Strong Bones for Life - Naturally (Part 2)

Your Bones, Your Choice

Of course, even old decrepit bone is better than no bone, the situation seen in osteoporosis, which results when osteoclasts' demolition work greatly outpaces osteoblasts' new construction. Fortunately, this unbalanced situation, which can develop if the body becomes chronically pro-inflammatory and/or lacks a good supply of all the materials needed to build new bone, can be prevented and treated without drugs.

Here's what you need to build strong bones for life, naturally.

Calcium
Daily calcium needs:

• Women 19-50: 1,000 mg


• Women 51+: 1,200 mg


• Postmenopausal women not taking HRT: 1,500 (if on HRT, 1,200 mg daily; if you are taking HRT, it should be bio-identical bi-est and progesterone compounded specifically for you after you have had your hormone levels - all three estrogen fractions and progesterone - checked, not Premarin and Provera! If your physician is not aware of this, switch physicians.)

Remember, you get calcium from both food and supplements, so keep a food diary for a week or two to estimate your typical calcium intake and then take enough supplemental calcium to reach the above amounts.

If you regularly eat dairy products (from cows, sheep, or goats), soyfoods with added calcium, sesame seeds, and greens such as spinach, collard greens, Swiss chard, or broccoli, you are likely getting about 600 mg calcium from food each day.

Choosing a Calcium Supplement
You will see different forms of calcium in supplements. Choose either chelated calcium or hydroxyapatite (#3 or #4 below). Here's why:

1. Naturally-derived calcium: may appear on labels as bone meal, oyster shell, limestone, or dolomite (clay). Avoid these supplements since naturally derived calcium may contain significant amounts of lead.


2. Calcium carbonate: the most commonly used form and the least expensive, but not nearly as well absorbed as chelated calcium. If taking calcium carbonate, take with meals when your stomach will be secreting hydrochloric acid to digest the food as it will also help you break down and absorb calcium carbonate.


3. Chelated calcium: will appear on the label as calcium-citrate, calcium-malate, calcium-gluconate or calcium-aspartate. In these chelated forms, the calcium is bound to an organic acid (citrate, malate, gluconate) or amino acid (aspartate), which improves its absorption. Chelated forms of calcium are more expensive than calcium carbonate, but build more bone for the buck, so are worth it.


4. Hydroxyapatite: sometimes appears as MCHC (microcrystalline hydroxyapaptite). The most expensive form of calcium, hydroxyapatite, is a complex crystalline compound that contains calcium linked with phosphorus in a pre-formed building block of the bone mineral matrix. MCHC contains hyrdoxyapatite plus bone-derived growth factors and all the trace minerals that comprise healthy bone. If you are at high risk of osteoporosis or have osteopenia, you should be taking MCHC.

Vitamin D
Vitamin D is essential for calcium's absorption both from the intestines and into bone.

You want vitamin D3, the natural form. The fully activated form of the vitamin in the body is titled 1,25-dihydroxycholecalciferol as know as "calcitriol".

Some supplements (especially the less expensive ones) contain synthesized D2 (called ergocalciferol). Current research shows this is not as biologically effective as the natural D3. (Houghton L, Vieth R. The case against ergocalciferol (vitamin D2) as a vitamin supplement. Am J Clin Nutr. 2006 Oct;84(4):694-7).

Anyone living in northern latitudes (e.g., the Pacific Northwest or New England) is at high risk for vitamin D deficiency and should have her or his blood levels of 25(OH)D3 checked. 25(OH)D3 is the major circulating form of vitamin D in the blood and the best barometer of vitamin D status. Be sure this is the vitamin D test your doctor orders for you; many labs/doctors test D2.

Adequate blood levels of vitamin D to provide for bone health (as well as protecting against colon and breast cancer, multiple sclerosis, inflammatory bowel disease, depression - and a host of other ailments) begin at 75 nmol/L of 25OH-D3. Blood levels of vitamin D between 90 and 100 nmol/L are optimal.

The amount of vitamin D you need will depend on the results of your blood test. A daily intake for all adults of >/=1000 IU vitamin D is needed to bring vitamin D concentrations up to 75 nmol/L in at least 50% of the population. If you live in northern latitudes or live in the south but get little sun exposure or wear sunscreen, you can start taking 1,000 IU of D3 daily right away. However, you may need 2,000 or even 5,000 IU of D3 daily for 6-8 months to restore adequate levels of this critical nutrient.

We are currently involved in a corporate wellness program in Canada. We found that 82% of the employees have low levels of vitamin D in their blood.

Magnesium
If your blood test reveals that you are significantly vitamin D-deficient (we've seen vitamin D levels around 30 nmol in many patients and levels as low as 13 nmol in several), and your physician recommends you take more than 2,000 IU/day for an extended period of time, you will also need to supplement with magnesium citrate, 500 mg, twice daily.

Calcium and magnesium counterbalance one another in numerous cellular activities. If you are taking high levels of vitamin D, you will be absorbing significantly more calcium and will need to ensure your magnesium levels are sufficient to maintain this balance.

This is very important: symptoms of magnesium deficiency include migraines and tension headaches, muscle weakness, leg cramps, restless legs, elevated blood pressure, transient ischemic attacks, and heart arrhythmia.

Vitamin K
Vitamin K, specifically vitamin K2 or menaquinone, activates a group of proteins (the Gla-proteins), which are responsible for where calcium gets delivered in the body. Vitamin K2 ensures that the calcium you consume (and which will be getting into your circulation in higher amounts now that you are taking vitamin D) is deposited where you want it—in your bones, and not where you don't—in your blood vessels and other soft tissues.

When your vitamin K2 levels are adequate, two of the Gla-proteins that are activated are: (1) osteocalcin, the protein responsible for anchoring calcium within bone, and (2) matrix Gla-protein, which prevents calcium from depositing in the heart, arteries, breast and kidneys.

Both vitamin K1 (phylloquinone) and vitamin K2 (menaquinone) are available as supplements. Vitamin K1 is primarily involved in helping your blood clot normally, although our bodies are able to convert a small amount of K1 into K2.

For bone health, K2 (menaquinone), particularly natural menaquinone derived from natto, which may be labeled MK-7 (menaquinone-7) is the most potent form. You may also see K2 as menatretrenone; this is MK-4, a synthetic version that must be taken in much higher doses because its half-life in the body is quite a bit shorter.

If you are taking MK-7, a daily dose of 45 mcg is sufficient. If taking MK-4, take 5 mg daily.

Best food sources of vitamin K (K1) include kale, spinach, Swiss chard, broccoli, Brussels sprouts, parsley and romaine lettuce. Natto, from soy, is an excellent source of K2, but is not easily available in the U.S., nor would the taste appeal to most Americans.

Boron
Boron protects against calcium loss by helping to maximize the activity of both estrogen and vitamin D in bone.

The drop in estrogen levels that occurs during menopause triggers an increase in the production of a pro-inflammatory mediator called interleukin-6, which stimulates the production and activity of osteoclasts. Boron is needed for the conversion of estrogen to its most potent form, 17-beta-estradiol, which allows the body to make the most use of its remaining estrogen.

Boron is also involved in the reaction in the kidneys in which vitamin D is converted to its most active bone-building form, (1,25-(OH)2D3)—a compound that is even 10 times more potent than D3.

In one study of postmenopausal women, supplementation with 3 mg/day of boron reduced urinary calcium excretion by 44%!

Best food sources of boron are apples, pears and grapes. Leafy greens, legumes and nuts can also be good sources of this mineral; however, since the boron content of fruits and vegetables depends upon that provided by the soil in which they were grown, which can vary dramatically, boron supplementation with 3 mg/day is recommended.

Omega-3s
Inflammation-related activation of osteoclasts plays a key role in osteoporosis. Not only do the omega-3 fatty acids lessen the production of pro-inflammatory cytokines that activate osteoclasts acids, these fats also stimulate the activity of osteoblasts. In contrast, the pro-inflammatory omega-6 fats so abundant in the typical American diet stimulate osteoclasts. (Fernandes G, Lawrence R, Sun D. Protective role of n-3 lipids and soy protein in osteoporosis. Prostaglandins Leukot Essent Fatty Acids. 2003 Jun;68(6):361-72; Heaney RP, Carey R, Harkness L. Roles of vitamin D, n-3 polyunsaturated fatty acid, and soy isoflavones in bone health. J Am Diet Assoc. 2005 Nov;105(11):1700-2; Watkins BA, Li Y, Lippman HE, Feng S. Modulatory effect of omega-3 polyunsaturated fatty acids on osteoblast function and bone metabolism. Prostaglandins Leukot Essent Fatty Acids. 2003 Jun;68(6):387-98.)

Experts suggest the optimal ratio of omega 6:omega 3 fatty acids is 4:1 or even 2:1. The standard American diet delivers a ratio somewhere between 10 and 20:1.

In a recent study, subjects consumed each of three diets for a period of 6 weeks. The first, a typical American diet, delivered a 9.6:1 ratio of omega 6:omega 3 fats. The second and third diets provided ratios of 3.5:1 and 1.6:1 omega 6 to omega 3 fats, respectively. Walnuts, a rich source of both omega 6 and the omega 3 fats, were the primary sources of omega-3s in the second diet; a little more than one ounce (37 grams) of walnuts and ½ ounce (15 grams) of walnuts were included in each day's meals in the form of walnut granola, walnut butter, walnut pesto or plain walnuts as a snack. The third diet contained about 20 grams (2/3 ounce) per day of flaxseed oil, a highly concentrated source of the omega 3 fat, alpha linolenic acid.

Indicators of bone loss called N-telopeptides (NTx, which are produced when osteoclasts break down bone collagen, were measured and found to be significantly lowered by the diets containing a lower ratio of omega 6 to omega 3 fats. The second diet, in which the ratio of omega 6: omega 3 was 3.5:1 reduced NTx 11.5%, while the third diet dropped NTx levels by 15.3%.

The researchers also measured levels of a pro-inflammatory cytokine called TNF-a (tumor necrosis factor alpha), which increases osteoclast production and activity. As the ratio of omega 6: omega 3 dropped, levels of TNF-a also dropped substantially. (Griel AE, Kris-Etherton PM, Hilpert KF, et al. An increase in dietary n-3 fatty acids decreases a marker of bone resorption in humans. Nutr J. 2007 Jan 16;6:2.)

In other research, a few weekly servings of salmon (14 ounces per week), has been shown to raise omega 3 levels more effectively than taking a daily fish oil supplement while also lowering blood levels of a number of pro-inflammatory chemicals including TNF-a. Researchers think omega-3s may be better absorbed from fish because fish contains these fats in the form of triglycerides, while the omega-3s in almost all refined fish oils are in the ethyl ester form. Once absorbed, omega-3s are converted by the body from their triglyceride to ester forms as needed. (Elvevoll EO, Barstad H, Breimo ES, Brox J, Eilertsen KE, Lund T, Olsen JO, Osterud B. Enhanced incorporation of n-3 fatty acids from fish compared with fish oils. Lipids. 2006 Dec;41(12):1109-14.)

Your Bones, Your Choice
You only have one body. Doesn't supporting its inherent drive to maintain strong, healthy bones by supplying the natural compounds it uses in normal bone remodeling make better sense than giving it a drug that poisons your osteoclasts and puts you at risk for abnormal heart rhythms and jaw bone death? Your bones, your choice.

~Joseph Pizzorno, ND and Lara Pizzorno, MDiv, MA, LMT

Part 1: Bisphosphonate Drugs

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Strong Bones for Life - Naturally (Part 1)

Bisphosphonate Drugs

It's true, as Sally Fields emphasizes in her TV ads for Boniva, that you have only one body; it's not true that Boniva and the other bisphosphonate drugs commonly prescribed to prevent osteoporosis offer the best way to take care of it!

Although prescribed to 30 million Americans each year, the bisphosphonates (e.g., Fosamax, Boniva, Actonel), have now been linked to serious potential complications.

A recent FDA alert warned physicians that all bisphosphonate drugs may cause "severe and sometimes incapacitating bone, joint, and/or muscle (musculoskeletal) pain...[that] may occur within days, months or years" after starting the medication, and in some patients, may not resolve even after discontinuing the drug.

Even more frightening are recent studies conclusively linking bisphosphonate use with jaw osteonecrosis or bone death. Osteonecrosis occurs when bone damaged as a result of poor blood flow or trauma is not removed and replaced with new bone. Initial symptoms include numbness, heaviness, swelling, pain and infection in the jaw, and progress to loosening of the teeth, decay and death of the jaw bone. Bisphosphonates accumulate in bones, particularly in the jawbone, and inhibit the bone's natural ability to repair everyday damage.

A Cochrane Review noted that age = or > 60 years, female sex and previous invasive dental treatment were the most common characteristics of patients taking bisphosphonates who developed osteonocrosis. (Pazianas M, Miller P, Blumentals WA, et al. A review of the literature on osteonecrosis of the jaw in patients with osteoporosis treated with oral bisphosphonates: prevalence, risk factors, and clinical characteristics. Clin Ther. 2007 Aug;29(8):1548-58.) Considering that the target population for bisphosphonate drug use is postmenopausal women, and many women now 60 or older have had some kind of invasive dental procedure in their lifetime, these risk traits for osteonecrosis with bisphosphonate use are far too common for comfort; so common that concerned dentists are highly reluctant to perform any type of dental surgery on women taking these drugs.

In one of the most recent studies, published in the Journal of Oral Maxillofacial Surgery in April 2008, researchers at the University of Southern California's School of Dentistry found a direct correlation between the development of microbial biofilms (bacterial colonies that cause chronic infections) in affected bone and the use of bisphosphonates. (Sedghizadeh PP, Kumar SK, Gorur A, et al. Identification of microbial biofilms in osteonecrosis of the jaws secondary to bisphosphonate therapy. J Oral Maxillofac Surg. 2008 Apr;66(4):767-75.)

Just how many people now have osteonecrosis of the jaw caused by bisphosphonates? Incidence of osteonecrosis among cancer patients, who are given an intravenous and more potent variety of these drugs (e.g., Zometa and Aredia), is estimated at between 1% and 10%. Among those with osteopenia/osteoporosis taking the lower-dose pill forms (Fosamax, Actonel, Boniva), no one knows for sure. Studies to provide firm answers are just beginning, but it has been established that invasive dental procedures, such as tooth extractions or root canals, greatly increase risk of osteonecrosis in women taking bisphosphonates. As for treatments, cutting away the dead bone just worsens the situation, so antibiotic rinses are used, but frequently fail to remedy the condition. And since bisphosphonates remain in bones for years, no one knows how long the risk of osteonecrosis remains, even if the drug is no longer being taken. (Kolata G. Drug for Bones is Newly Linked to Jaw Disease, New York Times, June 2, 2006)

Recent studies have also reported bisphosphonate use as a risk factor for atrial fibrillation (abnormal heart rhythm) in women. One study estimates that 3% of atrial fibrillation cases might have been due to bisphosphonate (specifically, alendronate) use. (Heckbert SR et al.) Physicians are warned that bisphosphonate use needs to be closely monitored in certain populations at high risk of serious adverse effects from atrial fibrillation (such as patients with heart failure, coronary artery disease, or diabetes). In other words, those at risk for serious side effects from bisphosphonates also include anyone with heart disease or diabetes, a significant percentage of the U.S. population. (Heckbert SR, LiG, Cummings SR, et al. Arch Intern Med. 2008 Apr 28;168(8):826-31; Cummings SR, Schwartz AV, Black DM. N Engl J Med. 2007 May 3;356(18):1895-6.)

Not surprisingly, hundreds of lawsuits have now been filed against the manufacturers of biophosphonate drugs, and a class action suit appears likely.

Manufacturers of Bisphosphonates

• Fosamax - Merck & Company
• Boniva - Roche and GlaxoSmithKline, popularized by Sally Field commercials
• Actonel - Proctor & Gamble Pharmaceuticals, Sanofi Pharmaceuticals
• Skelid - Sanofi Pharmaceuticals
• Didronel - Proctor & Gamble Pharmaceuticals
• Reclast and Zometa - Novartis Pharmaceuticals

How Bisphosphonates Work

Even if the bisphosphonates did not put you at risk for severe musculoskeletal pain, the loss of your jaw, or abnormal heart rhythms, these drugs would still not be your best choice for strong healthy bones. Why? Because all they do is suppress bone turnover and remodeling.

Our bones, unless inhibited by bisphosphonates, are constantly rebuilding themselves throughout our lives. Cells called osteoclasts break down old or damaged bone, signaling other cells called osteoblasts to replace it with strong new bone. Bisphosphonates kill osteoclasts. Bone density goes up on these drugs, but the bone they leave in place is worn out tissue your body would normally clear out and replace with strong new bone.

This is why bisphosphonates put people at risk for osteonecrosis (jaw bone death). Because these drugs suppress osteoclastic activity, damaged bone is left in place rather than resorbed, so the amount of damaged old tissue accumulates until it reaches a level when any trauma or insult will result in extremely poor healing, the exposure of necrotic bone to the oral environment, development of pain, and increased risk of microbial infection, which is precisely what is seen in bisphosphonate-associated cases of osteonecrosis of the jaw.

Next: Part 2 - Your Bones, Your Choice

~Joseph Pizzorno, ND and Lara Pizzorno, MDiv, MA, LMT

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Move Over Cholesterol

Can you imagine any substance getting a worse rap than cholesterol? After all, how many people do you know who (1) have never purchased a product that was labeled "low cholesterol" or "cholesterol free," or (2) have never seen an advertisement for Lipitor (atorvastatin), the $12.9 billion dollar, best-selling, cholesterol-lowering statin drug of 2006, or (3) have never had their cholesterol measured, either in a doctor's office or a shopping mall?

Well, it's time to start imagining a new substance moving onto health's center stage.

FULL STORY:

That substance is homocysteine - a relatively unknown amino acid that was the subject of 500 research studies in 2006 and nearly 2,500 studies over the past 5 years. Similar to elevated cholesterol, elevated homocysteine is now considered an independent risk factor for atherosclerosis (clogging of the arteries). It's also been linked to increased risk of stroke, diabetes-related kidney problems, and age-related cognitive problems.

What's unique about homocysteine is its place in our metabolism. When properly metabolized, homocysteine can help us detoxify environmental pollutants and other unwanted substances in our body. It can also bolster our antioxidant system and help prevent damage to our tissue from free radicals. But when it isn't properly metabolized and it builds up inside our bloodstream (a condition called hyperhomocysteinemia), homocysteine can cause a multitude of problems.

What researchers now understand is that homocysteine latches on to cells throughout our body (including cells along our blood vessel walls) and disrupts their activity. With nerve cells, the result is over-stimulation and eventual damage to the nervous system. With the endothelial cells lining our blood vessels, the result is a weakened cardiovascular structure and eventual heart disease.

Fortunately, we've got practical ways to lower our risk of hyperhomocysteinemia. We can start out by having our blood level of homocysteine measured, to see if it's too high. Second, we can often lower it (as well as prevent it from becoming too elevated) by increasing our dietary intake of vitamins B6, B12, and folate. Green leafy vegetables are a great start for the B6 and folate. Non-plant foods are better for B12. Shrimp, scallops, snapper, and salmon are some of our favorites.

References:

1. Homocysteine-lowering trials for prevention of cardiovascular events: a review of the design and power of the large randomized trials. Am Heart J. 2006 Feb; 151(2):282-7.
2. Carlsson, C. M. Homocysteine lowering with folic acid and vitamin B supplements: effects on cardiovascular disease in older adults. Drugs Aging. 2006; 23(6):491-502.
3. Castro, R.; Rivera, I.; Blom, H. J.; Jakobs, C., and Tavares de Almeida, I. Homocysteine metabolism, hyperhomocysteinaemia and vascular disease: an overview. J Inherit Metab Dis. 2006 Feb; 29(1):3-20.
4. Ceperkovic, Z. [The role of increased levels of homocysteine in the development of cardiovascular diseases]. Med Pregl. 2006 Mar-2006 Apr 30; 59(3-4):143-7.
5. Guthikonda, S. and Haynes, W. G. Homocysteine: role and implications in atherosclerosis. Curr Atheroscler Rep. 2006 Mar; 8(2):100-6.
6. Hankey, G. J. Is plasma homocysteine a modifiable risk factor for stroke? Nat Clin Pract Neurol. 2006 Jan; 2(1):26-33.
7. Jacobs, P.; Wood, L., and Bick, R. Homocysteine in vascular disease: an emerging clinical perspective. Cardiovasc J S Afr. 2006 May-2006 Jun 30; 17(3):135-9.

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When Patients Go Alternative

The scenario is becoming more and more familiar. A patient is on the examining table, the physical exam completed, and with a furtive look in his eye, says: "By the way, Doc, I've been taking Siberian ginseng for the past couple of months, and I'm wondering if it might cause any problem with my blood pressure pills." This event is usually followed by a few seconds of uncomfortable silence.

Americans are increasingly using unconventional therapies for everything from the common cold to cancer. They are mixing botanicals with blood pressure meds and acupuncture with antidepressants. However, 70% of CAM users do not tell their physician. So why aren't they telling their conventional doctor? The fact is that the majority of patients withhold such information because they fear embarrassment or censure. More surprisingly, this reluctance to confess applies not only to alternative therapies, but also to over the counter products and drugs prescribed by other physicians.

So what should your physician do when you finally inform him or her that you have been taking a botanical medication they know nothing about? The first order of business is to not scare you back into silence with judgmental attitudes. If the product has scientific backing for efficacy and safety, they should support its use while keeping an eye out for potential adverse effects. If it does not, they should gently guide you into making an informed decision as to whether to discontinue the product and possibly search for another approach, alternative or conventional (or both). Of course this would require that your doctors educate themselves as to the supplement in question, something they are unlikely to do given the time constraints of daily life.

But there is a solution. The conventional MD may not know about unconventional therapies, but they should know where to ask. The obvious choices are the pharmacist and the naturopathic physician, which brings us back to the definition of integrative healthcare. Collaboration. Appreciation of another's knowledge. Putting the patient before ego. Practitioners recognizing that they are not the source of healing, but the means by which patients discover, or actually rediscover, their own innate capacity to regain health. Both becoming active partners in choosing therapies consistent with communal values and philosophical beliefs, acknowledging that the basis of any relationship, therapeutic or other, is open communication and trust - both the trust that you will reveal the truth, and the trust that your doctor will listen and advise without judgment.

References:

1. Eisenberg DM, Kessler RC,, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N ENGl J Med. 1993;328:246-252.
   
2. Complementary and Alternative Medicine (CAM) in the United States
   Committee on the Use of Complementary and Alternative Medicine by the American Public
   Board on Health Promotion and Disease Prevention
   Institute of Medicine
   The National Academies Press
   Washington, DC
   www.nap.edu
   Executive Summary page 10, 2005
   

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Integrative Medicine Conference News

I just returned from the Integrative Medicine Conference for Health Care Organizations held April 12-14, 2007, in San Diego, CA. This was a very interesting three days attended by healthcare professionals and directors of integrative medicine clinical programs, academics, economists and researchers.

There were several presentations from integrative medicine leaders who are now showing successful models of integrating natural medicine into conventional hospital and clinical settings. Especially encouraging is the emerging research showing better patient outcomes.

Most thought-provoking for me were the lectures by Jennifer James, PhD, and Martin Merry, MD. Dr. James is a cultural anthropologist from Seattle who has been studying the cultural transformation underlying the huge public movement towards natural/integrative/holistic approaches to healthcare. She made several strong points that were insightful for me:

1. The current chaos in healthcare, while unpleasant for both practitioners and patients, creates the opportunity for fundamental change. But, while many may appreciate and welcome the new ideas, they do not want to let go of what they have learned and do not want to be made to feel they were "wrong" in the past.
   
   This helped me understand why many dedicated conventional healthcare professionals seem to find it so hard to accept well-documented natural therapies when this might imply that the pharmaceuticals they have used for so long are possibly not be as good and more dangerous.


2. We cannot expect healthcare change to come from the federal level as there is no strong political leadership, and too many vested interests resist any real change. The solutions will come at the state level.
   
   This was encouraging to me since this means local action by dedicated activists has the best chance to develop models that can then be evaluated and adopted more widely when they are shown to be effective.


3. As cultures advance, they become more kind. Healthcare is kindness-manifested. I liked this one! It resonated deeply with me, and I could see the same sense of appreciative self-understanding in others in the audience. Caring about others' health is the source and core of what I do.


4. Flattening of the hierarchy gives patients greater involvement in their own health care decisions. This is consistent with my perspective that each patient is his or her own best doctor.

Dr. Merry has been involved in healthcare quality improvement programs for almost 30 years. His message focused on the causes of the unacceptably high level of medical error and the necessary solutions.

He believes that most errors are due to "First Curve" or "physician-centered" thinking. This is manifested by our current healthcare system. Merry asserts that the old model of centering systems on the expert craftsman, which worked so well in the past, no longer works in our modern world. Increased complexity, increased amounts of information and broader patient access to information and technology that were once reserved to the specialist, all result in demands for a different way of functioning.

First curve care, even when optimally practiced, still yields what is called "4 sigma error," i.e., about 6,000 deaths due to errors for every 1 million patient interventions (and this does not include patient injury, which according to some studies may be as high as 25% of interventions1). The goal, of course, is to have no injuries or deaths due to medical errors.

Merry believes this is simply not possible in a physician-centered system. According to published research, most medical errors in hospitals are due to lack of communication amongst the professionals involved in a patient's care. As long as the system is physician-centered, these communication errors will continue to happen.

The "second curve" model is centered on the patient. All involved in providing care are fully engaged and regularly communicating. The hierarchy is flattened, and the needs of all involved are met, not just the primary doctor or the patient, and a culture of safety and excellence pervades the organization.

Merry presented a most interesting example: currently in the first curve medical system: When a woman goes to see her doctor because of the possibility of breast cancer, it takes 1 to 8 weeks before she knows the result of the biopsy. These are defined as the "sleepless nights." There is no real reason for the delay other than the long string of communications that have to occur before the patient is finally informed. In a second curve system, the patient is informed in 2 hours. Yes, the same day after a short delay, not endless days of worry later.

Merry believes that integrative medicine has already moved a long ways into the second curve model and is the future of healthcare. Nice to hear a non-IM physician recognize the importance of our movement!

Conclusion. This conference was a very positive experience, documenting the great strides this new medicine is making.

¹ Gandhi TK, et al. Adverse drug events in ambulatory care. BMJ. 2003;348:1556-64

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Fat and Inflammation

True or false: Fat cells are special storage centers for depositing excess fat. Too much body fat puts extra stress on our heart and causes heart disease. If you answered "true," you are correct. If you answered "false," you are also correct - because researchers have discovered something about fat cells that no one has ever suspected.

FULL STORY:

For most of their research history, fats cells (adipocytes) have been treated as fundamentally inactive cells that play a very limited role in our metabolism. Because fat cells have been regarded as simple storage centers for excess fat, the problems they bring to obesity have traditionally been regarded as physical problems. Fat makes us too big. It makes us too heavy. The excess weight contributed by fat puts too much stress on our heart and our joints.

Over the past five years, this traditional view of fat cells has been proven incorrect. Fat cells are anything but simple storage centers for fat! When excess fat is stored up in a fat cell, the fat cell goes to work metabolically and begins to act like an inflammatory trigger. It begins to produce a whole set of messaging proteins that are used by many kinds of cells to signal inflammation. It's this chronic, underlying layer of inflammation that links obesity to type 2 diabetes, and to cardiovascular disease as well. In addition, the elevated levels of inflammatory chemicals causes some people to experience a sense of always having a mild case of the flu, leading to chronic discomfort.

References:

1. Barros, R.; Moreira, A.; Fonseca, J.; Moreira, P.; Fernandes, L.; de Oliveira, J. F.; Delgado, L., and Castel-Branco, M. G. Obesity and airway inflammation in asthma. J Allergy Clin Immunol. 2006 Jun; 117(6):1501-2.
2. Bayes, B.; Granada, M. L.; Pastor, M. C.; Lauzurica, R.; Salinas, I.; Sanmarti, A.; Espinal, A.; Serra, A.; Navarro, M.; Bonal, J., and Romero, R. Obesity, adiponectin and inflammation as predictors of new-onset diabetes mellitus after kidney transplantation. Am J Transplant. 2007 Feb; 7(2):416-22.
3. Feve, B.; Bastard, J. P., and Vidal, H. [Relationship between obesity, inflammation and insulin resistance: new concepts]. C R Biol. 2006 Aug; 329(8):587-97; discussion 653-5.
4. Greenberg, A. S. and Obin, M. S. Obesity and the role of adipose tissue in inflammation and metabolism. Am J Clin Nutr. 2006 Feb; 83(2):461S-465S.
5. Mascitelli, L. and Pezzetta, F. Obesity, inflammation, and risk of atrial fibrillation or flutter. Am J Med. 2006 Jul; 119(7):e9; author reply e11.
6. Sbarbati, A.; Osculati, F.; Silvagni, D.; Benati, D.; Galie, M.; Camoglio, F. S.; Rigotti, G., and Maffeis, C. Obesity and inflammation: evidence for an elementary lesion. Pediatrics. 2006 Jan; 117(1):220-3.
7. Schwarzenberg, S. J. and Sinaiko, A. R. Obesity and inflammation in children. Paediatr Respir Rev. 2006 Dec; 7(4):239-46.
8. Wang, Y. H. and Cai, L. Diabetes/obesity-related inflammation, cardiac cell death and cardiomyopathy. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2006 Dec; 31(6):814-8.
9. White, P. J. and Marette, A. Is omega-3 key to unlocking inflammation in obesity? Diabetologia. 2006 Sep; 49(9):1999-2001.

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