All posts by Richard Saint Cyr MD

Losing Weight: Evidence-Based Advice

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 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. 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).

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!

多快好省的锻炼法则

(The original English version is here: “A 7 minute Workout That Really Works”. Translated for my New York Times Chinese health column here.)

“最小投入换取最大回报”——这似乎是深夜唬人的电视购物广告的台词,但它实际上是正式发表于美国运动医学会(American College of Sports Medicine)的《健康与健身杂志》(Health & Fitness Journal)5-6月刊上的一篇运动医学评论文章的副标题。尤其是经《纽约时报》报道后,这篇题为《身体自重高强度循环训练》(High Intensity Circuit Training Using Body Weight)的文章正成为全球各大媒体的头版头条。文章讨论的是一个热门话题——高强度间歇性训练(high intensity interval training),即短促而激烈的训练,并在训练过程中辅以短暂休息。之前备受推荐的是每个星期进行150分钟的适度训练或90分钟的高强度训练,而现在你只需每次进行15分钟的高强度间歇性训练,每周坚持3次,即可取得类似的健康益处。

首先,咱们先稍稍回顾一下锻炼的好处吧。包括美国疾病预防控制中心(CDC)在内的权威机构都推荐采取将有氧运动与肌肉力量训练相结合的方法,因为广泛的研究结果显示,这种训练方法能有效减少早亡以及罹患冠心病、中风、高血压、糖尿病、结肠癌和乳腺癌等疾病的风险。在对已有论文进行了荟萃研究后,美国疾控中心得出以下结论:每周仅进行90分钟的适度锻炼会使早亡的风险降低20%;在一定范围内,锻炼时间越长,降低早亡风险的效果越好,到300分钟时,风险会降低40%,达到最佳效果,超过300分钟后,效果便呈递减趋势。

但我们很多人每周的锻炼时间甚至达不到30分钟,更远低于90分钟或150分钟的推荐量。缺少锻炼是全球范围内主要的健康杀手之一,健康指标与评估研究所(The Institute for Health Metrics and Evaluation)是由美国华盛顿大学(University of Washington)主管的独立全球卫生研究中心,该机构研究数据表明,在美国缺乏锻炼名列第6大健康杀手,在中国是第10位。我们越来越不爱动了,所以多快好省的健身方法在我们当今社会发挥着至关重要的作用。早在1996年,高强度间歇性训练法首次获得推荐,当时由田畑泉(Izumi Tabata)教授领衔的一个日本研究团队将60分钟适度训练与4分钟室内健身自行车高强度训练进行对比后发现,高强度间歇性训练组的有氧运动量与低强度训练基本一致,而且前者在无氧运动方面有更显著提高。美国南伊利诺伊州立大学(Southern Illinois University)运动与健康教育系2011年对超重大学生进行测试后发布的一项研究表明,仅仅15分钟的高强度训练就能将他们静息能量消耗(代谢率)持续改变72小时,这相当于35分钟常规锻炼的效果。另外一项对新南威尔士大学(University of New South Wales)医学部教职员进行的研究显示,每次进行15分钟高强度间歇训练,每周坚持3次,与传统的耗时更长的锻炼相比,其减肥和降低胰岛素抵抗的效果实际上更好。我认为这些发现非常重要,因为在大部分国家,随着肥胖现象的增加,糖尿病患病率不断攀升。

谈到体育锻炼,我承认我不是一个运动狂,算是个很懒散的人,因此我更青睐某种立竿见影的快速健身法。我去年秋季第一次听说高强度间歇性训练法的时候,就开始每天早晨进行5分钟例行锻炼。先是30秒钟内进行尽可能多的下蹲后促腿运动(squat thrust),休息10秒后再重复10轮,如此下去,一共练习5分钟。除了这种运动,进行高强度的跪式俯卧撑、深蹲、立卧撑跳、平板、卷腹等动作也同样有效,前提就是每组动作练习到力竭,进行短暂休息后就立刻恢复练习。我承认,一个月后,我停止了这样的例行锻炼——每次我都是先下定决心要好好坚持锻炼但最后却半途而废。但坚持锻炼的那几周,我确实感觉自己体魄健壮、身体灵活了不少,而且每次锻炼后都感觉到了肌肉酸痛。我从上周开始执行这种纽约时报中文网新推广的7分钟循环锻炼,中途辅以30秒钟的间歇。通过循环训练,你不断交替地锻炼了不同的肌肉群,最终整套训练完成下来,你的所有肌肉群都得到了锻炼。你可以选择任何锻炼形式来进行高强度间歇性训练,但这种特殊的循环训练的一个额外优点是你不需要进行任何负重训练或借助运动器械,只需要一面墙、一把椅子和你自己的身体。这种训练在任何地方都可以实现——在你的家里、办公室或宾馆房间内。

训练方法为,练30秒、休息10秒,如此往复,每次训练共持续7分30秒。你也可以将这个过程再增加一到两遍,以便获得更好的效果。训练过程中的短暂休息很重要,因为这样能增加健康的代谢反应。训练过程中,你肯定需要借助工具来记时。对此,我发现许多智能手机或平板电脑应用程序是不错的选择。经过适当的设置,它们会很准确地在间歇时间发出提示声。你只需在你的应用程序库中搜索HIIT、Tabata或“间歇计时器”(Interval timer),然后在众多程序中进行挑选即可。

这里的关键是你需要真正强迫自己坚持下去,而不是随性地玩玩。关于运动强度,许多研究报告都提到了“不愉快”、“不舒服”等字眼。许多研究报告还提到了一种被称为“最大摄氧量”的概念。最大摄氧量是通过氧气传感器测量出来的,但它总体上能与你的最大心率值进行关联。因此,我们都应该知道自己的最大心率值。幸运的是,这很容易计算出,你可以在网上搜到网络计算器,也可以自己计算。科罗拉多大学博尔德分校(University of Colorado at Boulder)应用生理学和运动学的田中博美(Hiromi Tanaka)博士等人2001年发表的一篇研究报告推出的一个计算公式为:运动时最大心率=208-0.7x年龄。例如,我45岁,我的最大心率值(即最大摄氧量)是208-0.7×45=177(次/分钟)。如果我想达到每周150分钟的低强度运动目标,那么我的适度运动时的目标心率值为最大心率值的60%,即0.6×177=106(次/分钟)。做强度更高的运动时,推荐心率值为最大心率值的80%,对我来说,就是142(次/分钟)。我通常能通过30分钟的室内跑步或踏车训练使心率达到这个值,而且坦率地讲,这样的运动我并没有感到丝毫的不适。但对于更剧烈的高强度间歇性运动来说,最大心率值的90-100%为159-177(次/分钟)。所以每次完成上述的例行训练后,我确实感觉有点“不愉快”,因为心率达到了160,也是我应该达到的值。

所以现在我实在没有理由不进行锻炼了。我只需每天早起10分钟,或者早上其他事情做得更快一点,然后完成一到两轮的例行锻炼,每周坚持3次。有了这个运动量再加上我每天骑自行车上下班的运动量,在给病人提标准化生活方式的建议时,我可以更加底气十足了。

我觉得这种以亲身经历为证的运动研究是很有说服力的,因此它也改变了我以前给病人进行开导时惯常的话语方式。以前,我总是向病人提及惯常推荐的运动时长(即每周低强度运动150分钟或高强度运动90分钟),但现在我可以将运动形容得更有吸引力——15分钟一次,每周3次。当然,这对于已经在坚持健身或参加体育运动的人来说,并无吸引力。而且,关于高强度间歇性锻炼,目前还缺少长期效果和风险减少方面的数据。但对于像我本人这样几乎不参加体育活动的“沉默的大多数”而言,进行高强度间歇性锻炼很显然比什么都不做要好很多,而且从全球范围来看,它可以挽救数以百万计的生命

Arthritis Pain: What Supplements Work?

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? 

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’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?

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. 

COMMON COLD REMEDIES: 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 30 mg each, which at three times a day would help. 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.

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.

 

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.

This post was originally published on my new blog at MyFamilyHealthGuide.com. Please follow my new blog! (and my Facebook page