Health for life

While the national mainstream media focuses on Obamacares dimming prospects, internecine Republican conflicts over the merits of a government shutdown, pugnacious Democratic debates over government price controls and who should take credit for the drop in health care cost inflation, check out this local city paper article on the One Simple Idea (that) Could Revolutionize Health Care. As the reporter pointed out, there was no press release, no touting and no awards.  Simply results.

The DMCB agrees.

Barbara Schneider and her team work with Philadelphia health insurer Keystone Firsts community outreach and care coordination programs to intervene on the "sickest of the sickest" diabetics.  These are 35 patients who are admitted on average more than twice a month.  Patients who are on a first-name basis with all the local emergency rooms nurses on all the shifts. Patients who live in run-down boarding houses on a good day.  Patients who are lucky if their blood sugar is only 600 mg%.  Were talking hundreds of thousands of dollars in health care costs.

Dr. Schneiders lay community health workers (more info on the science here) are seeing these individuals in parking lots, McDonalds, row homes and halfway houses  to cajole, coach, text, call, shuttle and haggle with patients, families, social workers, pharmacists and insurers to dismantle barriers one patient at a time.  If a patient isnt ready to stop abusing drugs, that doesnt mean he cant be taught to use a glucose meter.  While living circumstances may be chaotic, that doesnt mean she cant use a cell phone instead of just going to the emergency room.

As Dr. Gawande noted in his The New Yorker article about the super-utilizers, those kinds of interventions can add-up significant savings.

While Keystone has yet to release an analysis on the impact on claims expense for these patients, a cursory review of the data shows emergency room visits have been cut by a third, while inpatient stays declined by more than half.  Even with the DMCBs limited background in analytics, it suspects that when the return on investment is finalized, Keystone will conclude that the program was an unqualified success.

To the DMCB, this is what its all about.  Washington DC can continue its partisan scorched earth battles while, in the meantime, small regional community minded health insurers like Keystone First are figuring out how to do right by patients using novel programs like this. 

Image from Wikipedia

A small study conducted by researchers at Arizona State University found that low blood levels of vitamin C were associated with decreased fat oxidation - the burning of fat for fuel.

"Free-living individuals with marginal vitamin C status oxidized 25% less fat per kg body weight during a 60-minute treadmill walk as compared to individuals with adequate vitamin C status."

They site a possible mechanism: Vitamin C is used by the body to make carnitine, and carnitine is necessary for fat oxidation.

They also found that the less fat participants oxidized, the greater their fatigue, leading them to speculate that:

"Vitamin C depletion may result in weight gain by two mechanisms: indirectly by fatigability and exercise intolerance and directly by lipid accumulation."

When researchers supplemented the depleted subjects with 500 mg/day of vitamin C, they increased their amount of fat used for energy by a factor of 4.

________
For the study, published in Nutrition and Metabolism:
Marginal vitamin C status is associated with reduced fat oxidation during submaximal exercise in young adults

Orange Juice

Susan Mahy, Director of the Cosmetic Executive Women UK, said: "These essential nutrients you need for healthy skin, hair and nails are the most beneficial when ingested as part of your meal." "Panel executive women in the field of perfumes, cosmetics and hairdressing concluded that they have a direct effect on the skin,”

Orange Juices

How much vitamin C is in orange juice?

Vitamin C in Orange Juice

 

So this past weekend, I was able to attend AHS 2012 in Cambridge, MA.  For those of you who dont know, the Ancestral Health Symposium is an annual event that began last year, and it brings together all of the most well-known people in the paleo community for a weekend full of lectures, debates, paleo food, and apparently, large amounts of free chocolate and coffee.  Or maybe it was only me who spent half the conference eating free dark chocolate samples and drinking americanos.  Oh well, coffee is life.

Caveman chocolate.

It was a great weekend, and I got to meet some great people who Ive learned so much from over the past couple of years.  Stephan Guyenet, Chris Kresser, Mark Sisson, just to name a few.  Also got to meet Laura from Ancestralize Me, which was great because shes also on the RD track and I love bitching about My Plate.  I did NOT get to meet Robb Wolf, which I was really disappointed in since hes sort of the ring leader of this whole paleo movement.  Maybe next time.  I was so pleasantly surprised to learn how down to earth and approachable these people were.  Despite their status in the community, they were willing to socialize with everyone and blend in.  I really appreciated their everydayness.

Anyway, over the next few days Ill be discussing my thoughts on some of the main topics from AHS this year, and also talk about the event as a whole and what it means for the future of the paleo community. So without further ado...


Safe Starch Debate
One of the best presentations of the weekend was the safe starch debate involving Paul Jaminet, Chris Kresser, Cate Shanahan, and Ron Rosedale.  Let me first just say how ridiculous it is that were even asking the question "Is there such a thing as a safe starch?"  Im sorry but its stupid.  Especially when it followed Chris Masterjohns great presentation, which explained very clearly how humans, as compared to apes, have evolved the ability to digest greater amounts of starch through salivary amylase.  This is not debatable.  Of course starch is safe.  The question is, how much starch is safe for a given person?  Well, according to Chris Masterjohns data, humans have varying abilities to produce salivary amylase.  So there is a spectrum in terms of the ease at which humans digest starch.  Some can handle it very easily and perhaps in large quantities, while others may have a hard time digesting a lot of starch.

Chris Kresser (middle) dominating the safe starch debate

The obvious answer to safe starch debate is... it depends.  One person may be just fine on a diet high in starch from potatoes and sweet potatoes, while another person may be better off limiting their potato consumption.  There is no one diet for everybody, which is why I think Chris Kresser clearly came out on top in this debate, because he understands this concept.  Ron Rosedale came off as a complete idiot, in my opinion, although he did make some interesting points.  He advocates a low-carb, ketogenic diet for everyone, which I completely disagree with.  Cate Shanahan was on the low-carb side as well, although she was not as militant about it, and I was happy to hear her conclude with the idea that eating real food is what matters most.  Not to forget about Paul Jaminet, I thought he was great in this debate as well, but having read his book, I know he is of the opinion that the optimal human carbohydrate intake is fixed at between 100-150g per day.  Any more, according to him, is toxic.  I just cant agree with that.  So Kresser for the win.

Oh, and theres also that pesky fact that nearly all 7 billion people on earth eat a starch-based diet.  I know that doesnt mean its optimal, Im just saying.  Theyre not killing us.


LDL-P
The concept of LDL-P seemed to be a theme this past weekend.  LDL-P stands for LDL particle number.  In a typical lipid panel from your doctor, they are measuring LDL-C, or LDL concentration.  According to Peter Attia, and Robb Wolf mentioned it in his talk as well, LDL-P is a much better predictor of heart disease than LDL-C. 

From Dr. Attias presentation.  This graph compares LDL-C levels with incidence of heart attack.  Most heart attacks occurred in people with what is considered a "normal" level of LDL-C.  What would conventional medicine do?  Lower the erence range and prescribe more statins.  What should we do?  Get a new fucking risk factor.

Lets make up an example.  Say you have a healthy LDL-C, as measured by your doctor, at 120 mg/dl.  Thats a good thing, as far as hes concerned.  But LDL can vary in size.  If all those particles are small LDL particles, then there must be a lot of them to make up that concentration of 120 mg/dl.  If you have a lot of LDL particles, youre at high risk of heart disease, regardless of what your LDL-C says.  On the other side of the coin, you may have large LDL particles.  In this case, you have fewer total particles that make up that 120 mg/dl.  Here, you would be at low risk.  Of course, you could also look at someone with high LDL-C, say 200 mg/dl, and you could make the case that he or she may or may not be at risk, depending on the size and total number of LDL particles.

I  have been familiar with the LDL particle size idea for a while now.  But according to Dr. Attia, particle size is largely irrelevant in its own rite.  Small, dense LDL particles are very much associated with a higher risk for heart disease, but it is not the small LDL that are causing disease.  It is because small LDL often indicates a large particle number that explains the association with heart disease.  It is not the small, dense LDL itself.  In a situation where someone might have low LDL-C, low LDL-P, and small particles, the risk of disease remains low.  Or if someone has high LDL-C, high LDL-P and large particles, their risk of heart disease is high.

I realize this may be confusing.  But heres the take home message:  It looks like the LDL-C measurement, the one doctors are currently using, is largely useless.  While higher LDL-C may increase the chances that youve got a high LDL-P (only makes sense, right?), the two are not necessarily connected.  We need to start measuring LDL-P if were ever going to get an accurate measurement of heart disease risk.


Thats it for part 1 of my AHS review.  Ive got much more to talk about, so stay tuned for the next part!