Wheat brain

Among the most common effects of wheat are those on the brain.

Consume wheat and susceptible individuals will experience a subtle euphoria. Others experience mental cloudiness or sleepiness. (This is what I personally get.)

It gets worse. Children with ADHD and autism have difficulty concentrating on a task and have behavioral outbursts after a cookie. Schizophrenics experience paranoid delusions, auditory hallucinations, and worsening of social detachment. People with bipolar disorder can have the manic phase triggered by a breadcrumb. All these effects are blocked by administering drugs that block the brain's opiate receptors. (This is why, by the way, a drug company is planning to release an oral agent, naltrexone, formerly administered to heroin addicts to help control addiction, for weight loss: block the euphoric effect, take away the temptation, lose weight.)

Here is Heart Scan Blog reader, Nicole's, mental fog story:

I have been grain-free (no gluten free grains either) for quite a long time (about a year and a half). Earlier this week, I decided to try white bread and pasta. The experiment only lasted two days. I had horrible terminal insomnia both nights, causing me on the second night to wake up at 2:30 am unable to get back to sleep at all. I felt drugged and in a mind-fog all the next day and even dozed off a few times! Luckily I had the day off work.

I had very bad forgetfulness also. I forgot that I left my bag and groceries at work, so I had to go back for them. Then I had to use my husband's keys to get in because I thought my keys were in my bag, but it turns out they were in my pocket. Then I got my bag, set the alarm, locked the door and then realized I forgot my groceries. So I had to re-open the door, unset the alarm, and go back for the groceries. Then I locked the door, forgetting to set the alarm, so I had to unlock it, open up and set the alarm. It was just ridiculous, I am NEVER like that!

In addition to the insomnia and forgetfulness, I also had horrible anxiety and paranoia, almost to the point of panic. Which I NEVER have, I am usually very easy-going, even-tempered, and worry-free. But this was horrible, I really was quite paranoid and anxious about everything. Weird!

And the worst, was that in just two days of eating wheat, I gained 4 lbs and 2% bodyfat!! It's two days wheat-free now, and it's finally going back down, but wow. Just two days of wheat-eating caused that much weight and fat gain!

Anyway, I've learned my lesson and will continue to avoid grains (including gluten free grains) entirely.


Eat more "healthy whole grains"? Modern dwarf Triticum aestivum, perverted even further by agricultural geneticists and modern agribusiness, subsidized by the U.S. government to permit $5 pizza, is better than any terrorist plot to discombobulate the health and performance of the American people.

The Westman Diet

Dr. Eric Westman has been a vocal proponent of carbohydrate restriction to gain control over diabetes, as have Drs. Richard Bernstein, Mary Vernon, Richard Feinman, and Jeff Volek.

Several studies over the years have demonstrated that reductions in carbohydrate content of the diet yield reductions in weight and HbA1c (glycated hemoglobin, a reflection of average blood glucose over the preceding 60-90 days).

Among the more important recent clinical studies is a small experience from Duke University's Dr. Eric Westman. In this study, obese type 2 diabetics reduced carbohydrate intake to 20 grams per day or less: no wheat, oats, cornstarch, or sugars. Participants ate nuts, cheese, meats, eggs, and non-starchy vegetables.

After 6 months, average weight loss was 24.4 lbs, BMI was reduced from 37.8 to 34.4. At the end of the study, 95% of participants on this severe carbohydrate restriction reduced or eliminated their diabetes medications.

That was only after 6 months. Note that the ending BMI was still quite well into the obese range. Imagine what another 6-12 months would do, or achieving BMI somewhere closer to ideal.

Curiously, this idea of severe low-carbohydrate restriction to cure or minimize diabetes is not new. Sir William Osler, one of the founders of Johns Hopkins Hospital and author of the longstanding authoritative text, Principles and Practice of Medicine, advocated an diet identical to Dr. Westman's diet. So did Dr. Frederick Banting, discoverer of the pancreatic extract, insulin, to treat childhood diabetics. Before insulin, Banting and his colleagues at the University of Toronto used carbohydrate elimination (less than 10 g per day) to prolong the lives of children with diabetes.

This lesson was also learned many times during war time, when staples like bread were unavailable. The Siege of Paris in 1870 yielded cures for diabetes in many (or at least they stopped passing urine that tasted--yes, tasted--sweet and attracted flies), only to have it recur after the siege was over.

These are lessons we will have to relearn. As long as the American Diabetes Association and most physicians continue to advocate a diet of reduced fat, increased carbohydrate that includes plenty of "healthy whole grains," diabetics will continue to be diabetics, taking their insulin and multiple medications while developing neuropathy (nervous system degeneration), nephropathy (kidney disease and failure), atherosclerosis and heart attack, cataracts, and die 8 to 10 years earlier than non-diabetics.

All the while, we've had the combined wisdom from antiquity onwards: Carbohydrates cause diabetes; elimination of carbohydrates cures diabetes.

(This applies, of course, only to adult overweight type 2 diabetics, not type 1 or some of the other variants.)

Handy dandy carb index

There are a number of ways to gauge your dietary carbohydrate exposure and its physiologic consequences.

One of my favorite ways is to do fingerstick blood sugars for a one-hour postprandial glucose. I like this because it provides real-time feedback on the glucose consequences of your last meal. This can pinpoint problem areas in your diet.

Another way is to measure small LDL particles. Because small LDL particles are created through a cascade that begins with carbohydrate consumption, measuring them provides an index of both carbohydrate exposure and sensitivity. Drawback: Getting access to the test.

For many people, the most practical and widely available gauge of carbohydrate intake and sensitivity is your hemoglobin A1c, or HbA1c.

HbA1c reflects the previous 60 to 90 days blood sugar fluctuations, since hemoglobin is irreversibly glycated by blood glucose. (Glycation is also the phenomenon responsible for formation of cataracts from glycation of lens proteins, kidney disease, arthritis from glycation of cartilage proteins, atherosclerosis from LDL glycation and components of the arterial wall, and many other conditions.)

HbA1c of a primitive hunter-gatherer foraging for leaves, roots, berries, and hunting for elk, ibex, wild boar, reptiles, and fish: 4.5% or less.

HbA1c of an average American: 5.2% (In the population I see, however, it is typically 5.6%, with many 6.0% and higher.)

HbA1c of diabetics: 6.5% or greater.

Don't be falsely reassured by not having a HbA1c that meets "official" criteria for diabetes. A HbA1c of 5.8%, for example, means that many of the complications suffered by diabetics--kidney disease, heightened risk for atherosclerosis, osteoarthritis, cataracts--are experienced at nearly the same rate as diabetics.

With our wheat-free, cornstarch-free, sugar-free diet, we have been aiming to reduce HbA1c to 4.8% or less, much as if you spent your days tracking wild boar.

Battery acid and oatmeal

Ever notice the warnings on your car's battery? "Danger: Sulfuric acid. Protective eyewear advised. Serious injury possible."

Sulfuric acid is among the most powerful and potentially harmful acids known. Get even a dilute quantity in your eyes and you will suffer serious burns and possibly loss of eyesight. Ingest it and you can sustain fatal injury to the mouth and esophagus. Sulfuric acid's potent tendency to react with other compounds is one of the reasons that it is used in industrial processes like petroleum refining. Sulfuric acid is also a component of the harsh atmosphere of Venus.

Know what food is the most potent source of sulfuric acid in the body? Oats.

Yes: Oatmeal, oat bran, and foods made from oats (you know what breakfast cereal I'm talking about) are the most potent sources of sulfuric acid in the human diet.

Why is this important? In the transition made by humans from net-alkaline hunter-gatherer diet to net-acid modern overloaded-with-grains diet, oats tip the scales heavily towards a drop in pH, i.e., more acidic.

The more acidic your diet, the more likely it is you develop osteoporosis and other bone diseases, oxalate kidney stones, and possibly other diseases.

Here's one reference for this effect.

What'll it be: Olive oil or bread?

We frequently discuss the advisability of consuming fats, carbohydrates, and various types within each category.

But what's the worst of all? Combining fats with carbohydrates.

Putting aside the wheat-is-worst form of carbohydrate issue and treating bread as a prototypical carbohydrate, let's play out a typical scenario, a make-believe feeding study in which a theoretical person is fed specific foods.

John is our test person, a 40-year old, 5 ft 10 inch, 210 lb, BMI 27.7 (roughly the mean for the U.S.) He starts with an average American diet of approximately 55% carbohydrates and 30% fat. Starting lipoproteins (NMR):

LDL particle number 1800 nmol/L
Small LDL 923 nmol/L


(The LDL particle number of 1800 nmol/L translates to measured LDL cholesterol of 180 mg/dl, i.e., drop last digit or divide by 10.)

Also, calculated LDL cholesterol is 167 mg/dl (yes, underestimating "true" measured LDL), HDL 42 mg/dl, triglycerides 170 mg/dl.

We feed him a diet increased in carbohydrates and reduced in fat, especially saturated fat, with more breakfast cereals, breads and other wheat products, pasta, fruit juices and fruit, and potatoes. After four weeks:

LDL particle number 2200 nmol/L
Small LDL 1378 nmol/L

Note that LDL particle number has increased by 400 nmol/L due entirely to the increase in small LDL particles triggered by carbohydrate consumption. Lipids show calculated LDL cholesterol 159 mg/dl--yes, a decrease, HDL 40 mg/dl, triglycerides 189 mg/dl. (At this point, if John's primary care doctor saw these numbers, he would congratulate John on reducing his LDL cholesterol and/or suggest a fibrate drug to reduce triglycerides.)

John takes a rest for four weeks during which his lipoproteins revert back to their starting values. We then repeat the process, this time replacing most carbohydrate calories with fats, weighed heavily in favor of saturated fats like fatty red meats, butter and other full-fat dairy products. After four weeks:

LDL particle number 2400 nmol/L


Let's

Chocolate peanut butter cup smoothie

Here's a simple recipe for chocolate peanut butter cup smoothie.

The coconut milk, nut butter, and flaxseed make this smoothie exceptionally filling. If you are a fan of cocoa flavonoids for reducing blood pressure, then this provides a wallop. Approximately 10% of cocoa by weight consists of the various cocoa flavonoids, like procyanidins (polymers of catechin and epicatechin) and quercetin, the components like responsible for many of the health benefits of cocoa.


Ingredients:
1/2 cup coconut milk
1 cup unsweetened almond milk
2 tablespoons cocoa powder (without alkali)
2 tablespoons shredded coconut (unsweetened)
1 tablespoon ground flaxseed
1 teaspoon almond extract
1 1/2 tablespoons natural peanut, almond, or sunflower seed butter
Non-nutritive sweetener to taste (stevia, Truvia, sucralose, xylitol, erythritol)
4 ice cubes

Combine ingredients in blender. Blend and serve.

If you plan to set any of the smoothie aside, then leave out the flaxseed, as it absorbs water and will expand and solidify if left to stand.

For an easy variation, try adding vanilla extract or 1/4 cup of sugar-free (sucralose) vanilla or coconut syrup from Torani or DaVinci and leave out the added sweetener.

The compromise I draw here is the use of non-nutritive sweeteners. Beware that they can increase appetite, since they likely trigger insulin release. However, this smoothie is so filling that I don't believe you will experience this effect with this recipe.

Letter from the insurance company

Claudia got this letter from her health insurance company:

Dear Ms. ------,

Based on a recent review of your cholesterol panel of January 12, 2011, we feel that you should strongly consider speaking to your doctor about cholesterol treatment.

Reducing cholesterol values to healthy levels has been shown to reduce heart attack risk . . .


Okay. So the health insurer wants Claudia to take a cholesterol drug in the hopes that it will reduce their exposure to the costs for her future heart catheterization, angioplasty and stent, or bypass surgery. This is understandable, given the extraordinary costs of such hospital services, typically running from $40,000 for a several hour-long outpatient catheterization procedure, to as much as $200,000 for a several day long stay for coronary bypass surgery.

So what's the problem?

Here are Claudia's most recent lipid values:

LDL cholesterol 196 mg/dl
HDL 88 mg/dl
Triglycerides 37 mg/dl
Total cholesterol 291 mg/dl

By the criteria followed by her health insurer, both total and LDL cholesterol are much too high. Note, of course, that LDL cholesterol was a calculated value, not measured.

Here are Claudia's lipoproteins, drawn simultaneously with her lipids:

LDL particle number 898 nmol/L
Small LDL particle number less than 90 nmol/L (Values less than 90 are not reported by Liposcience)

LDL particle number is, by far and away, the best measure of LDL particles, an actual count of particles, rather than a guesstimate of LDL particles gauged by measuring cholesterol in the low-density fraction of lipoproteins (i.e., LDL cholesterol). It is also measured and is highly reproducible.

To convert LDL particle number in nmol/L to an LDL cholesterol-like value in mg/dl, divide by ten (or just drop the last digit).

Claudia's measured LDL is therefore 89 mg/dl--54% lower than the crude calculated LDL suggests.

This is because virtually all of Claudia's LDL particles are large, with little or no small. This situation throws off the crude assumptions built into the LDL calculation, making it appear that she has very high LDL cholesterol.

Do you think that Big Pharma advertises this phenomenon?

Healthy smoothies

I've now seen several people who have either caused themselves to be diabetic or to have other phenomena associated with excessive consumption of carbohydrates, all by innocently indulging in a carbohydrate-packed smoothie every morning.

Kay, for instance, has a smoothie of a half-pint blueberries, a banana, a scoop of whey, low-fat yogurt, a cup of milk every morning. The rest of her diet was fairly healthy: salads with oil-based dressing for lunch, salmon and asparagus for dinner, only an occasional carbohydrate indulgence outside of her morning smoothie ritual. Yet she had a HbA1c (a reflection of prior 60 to 90 days average blood sugar) at the near-diabetic range of 5.9%.

The mistake most people make when making smoothies is relying too heavily on carbohydrates like fruit. A smoothie like the one made by Kay can easily top 50, 60, or 70 grams carbohydrates per serving, more than sufficient to send blood sugars up to 150 mg/dl or more.

So what can you put in your smoothie and not send you over the edge to diabetes, small LDL, and all the other undesirable phenomena of excessive carbohydrates? Here's a list:

--coconut milk, unsweetened almond milk. Less desirable: milk, full-fat soymilk
--ground flaxseed
--oils: flaxseed oil, coconut oil (melted), extra-light olive oil, walnut oil
--dried coconut
--extracts: vanilla, almond, coconut, cherry, hazelnut
--spices: cinnamon, nutmeg, ginger
--herbs: mint leaves, cilantro
--cocoa powder (unsweetened)
--nut or seed butters (peanut butter, almond butter, sunflower seed butter)
--tofu
--exotic ingredients (ingredients you wouldn't expect in a smoothie): spinach, kale, cucumber

How do you sweeten a smoothie? This is what trips up most people. If you resort to fruit like bananas, pineapple, or apple, you will readily send your blood sugar skyward. Honey, agave syrup, and sugar, of course, all increase blood sugar and/or have the adverse effects of fructose. Be careful of yogurt, also, for similar reasons.

Therefore, to sweeten your smoothie, consider:

--Small servings of berries, e.g., 8-10 blueberries, 2 strawberries, a few wedges of apple, half a kiwi
--Non-nutritive sweeteners like stevia, Truvia, sucralose, xylitol, erythritol. Also, sugar-free (sucralose-based) syrups like those from DaVinci and Torani are useful. (Just be aware that non-nutritive sweeteners can increase appetite--use sparingly.)

Also, note that, if you have divorced yourself from wheat, cornstarch, and sugars, your desire for sweet should be much reduced. Foods other people find just right will taste sickeningly sweet to you. You might therefore find that foods like peanut butter or coconut milk have a mild natural sweetness; added sweetness is only minimally necessary.

Coming next: I'll share a smoothie recipe or two of mine. Anyone want to share a recipe?

Insulin secretagogue

Dairy products have the peculiar property of triggering pancreatic release of insulin. The research group at Lund University in Sweden have contributed the most to documenting this phenomenon:




Mean (±SEM) incremental changes (?) in serum insulin in response to equal amounts of carbohydrate from a white-wheat-bread reference meal (x) and test meals of whey (?), milk (?), cheese (?), cod (?), gluten-low (?), and gluten-high (?) meals. From Nilsson 2004.

Note that it is the area under the curve (AUC), not the peak value, that assumes greatest importance.

Dairy products, especially milk, whey, and yogurt, are insulin secretagogues: they stimulate pancreatic release of insulin. The effect is likely due to amino acids and/or polypeptides in dairy products. (The effect is less prominent with cheese. Also see this study.)

By conventional wisdom, this may be a good thing, since the excess insulin will blunt the glucose rise after consumption. However, in my book, this is not such a good thing, since most of us have tired, beaten, overworked pancreatic beta cells from our decades of carbohydrate overconsumption. I fear that the effect of dairy products just take us a bit closer to beta cell failure: diabetes.

Good news: The effect is least with cheese.

Be gluten-free without "gluten-free"

While I've discussed this before, it is such a confusing issue that I'd like to discuss it again.

I advocate wheat elimination because consumption of products made from modern dwarf Triticum aestivum:

--Triggers formation of extravagant quantities of small LDL and LDL particle number (or apoprotein B)
--Triggers inflammatory phenomena like c-reactive protein, increases leptin resistance, and reduction of the protective adipocytokine, adiponectin.
--Encourages accumulation of deep visceral fat ("wheat belly") that is inflammatory and causes resistance to insulin
--Increases blood sugar more than nearly all other foods--higher than a Milky Way bar, higher than a Snickers bar, higher than table sugar.
--Is being linked to a growing number of immune-mediated diseases, including celiac disease (quadrupled over past 50 years), type 1 diabetes in children, and cerebellar ataxia and peripheral neuropathies.

This last group of wheat-related phenomena are primarily due to gluten, the collection of 50+ proteins found in each wheat plant. For this reason, people diagnosed with celiac disease are advised to eliminate gluten from wheat and other sources (barley, rye, triticale, bulgur) and to eat gluten-free foods.

Gluten-free has therefore come to be viewed as wheat-free and problem-free. It ain't so.

Among the few foods that increase blood glucose higher than wheat: cornstarch, rice starch, potato starch, and tapioca starch--Yup: the ingredients commonly used to replace wheat in gluten-free foods. They are also flagrant triggers of the small LDL pattern, along with increased triglycerides, reduced HDL, increased visceral fat, increased blood pressure. In short, gluten-free foods lack the immune and brain effects of wheat gluten, but still make you fat, hypertensive, and diabetic.

I tell patients to view gluten-free foods like jelly beans: Gluten-free pancakes, muffins, breads, etc. are indulgences, not healthy replacements for wheat. It's okay to have a few jelly beans now and then. But they should not be part of a frequent or daily routine. Same with gluten-free foods.

Is it mainstream or alternative?

A question I get about once a week: "Is your program a kind of alternative medicine?"

Our program for control and reversal of coronary plaque using CT heart scans applies an eclectic panel of tools to achieve its goals. We use high-tech methods like lipoprotein analysis and CT heart scans; nutritional supplements like fish oil, vitamin D, and l-arginine; diet strategies and "functional foods" (using foods as a therapeutic tool); and conventional medication.

I don't consider this approach "alternative" in the sense that it uses unmeasurable or spiritual strategies. But I don't consider it mainstream, either, since current mainstream practice of heart disease prevention is far less rigorous with far less satisfactory results.

I think I can sum up the Track Your Plaque approach by saying that we use tools that work. Our measure of success is whether or not your heart scan score is stopped or reduced--that's hard to fudge. You can call it what you will, but I call it the best program for heart disease prevention I know of, alternative or mainstream.

Want to see someone turn diabetic?

If you want to witness the transformation of someone into a pre-diabetic or diabetic, put them on a low fat diet.

Dr. Dean Ornish's program, detailed in his books, Dr. Dean Ornish's Program for Reversal of Heart Disease and Eat More, Weigh Less , are woefully outdated in 2006. Yet the low fat notion continues to show up in the consciousness of people I talk to about heart disease reversal.

"I'm already on a low fat diet. Do you think my heart scan score has reversed?"

Highly unlikely. What Dr. Ornish (as a non-cardiologist, by the way) failed to recognize is that what he did manage to reverse in a small number of people is something called "endothelial dysfunction", but he did not reverse or shrink coronary plaque.

Given the limitations of technology when the Ornish concept got its start, it appeared as if reversal was obtained. In reality, all his approach accomplished was a relaxation in tone of abnormally constricted arteries, thus giving the appearance of reversal. Increased artery tone, or endothelial dysfunction, is extremely common when atherosclerotic plaque is present.

Any cardiologist will tell you that there are many ways to reverse endothelial dysfunction: exercise, weight loss, cholesterol drugs, drugs for high blood pressure, fish oil, hormonal therapy, vitamin C, l-arginine, etc. There is nothing special about a low fat diet.

In fact, Track Your Plaque followers will recognize that a low fat diet is, in fact, potentially harmful, particularly when low HDL or small LDL is part of your pattern.

Let's bury the outdated ideas of the Ornish low fat diet once and for all. It doesn't work. All it may do is confuse you and set you back from your real coronary plaque reversal program.

Inulin: A fiber for weight loss

Here's an interesting product that seems to be gaining some popularity for weight loss: Inulin.

Not to be confused with "insulin", with which it is completely unrelated, inulin is a naturally-occurring plant fiber. It's found in broccoli, asparagus, celery, etc. Like beta-glucan from oats or pectin, inulin is a so-called soluble fiber, a fiber that assumes a gel-like consistency when exposed to water.

Inulin has the effect of increasing satiety, or the sensation of fullness. This cuts your craving for foods. I've tried it recently and I prefer it over glucomannan, another soluble fiber for satiety.

The people at Stonyfield Farms have been adding inulin to their yogurts from some time. The nutritionist at the company tells me that there's 2-3 grams of inulin per 6 ounce container of their yogurt.

You can also find inulin as a supplement that you can add to foods, available from some health food stores and online supplement companies. I came across a neat product called Fiber Choice that's now being distributed widely throughout the U.S. I tried their Weight Management version. It was a delicous strawberry taste. The label says take two chewable tablets twice a day, but I found that two tablets three times a day somewhat better. It's best taken around 30-60 minutes prior to each meal and it causes you to be fuller with less food. One caution: It'll cause loads of gas, especially in the beginning. For that reason, you might try starting with a smaller dose, or start on the weekends when you have the option of some privacy!

More info on the Fiber Choice product can be found at their website, http://www.fiberchoice.com.

Disclaimer: I have no relationship with the manufacturer of this product. I'm simply passing on some thoughts on my experience with this interesting possibility for weight loss.

Will you recognize the truth when you see it?

Do you ever wonder that, if the truth were given to you, that you'd recognize it as such? Or would you dismiss it as just another bunch of nonsense?

After all, you and I live in the Information Age. It means that we have access to mountains of information like never before in human history. But it also means that the truth is often drowned out by an avalanche of mis-truths, sales pitches and marketing, and just plain nonsense.

This struck me the other day when I was talking to a patient.

64 years old with a high heart scan score placing her at significant risk, she looked confused. I'd just described the multitude of causes of coronary plaque that we'd uncovered. The heart scan alone had been a shocker.

"I don't understand. My doctor told me that I had nothing to worry about. I've known him for years and he knows me really well. He did a stress test. That was fine. I don't get all this other stuff you're telling me--lipoprotein whatever..."

Despite my efforts to help her gain an understanding of our intensive approach, she just became increasingly more frustrated. "I just don't think I can do this."

That's the last I've heard from her. As far as I know, she's returned to the comfort of her family doctor who has reassured her over the years. And perhaps there's some good in that. But I do fear for the day when, unexpectedly, she suffers some catastrophe that we told her was coming sooner or later unless real preventive efforts were started.

You could say that she failed to recognize the truth when it was given to her-- boldly, unadorned, and with far greater scientific certainty than the casual reassurances she was accustomed to. But, unfortunately, that's all that some people want.

Don't neglect the basics in your heart disease reversal program

Carl loved new ideas and novel approaches. You could tell by the sheer number of nutritional supplements he took. His list had grown to 18 different supplements over the past two years.

Carl came to me for coronary plaque regression. Lipoprotein analysis did uncover several previously unsuspected abnormalties, most notably small LDL particles and lipoprotein(a). In addition, Carl's LDL cholesterol ranged between 111 mg-156 mg and he was clearly hypertensive, with systolic blood pressures consistently around 150-160. (Recall that people with Lp(a) are more prone to hypertension.)

Carl was more than willing to have his lipoprotein(a) reduced. We did so with niacin and testosterone and the level dropped to near zero. Likewise, we corrected his small LDL pattern with niacin, fish oil, and a reduction in processed carbohydrates.

But Carl really resisted doing much about his LDL cholesterol and high blood pressure. I got the sense that these "boring" issues simply didn't interest him. After all, LDL cholesterol and blood pressure were the stuff of TV commercials and the popular conversation propagated by drug companies.

Carl's follow-up heart scan, however, finally persuaded him: a 24% increase in one year, likely due to the neglect of the basic issues.

I liken Carl's case to being like the teenager with a new car who polishes the paint to a bright finish, puts new wheels and tires on it, spruces up the interior with various doodads--but then fails to change the oil. Sometimes it's the most basic issues that can diminish your success.

Issues like LDL cholesterol and high blood pressure aren't the most glamorous, but they do count in your coronary plaque control program.

Is your doctor a hospital employee?

There's a disturbing trend that's growing--silently but rapidly.

In Milwaukee, three hospital systems compete for the local health care dollar. To gain more control over revenues and the routing of patients, the hospitals are aggressively hiring physicians to work for them. I've witnessed many of my cardiology colleagues, primary care doctors, and a substantial number of procedural specialists enticed by the offers made by hospital employers.

This phenomenon is not unique to Milwaukee but is being used in many, perhaps most, major cities in the U.S.

This means that physicians are employees of the hospital. That way, employee-physicians are obliged to use only the hospital system that employs them. In the old days, your doctor could use any hospital he/she desired, depending on the quality, location, facilities, etc. Now, many physician-employees are given no choice but to use the hospital that pays their salary.

That by itself is not necessarily bad. But combine salary with incentives for bringing in patients for hospitalization and procedures--that the rub. In other words, physician-employees are incentivized to generate more revenue for the system, just as employees in many other industries.

If you're a salesman for an insurance company, your job is to bring in more business. If you're a worker on an auto production line, you're expected to meet certain quotas. These same principles are now being applied to many physicians.

How does this affect you? Well, if your physician--especially procedure-driven specialists like cardiologists, general surgeons, orthopedists, etc.--is a hospital employee, BEWARE! Do you really need that procedure, or is your doctor suggesting you have a procedure because it will add to his track record?

Prevention? In this model of health care, why bother? It certainly doesn't pay for a hospital to keep you well. Then why should your physician-employee?

Be careful who you're dealing with. If your physician is a hospital-employee, don't bet on getting preventive care. It's more likely you're that just a future source of revenue when it's time for your bypass operation, hip replacement, carotid endarterectomy, etc.

What more powerful argument is there for increased self-empowerment and information for health care consumers?

Take a walking vacation

If you're planning a vacation, why not consider a walking vacation?

The concept is really taking off. All you need is a pair of comfortable shoes and an interesting locale. More and more services are popping up to help you plan fun and interesting destinations and itineraries. One such catalog can be found at http://walking.about.com/od/tours/a/walkingvacation_3.htm

Lengthier walks may require some advance planning and toting some supplies. Don't forget the water!

From a health viewpoint, a walking vacation sure beats the heck out of a cruise that packs on 12 pounds of extra weight from the 24-hour a day buffet. If you're in the midst of a weight loss effort, several hours of walking through interesting locales and scenery can make it effortless.

There's loads of neat places to visit from a walker's perspective. One interesting website is www.waterfallwalks.com that lists trails that provide spectacular views of waterfalls.

Another variation on this theme is biking vacations. My wife and I are trying to set the time aside for a biking tour of wineries in the French countryside. That's our kind of multi-tasking!

"Expanded indications for implantable defibrillators"

So reads the headline on a magazine I received recently (along with thousands of my colleagues) from a major hospital system.

It goes on to say: "In January 2005, indications for implantable cardioverter-defibrillators (ICDs) were substantially broadened [emphasis ours] to include most patients with a left ventricular ejection fraction (EF) of 35% or less. This change translates into a 2- to 3-fold increase in the number of Medicare beneficiariries eligible for ICDs."

Ka-ching!!! Hear the money piling up in the bank?

The device manufacturers are constantly churning data and lobbying for reimbursement to expand the use of their devices to more and more people. Defibrillators in particularly are generally a $25,000 to $50,000 opportunity for the device manufacturer alone, not counting the costs incurred at the hospital for implantation.

Beware. As reimbursement for stents and other procedures diminishes, expect a sudden "demand" for more and more people to get implantable defibrillators. Better yet, stay away from the whole issue by preventing your heart attack.

Get a heart scan--but then don't delay taking action!

I just came from one of the local hospitals after having performed a heart catheterization on a patient I met earlier this week.

Jack had gotten a heart scan a year ago with a score of 246, placing him in the 76th percentile. The "event" rate with this percentile rank is around 3% per year--not very high but enough to pose risk over a long period.

Jack chose to ignore his score. After all, the pressures of work at the University, maintaining his home and yard, etc. consumed all his energies. He came to my office--now one year after his scan--and told me about the chest pressure he was getting. Initially, his chest pains occurred with extended walking. In the past week, however, Jack was experiencing chest pressure with just walking 30 feet.

This pattern of increasing symptoms is called "accelerated angina", meaning that Jack was rapidly heading towards a heart attack. So I advised a heart catheterization in near future.

Jack's catheterization showed extensive plaque including a 50% blockage in the mainstem artery and 90% in the artery to the front of the heart (left anterior descending artery). Jack is going to have a bypass operation tomorrow.

What if Jack hadn't ignored his heart scan from a year ago? Well, I'd be very confident in saying that he would not be undergoing bypass surgery tomorrow.

The lesson: Don't dilly-dally on taking action to keep your plaque from growing. While it's not an emergency, it can easily become one if you choose to ignore your scan.

Feel that nudge in your back?

You feel that nudge in your back? That's your local hospitals competing for your bypass surgery business.

Just this morning while watching a morning news show, I saw three advertisements for hospital bypass surgery programs. One ad featured a man in his 50s telling his story:"The cardiologist determined immediately that I needed a triple bypass operation. My family and I are very grateful to _____ hospital!"

In what other field is failure celebrated so prominently? When I see these ads, I hear "My doctors failed to provide early detection and then prevent what became a life-threatening condition, even though heart disease is a chronic process that requires decades to develop." What if our man said instead,"I had a heart scan and my score was high. So I was shown why I had so much plaque. They then showed me how to control and even reduce the amount of plaque I had. I'm living safely and symptom-free without need for surgery or procedures."

Of course, the hospital is out $60,000-100,000 for the surgery. How else could they afford ad campaigns costing several million dollars a year? See these advertisements for what they are: Marketing generated by profit-seeking businesses competing for your dollars--lots of them.