Diabetes & Alzheimer's Disease: What's the Link? Part 2

Diabetes is not a good thing to get.  Uncontrolled or even poorly controlled diabetes can shorten one's life by 6 years while increasing one's risk for strokes, heart attacks, kidney failure, blindness, amputations & erectile dysfunction.  And in a very small study published in January earlier this year, the authors noted that insulin resistance might be a marker for Alzheimer's disease.  Being a lumper & not a splitter, I was not overly surprised by yesterday's release of a prospective study linking diabetes to dementia.

The authors followed over a thousand community-dwelling dementia-free participants >60yo for 15yrs.  Fasting glucose & oral glucose tolerance tests were performed at baseline.  While the former was not associated with all-cause dementia, Alzheimer's disease, or vascular dementia, the latter showed a strong correlation when abnormal.  Of course the next question is how abnormal is abnormal?  Those at lowest risk for developing all-cause dementia or Alzheimer's disease had a 2 hour post-prandial glucose <120mg/dL compared to those in the 140-198mg/dL range.  Risk for vascular dementia was increased in those with 2 hour post-prandial glucose >198mg/dL.

What's the moral of this study?  Avoid getting diabetes at all costs.  Change your lifestyle for the better.  Stop smoking.  Get physically active regularly.  And eat better - nothing controversial, you know what's good for you and what's not.  Choose to get healthy.

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Lifestyle Affects Erectile Function

Lifestyle modification.  We know it's good for us but we can't seem to make those necessary changes to our daily habits, even though doing so will decrease our mortality as well as improve our health.  Guys are especially problematic since we typically won't even go see a doctor unless a limb or appendage falls off (it's medically analogous to refusing to ask for directions until we're clearly lost in the middle of nowhere).

So is there a better incentive for guys than a longer, healthier life?  How about better erectile function?  In a study released early online, the authors concluded that lifestyle modification can effectively improve erectile dysfunction as determined by validated questionnaires.  Statins that reduced cardiovascular risk factors also improved sexual function.

Well, maybe "can" is too strong a word since the study was a meta-analysis of 6 randomized controlled trials involving 740 men in 4 countries, ranging from 8wks to 2yrs in duration.  Average age in the individual trials varied significantly from 43yo to 64yo.  4 of the trials focused on lifestyle modification while 2 involved statins.  Lifestyle modifications also varied from Mediterranean diet to interval exercise to weight loss to exercise plus "lifestyle change".

While this is a small relatively short analysis, it's heartening to note that improving one's lifestyle in any fashion can improve erectile dysfunction in Iran, Italy, Nigeria, and the States.  Best of all, it's free and there are no side effects or contraindications.  You can't say that about Cialis, Levitra & Viagra!

White-Fleshed Fruits & Vegetables vs Stroke Risk

Diet, schmiet.  We know what healthy food is, just as we know what unhealthy food is.  It's more a matter of acting upon what we know.  So is it any surprise when the only diets that have survived the test of peer-reviewed publication (as opposed to Internet & TV show advertorials) include a varied number of fruits & vegetables in them, eg Mediterranean diet, DASH diet, etc.  Specifically, one way to teach our kids to eat is to consume the colors of the rainbow each day in terms of fruits & vegetables (not Skittles and M&M's).  Of course, that raises the question of which fruit or vegetable is more important.  For instance, the darker ones theoretically have more antioxidants.

However, in a nice twist, a study was published early online last week (prior to release in print in November) concluding that high consumption of white-fleshed fruits & vegetables is associated with lower stroke risk, all other things being equal.  Just what are these white-fleshed fruits & vegetables?  Apples & pears, apple juice & sauce, bananas, cauliflower, chicory, cucumber, mushroom, garlic, leek & onion.

In the prospective, population-based cohort study, the authors followed for 10 years 20,069 men & women average 41-42yo w/o known baseline cardiovascular disease.  Consumption of green, orange/yellow & red/purple fruits & vegetables was not associated with stroke risk while each 25g/d increase in white-fleshed fruit & vegetable consumption lowered stroke risk by 9%.  Given that the participants consumed 118g/d of white-fleshed fruits & vegetables, this calculates out to a 42% reduction.  When comparing those in the upper quartile of consumption (>171g/d) to those in the lowest quartile (<78g/d), the authors noted a 52% lower risk of stroke.

I found it particularly gratifying to know that the average participant also consumed 62g of green, 87g of orange/yellow, and 57g of red/purple fruits & vegetables daily in addition to their 118g/d of white-fleshed fruits & vegetables.  Still, when all is said & done, I'm a lumper & not a splitter.  Rather than have you eat just one color, I still recommend eating the colors of the rainbow each day.  By the way, don't forget to optimize your blood pressure, cholesterol & sugar for your best bet at avoiding a stroke!

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This Weekend

With all due apologies, this will be the extent of my posting this weekend as I am tied up presenting at the AAFP's Scientific Assembly and will not have time to devote to answering questions until I return home. Please check back in on Monday, September 19th, for my 2 cents on a new study. Thank you!

Do You Keep A Firearm In Your Home?

Last summer, a young Florida mother got upset when her child's pediatrician asked if there was a firearm in the home.  When she refused to answer on the grounds that it had nothing to do with her child's health, the pediatrician fired them from his practice.  In retrospect, I think that this disagreement should obviously have been handled differently.

Instead, the Florida legislature proposed a state law that would prohibit physicians and other health care providers from asking patients whether they own or keep a firearm in the home.  Furthermore, the law would forbid a physician from refusing to treat a patient who refused to answer the question.  Finally, the law would prohibit a physician or health care provider from making note of the answer in the medical record.  The legislature proposed that physicians & health care providers be charged with a 3rd degree felony and fined as much as $5M for violating these provisions.

An amended & toned down version of this bill (reducing the fine for a 1st offense down to $10K) was passed earlier this summer to the consternation of physicians nationwide.  Can you imagine the next (il)logical step?  Physicians could then be restricted from asking about sexual orientation, sexual activity, alcohol consumption, drug use, etc.  After all, firearms are linked with death (and as such, are a public health issue).  In order to be your family physician, we need to know all about you.  But we also need your trust in our professionalism that we will not divulge anything you tell us to anyone else under pain of death (well, maybe not that far)!

Thank goodness for common sense and freedom of speech.  Yesterday, a federal judge declared the law unconstitutional.  We can now freely ask you anything that might impact your health.  Of course, you can always feel comfortable refusing to answer on any grounds that you choose.  Just know that I may not be able to make the best recommendation for you if I don't know all about you.  But no, I won't kick you out of my practice if you don't feel comfortable answering a question.  However, I do reserve the right to attempt to gain your trust as I help you obtain & maintain optimal health.

One last interesting tidbit.  Guess who supported the American Academy of Pediatrics in filing to overturn the law?  Family physicians via the Florida chapter of the American Academy of Family Physicians.  In fact, a family physician was the lead plaintiff.  And who stayed silent?  The Florida Medical Association.  

The Good, The Bad, and The Ugly

Yesterday, I wrote about the good that is family medicine.  Recently, I pointed out a couple of bad apples (specifically, cardiologists & gastroenterologists) in the House of Medicine which hasn't done such a wonderful job of keeping its promise to put the patients' interests first.  However, it's been brought to the attention of the nation, and probably globally, by USA Today that there is an even uglier side to medicine whereby patients are actually harmed, gravely so in some very unfortunate instances, by doctors performing procedures without adequate training.  

There's that ugly word again, procedures.  But are procedures inherently bad, in and of themselves?  Dr. Glen Stream, the newly appointed president of the American Academy of Family Physicians, pointed out yesterday that the hands of the family physician are trained to deliver babies, inject joints, set fractures, and sew up lacerations; these, too, are procedures.  Moreover, these trained hands hold those of ill patients, and comfort others at the end-of-life.  So yes, family physicians do perform procedures.  We just haven't shouted loudly enough from the mountaintop that we do so.  

Unfortunately, there are clearly instances where a specialist is reimbursed dramatically more for performing the exact same procedure that a family physician performs.  I dare say that perhaps we should lay the blame on our current healthcare system (once more!) when otherwise good people/physicians succumb to greed because they can't get adequate reimbursement for their cognitive skills (not to denigrate the tremendous thinking required to perform complicated surgeries & invasive procedures).  After all, is there any stronger motivator than the want/love of money?

So we're human.  We're fallible.  We can be tempted.  We have a price.  I would posit, however, that most of us, the majority of us, all the attendees at this Scientific Assembly and those holding down the fort for us back home, are beyond temptation and have no price.  We are family physicians.  We chose the specialty of family medicine for the ability to do all that we do.  We did not choose family medicine for its reimbursement & remuneration.  You can trust us to look out for your best interest and place yours above all else.

How can you find us?  For starters, try the American Board of Family Medicine and your state board of medicine.  And if you can't afford medical care, don't go without.  Check out the "Low Cost Medical/Dental/Pharmacy Options" tab at the top of this page.  I can almost guarantee you that any family physician working in such a clinic or facility has placed you first on top of his/her own financial well being.  In fact, the AAFP Foundation has rolled out its Family Medicine Cares program in conjunction with Volunteers in Medicine to equip new free clinics around the country.

But just in case you still want that cosmetic procedure, consider what the USA Today recommends when searching for a plastic surgeon.  Ask your family physician what s/he knows about this physician and procedure.  And remember that you only have one body, so try not to make your decision based just upon pricing.

Family Physicians Find Ways to Treat Uninsured Patients

As Secretary-Treasurer 2011-2012 for our state's chapter of the American Academy of Family Physicians (AAFP), I'm a newbie sitting in these past few days on the policy-making body of the AAFP, its Congress of Delegates.  What surprises me is how different we all are.  Academicians vs private practice.  Solo vs group.  Urban vs rural.  Those still providing full range of practice from obstetrics to endoscopy to surgical assist to intensive/critical care vs outpatient only.  And because of our differences, we can be a contentious & ornery bunch because everyone else should see things our way.  Not your way, but my way.  But in the end, we're all family physicians.  We take care of our patients and their families.

So it's no surprise that I picked up a copy of the USA Today two days ago and found an article entitled "Doctors find ways to treat uninsured patients", which is nice considering the bad press that some of our specialty colleagues have garnered recently.  But if you take time to read the article, it's not about cardiologists & gastroenterologists (all of whom we need) but rather about family physicians stepping up to the plate and helping their patients get the care that they need regardless of their ability to pay.  That's why I'm proud to stand up and say that I'm a family physician.  And I'm damn proud of my AAFP colleagues.  

But we can't expect our family physicians and other primary care colleagues to continue to bend over backwards in a healthcare system that rewards procedures over all else.  I grant you that cognitive skills are necessary to perform said procedures but when the ratio of specialists to primary care physicians becomes too great and we emphasize, incentivize and pay for doing rather than caring, we're setting ourselves up for a disaster (especially with millions of currently uninsured suddenly being added to the number of insured patients without commensurately increasing the number of family physicians and general internists to care for them).  What good is insurance if you still can't find a family physician with an open panel to care for you?

Just in case you know someone who needs medical care but can't afford it, take a look at the "Low Cost Medical/Dental/Pharmacy Options" tab at the top of this page.

TV Might Not Be So Good For Our Kids Either

We know watching too much TV is bad for adults.  But what about kids?  In a randomized controlled study published online yesterday in Pediatrics, the journal of the American Academy of Pediatrics, the authors concluded that watching just 9 minutes of a fast-paced animated cartoon (SpongeBob SquarePants) negatively impacts a 4 year old's executive function vs watching an educational Public Broadcasting Service cartoon about a pre-school aged boy (Caillou) or drawing for 9 minutes.

The editorialist argued that watching 9 minutes isn't the same as watching the whole show.  Perhaps watching more wouldn't be any worse (you know, some sort of ceiling effect).  Perhaps this is negative impact is transient, rather than permanent.  So we know the effect on 4 year olds but what about 3 year olds or 5 year olds?  Does age matter?  And while the quantity of television watching might be of greater importance for adults, perhaps we should also consider the quality of the television shows that our children are watching?  Of course, that assumes that distractability, shorter attention spans, and multi-tasking aren't ideal.  Attention deficit, anyone?  

So while this study attracted a lot of media attention (ABC, CBS, MSBNC, etc), it really raises more questions than it answers (for instance, it only included 60 middle- to upper-middle class Caucasian 4 year olds).  I grew up watching Bugs Bunny and a bunch of other TV shows.  I don't think I turned out half bad.  But then again, just think how much better I'd be now, how much more I could have accomplished if I hadn't spent all those hours, every Saturday morning, glued to the front of the tube.  Woulda, coulda, shoulda.

Alzheimer's Disease & Serial (Not Cereal) Brain MRI

I'm attending the AAFP Congress of Delegates meeting this week followed by the Scientific Assembly so my output probably won't be the same as it usually is until I return home next Sunday.  With that said, I wanted to expand upon last Wednesday's post in which biomarkers weren't really useful in predicting the conversion of mild cognitive impairment to Alzheimer's disease, although cognitive testing & brain imaging was.

It turns out that a case-control study published last month in Archives of Neurology pointed out similar findings: patients w/presymptomatic Alzheimer's disease had significantly thinner cortical regions compared to normal patients although both had normal hippocampal volumes.  In those patients who progressed onward towards Alzheimer's disease, their rate of cortical thinning actually increased, peaking around a Folstein Mini-Mental State Examination (MMSE) score of 21 (out of 30 maximum), after which the rate of thinning declined.  However, hippocampal volume loss increased during this whole period down towards an MMSE of 15.

My take home point is that a single image isn't enough.  Serial imaging is required.  Now that that's settled, we just have to come up with the funding!

Likewise, a single cognitive test isn't enough but rather, serial testing is required.  So regardless of whether your patient comes in complaining of upper respiratory symptoms, to follow up his/her chronic diseases, or to re-evaluate his/her cognitive function, we should also check his/her MMSE and look for trends (sudden drops should make us suspicious for a coincident worsening or new onset medical condition).

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