines, especially after the New York Times picked up on it. It discusses the hot topic of high intensity interval training, which essentially means a very short burst of intense exercise plus quick breaks. So instead of the recommended 150 minutes a week of moderate exercise or 90 minutes of strong exercise, you could spend 15 of HIIT, three times a week — and get similar health benefits. Is it too good to be true?

Let’s step back a minute and review the benefits of exercise. Most guidelines, including those from the U.S. CDC, recommend a combination of aerobic activity and muscle strengthening activity based on extensive research showing strong evidence of exercise lowering risks of early death; coronary heart disease; strokes; high blood pressure; diabetes; colon and breast cancer, among others. Even 90 minutes of moderate exercise lowers your risk of premature death by 20%; more is better but the effects start to tail off after 300 minutes, maxing out at 40% reduction.

But very few of us achieve even 30 minutes a week, much less the 90 or 150 minutes recommended. Physical inactivity is one of the world’s leading risk factors for disease, ranked #6 in the USA and #10 in China. That’s why any research showing benefits with less time committment is crucial for our modern societies, all increasingly less active. HIIT got its first boost in 1996 when a Japanese research team led by Professor Izumi Tabata compared moderate intensity training of 60 minutes versus a 4 minute high intensity training on stationary bikes. The HIIT group not only had a similar increase in aerobic activity but also had a much better improvement in anaerobic activity. One study published in 2011 from the Department of Kinesiology and Health Education, Southern Illinois University tested overweight college students and found that just one 15 minute session of high intensity activity changed their resting energy expenditure (metabolic rate) for 72 hours. This was just as effective as a more routine 35 minute workout. Another study from the Faculty of Medicine, University of New South Wales showed that a 15 minute HIIT workout three times a week, compared to more traditional longer workouts, actually had better outcomes losing total body fat as well as insulin resistance. I consider these latter improvements very significant as diabetes continues to skyrocket right along with obesity in most countries.

When it comes to exercise, I confess I am much more sloth-like than a fitness freak, so I love the idea of a quick fix for health which actually works. I first heard about HIIT last autumn and started to do a 5 minute routine each morning. I went all out for 30 seconds performing as many squat thrusts as I could, then took 10 second breaks, then repeated 10 times for a total of 5 minutes. I confess that I stopped this routine after a month, as I do with most of my ambitions for exercise. But I definitely had felt stronger and more alert during those weeks, and I certainly felt that achy muscle sensation after these sessions. Last week I started this newly publicized 7 minute routine, combining 30 second intervals with circuit training. With circuit training, you rotate your exercises between focused muscle groups, and finishing the entire routine ideally will have covered all muscle groups. You can choose any exercises for HIIT, but one additional benefit of this particular cycle is that you don’t need any weights or machines, just your own body, a wall and a chair. You can perform this anywhere, from your hotel room to your office and home. Here’s an image of the routine, from the original New York Times page:

Each exercise should be done for 30 seconds, with 10 seconds of rest in between, for a total of 7 minutes and 30 seconds. You could also repeat this cycle one of two more times for added benefit. It’s important to take these very short breaks as it increases the healthy metabolic response. You will definitely need help keeping track of these seconds, and I found a wide collection of apps for smartphones and tablets which can be custom set to beep at the correct intervals. Just search your app store for HIIT, Tabata or “interval timer” and take your pick.

The key here is to really push yourself, not take a leisurely pace. In terms of intensity, most of these research papers’ recommendations mention “unpleasant” or “discomforting”. Many papers also mention something called VO2max, which is officially measured using oxygen sensor machines but otherwise generally correlates to 100% of your maximum heart rate. Thus we all should know our maximum heart rate, and fortunately this is easy to calculate. You can find online calculators, otherwise you can do the calculation yourself. The formula for maximum workout heart rate, calculated in a 2001 research paper, = 208 – .7 * age.  For example, I am 45 years old and my maximum heart rate (VO2max) is 208 -.7*45 = 177 beats per minute. If I wanted to reach the 150 minutes a week goal of moderate exercise, my target heart rate for moderate exercise would be 60% of max: 0.6 x 177 = 106 beats per minute. The recommended target for more intense exercise is 80% of max, which for me is 142. I usually get up to this rate with a thirty minute treadmill or elliptical machine workout, and quite honestly it didn’t feel too uncomfortable at all. For the more aggressive HIIT therapy, shooting for 90-100% maximum heart rate works out to 159-177 beats per minute. After I performed the above routine I definitely felt a bit “unpleasant” with a pulse of over 160 — exactly where I should be.

So now I’ve finally run out of excuses for not exercising. I can simply get up 10 minutes earlier each day or just be more efficient in the morning, and perform one or two cycles of this routine, ideally three times a week. Add this to my bicycling to and from my clinic and I can finally hold my head up high when I give my standard lifestyle lecture to my patients.

I think this type of evidence-based exercise research is powerful and certainly has altered my usual speech to patients. I previously would always mention the usual recommended minutes of exercise (150 moderate, 90 intense) but now can make it even more appealing: 15 minutes, three times a week. Certainly this wouldn’t appeal to people who already exercise or play sports. And data is still lacking on the long-term benefits and risk reductions from HIIT. But for the silent majority like myself who do almost no activity, HIIT routines are clearly far better than nothing, and could save millions of lives worldwide.

 

My New York Times Chinese version is here.

Combating the Common Cold: What Herbals Work?

Isn’t it humbling that we have no cure for the world’s most common illness? Yes, the common cold, globally the #1 cause of sick days and doctor visits, still stampedes across the world, blissfully immune to any Eastern or Western prescriptions. As a family doctor, I’m always a bit frustrated that I can’t offer much to these patients, at least in terms of Western allopathic medicines. So, I decided to scour the literature again to see if any new research has shown benefits from herbals and supplements. And the good news is yes: there may actually be a couple of supplements which can help you get better, quicker. Here’s my advice below. (Please note that this research is for treating, and not preventing, colds and flu.)

Evidence-Based Literature Search

When it comes to supplements and natural therapies, I use only a tiny handful of resources that I consider trustworthy. All are certified by the Health on the Net Foundation as sources of trustworthy medical information. All these sites would review only the best, most unbiased research, which usually means the gold standard of all research: placebo-controlled, randomized controlled trials. I strongly recommend that everyone use HONCode’s search engine anytime you’re looking for medical advice, especially regarding supplements. For example, you’ll never see the anti-vaccine snake-oil salesman Dr. Mercola on their list. Here are my favorite medical resources, and their evaluations of therapies for the common cold:

Cold_symptoms_cdc
A graphical image and time line for cold symptoms. Note how the cough is always the last to improve…

 

Let’s break it down into the supplements that have the most evidence:

  • Zinc: This seems to have the most support, especially higher doses (>75 mg daily) of lozenges containing zinc gluconate or zinc acetate. Some good studies show reduction in cough, runny nose, headache, sore throat and overall time of illness. But side effects are common, especially nausea and a bad taste in the mouth. Also, definitely do not do the zinc nasal sprays, which have clear evidence to permanently cause loss of smell. The data suggests you should stick with lozenges and not pills. I see a few brands of logenzes up to 23 mg each, which at three times a day would help. The test results from ConsumerLab show 23 mg in Nature’s Way Zinc lozenges, and 13.8 mg in Cold-Eeze Cold Remedy Lozenges (but much more expensive). I see a few popular brands with only 5 mg zinc each, which seems far too low to work. I wouldn’t advise using these for children.
  • echinaceaEchinacea: This is probably the one you’ve heard about, and the evidence is encouraging — but not totally clear. Some “double-blind, placebo-controlled studies have found that various forms and species of echinacea can reduce the symptoms and duration of a common cold, at least in adults. The best evidence is for products that include the above-ground portion of E. purpurea rather than the root.” But it’s very difficult for me to recommend a proper dose, as studies have used multiple regimens via drops, pills and teas, also using many types of echinacea, as well as different combinations of root and plant. Here’s a useful list of test results from ConsumerLab showing which brands in the USA have proper amounts of the herb.
  • andrographisAndrographis peniculata: An Indian herb very popular in Ayurvedic medicine and now in Europe, I think this actually has some good evidence.  A handful of double-blind, placebo-controlled have shown benefit in reducing the duration and severity of cold symptoms, especially cough. An excellent meta-analysis of herbals from Germany showed significant improvement in severity and duration of a cough, especially via liquid formulation. The usual dose seems to be 48-500mg of the andrographolide aerial parts, usually divided three times a day. You can find a good list of andrographis brands on iherb.com. I keep reading about a Swedish patented combination with eleutherococcus and sambucus (Kan Jang Plus), but I don’t see it sold anywhere in the USA.
  • pelargonium-409238_960_720.jpgPelargonium sidoides (Umckaloabo): This is an interesting herbal, very popular in Europe and perhaps should be more popular here in the USA. That same German meta-analysis I mentioned above found strong evidence that it helped with cough, fevers, and sore throat — including for children as young as one year old, although the German independent Institute for Quality and Efficiency in Health Care says it shouldn’t be used for children under six years. The Cochrane Library also reviewed this herb and concluded, “P. sidoides may be effective in alleviating symptoms of acute rhinosinusitis and the common cold in adults, but doubt exists.” As with andrographis, the liquids and syrups were better than tablets. I see on iHerb a series of pelargonium products called Umcka with good reviews.
  • Probiotics: Probiotics actually have pretty good evidence that taking them for months, especially over the winter, can markedly improve both the frequency and the severity of colds — for kids and for adults (as does vitamin D). That’s great news! But for symptom relief during a cold, the evidence is much more scant. I couldn’t find one good study for this; none of the groups above recommend probiotics as treatment.
  • Vitamin C: Here’s another super popular supplement, which many people swear by. But again the evidence isn’t conclusive, and the few studies that do show a benefit show only mild improvement. Still, at least it seems safe for adults and children, and evidence is even stronger as a preventive during the cold seasons.

cold-1974481_960_720

My Bottom Line

For immune boosting,  don’t forget the most important advice: get a good’s night sleep; eat a lot of anti-oxidant foods; and stay well hydrated.

In terms of supplements, I think it’s appropriate for adults (not kids) to try some of the above supplements — and the sooner, the better, within 24 hours of your symptoms starting.

For what it’s worth, here’s my plan for myself and my wife the next time we get a cold: we’re going to continue our usual vitamin C + zinc bursts, usually using Airborne effervescent tablets, three times a day. Emergen-C and Wellness Formula also are similar, all three with a ton of vitamin C, some zinc and an assortment of herbals, many of which are mentioned above. I’m also adding andrographis 400mg twice a day and also pelargonium; and I’ll continue doubling up on my probiotic supplement, despite the lack of evidence. (One small note: last week my wife tried andrographis for the first time and had a horribly itchy rash for days. I was fine.)

In general, for children, I’m still hesitant about using any of these herbals for children under 6 years old, and I remain cautious about what I use with my own kids, both under 4 years of age. I still like probiotics during a cold, and I’m a big fan of honey for cough for all ages above one year, which studies show works better than any OTC syrup. I’m encouraged with the European studies using pelargonium and also ivy/primrose/thyme syrups, some of which are partially included in American brands like Zarbees. For more age-specific advice, please look at the recommendations in my previous article about curing a cough.

What herbals and supplements have you used? Please leave comments below.

 

Supplements for Arthritis Pain: A Review

I just turned 49 in March, which was no big deal. But when I realized that I’d turn 50 next year, I suddenly felt an anxious pang of — something. Mortality? Life winding down? Being put out to pasture? Fortunately, it was difficult to brood too long with two toddler boys running me around in circles (literally). In general I’m extremely grateful for my good health, but I know that as the years go by, I’ll get aches and pains somewhere in my joints, as it does with most of us when we age.

In my family medicine clinic I take care of many patients with painful arthritis, struggling to maintain a healthy and active lifestyle. Most manage with the usual acetaminophen and NSAIDs, but for many that’s not enough. Quite a few are on much stronger pain medicines, dealing with their many side effects. So it’s no surprise that so many try supplements that are alleged to help with the pain and mobility. But which ones really work, and which are a waste of money? To help my patients better, I did a literature review, and I’d like to share what I learned with others. Please feel free to share this with your colleagues and loved ones. You can also download and print a PDF version here.  (please note that this review discusses osteoarthritis and not rheumatoid arthritis, a much more serious inflammatory disease).

Don’t Forget The Basics

I can’t stress enough how no supplement is as important as keeping your bones healthy from a healthy diet and exercise. No matter your pain levels, multiple studies show long term benefits with light activity and mind-body exercises such as tai chi and yoga. And a healthy diet full of calcium and healthy anti-inflammatories (fruits and vegetables) is also crucial. All women should also make sure they’re getting enough calcium and vitamin D, at all ages.

Swan_neck_deformity_in_a_65_year_old_Rheumatoid_Arthritis_patient-_2014-05-27_01-49

And since obesity is a major cause of arthritis, especially in the knees, it’s always important to lose weight, no matter your age or what medicines you’re taking.

Having said that, here’s what I found about supplements:

  • Glucosamine and chondroitin: let’s discuss this first, as this combination is very popular. People may be surprised that the evidence actually isn’t as strong as most people think. One reviewer says “it appears that most of the positive studies were funded by manufacturers of glucosamine products, and most of the studies performed by neutral researchers failed to find benefit.” What seems certain from reviews such as Cochrane is that you should stick with glucosamine sulfate (the “Rotta preparation”) and not glucosamine hydrochloride; fortunately most formulations seem to have the first, more effective one. I was intrigued by the two studies that show possible actual improvement in joints — but these studies were sponsored by the drug makers, and many other studies don’t show much improvement, if any.
    Most of my primary care colleagues are unenthusiastic about this supplement. Still, I think it’s reasonable to try this for three to six months at the most, and if people see no improvement at all in pain and movement, they should just stop it. The usual dose seems to be 1,500 mg of the glucosamine sulfate. The price isn’t so bad, either; for example, a generic from Costco is only $6.40 a month. One note: most seem to also combine MSM, and while the evidence for this supplement is very poor, at least there’s no reported harm.
  • SAMe (s-adenosylmethionine): I’m more impressed about SAMe than glucosamine for osteoarthritis; the Natural Medicines Database says that “multiple clinical trials show that taking SAMe orally is superior to placebo and comparable to NSAIDs, including the COX-2 inhibitor celecoxib (Celebrex), for decreasing symptoms associated with osteoarthritis. SAMe is associated with fewer adverse effects than NSAIDs and is comparable in reducing pain and improving functional limitation.” But one limitation could be the cost: most studies used 600-1200 mg daily, and taking 400 mg twice a day using the best values on iHerb (for example) would be at least $45-50 a month. But some studies using only 400-600 mg a day, even for up to two years, showed effectiveness, bringing your monthly cost to a reasonable $20. SAMe is reported to take up to a month to notice a difference. But otherwise, this could be a good option for many. If you take it for three months and don’t notice any help, you should just stop it.

Those two supplements seem to have the most research, and probably should be tried first. The next level of research includes:

  • Curcuma_longa_roots_turmericTurmeric: This wonderful spice seems to have some health benefits, including alleviating pain. There are a few double-blind studies which do show improvements in pains, similar to improvements from NSAIDs like ibuprofen, with less risks to the stomach. Most studies used 1,000 mg a day, which usually would be 500 mg twice a day. There seem to be a few formulas which combine ginger and boswellia, which could be a better value.
  • Boswellia_sacra_-_Köhler–s_Medizinal-Pflanzen-022Indian frankincense (boswellia):  This is another ancient Ayurvedic medicine which has a few randomized studies which show benefit for arthritis pain and function, comparable to the usual NSAID medicine. Benefits also seem to last up to a month after stopping the medicine, which is much better than an NSAID, which stops working immediately. It takes about a week to start working. There aren’t a lot of studies, but it’s promising, and perhaps worth a try. The dose seems to be 100-300 mg a day, divided into two doses.
  • Avocado Soy Unsaponifiables (ASU): This oil extract is a very interesting chemical, as researchers are excited that it may actually heal damaged cartilage, or at least slow down progression of damage (here’s a good review article). And a few RCT studies have shown reductions in pain and stiffness while improving joint function. But a longer study didn’t show much benefit, and other studies haven’t found improvements in the joints. It also may take a few weeks to notice an effect. Still, this could be an interesting option if you’ve already tried and failed the more traditional supplements. The usual daily dose seems to be 300-600 mg daily.
  • ginger_spice_freefoodphotosGinger: Here’s another wonderfully fragrant root which also seems to benefit arthritis — but the evidence is relatively limited, and it also seems to take more than three months to notice a benefit. There are also quite a bit of side effects, especially if patients are also taking blood thinners like coumadin, aspirin or NSAIDs. I’d be hesitant to try this one as a supplement — but it sure is lovely in food!
640px-Tai_Chi_Chuan_at_Temple_of_Heaven_on_a_Sunday
Tai chi

General Consensus?

Let’s now step back a bit and review the evidence, especially from my favorite evidence-based sources, all of whom are certified by the Health on the Net Foundation as sources of trustworthy medical information. By the way, I strongly recommend that everyone use their HONCode search engine anytime they’re looking for medical advice, especially regarding supplements.

Where To Buy? 

I’m a big fan of Costco’s supplements for value and quality; for online purchases, the iHerb website is much easier to use than simply using Amazon, with very good prices and free access to The Natural & Alternative Treatments database. iHerb is also fantastic for shipping to other countries; when living in China, we used iHerb constantly, for very little added shipping cost.

And since there’s such a a wild range of active ingredients in these unregulated herbals, I highly recommend the independent ConsumerLab.com, as they’ve tested thousands of supplements and have objective data which brands are the best, for both quality and value.

My Bottom Line

In general, if your supplement does no harm, and has some evidence it may help improve pain and your quality of life, why not try?

Don’t forget first to make sure your supplement doesn’t have bad side effects with your prescription drugs: you can use the free multi-drug interaction checker from Medscape here, which is savvy enough to include supplements as well as prescription drugs. And don’t forget to tell your doctor which supplements you use! They definitely need to be aware of potential side effects and drug interactions (especially those blood thinners).

I think for most people with osteoarthritis, trying a supplement on top of your usual treatments is perfectly reasonable. I’d start with three month trials of glucosamine-chondroitin sulfate, and then SAMe. Next choices could include boswellia, ASU or turmeric. And if if works, keep going with it, and you can consider adding a second supplement for extra benefit. Good luck!

What do you use, or prescribe? Feel free to leave comments below. 

Alcoholism: A Family Scourge

I miss my father. He should be around to be granddad to my wonderful boys, helping me raise them to be good men. But he’s not around, dying far too early, from alcoholic cirrhosis of the liver. Only in his mid-60’s, he was a wonderfully warm-hearted man with a deep belly laugh, very much the average-guy Martin Crane to my Frasier Crane-like stuffiness. But he was also an alcoholic who slowly drank himself to death.

I have countless fond memories of us over the years, but I also have nightmare memories of holding his hand as he died in the hospital, in a coma, his skin yellow and lungs filled with fluid as his kidneys and liver finally gave up from the years of toxic abuse. These are memories that no child should have — but so many do.

My father

Why is alcoholism such a scourge to society? When compared to many other common diseases such as heart disease, alcoholism has a much more devastating social effect — not just on that person, but also their family, who painfully watch for years, helplessly, as their loved one slides into decline. Yes, many diseases are terrible and affect others; smoking can cause secondhand smoke diseases to family members. But alcoholism is a sad disease, and it’s those bad memories that really haunt families of alcoholics — memories of being afraid as we weave across wintry roads as dad drives home tipsy; memories of mom crying as dad refuses to hand over the car keys; memories of watching his belly get bigger and his memory weakening as his liver starts to fail.

So as we honor Alcohol Awareness Month this April, I’d like to use this opportunity to spread the word about alcoholism, hopefully to help a few people out there.

The first step, as anyone in 12-step programs will tell you, is to admit there may be a problem. If you’re not sure, just answer these four simple questions:

  1. Have you ever felt you needed to Cut down on your drinking?
  2. Have people Annoyed you by criticizing your drinking?
  3. Have you ever felt Guilty about drinking?
  4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

If you’ve answered “yes”  to 2 or more, then you indeed may have a problem with alcoholism and may already be causing liver damage. These questions above are called the “CAGE questionnaire” and are used by doctors as a screening tool for alcoholism.

What If You May Be Alcoholic?

First of all, congratulations if you’re honest enough to admit you may have a problem. Secondly, you need to know that you are not alone, and many people and organizations can help you:

  • Your family doctor can check out your liver and kidney health.
  • Some newer medicines, like naltrexone, may actually help you quit drinking; your doctor can discuss these with you.
  • Twelve step programs such as Alcoholics Anonymous aren’t for everyone, and there’s contradictory evidence as to how effective they are. But for many recovering alcoholics, they’ve been a source of strength, all over the world. You can find a list of AA sites in the US here.
  • Psychologists and psychiatrists can help you in many ways, from quitting drinking to processing underlying stresses and depression, to fixing family and job problems related to your drinking.

    dad on the twins second birthday
    My dad with us, at 2 years old. That’s me on the right (I think)

My Dad’s Legacy

Clearly, living through my dad’s illness has had a profound influence on me as a doctor, and I do find myself drawn to these patients. I’m sure it’s partly an effort to make up for what I couldn’t do for my own dad.

But despite all the pain of those later years, my strongest memories are the good ones. I will always remember his laugh, and to this day I vividly remember how he could light up a room. I’d like to end with a poem from Ralph Waldo Emerson, which we used at his wake:

To laugh often and much;
to win the respect of intelligent people
and the affection of children;
to appreciate beauty;
to find the best in others;
to leave the world a bit better
whether by a healthy child,
a garden patch, or a redeemed
social condition; to know even
one life has breathed easier
because you have lived.
This is to have succeeded.