A breakthrough for type 2 diabetes?

By Tracy Kelly

Can we put type 2 diabetes into long-term remission? It’s a question that’s asked often and to date we don’t have the answer – but that could all change within a few years. 

That’s because Diabetes UK has recently awarded a £2.4 million research grant to look into whether losing weight – and keeping it off – through a low-calorie liquid diet is a feasible long-term treatment for putting type 2 diabetes into remission.  

As part of the Diabetes Remission Clinical Trial (DiRECT) study, researchers will recruit 280 overweight people with type 2 diabetes and put them on two separate diets. This new trial follows a 2011 study that found that 11 overweight people with type 2 diabetes saw their insulin production return to normal and their type 2 diabetes put into remission after eight weeks on a low-calorie liquid diet. 

Following the huge media interest in this study, many people with type 2 diabetes were interested in this approach. But as exciting as these findings were, the study did not focus on the effects of the diet in the long term and there is still much about low-calorie diets that we are yet to understand.

As part of the new trial, one group of 140 people will spend between eight and 20 weeks on a low-calorie diet of 800 calories a day – mainly nutritionally complete diet soups or shakes, plus ample fluids. Then, as normal food is reintroduced, they will learn how to change their lifestyles permanently. 

The results of this group will be compared with an equal number in the second group, who will follow what is currently accepted as the best advice for weight loss and weight maintenance. 

Both groups will be monitored for two years to study the long-term effects of their diets on weight. MRI scans will look at what’s happening inside their bodies during the diet.

The aim is to see whether the stress and effort of following a restrictive diet for several months is beneficial in the long run. After all, 800 calories is not a lot – people following such a diet are likely to feel hungry quite a lot of the time. Also, will they be able to stick to it for long enough for it to be successful? Even more fundamentally, this kind of diet is not an easy option or a ‘quick fix’ and people will still have to follow a healthy lifestyle afterwards to stop their type 2 diabetes coming back. It’s a fact that weight regain after liquid diets is common.

Type 2 diabetes will always be a serious condition, but perhaps it won’t always be seen as a condition that people have to manage for the rest of their lives – and that inevitably gets worse. If this study shows that low-calorie liquid diets can be used safely, on a bigger scale and as part of routine care, it could completely change what we know about type 2 diabetes and how it is treated by the NHS. It could also provide an accessible way to help people with this condition live longer, with a better quality of life and a reduced risk of serious health complications.  

For more information about the trial visit www.diabetes.org.uk/DiRECT

New Post on Eat Move Sleep Blog

Yesterday, the Dan's Plan blog Eat Move Sleep published a blog post I wrote about sleep, artificial light, your brain, and a free computer program called f.lux that can help us live healthier lives.  Head over to Eat Move Sleep to read it.

A Walk-In Clinic on St. Clair West

I had this woman call me today in complete desperation. She had been to a walk in clinic on St. Clair West and had a terrible interaction with the MD. I knew right away who she was talking about and asked if she had gone to Solutions Health Care Associates. I had been to this walk-in clinic myself and remembered how awful this doctor was. It was my wedding day. I had strep throat and needed a quick prescription. I was educated in medicine and knew what I needed so his terrible bedside manners did not affect me.

This woman saw him yesterday in terrible pain, from what I believe is an infected site. She told me that he barely assessed her, as in he sat across the room from her and then simply sent her off with antibiotics. She woke up this morning worse and was unable to cover the wound due to restricted movement and went back to see him. She waits to see him and he tells her, that it is not the MD's job to put on a dressing and to continue with the antibiotics. She is in excruciating pain, visibly upset and desperate for help. She tried to see her family doctor but could not get an appt. for 2 weeks. Welcome to Canada and free health care.

She came to see me a few hours after him. I looked at the site and noticed how fire red it was. There was spreading of reddness with defined margins from the area, as well as it feeling warm to touch.  She was also in excruciating pain and had limited range of motion. My slightest touch elicited pain. I sent her to the ER for a proper assessment and treatment plan. I will call her tomorrow to see how she is doing. It breaks my heart that this was her experience and that our system treated her this way.  

She told me how compassionate I was. It's kind of her to say that, but really all I did was attentivley listen and genuinely try to help her. I made eye contact, passed her a tissue as she sobbed and sat beside her for reassurance. It took all of about 10 minutes. It does not take that much effort to help another person in need. I am going to approach this MD tomorrow morning to tell him negligent and hurtful he was. I'm sure he won't give a sh*t but I'll feel better.
keep you posted.....

Change is a Learning Process

Winning organizations recognize the importance of learning. Companies that don’t learn new ideas don’t change to meet the demands of those they serve. When an organization doesn't change to meet new demands, it eventually fails. That is why we set aside time for learning.

Last Thursday, GBMC leadership had a marvelous day of learning with our teachers from Next Level Partners who taught us about focused problem solving to get better execution of meaningful change.

The former President of the Institute for Healthcare Improvement, Dr. Don Berwick, says there are three important factors required for improvement:
1. The will to change
2. Ideas
3. Execution

I have no doubt that at GBMC our people want to change. They embrace our vision of providing the care that we would want for our own loved ones to every patient, every time. We have the will to change.

I know that GBMC has a workforce made of many intelligent individuals with great ideas to improve our processes. I also know that with the Internet, many solutions are just a few clicks away. So, there is no lack of great ideas.

Our dilemma is number 3: execution. Healthcare in general has not been particularly good at executing change. Many healthcare service processes haven’t changed much since the mid twentieth century. Many companies have unwittingly instilled the notion into their people to hold on to the status quo, and to learn to deal with systems that don’t work, rather than getting them the idea that not only is it their right to fix broken systems – it is their duty.

We are implementing Lean Daily Management to change this. Since we started this technique last April, our senior team visits departments and units every day. On our daily walk, members of the unit and department teams tell us about the performance of key indicators from the day before. They tell us about the reasons why goals were missed and about their problem solving to improve the process.

A great example of excellent problem solving can be seen in the work done by both the Emergency Department and inpatient unit teams, including doctors, nurses and techs, with the help of housekeepers and transport aides, to move patients more quickly from the ED and into a hospital bed. We have reduced the time in the ED of patients admitted to the hospital by more than two hours.

So, our friends at Next Level Partners taught us more of the science of improvement to help us execute faster. It was a great day of learning for GBMC leaders. Such offsite trainings make us stronger as an organization and make our people more skilled. We all came back to work more inspired and better prepared to move us faster toward our vision.

Tina tries... facing her running demons

I can’t express how much I hate running (and rain). As far as I’m concerned it’s the devil’s exercise – I’m still haunted by the schoolgirl memory of running 400m, then throwing up at my PE teacher’s feet.

But the time came to face my fear. Lloyd, my personal trainer, suggested I try a form of exercise that’s easy to do outside of our gym sessions. And even after telling him of (yet another) class of ‘86 drama, he seemed willing to take on the challenge of getting me running again.

Lloyd explained that for a newbie it’s not all about pounding the tarmac for minutes on end. He wanted to set an initial pace that wouldn't scare me, so I can build on it in time. We began with a 10-minute warm-up of fast walking, then set to work on 40 minutes of walking and running at a 2:1 ratio – two minutes of fast walking, then one minute of running. He explained how important it is not to fly off too fast at the beginning as you’ve got to keep going for the 40 minutes. ‘Easy!’ I hear you cry, but those 60-second bursts of running felt longer and longer. I did make it through, though, with a small sense of achievement and a very fetching pair of rosy cheeks – thankfully there was no vomiting.

Go on, then, I'll admit it wasn’t that bad, even in the rain. (Did I just say that out loud?) I can only think this was down to Lloyd keeping my spirits up. He also pointed out that varying the terrain and running on softer ground is a lot less stressful on your joints. It was a great way to get into running and I’ll be intrigued to see if I'm ever able to complete a parkrun (parkrun.org.uk) without stopping… 

So, the big question: would Tina try it again? Yes, I already have! With the help of my very patient, marathon-running boyfriend, I upped the ratio so I can now run for longer and walk for shorter periods. And after a particularly frustrating train journey out of London at the weekend to visit my folks in Suffolk, there was nothing for it – I had my trainers and the countryside on my doorstep: I was going for a run.

I even stopped the obsessive 60-second-clock watching. Not that this particular run didn't come with its share of danger moments: farmers with guns, dog walkers, a fallen tree in my path and, worst of all, forgetting to put a bra on! But all my train traumas were soon a distant memory. How satisfying.

I now have to clean my trainers for all the right reasons (NOT because I've been doing the gardening in them). I may need a second pair – I may even have to venture into a sports shop. Note to self: pick up a sports bra while I’m there.

NEXT TIME: Tina tries those big scary machines at the gym

Hatha and Ashtanga - Further Thoughts

Having said that Ashtanga Yoga is not Hatha Yoga, certainly some elements of Hatha Yoga are also found in Ashtanga Yoga as taught by Pattabhi Jois and in the teachings of T Krishnamacharya. In fact, Krishnamacharya used a wide variety of techniques and taught the Hatha texts as well as Patanjali Yoga and many other subjects, whereas Guruji tended to favor fewer techniques and a concentration on the Patanjali Yoga and Advaita Vedanta.

Guruji saw yoga as one. Different techniques for different people in different circumstances. But he was clear that what he was teaching was Patanjali Yoga - so any Hatha techniques he utilized were in the pursuit of that goal rather than vice versa. In fact, although the Hatha texts state that the purpose of Hatha Yoga is Raja Yoga and some passing lip service is paid to the angas of Ashtanga, the development of practice and practices as well as the the culmination of the goal are clearly significantly different.

Gerald James Larson, in his monumental Volume XII of The Encyclopedia of Indian Philosophies says:

"In addition to Patanjali Yoga, there are all sorts of other traditions (including Hatha Yoga) that use the word yoga in a different, non-philosophical sense. That is, there are a variety of traditions that are clearly influenced by Patanjali Yoga but diverge considerably from it. These traditions either explicitly disavow an interest in philosophy of Patanajali Yoga, or perhaps more to the point, choose to make use of some terms and practices of yoga for purposes that are quite often quite distinct from Patanjali Yoga. Moreover, they are all without exception sectarian religious traditions."

Larson goes further to say that this includes the Bhagvad Gita - one of the three important texts for the followers of Advaita Vedanta and one of Guruji's favorites.

Patanjali Yoga is generally regarded as a dualistic text influenced by or incorporating Sankhya philosophy, whereas the Bhagvad Gita is a non-dual text - a text of Advaita Vedanta. For Guruji there was no conflict. He saw sankhya and yoga as one - as is stated in the Gita. He also saw the advaita (non-dual) "evolving" out of the dvaita (dual). This he explained as the transition from the external limbs and extraverted awareness (dual) to the internal limbs and meditative absorption (non-dual). I think it is justifiable to say that the Sutra is both a dual and a non dual text: it utilizes our experience of duality and leads us to an understanding of the non-dual state (samadhi).

Pure Patanjali Yoga does not include the specifics of Hatha Yoga, but many elements can be inferred under the category of tapas. We know very little about what was said in the Yoga Korunta which is the text which puts Guruji's teaching in context, but he was not shy of quoting the Hatha Yoga Pradipika as well.

A cursory review of the Hatha Yoga Pradipika and the Gheranda Samhita will reveal how different these practices are from Patanjali Yoga (and indeed, from any yoga practiced in the West), and in the light of this, the end which the means provide must also be different. Even though the Hatha Yogis identify their state of realization with Raja Yoga - a term used to describe Patanajali Yoga, this state is not achieved by chitta vritti nirodhah but by a series of tantric practices.

~

Guruji did not prescribe a way to navigate the internal practices, he was much more concerned with establishing the external ones and creating a strong foundation. But he did prescribe a method for these external practices, at least for asana and pranayama and for him these fit very distinctly into the succession of eight steps which are Ashtanga Yoga.

I think that neither Krishnamacharya nor Pattabhi Jois necessarily saw yoga as the central means to their own personal liberation, although yoga is samadhi, is meditation, is advaita vedanta. They were both religious men and I think they saw realization as coming through meditation on Narayana in the case of Krishnamacharya and on the non-dual Brahman in the case of Guruji. These devotions were carried throughout their lives from the age of 3-4 to 101 in Krishnamachrya's case and to 93 in Guruji's. These practices were learned prior to an exposure to yoga and continued after yoga (asana) practice had ceased.

We are left with a choice as to the content of our meditations. Some are religious in nature, some musical, some philosophical and some are inclined to extreme renunciation... for each individual there is a unique entry to the internal limbs of yoga.

Grass-Fed Animal Foods and Diseases of Civilization: Cardiovascular Disease in Ancient Civilizations

Vilhjalmur Stefansson was an Artic explorer known for his observations on the traditional living Inuit-Eskimo, which he lived together with in the winter of 1906-1907 in the Mackenzie Delta of Canada. Stefansson asserted that during this time he subsisted on traditional Inuit fare, based almost exclusively on flesh. In part based on less than extensive observations of the health of the Inuit, Stefansson hypothesized that a number of chronic and degenerative diseases, including cancer are diseases of civilization which can be prevented by adherence to a pre-modern diet and lifestyle. However, Stefansson did not suggest that only flesh based dietary patterns, such as that consumed by the traditional living Inuit, but also primarily vegetarian diets, such as that consumed by the Hunza may protect against such diseases.1 

The term diseases of civilization, which Stefansson has contributed to the popularization of is frequently referred to by proponents of Low-Carb, Paleo, Primal and Weston A. Price Foundation type diets. Many of these proponents have extrapolated limited suggestive evidence that obesity, type 2 diabetes, coronary heart disease, certain cancers, and a number of other chronic and degenerative diseases were uncommon during the Paleolithic period to suggesting that foods derived from naturally raised, grass-fed animals, as was consumed by Paleolithic humans must therefore somehow provide protection against these so-called diseases of civilization. Many of these proponents have also claimed that a vast number of scientific studies that have been used as evidence to conclude that animal foods increase the risk of such diseases have been complicated by confounding of other unhealthy foods and lifestyle factors, or by the use of unnaturally raised animal foods. This series of posts will examine the evidence to help determine whether these claimed confounding variables can actually explain the evidence linking animal foods with certain chronic and degenerative diseases, often referred to as diseases of civilization, but also as western diseases, lifestyle diseases and diseases of affluence.

In 1928, Stefansson and his colleague Karsten Anderson participated in a monitored experiment partly funded by the meat industry in which they consumed a flesh exclusive diet for the period of one year. Although the researchers concluded that these two men were in good health throughout the experiment, Anderson experienced a severe elevation in blood cholesterol, with measurements as high as 800 mg/dl on one occasion, which returned to pre-experiment levels after resuming a higher carbohydrate diet.2 A glucose tolerance test carried out immediately after the termination of the meat based experiment showed a marked rise in blood sugar in both men compared to a subsequent test carried out after resuming a higher carbohydrate diet. Glucose was detected in the urine of Anderson in the test following the meat based experiment, a marker of untreated diabetes. This abnormality was not detected in the subsequent test after resuming a higher carbohydrate diet.3

Short-term experiments such as this cannot provide adequate insight into the long-term consequences of following such a diet, as it can take many decades for diseases caused by exposure to harmful substances to become clinically significant. For example, the greatest risk of excess death from radiation-related solid cancers among the atomic bomb survivors of Hiroshima and Nagasaki was more than half a century after exposure.4 Furthermore, other flesh based experiments have resulted in considerably more unfavorable outcomes. For example, in 1906, Russell noted an even earlier experiment: 

A recent instance occurred in South Africa, where about twenty natives out of some hundreds who were supplied with a large amount of flesh, as an experiment, by mine-owners, died, and many others were ill.5

Cardiovascular Disease in Ancient Civilizations

The traditional living Inuit's were certainly
not immune from atherosclerosis

If a diet rich in naturally raised animal foods provides protection against cardiovascular disease as many proponents of Low-Carb type diets claim, it would be expected that traditional living populations consuming such a diet, particularly those living prior to the rapid westernization of the globe would demonstrate evidence of superior cardiovascular health compared to those populations who subsisted primarily on starchy staples, including grains, legumes and tubers. Populations who have inhabited the arctic, where scant plant matter is available throughout most parts of the year, such as the Inuit and Aleut were forced to subsist almost exclusively on hunted marine animals for extensive periods of time.1 6 This should make these populations suitable to study the hypothesis that naturally raised animal foods protect against cardiovascular disease.

Contrary to claims of the traditional living Inuit being immune from cardiovascular disease, evidence of severe atherosclerosis has been identified in several frozen mummies of Alaskan Inuit dating back to 400 CE and 1520 CE, both instances predating European contact.7 8 Atherosclerosis has also previously been identified in several artificially prepared mummies of Aleut-Unangan hunter gatherers who lived in the 18th century in the Aleutian Islands in Alaska.9 10 Recently the HORUS study, which examined an additional five recovered mummies of Unangan hunter gatherers who lived in the mid and late 19th century found definite evidence of atherosclerosis in several major arteries in all three who were over the age of 25.11

When considering the findings from all of these Alaskan Inuit and Aleut mummies it becomes evident that these Alaskan natives likely experienced a greater incidence of atherosclerosis, especially given the young mean age compared to the three other ancient populations studied in the HORUS study. Unlike the Alaskan natives, these other three populations, which were the ancient Egyptians, ancient Peruvians and Ancestral Puebloans practiced agriculture and consumed grains. 

In addition to evidence of atherosclerosis from native Alaskan mummies, reports from medical officers provide further evidence of unfavorable rates of cardiovascular disease among the Inuit before the rapid transition to the western diet. In 1940, based on decades of clinical practice and reviewing reports of medical officers dating all the way back 175 years ago, Bertelsen, who is considered the father of Greenland epidemiology stated in regards to the mortality patterns among the Greenland Inuit that: 

...arteriosclerosis and degeneration of the myocardium are quite common conditions among the Inuit, in particular considering the low mean age of the population.12

Bjerregaard and colleagues performed a literature review for studies addressing the incidence of atherosclerosis and cardiovascular disease among the Inuit of Alaska, Canada and Greenland spanning from the 1930s to more recent decades. The researchers found that the incidence of atherosclerosis was generally similar to that of other western populations that suffered from high rates of cardiovascular disease. Mortality from stroke was found to be even higher, and mortality from all cardiovascular diseases combined was found to be similar or even higher among the Inuit. The researchers also found that mortality from coronary heart disease among the Inuit was not significantly different after adjusting for ill-defined causes of cardiovascular death, suggesting that the substantial proportion of cardiovascular deaths being classified as ‘garbage codes’, particularly in Greenland may have hidden a significant portion of deaths from coronary heart disease. The researchers concluded: 

The mortality from all cardiovascular diseases combined is not lower among the Inuit than in white comparison populations. If the mortality from IHD [ischemic heart disease] is low, it seems not to be associated with a low prevalence of general atherosclerosis. A decreasing trend in mortality from IHD in Inuit populations undergoing rapid westernization supports the need for a critical rethinking of cardiovascular epidemiology among the Inuit and the role of a marine diet in this population.12

A similar phenomenon to the misclassification of deaths from coronary heart disease among the Inuit populations has also been observed in France, which may largely explain the so-called French Paradox. Data from the World Health Organization MONICA Project suggests that the official mortality statistics for France significantly underreport deaths from cardiovascular disease compared to other countries, with deaths from coronary heart disease being underestimated by 75%. Other reports suggest that this is likely explained by a much higher rate of French doctors classifying deaths as due to ‘other causes’ than in other countries.13 14

It has been observed that among the Alaskan Inuit a higher intake of saturated fat is associated with elevated blood pressure, insulin resistance, glucose intolerance and carotid atherosclerosis, suggesting that the traditional Inuit foods relatively rich in saturated fat were likely to have been detrimental to the cardiovascular health of the Inuit.15 16 17 It has also been observed that among Alaskan Inuit elevated LDL cholesterol is associated with a greater than fourfold increased risk of cardiovascular disease.18 Furthermore, rheumatic disorders that have been linked to cardiovascular disease, such as gout and rheumatoid arthritis have been found to be just as, or even more common among the Eskimo populations compared to that of the general North American population.19 20 Established risk factors, a number of which are likely adversely affected by the traditional Inuit diet can probably in part explain the evidence of severe atherosclerosis and unfavorable rates of cardiovascular disease observed among the traditional living Inuit and Aleut populations. 

In the HORUS study it was found that two of the four Ancestral Puebloan who lived in southwestern United States dating between 1500 BCE and 500 CE exhibited probable evidence of atherosclerosis, the two other both being under the age of 30. These Ancestral Puebloans were identified as being from a time when they were transitioning from hunter-gatherers to farmer-foragers, and were likely to have relied on hunted animal foods to supply at least a modest portion of their diet. An additional Ancestral Puebloan mummy aged 18-22 found from a later period after a greater transition towards agriculture did not exhibit any evidence of atherosclerosis.11

In the HORUS study the ancient Egyptian mummies exhibited the next greatest frequency of atherosclerosis, with 29 (38%) of the 76 of the mummies exhibiting at least probable evidence of atherosclerosis.11 In their book Protein Power, Michael and Mary Eades assert that the ‘diet of the average [ancient] Egyptian consisted primarily of carbohydrates’, which they suggest was ‘a veritable nutritionist’s nirvana… rich in all the foods believed to promote health and almost devoid of saturated fat and cholesterol'. These authors go on to suggesting that the carbohydrate rich diet of the ‘average Egyptian’ which they describe as being based on whole-grain wheat and barley supplemented by a variety of fruits, vegetables, legumes, nuts and some goats milk is responsible for the atherosclerosis and obesity exhibited by the ancient Egyptian mummies.21

The authors of Protein Power suggest that complex carbohydrates, such as wheat made the ancient Egyptians obese

There is much evidence that casts doubt on these authors description of the diets of the ancient Egyptian mummies. For example, Macko and colleagues have shown that isotope analyses of the amino-acid composition of hair from the ancient Egyptian mummies far more closely resemble that of modern westerners following an omnivorous diet than a vegetarian, and especially vegan diet.22 In addition, David and colleagues showed that evidence from hieroglyphic inscriptions on ancient Egyptian temples suggest that the elites of ancient Egyptian society, being those who were primarily mummified consumed a diet rich in flesh and saturated animal fat. These researchers addressed the confusion surrounding the diet and atherosclerosis of the ancient Egyptian mummies, asserting: 

It is important to point out that there was a marked difference between the mainly vegetarian diet most Egyptians ate and that of royalty and priests and their family members whose daily intake would have included these high levels of saturated fat. Mummification was practised by the elite groups in society, ensuring that their remains have survived to provide clear indications of atherosclerosis; by contrast, there is a lack of evidence that the condition existed among the less well-preserved remains of the [mainly vegetarian] lower classes.23

The findings of a lower incidence of atherosclerosis among the lower classes of ancient Egypt who subsisted primarily on a carbohydrate-rich vegetarian diet are consistent with observations in Egypt in the early 20th century. In 1934, Rosenthal asserted:

Of interest is the report of Ismail in Egypt, who has communicated that among his private patients, whose diet is similar to that of the Europeans, the incidence of atherosclerosis is high, while in his hospital practice, composed mainly of natives, who subsist largely on a carbohydrate diet, the incidence of atherosclerosis is low.24

It is clear that the authors of Protein Power have confused the diet of the elites of the ancient Egyptian society, who certainly cannot be considered as the 'average Egyptian' with the largely vegetarian diet of the of the lower classes who exhibit a lack of atherosclerosis, and which scant evidence suggests were obese. The findings from ancient Egyptian mummies do not support the claimed benefits of a low carbohydrate, high saturated fat diet promoted by these authors.

In the HORUS study, despite having the highest mean age, nearly 10 years older than that of the Unangan and Ancestral Puebloans mummies, the ancient Peruvians exhibited the lowest incidence of atherosclerosis, being evident in 13 (25%) of 51 of the mummies. Compared to these other studied ancient populations, the Peruvians likely relied more on staple plant foods, such as corn, beans and tubers, although did consume some domesticated and hunted animals.11

The researchers of the HORUS study suggested that exposure to smoke from fire used for cooking and25

heating may help explain some of the degree of atherosclerosis identified in these ancient populations. However, the description of the use of fire for cooking in ancient Egypt provided by these researchers would apply primarily to the lower classes of ancient Egypt which exhibit a lack of atherosclerosis, rather than the mummified elites that these researchers examined who would typically have had servants to cook for them.

Gout was known to be common among 

the Mongols of the Golden Horde

In regards to the traditional living Inuit and Aleut, it has been suggested that the extensive exposure to seal oil lamps may help explain the relatively severe degree of atherosclerosis in these populations.  These findings should however be considered in light of evidence of atherosclerosis in other populations which have high exposure to hazardous smoke but consume contrasting diets. For example, it has been observed that the Papua New Guinean highlanders have a smoking prevalence of greater than 70% for males and 20% for females while also being exposed to smoke for up to twelve hours a day due to the use of centrally placed open wood fires in their houses which lack both ventilation and chimneys. Despite such a high exposure to hazardous smoke it has been observed that the Papua New Guinean highlanders have among the lowest age-adjusted incidence of atherosclerosis of any studied population. However, unlike the Inuit, the Papua New Guinean highlanders traditionally consumed a plant based diet with carbohydrate supplying more than 90% of total energy intake, predominantly derived from sweet potatoes.26 27

Another population that have historically been documented to subsist almost exclusively on a diet derived from grass-fed, free-ranging animals are the largely nomadic Mongolians. John of Plano Carpini who visited the Mongols in the mid-13th century noted:

[The Mongols] have neither bread nor herbs nor vegetables nor anything else, nothing but meat… They drink mare’s milk in very great quantities if they have it; they also drink the milk of ewes, cows, goats and even camels.28

Smith reviewed the literature regarding the health of the Mongols from the 13th century and noted that a number of unfavorable cardiovascular risk factors, including obesity and gout were both common disorders. Smith went on to state:

Cardio-vascular problems, although not then subject to diagnosis, may be suspected as well.29

In 1925, Kuczynski reported on the nomadic pastoralists of the Kirghiz and Dzungarian Steppes in Central Asia and northern China that were of Mongolian descent. Similar to the observations of the diet of the nomadic Mongols of the 13th century, Kuczynski observed that these nomadic pastoralists subsisted almost exclusively on enormous quantities of meat and milk from grass-fed, free-ranging animals. Other authors have also come to the same conclusions regarding the composition of the diet of the nomadic pastoralists of the Central Asian Steppes. For example, Tayzhanov asserted:

…the people [of the steppe] lived exclusively on meat, fat and sour milk. Bread was added only later and even then some households did not adopt or consume this food.30

Similarly, Barfield asserted:

In good legendary style, the pure Central Asian nomads eat only meat, marrow, and milk products {preferably ferments}. They despise farmers, farming, and grain…31

These findings suggest that the diet of these nomadic pastoralists of the Central Asian Steppes was almost exclusively animal based, virtually devoid of grains, legumes and refined carbohydrates. This should make these populations also suitable to study the hypothesis that naturally raised animal foods protect against cardiovascular disease. However, not only did Kuczynski observe that these nomadic pastoralists suffered from high rates of obesity and gout similar to the Mongols of the 13th century, Kuczynski's observations further extended to the diagnosis of cardiovascular disease and other dietary related disorders. Kuczynski asserted:

They get arteriosclerosis in an intense degree and often at an early age as shown by cardiac symptoms, nervous disordes, typical changes of the peripheral vessels, nephrosclerosis and, finally, apoplectic attacks. Even in men thirty-two years old I frequently observed arcus senilis.32

It was also observed that in the 1960s the prevalence of coronary heart disease among the nomadic pastoralists in Xinjiang in northern China who consumed large quantities of animal fat from grass-fed, free-ranging animals was more than seven times higher than that of other populations both within Xinjiang and throughout China which consumed significantly less animal fat.33 These observations support the suggestion that cardiovascular disease was common among the Mongols of the 13th century who subsisted almost exclusively on a diet based on grass-fed, free-ranging animals.

Dispelling Grass-Fed Fairy Tales

These findings from populations living before the 20th century suggest that similar to the findings from people studied in more modern times, a greater intake of minimally refined plant foods strongly predicts a lower prevalence of atherosclerosis and cardiovascular disease. These findings cast doubt on the hypothesis that foods from organic, naturally raised animals protect against cardiovascular disease compared to staple plant foods. Furthermore, these findings suggest that the traditional living populations that relied predominantly on naturally raised animal based foods suffered from complications related to cardiovascular disease at a relatively young age and are poor role models for health.

Future posts in this series will further address how naturally raised animal foods influence cardiovascular disease, as well as other so-called diseases of civilization.


Please post any comments in the Discussion Thread.

easy home remedies

i take this herb class every thursday evening with john redden. he's amazing. his herb clinic and shoppe are called viriditas and it's amazing how much knowledge and information this man has.
here are some of the things we've been busy with.

 garlic honey

whole garlic cloves topped with organic honey. we let this sit for about a month. then strained the garlic out and were left with the honey infused garlic. 

kai had a terrible cough last week. i put dropperfuls of this into his mouth, he gladly opened, and within 2 days his cough was gone. this is a really great home remedy and super easy to make.

 horseradish

blended in the vitamix

on the left- horseradish with mustard powder and apple cider vinegar

on the right- horseradish with mustard powder, apple cider vinegar and tumeric

this stuff tastes amazing! it is a bit spicy and full of amazing medicinal qualities.

horseradish for the lungs, tumeric for its anti-inflammatory/anti-oxidant/anti-cancer and liver promoting properties and mustard powder for its anti-inflammatory/immune enhancing benefits

i made a salad dressing tonight with olive oil, lemon and honey and then added a tsp of this paste into the dressing and tossed onto the salad. so easy to get into the kids this way! (mine eat salad. you can also put into rice, pasta sauce, soups and stews)

Continuous Improvement – The Method that Will Get Us to Our Vision

GBMC HealthCare is using the management science that other excellent organizations use to provide ever-increasing value to those they serve. This way to manage, created by the likes of W. Edwards Deming and Walter Shewhart in the 20th Century, is what is helping us get closer to our vision every day. How are we doing at using this science? Well, we recently “took a test” when examiners from the Maryland Performance Excellence Awards program reviewed us. The examiners studied GBMC through the lens of the Malcolm Baldrige Performance Excellence criteria.

On October 15th, I attended the Maryland Performance Excellence Awards dinner with a group of my colleagues. GBMC received a silver award. Congress established the Baldrige Program in 1987 to recognize U.S. companies for their achievements in quality and business performance and to raise awareness about the importance of quality and performance excellence.

Forward thinking organizations like GBMC utilize the National Malcolm Baldrige Criteria for Performance Excellence to make themselves better, faster. This was GBMC’s first application for this distinction, and to be honored with the silver award recognizes the advances our organization has made in improving care to our patients. Our vision is a vision of perfection, and we won’t get there unless we use scientific management. We will apply for the award again next year, because it is a great way to learn and improve our management systems.

At the awards dinner, I had the opportunity to explain our vision to a large group of people assembled from other industries. I told them about our quadruple aim (Better Health, Better Care, with the Least Waste and the Most Joy for those providing the care) and I gave them some examples of the progress we were making. As I was speaking I realized how proud I was of everything that our people were accomplishing, but I also recognized how much work there still is to do to become even more patient-centered.

Our vision of perfection includes always delivering the correct medication at the correct dose to the correct patient. This is the definition of a highly reliable medication delivery system. Our Pharmacy team is using continuous improvement to build this highly reliable system. And, with this week being National Pharmacy Week, I asked our pharmacy team to explain their expanded role in patient care and safety.

Todd Jackson, Automation Systems Analyst, Pharmacy Informatics explains:

“In both the hospital and community setting, Pharmacists play an integral role in patient care by preventing medication errors, advising physicians on the best drug choices, safeguarding against medications allergies and drug interactions, and working with nurses to ensure that patients understand how to use their medications safely and effectively.

Several members of the Pharmacy team including (L-R):
Mahsa Mahmoudian, C.Ph.T, Nicole Garrison, R.Ph, Dana Hack, R.Ph.,
Heather Orach, C.Ph.T., Peter Furgiuele, R. Ph.
(Not pictured: Min Min Than, R.Ph., Pharmacy Director, and Todd Jackson)

Certified pharmacy technicians play an equally important role in the healthcare continuum. Incorporating a high level of multitasking ability, they are involved in compounding medications, packaging and labeling, and delivering medications.

Pharmacists and certified technicians have taken on enhanced patient care roles through the use of special technologies including DoseEdge, Medex, RobotRX, as well as the Acudose and Anesthesia RX stations.  Here at GBMC, technology is utilized at many points in the pharmacy workflow. 

Computers also help pharmacists monitor every patient’s medication therapy and provide quality checks to detect and prevent harmful drug interactions, reactions, or mistakes. But, it still takes a human being to evaluate what the computer says and to know what to do to prevent adverse medication events.”

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To move toward our vision of perfection: “To every patient, every time, we will provide the care that we would want for our own loved ones,” we must continue to have outstanding professionals who continually improve our systems. I thank teams throughout GBMC, such as our Pharmacy team, for holding themselves accountable for the attainment of our vision.

What are your teams doing to redesign systems and improve quality in your departments?

Lentil Butternut Squash Soup with Chard

this beautiful chard was the inspiration for this soup. i was at the barns on saturday for the weekly farmer's market and saw this rainbow chard. i found this recipe online which looked easy enough.

butternut squash and carrots

 leeks

 sauteed leeks, garlic, squash and carrots

 all cooked up. the chard went in at the end. i also did not use the dried herbs but at the end added fresh coriander (can't get enough of this herb!) and fresh basil.

when bella got home we decided to make pumpkin squares. i made them back here

i now put in 1/2 cup of oil and 1/2 cup of sugar instead of the 3/4

bella basically made them herself. i measured and she poured and mixed.

 and then kai, hanging about...

Important Insights for Breast Cancer Awareness

You may have noticed that the world looks a little more “pink” in October. This is because October is national breast cancer awareness month and to recognize the important strides GBMC’s Comprehensive Breast Care Center has made in diagnostics, treatment and overall care for our patients, I’ve asked Dr. Lauren Schnaper, Director of the GBMC Sandra and Malcolm Berman Comprehensive Breast Care Center, to be a guest blogger this week. Dr. Schnaper is nationally recognized for her breast cancer expertise and patient care and has been active in a number of national clinical trials. She was named one of Maryland’s Top 100 Women in 2010 and is passionate about sharing lifesaving information with women. I hope readers of this blog will find Dr. Schnaper’s observations on breast cancer screening and biases as enlightening as I did:

Dr. Lauren Schnaper

Dr. Schnaper writes…

The first mammograms were performed in Europe, as early as 1913.  They were not the high tech digital films we know today and did not catch on for many decades because surgeons treated all breast tumors, no matter the size or the behavior, with radical surgery.  Finding smaller tumors that might be treated with more limited procedures was a concept foreign to physicians. They believed, erroneously, that removal of as much tissue as possible was the only way of keeping breast cancer from “coming back.” That is a tenacious concept, still believed by many people.

By the early 1960s, when surgeons began to question radical mastectomy dogma, mammography was resurrected and the first screening trials began. Screening mammography was not widely performed until the 1980s.

The definition of a screening test for a population or an individual means that they are asymptomatic (no lumps or bumps, skin changes, nipple abnormality, etc).  The screening criteria also may not apply to individuals who are considered to be at high risk (strong family history or genetic mutation carrier, previous breast cancer).  The benefits (reduction in the risk of dying from breast cancer) must be weighed against the financial and non-financial costs (radiation exposure, additional tests and biopsies, anxiety, money per test).

There are two major problems with screening:  Underdiagnosis means that the mammogram failed to find a cancer that will eventually be discovered when it becomes a lump or presents with some other symptom. Overdiagnosis means: (1) that an abnormality is found that is not a cancer but is evaluated with multiple procedures as if it was a cancer or (2) a true cancer is found but one that would never become clinically significant during the indivdual’s life-time and would not influence how they are treated, how they live or die.

In America, we have trouble with the concept of costs vs. benefit.  We believe that if a million women need to be screened to save one life, then so be it.  We picture ourselves or our loved ones as that one life saved.

The non-financial costs of screening are influenced by several biases:

Lead time bias means two women develop a deadly breast cancer on the same day.  They die of that cancer on exactly the same day, five years after diagnosis.  They both have treatment but no treatment that they receive will change the behavior of their cancers or save their lives but they are not aware of that fact.  The first woman’s cancer is picked up on a mammogram in year #1 after the cancer is born.  She and her family believe that mammography has benefited her because she has had four additional years of life following her diagnosis.  The second woman never had a mammogram.  Her cancer is picked up as a lump in year #4.  Her survival appears to be shorter than that of the first woman, even though it is identical to the first woman’s.  To be effective, screening must decrease mortality from the disease, not just give the appearance of doing so.

Length time bias speaks also to the variable behavior of cancer.  More poorly behaved fast growing tumors do not lend themselves to screening as they often occur in between the screening test interval and have already spread before they are detectable.  Slow growing tumors are amenable to screening because they might hang around for a long time before doing any damage.

The concept of “early detection” is a simplistic view of a disease that has numerous and complex behaviors; no two cancers are the same.  In the extreme, a few are deadly from the day they are born but most require treatment and are ultimately curable.

Herein lies the controversy that waxes and wanes in the popular press.  Who should be screened and how often?  The United States Preventive Services Task Force (USPSTF) has reviewed screening mammography studies in 2002 and 2009.  The members took many factors into account.  In 2002, they recommended that the screening interval be changed to one to two years.  In 2009, they changed their recommendation to every two years because they saw the same decrease in the death rate in the annually screened groups as in the longer screening interval groups.  They also found that there was no difference in the chances of detecting an aggressive cancer between the one year and the two year screening interval.

The risk of developing breast cancer increases with age.  The “readability” of mammograms gets better after menopause when breast tissue goes away and is replaced by fat.  The average age of menopause in America is 52. The behavior of breast cancer is also less aggressive in older women.  The USPSTF recommend screening every two years between 50 and 74 and individualized screening for women over 74.

In women who are still menstruating, there is a lot of breast tissue which is referred to as “breast density” on mammogram – as if this is an abnormality or a disease.  It is not. The breast is a round object, compressed by the mammogram plate to be a flat picture.  The overlapping shadows of the tissue are white on the film.  Because all of the abnormalities – good or bad – are also white, they may not be seen if transposed on a white background.  Digital mammography has more contrast and is more sensitive to changes in mammograms of menstruating women or those on exogenous hormone therapy.  Again, the USPSTF recommends individualized screening decisions for women in their forties but at a two year, rather than a one year, interval.

It should be noted that the American College of Radiology, the National Comprehensive Cancer Network, and the American Cancer Society continue to recommend annual screening for all women over 40.  They do not offer an opinion as to at what age mammography screening should stop.

The National Cancer Institute advises screening every one to two years beginning at age 40.  The American College of Physicians, every one to two years age 50-74 with individualized recommendations ages 40-49.  The American College of Ob/Gyn recommends every one to two years from 40-49 and annually thereafter, with no stopping recommendation.

Interestingly, the United Kingdom National Health Service recommends screening every three years from age 47-73.

NO organization recommends a baseline mammogram at age 35.

In order for a screening test to be adopted or changed it must improve on all of the parameters already discussed.  Touted as the new era in breast imaging is Tomosynthesis or 3D Mammography.  It is a digital mammogram, that instead of taking a flat top-to-bottom and side-to-side picture, the machine swings around the breast, taking as many as 60 thin “slices” through the tissue.  This may benefit women with dense breasts on imaging as it does away with overlapping tissue shadows so that white lesions can be separated from the white tissue background.  Another advantage is that there will be fewer call-backs for additional films to evaluate vague areas of density.

Although some say there is less pain during a 3D mammogram, this is not true.  Compression is the same. Other disadvantages:  Although 3D mammography has FDA approval, there may be additional out-of-pocket expense to the patient because there is no insurance reimbursement at this time.  There is increased radiation exposure, approximately that of the old analog films, because both 2D and 3D mammograms are performed at the screening visit.  The 2D films will probably not be needed after the technology for creating a 2D picture out of the 3D slices is improved.  Radiologists have to be trained in new reading techniques and interpreting the films takes about twice as long as for the 2D films alone.  In terms of increasing ability to detect cancer or decreasing mortality from breast cancer, studies are underway.

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I thank Dr. Schnaper for her insights and continued work on behalf of all the patients who turn to GBMC for superior breast care.

For anyone who isn’t familiar with GBMC’s program, the Comprehensive Breast Care Program and its affiliated Advanced Radiology Breast Imaging Center have received national accreditation as Centers of Excellence, which speaks to the integrated and superior care our patients receive. From the Breast Cancer Risk Assessment Program to GBMC’s Rapid Diagnostics Program, our patients truly benefit from the expertise of our physicians and care providers and the advanced technology available for diagnosis and treatment of breast cancer. But, most importantly, our team of specialists takes to heart GBMC’s vision of treating every patient, every time, the way they would want their own loved ones to be treated.

Finally, GBMC is currently offering 3D Tomosynthesis Mammography at the Breast Care Center. You can call 443-279-9639  for more information or to make an appointment or visit the Comprehensive Breast Care Center page on GBMC’s website to learn more.