Category Archives: Prevention

Obesity: 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:

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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. The summary graph is here:

JAMA-weight-loss
Source: JAMA. 2016;315(22):2424-2434

The take-home message from this review is as follows:

  • The medicine phentermine/topiramate (Qsymia) is the most effective at weight loss, 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 more side effects, and also some debate about its safety with heart disease.
  • The OTC medicine orlistat (Xenical/Alli) is the least effective, 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, 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.

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.

Diabetes: Healthy Lifestyle Choices Are Key

I’ve been a family doctor for fifteen years, and one of the more dramatic changes I’ve noticed is a big spike in the incidence of prediabetes and diabetes, in all age groups. I had worked in China for ten years until last summer, and all us family doctors at my Beijing clinic weren’t surprised at all with the 2013 paper published in JAMA confirming the frightening reality in China: more than half of all adults in China now are prediabetic. Even worse, 11.2% have diabetes, giving China the dubious distinction of having the highest prevalence of diabetes in the world — higher than in the USA, an extraordinary statement given the far higher rate of obesity in the USA. As this epidemic spreads,  I felt a timely urgency to share my advice on how to avoid this disease – or at least to slow it down.

It helps me to think of diabetes as a modern lifestyle disease, mostly caused by all developing countries’ gains in weight, less physical activity, and changes in diet. Diabetes now is a global pandemic. Tens of millions of people have diabetes, and many people are undiagnosed because they’ve never been tested. There are two types of diabetes, and type 2 diabetes accounts for 90 to 95 percent of diagnosed diabetes in adults.

Prediabetes concerns us doctors because it means you are at extremely high risk of developing diabetes in the next few years. Studies show that a prediabetic person has a 25% risk of developing diabetes within three years, and a majority within ten years. The greatest risk factor by far is overweight and obesity. Having a BMI under 23 is ideal, and a BMI of 25 increases your lifetime risk of diabetes by 600%. A BMI of 30 increases your risk by 4,000% — that’s 40 times the risk! That’s an extraordinary number which should worry us all, since in the USA over two thirds of adults are overweight and over a third are obese.

But here’s the good news: the crucially important message for everyone is that you have great control over whether or not you develop full diabetes. You should think of prediabetes as an early warning sign by your body, a major wake up call that whatever you’ve been doing to your body isn’t too healthy. Most people with prediabetes fit one or more of these three major risk factors: body mass index (BMI) over 25; lack of enough exercise; and unhealthy food choices as well as portion sizes.

So let’s say that you’re one of the many people who has prediabetes: what can you do right now to help? If you follow the three lifestyle steps below, you can lower your risk more than half! One of the most important public health research studies ever, the Diabetes Prevention Program, proved that lifestyle changes worked better than pills in reducing progression to diabetes. Lifestyle changes lowered a prediabetic person’s risk by 58% over three years — much better than the 31% improvement with a daily pill (metformin).

So what are these magic steps? Without further ado:

  1. Lose weight. Weight gain and obesity are the top causes of type 2 diabetes, and losing weight is now proven to be the most effective prevention. In the DPP study, the goal was to lose at least 7% of your body weight. Your goal should be to lose 5-10% of your body weight.
  2. Exercise. Exercise may not directly cause much weight loss, but exercising muscles absorb sugars much more effectively. This is why exercising is crucial to help control sugars, both in a prediabetic as well as in diabetics. How much exercise is enough? We usually recommend 150 minutes a week of moderate exercise, but any amount is better than nothing. Also, as I mentioned in an earlier column, shorter, more intense workouts can help as much as moderate exercise.
  3. Proper diet. Healthy food choices also are crucial to control your sugars. One of the most common misperceptions about diabetes and prediabetes is that it’s “a sugar problem” and you must cut down on sweets and desserts. The bigger culprit are total starches — pastas, breads, rice and potatoes. In all these cases, processed versions are never as healthy as the originals.

Here are a few quick tips on nutrition:

  • Brown is always better than white: Processed white bread and flour have lost all the nutritious fiber which helps regulate your bowels as well as your sugar spikes after a meal. If you love your carbs, at least try to switch to whole wheat pastas, breads and rice.
  • Portion control: Total calories are also important, as most likely you are taking in a bit more than you realize. These extra calories will get deposited as fat, which leads to more risk of diabetes.
  • Cut back on sodas, beer and juices: All of these are empty calories, full of processed sugars which stress out your liver and pancreas. These unhealthy carbs, especially in sodas, are a major cause of obesity and diabetes in both children and adults.

Type 2 diabetes is partly genetic, so no matter how healthy you are, it still may be inevitable. But these above steps are always good advice for all of us. Another great thing about these healthy life changes is that they also dramatically reduce your risk of heart disease, many cancers, and early deaths from all causes.

Don’t get discouraged — you have control over the next steps!

Not Sleeping Well? Here’s My Advice.

This week, March 6 – 13, is National Sleep Awareness Week, so it’s a good time to review healthy sleep habits. I see a lot of adults and teens in my clinic who are chronically tired and have troubles sleeping — both falling asleep and staying asleep.

How Much is Enough?

According to the National Sleep Foundation’s research, here’s the amount of sleep we need:

  • Newborn (0-3 months): 14-17 hours
  • Infant (3-12 months): 12-15 hours
  • Toddler (1-2 years): 11-14 hours
  • Preschool (3-5 years): 10-13 hours
  • School age (6-13 years): 9-11 hours
  • Teenager (14-17 years): 8-10 hours
  • Adult (18-64 years): 7-9 hours
  • Older adult (>65 years): 7-8 hours

One of the main problems with insufficient sleep is the daytime sleepiness, an obvious consequence of not sleeping enough. A fascinating series of tests in children showed that insufficient sleep and daytime sleepiness both lead to worse school performance. Most of these children went to bed at 9-9:30 am and almost all got up at 7 am, causing a daily sleep debt of 1/2-1 hour for many children. While that may seem like a small amount, like any debt, it must be paid back, and most children cannot recover all of this lost time by sleeping late on weekends.

One good bit of news from the same study describes how delaying school start times even by just a half hour can significantly improve sleep duration and daytime sleepiness. In their interventional study with six primary schools in Shanghai, delaying school openings from 7:30 to 8 or 8:30 gave the children almost an hour of extra sleep — and more importantly, less complaints of daytime sleepiness. This fits with studies in other parts of the world and supports the growing movement, led by pediatricians, to delay school opening times to 8:30 am. Just doing this could allow better sleep and improved test scores for all students!

Besides school performance, poor sleep also leads to an increased risk of overweight and obesity in children (as well as adults). A 2007 meta-analysis of 36 studies across the world showed a strong, independent association between short sleep duration and weight gain in children, which continues into adulthood.

For adults,  poor sleep can cause long-term problems with high blood pressure, depression, diabetes and obesity. It can also cause dangers such as sleeping behind the wheel or more errors at work (medical training and internships are notorious for this, as are night shift workers driving home).

My tips for sleeping well

Get all screens out of the bedroom. Technology is changing so quickly that it’s difficult for research to keep up. But it’s clear that many people are having a lot more sleeping troubles when using their iPads and cell phones at bedtime. It’s partly because their backlight alters our sleep hormones, but also it’s distracting us with answering text messages even after lights out. I think a great general rule, for adults and kids, is no screen time two hours before bedtime (that includes TV), and definitely get all screens out of your bedroom while you sleep.

Exercise often — but early. Exercise has been shown to improve sleep habits, but only if done at least four hours before bedtime. Otherwise, you still may have too much metabolic energy and will have trouble falling asleep. This is also a good tip for kids who are having sports practices late into the night.

Avoid alcohol and smoking before sleeping. Alcohol is a major cause of insomnia for many. Drinks will certainly make you sleepy, but your body will rebound and wake you up in the middle of the night. It’s far better to have only a drink or two, at least 2 hours before bedtime. Smoking causes the same problems; that initial relaxation quickly wears off and the nicotine stays in your system for hours.

Caffeine is another major cause of poor sleep. As we get older, we cannot handle the triple-shot cappuccinos which we had in college, and it’s very common to have poor sleep with any caffeine drinking after lunchtime. So if you’re having light sleep, definitely take a look at your caffeine habits first; any tea, sodas or coffee after lunch may be keeping you awake. If you must have your afternoon coffee, at least try to switch to decaf.

Other tips include not staying in bed if you can’t sleep. If you can’t fall asleep, after 20 minutes of trying you should get up and try to relax in another room. Staying longer in bed generally makes you more anxious, making it even harder to fall back asleep.

Take a nap. Napping, even if only 20-30 minutes when needed, has been shown to have great benefit for short term memory and concentration. As I get older, I definitely lag more in the afternoon, and a 15 minute power nap at lunch really helps me get through a busy clinic afternoon (as does a lighter lunch).

What about natural medicines and non-prescription pills? Many people use over the counter pills such as Tylenol PM. It does work well, in the short term, for many people — but I strongly advise not taking it regularly, as the Tylenol component is totally unnecessary and can cause liver problems if taken chronically. If you must use this medicine, please buy only the active ingredient, diphenhydramine (Benadryl) separately and only use that. As for natural medicines, melatonin works for some types of insomnia but is rarely very effective. Others may consider an herbal capsule with valerian and other compounds such as passionflower, hops or lemon balm.

 

 

Rubber Ducky You’re The One — To Cause Diabetes and Cancer?

My boys are now both over two years old, but they still like the occasional chew on their toys, which are mostly made of plastic. Rubber duckies, Lego men, Brio trains — it’s still a ton of fun to put in their mouths if it makes mommy and daddy really mad. I choose my battles with them, but I try to stop them partly because I’m worried about the chemicals in the plastic. Surely, microscopic parts of that plastic must be getting into their systems? One set of bath toys was very typical, made in China but exported to America, from a company vowing they are “safe and dependable”, with standards that “meet and exceed” US laws. What exactly does that mean? What are these laws? Should I be worried? And just how well can I or any parent protect our children from all environmental harms?

When I think about our modern world’s reliance on chemicals and plastics, I’m reminded of what Donald Rumsfeld called the “known unknowns” – we know that we understand almost nothing about the safety of the 80,000 consumer chemicals created since World War II, because they’ve never been required to be tested on humans. As the WHO states in their 2012 report State of The Science of Endocrine Disrupting Chemicals, “the vast majority of chemicals in current commercial use have not been tested at all.

bathtoy

The chief concern is that some of these chemicals are endocrine disruptors, which are chemicals whose molecular structure is similar to our natural hormones. With this mimicry, they can bind to the same receptors that our natural hormones do, thus altering our normal endocrine activities which control  just about every aspect of our health. We are mostly worried about children because these endocrine disruptors could cause permanent damage during our most sensitive growth spurts: while still developing in the womb, and later during puberty. The most notorious example of an endocrine disruptor is diethylstilbestrol (DES), a synthetic estrogen which was given to many pregnant women in the decades after World War II as a treatment to prevent birth complications. But slowly it became clear that many newborn girls of these mothers were getting a rare vaginal cancer, and DES was banned and declared a carcinogenic — but even right now many of these same “DES daughters” are continuing to have reproductive health problems both for themselves as well as in their own children, which means some endocrine disruptors can permanently alter our DNA, affecting generations.

The US Endocrine Society published an even more damning document, their 2015 Scientific Statement on Endocrine-Disrupting Chemicals, which concludes that

…there is strong mechanistic, experimental, animal, and epidemiological evidence for endocrine disruption, namely: obesity and diabetes, female reproduction, male reproduction, hormone-sensitive cancers in females, prostate cancer, thyroid, and neurodevelopment and neuroendocrine systems.

The prestigious JAMA Pediatrics published their own review of endocrine disruptors in 2012, essentially agreeing with the WHO’s assessment that while hard data on humans isn’t very strong, there’s enough concerning data to conclude that “efforts to reduce EDC exposure as a precaution among pregnant women and children are warranted.” Chemicals such as BPA, PVC and phthalates are most often mentioned as causing harm in boys and girls, associated with infertility, obesity, cancers and neurodevelopmental problems such as behavioral issues and a lower IQ.

Plastic ID Codes and Properties. Source: tinyurl.com/o487x9o
Plastic ID Codes and Properties. Click to enlarge. Source: tinyurl.com/o487x9o

So what can we all do to protect ourselves? After all, everything we touch almost literally has plastic as part of it. I’ve found a few consumer groups and blogs that offer helpful advice for worried parents. My favorite is The Soft Landing blog, which has a very useful collection of safer product shopping guides. The Pediatric Environmental Health Specialty Unit also offers similar advice. Here’s a small summary of what most are advising:

  • Try to buy products (especially for babies) that are free of BPA, phthalates and PVC (The Soft Landing website has great blog lists).
  • Switch all your plastic food containers to glass.
  • With the Plastic Coding System, avoid numbers 3, 6 and 7 and try to use numbers 1,2,4 or 5.
  • Consider buying organic produce to reduce exposure to pesticides..
  • If you must use plastic cling wrap, only use PE wrap; minimize contact of cling wrap plastic with the food; and try not to microwave with the plastic on it. Especially don’t let the plastic sit on top of liquids, whether cold or hot.
  • Reduce indoor dust exposure by cleaning carpets and dusty surfaces regularly using a vacuum cleaner with a high-efficiency particulate air (HEPA) filter.
  • Always immediately transfer your restaurant leftovers into glass containers at home, and never reheat your leftovers or eat directly from takeaway plastic containers.

We’ve put most of these into practice in our home, so I feel a bit less stressed about this issue.  And the boys’ bath toys? While The Soft Landing blog reassuringly listed them on their list of safer bath toys, their own company rep emailed me to confirm they are “BPA-free, phthalate-free, and non-phthalate PVC”. So I am letting them munch away — for now. Choose your battles…

Why I Became A Family Doctor

I am a family medicine doctor – but that is only a small part of who I am. Father, husband, photographer, social media guru, writer, singer — these are only a few of the many ways I define myself. But when I am on my deathbed, hopefully many decades from now, and looking back on my life, what will I list as my top accomplishments? What will resonate deep in my heart that I’ve lived a full life? Would it be my career? Actually, yes, this would be partly true. Of course my most satisfying moments will be a legacy of family and children, and I’m happily on that path. I am sure that I won’t find any more joy than surrounding myself with my wife, children and future generations. But regarding a career, I am extremely fortunate that I truly love my job and derive deep satisfaction from my 9-to-5 career. Very few people can say that about their job. Can you? And if you can’t say that, then perhaps you should do what I did – change your career path. It’s never too late.

Becoming a family medicine doctor was a second career for me, a life-changing decision that I made far after my undergraduate years at Columbia University. I never grew up thinking about becoming a doctor. My wonderful parents were very American in their approach to raising their four children – very hands off, letting us all figure out our career paths on our own, no matter how late we were in deciding. I almost wish my parents did have a bit more Chinese “tiger mom” strict parenting style and had guided me with a firmer hand while growing up. But now that’s neither here nor there, and I consider myself a much more well rounded person by becoming a doctor later in life.

Alex at my clinic

My desire to have a career helping people started during my high school days with two pivotal events. The first was my two year stint in Peer Ministry, where I and other students hosted weekend or overnight events and meetings with other teens, from schools across our state of Massachusetts. Our mission was mostly to help other teens cope with typical teenager struggles: parents, relationships, self esteem and the like. During these wonderfully open sessions, I blossomed into a self confident young man, finding deep satisfaction in helping others with their problems.

My second pivotal event occurred during my sophomore year of high school, during a student trip to the poor towns of West Virginia state, filled with old, abandoned coal mines. We helped rebuild homes and also assisted in teaching Bible school to a group of seven year old kids. They were too young to really understand Bible stories, but I had loads of fun dressing up as a cow and crawling around the gymnasium floor, with two dozen adorable kids happily crawling behind me, mooing and ringing their bells. I felt a deep emotional satisfaction bringing joy to those kids, and even right now I can still remember that feeling I had during that all too short week.  A child is a miracle of hope and happiness!

Ever since those two pivotal events in my life, I had tried to find a career that could recreate that deep emotional satisfaction from helping others. In high school I enjoyed and excelled at math and science and was considering becoming an engineer (not a doctor). I also was thinking that if I became skilled at these sciences, I could later become a professor and teach others. So I was thrilled that I got into Columbia University’s College of Engineering, and off I went to New York City. annual tailored health check New York City was an intense new world for me, but I definitely felt like a “country mouse in the city,” overwhelmed by the city’s intensity. It took me a while to find my groove, and I soon realized that my Columbia College friends were having a lot more fun than I was in Engineering. My liberal arts friends filled their days reading classic books, taking in the theatre, and discussing politics. How much more exciting for me! I decided to switch from the Engineering College to the Liberal Arts College, eventually graduating with a Bachelor of Arts in English. I especially loved my senior year, sitting on the great lawn in Central Park and reading Plato and Hunter Thompson in the glorious spring sunlight. It was there at Columbia that I honed my writing skills, mostly focusing on creative writing and drama. I especially loved my senior year when I wrote and acted with a hilarious and talented group of students for a comedy TV show. We called it “The Velveeta Players” because it was so cheesy! (Velveeta is a famous American brand of processed cheese).

I graduated from Columbia with an English degree and great enthusiasm for my future, but I still wasn’t sure which career path was best for me. I still loved the idea of teaching, but I didn’t feel like a master in any subject enough to teach. I loved to write and edit, but even a Columbia grad needed to start entry level in a publishing house, slowly climbing the career ladder. I moved back home, looking for editorial work in Boston, when my identical twin brother volunteered for a sleep research study at Harvard University School of Medicine, spending 35 days and nights there. He made quite a bit of money doing this, and the doctors were thrilled at the chance to perform sleep deprivation tests on identical twins. So I also volunteered, and we both spent 11 days and nights inside their lab, in separate rooms, completely isolated from all time cues from the outside world, with no windows, TV or radio (this was pre-internet). I was literally poked and prodded every couple hours, constantly monitored with machines and blood tests, saliva samples, video cameras, memory tests and mood scales. Every night they glued a dozen electrodes to my scalp and monitored my brain waves. I found out later that they had us on a 22 hour day, thus cutting away 2 hours a day from normal life and flipping our sleep cycles completely in a week. At the end, to reset us back to normal, they kept us upright in a bed, forcing us to stay awake for around 50 hours using any means possible; we played a lot of cards and sang silly songs. It was all quite surreal and strange and fascinating, and it was my first true foray into medicine. All the lab workers were medical students or doctors, and they loved their work and the science. I was hooked on medicine for the first time! But I still wasn’t ready to become a doctor. It took another year or so, after moving to wonderful San Francisco and still struggling to find a decent editing job, that I again found myself in the medical world. This time I was an editor and desktop publisher for a private medical company deep in the foggy cliffs of the Veterans Administration (VA) Hospital. Again I was surrounded by doctors and medical students doing fascinating research, loving their work, and getting paid well for it. And finally it clicked: I should become a doctor! Medicine was — and still is — the perfect mixture of my skills and desires: I could help people every day, in truly life-changing ways. And as a family doctor, I would never get bored, even forty years later, as every patient would be a new dilemma, with a new story.

I went back to school part time and aced my premedical classes, volunteering at Shriner’s Hospital for Children and other places to get more experience. I vividly remember my first real test: watching a person get open heart surgery. I’ll never forget the surreal sound of a saw cutting open his rib cage, or the smell of his burning flesh from a cautery gun stopping small bleeding, or looking down into his open chest, watching his heart beating. Many people would just pass out at that moment — but I thought, “wow, this is really cool!” Richard Saint Cyr portrait I eventually took the grueling and exhausting MCAT exam and soon got accepted into Saint Louis University’s School of Medicine. I had finally found my calling – and I remain thankful that I pursued this dream. In my life choices, my number one most important decision was asking Joanna to marry me; my second most important was deciding to become a doctor.

Many people ask me why I decided to become a family doctor and not specialize in something like cardiology or neurosurgery. I especially got this question while living in China because almost all doctors specialize there, and there really isn’t even a developed program for primary care doctors in China. Most Chinese people don’t realize that family medicine actually is a specialty, complete with extra training and our own medical exam and certification.

The classic American view of a doctor is of a small town doctor who the community knows and loves dearly, who has delivered generations of babies over their 40 years of practice. A good family doctor is deeply involved in their community’s health, their schools, their public safety. I always loved that classic American image of a doctor, and that’s what I strive for each day in my practice. I see people of all ages, from newborns to the elderly, and I follow them for years. It’s a deeply satisfying career, a true honor to deeply understand a patients’ health and history, and to do all I can to keep them thriving and healthy.

 

(this is an excerpt from my book translated into Chinese. I moved back to the USA last summer and now work at Swedish Bainbridge Island Primary Care Clinic in Washington state.)