January 20, 2010 - In this Issue

The Rule of 80:20 in Medicine
by Terry Grossman, M.D.

There is an interesting observation that applies to many aspects of sociology and economics known as “The Rule of 80:20." It began one hundred years ago when an Italian economist named Vilfredo Pareto observed that 80 percent of the land in Italy was owned by 20 percent of the population. Since then other individuals have observed that this 80:20 ratio has numerous applications beyond land ownership. For example, it is not uncommon for 80 percent of the time allotted to a business meeting to be spent dealing with 20 percent of the agenda, and salesman will often derive 80 percent of their revenue from the best 20 percent of their customers. Timothy Ferriss, author of the bestseller, “The 4-Hour Work Week," notes that the most bothersome 20 percent of a business’s clients create 80 percent of their problems. Eighty percent of the time people wear the favorite 20 percent of their wardrobe and spend 80 percent of their leisure time with 20 percent of their friends. The list goes on and on.

I have personally discovered that The Rule of 80:20 also has numerous applications in medicine which have not previously been described. Yet the implications of the Rule of 80:20 are profound to medicine in general and to antiaging/preventive medicine in particular. Here are but a few examples:

• If a cardiologist performs an angiogram, surgical treatment such as angioplasty or bypass will not usually be recommended for atherosclerotic blockages until they reach a point where they occlude about 80 percent of the lumen of the artery. Blockages of 60 or 70 percent or less are typically treated more conservatively. But when they reach 80 percent cardiologists feel they are likely to create problems and may soon represent a threat to the patient.

• In cases of chronic kidney disease, renal function is maintained until about 80 percent of the functioning nephrons are damaged, at which time, symptoms of kidney failure appear as manifested by rising creatinine (the blood test that indicates kidney function).

• Blood sugar only begins to rise and the diagnosis of diabetes is made when 80 percent of a patient’s insulin-producing islet cells have been damaged.

• A smoker will typically begin to experience shortness of breath and other manifestations of emphysema or chronic pulmonary disease at the point at which 80 percent of their alveoli have been destroyed.

In addition, even though 80 percent of the critical elements of each of these organs or tissues will have been damaged by the time symptoms occur, they will still typically only represent a loss of about 20 percent of the function of the organ. For instance, in the case of chronic kidney disease, by the time that 80 percent of the nephrons are damaged, kidney function will have only deteriorated 20 percent or so. Similarly, by the time that 80 percent of insulin-producing cells in the pancreas have been destroyed in diabetes, the blood sugar will have only risen a little (20 percent or so) from the normal range 100 up to 120-130, at which point diabetes is diagnosed.

The human body has an enormous capability of continuing to function moderately well on only a fraction of its original cellular equipment. However, when the loss of cells or function reaches the critical 80 percent threshold, the situations begins to change rapidly. At the point at which 80 percent damage has occurred, there will still only be a 20 percent loss of function. But at 90 percent damage, loss of function will more than double to 45 percent and at 95 percent tissue damage loss of unction will rise nearly four-fold to 75 percent. If we plot healthy, functioning cells against function on a graph, we find that there is a knee in the curve at 80 percent. When this critical point is reached, rapid and often severe deterioration will occur unless stringent measures are taken to slow or stop disease progression.

Imagine a graph where you would see a slow early phase where deterioration of 20 percent of the function in an organ occurs as 80 percent of the cells are lost. Because the loss of function occurs so slowly, the individual may not experience symptoms that will bring them to a doctor. The damage is occurring silently but relentlessly. When the critical 80 percent cellular loss is reached, there is a knee in the curve after which loss of function occurs much more quickly. After 80 percent cell loss the individual begins to experience progressive symptoms and rapid deterioration unless corrective action is taken. Unchecked, the loss of the remaining 80 percent of function will occur much more quickly.

This explains why a smoker can smoke 2 packs of cigarettes a day for 40 years with only a small (say 20 percent) loss in lung function. They may only experience a bit of coughing (“smoker’s cough”) and some mild shortness of breath with exertion at this point. But if they continue to smoke (and don’t get lung cancer or a heart attack first), with the next five years of smoking there will be an additional 25 percent loss of lung function. They will lose even more of their lung function in the last 5 years as they did during their first 40 years of smoking. When they only were at a 20 percent loss, they noticed shortness of breath walking up a flight of stairs. At 45 percent they are short of breath simply combing their hair and may find they are uncomfortable without supplemental oxygen.

Think of it as two main intervals. The first is a longer period of time during the early stages of a disease, where damage occurs slowly and before symptoms occur. Then there is a shorter interval later on in the course where the patient experiences increasing symptoms and deterioration happens much more quickly. A failing of conventional modern medicine is that physicians don’t usually intervene until after this critical 80 percent threshold loss of function during the early stage and before symptoms occur has been reached. After this point patients begin to develop symptoms bothersome enough to bring them to the doctor and doctors are taught to treat symptoms. It is far better to “anticipate and prevent” disease early in its course before significant damage has occurred than to “diagnose and treat” a patient who has already developed symptoms.

In conventional medicine the patient’s symptom has been king since William Osler established the residency system for training physicians in the 19th century. When I was in medicine school some 30 years ago I was taught to write SOAP notes on my patients. S stood for symptoms, the patient’s complaint. I was taught that any patient encounter should begin by focusing on the patient’s symptoms. The other letters stood for Objective findings (results of examinations and testing), then Assessment (diagnosis) and finally the treatment Plan. But everything is driven by the S, the symptoms of the patient. This reactive approach to patient care has been the standard of medical care for more than a century and it remains the accepted standard which is still being taught to medical students today.

Patients don’t help the problem since, in the majority of cases, people delay seeking medical care from their conventional doctors until the point at which they get symptoms. It then becomes the physician’s job to find out what has gone wrong and to come up with a treatment plan to try to repair the damage. Yet, the patient’s symptoms can be compared to the tip of the iceberg that is visible above the water’s surface. The vast majority of the damage - the 80 percent damage to cells that has occurred prior to the onset of symptoms - like the iceberg, remains hidden beneath the surface. The symptoms which bring the patient to the doctor have often been preceded by a long period of time during which damage has been slowly taking place. It is during this long period of time before symptoms occurs that physicians who take preventive medicine seriously have an opportunity to “anticipate and prevent” problems before they manifest rather than waiting for symptoms to appear and trying to “diagnose and treat” – after the fact.

I think this is the real value of the type of medicine that we offer at Grossman Wellness Center. As an antiaging and preventive medicine clinic, the last thing we want is to wait for our patients to develop symptoms and then see how good we are at diagnosing their problems and figuring out what to do about them, which is the ”standard of care” for conventional physicians. Of course, we pride ourselves on our abilities to diagnose and have certainly diagnosed our fair share of disease over the years. But, we are passionate about our mission and feel our true value to our patients lies in moving to the top of the curve - to the place where only a minimal amount of damage has begun, and long before a patient develops any symptoms at all. We want to anticipate disease before it becomes manifest and never let it become manifest.

We encourage our patients to come see us for health evaluations for early detection of disease before symptoms occur. At Grossman Wellness Center we like for our SOAP notes to begin, “Patient currently doesn’t have any symptoms and wants to stay that way.” To learn more about how a comprehensive health evaluation can help you remain healthy and symptom-free throughout your life, please visit us at www.grossmanwellness.com.

 

Macuna Pruriens: Concerns About Long-Term Side Effects and Misuse
by Karen Kurtak, L.Ac.

As an herbalist, I have strong concerns about the growing popularity and widespread use of the ancient herb, Mucuna pruriens, as an herbal and dietary supplement. Mucuna pruriens has an almost magical ability to improve motivation, well being, energy and sex drive along with decreasing the tendency to overeat. These properties are a result of its contents of natural L-dopa, a direct precursor to the neurotransmitter dopamine. Dopamine is always present in the nervous system. Ultra-low levels (or dysfunction of dopamine receptors) lead to conditions like Parkinson’s. Normal levels maintain proper function of the nervous system, promote normal motivation and sex drive and help to regulate the appetite. We experience a stronger sense of well-being when dopamine is released in response to activities such as engaging in something novel or seeing a beautiful sunset. We release even more if we accomplish a long-term goal or have a profound experience. Dopamine is artificially elevated in response chemicals contained in alcohol, cigarettes, cocaine, crystal meth and heroin as well as from overeating. Excessive exposure to dopamine results in dopamine receptors not working properly. As the nervous system needs higher and higher levels of dopamine to produce the same response, an individual seeks out more and more of the stimulating substance or activity. This is the heart of addiction.

With its naturally-occurring L-dopa, Mucuna can be carefully used as a natural remedy to treat conditions such as addiction, obesity, dopamine-related depression or Parkinson’s. However this MUST be done in conjunction with rehabilitation of the dopamine receptors. Otherwise, it actually exacerbates the problem and causes further damage. If given to people who suffer with depression from low serotonin, Mucuna can actually make the depression more severe by further lowering serotonin levels. (Dopamine tends to suppress serotonin)

The addition of Mucuna to general dietary supplements and even to some multivitamins is completely irresponsible. It has great capacity for misuse and in the long term could have health consequences. Because of the seemingly magical effects of L-dopa, almost all people notice they feel better on these supplements and notice they feel worse when they stop them. This is no different than creating another addiction.

Because of its effectiveness, I also have concerns about other herbalists and health care practitioners carelessly prescribing it without fully understanding its mechanism of action. I am pro-education and anti-regulation. I think Mucuna pruriens is a natural substance that practitioners need to actively educate themselves and the general public about.

 

Exercise and Menopause
by Diane Henry, Fitness Director

Exercise is very important for women, especially as they get older. The benefits go far beyond just losing weight. For women entering menopause, exercise is extremely important to help maintain hormone balance. During menopause, the changes that a women’s body goes through are profound. Research has suggested that women who are physically active may have fewer and milder menopause symptoms than those who are sedentary. Some of the symptoms may include: hot flashes, night sweats, vaginal dryness, sleep disturbances and emotional ups and downs, and many women complain of weight gain. As hormone levels decline, weight gain is likely, especially around the belly and waistline. Estrogen and progesterone protect against osteoporosis and heart disease, and when these levels drop as happens with menopause, women can be much more vulnerable.

The pattern of fat deposition is different in menopausal women. This is because women’s sex hormones seem to promote the pear shape instead of the apple shape. A women who has historically deposited fat in her hips, may now find herself gaining fat in her abdominal area. Unfortunately, this shift is associated with increased risk of heart disease and diabetes.

In addition to shifting fat deposits, other imbalances occur to the menopausal body which factor into the increased risk of heart disease and diabetes. Exercise can provide its own protective effects to decrease these risks for menopausal women. You should try to establish a weekly exercise schedule including the following elements.

• Aerobic activity for heart health and calorie burning. (Reduces the risk of heart disease and diabetes, lowers blood pressure, improves lipid profile and decreases weight gain).

• Strength training for muscles, bones and metabolism. (This can help keep the bone density you have).

• Stretching for flexible muscles and fluid movement. (Improves and stabilizes moods).

Try to exercise at least three times a week. It is important to note that sedentary women beginning a regular exercise routine should consult a doctor beforehand. If there are any conditions that require limitations, the doctor can give the best advice to prevent injury or illness.

 

Personal Health Care Reform
by Lolita Hanks, Family Nurse Practitioner

Health care reform has been a focus this last year in the U.S. While it would be interesting to debate the impact this would have on our federal budget, insurance companies, freedom of choice, alternative medical options, I suggest that instead let’s focus on Personal Health Care Reform and stay healthy.

How do we reform our own health? First, evaluate your food and beverage intake. What is the nutritional value of the foods and drinks you consume on a regular basis? Does it include words you cannot pronounce, have a shelf life that will outlive you and is it full of unnecessary, useless sugar? How was your food made, under polluted and chemical laden conditions or in a more pristine environment? Do you take time to eat, chew your food thoroughly or are you inhaling your food at lightning speed?

Next, review your lifestyle. Do you run from one place to another? Is your life stressful? Do you have time for relaxation, rest and exercise? Are you content with your life? If not how can it improve? Do you have meaningful relationships with other people; will they help you in times of trouble and celebrate with you in times of gladness and can you reciprocate? Do you wake up rested or dreading the day coupled with fatigue? Are your bowels functioning normally everyday or do you find that everything is stopped? When negative events occur, do you learn from them or hold the negative emotions inside?

Preventative medical interventions can be useful in early detection of disease or potential problems. Annual general blood testing can evaluate your cholesterol, blood chemistry and electrolytes, kidney and liver function, blood count, hormone levels, thyroid function and vitamin D level. Other early detection tests which are useful include colonoscopies (virtual also available), breast thermograms (imaging utilizing heat to detect abnormalities that can be done in place of mammogram), full body ultrasounds to evaluate for arterial plaque buildup, as well as any other hidden issues, bone density screenings and direct physical exam.

There is a lot of information (online and in books) discussing the health benefits of supplementation. Here are few basic supplements which are beneficial for most: Fish oil is known to help decrease inflammation in the body, support brain function and provide the body with the essential fatty acids that maintain the health of our cells. B vitamins are vital for our nervous system and emotional well being. Our brain and heart function depend on adequate levels of B vitamins (dementia is increased for those with low vitamin B12 levels). Minerals are necessary for a multitude of body functions. Magnesium is used by more than 300 biochemical processes in the body. COQ 10 is made by our body, but the production is hampered by age. COQ 10 is a powerful antioxidant that protects tissues and organs from damage and it also is the powerhouse for cells to produce energy. Everyday, vitamin D is found to have more benefits. It acts as a hormone and provides antioxidant protection, has restorative properties and prevents disease. And last but not least, a good food based multivitamin will provide supplementation where are our dietary intake may fail or be insufficient.

Unfortunately, the current medical model rarely addresses the areas of prevention, nutrition, supplementation and lifestyle changes during primary and/or specialty care provider visits. Take responsibility to be informed about your medical condition(s), medications and preventative measures. It is your body. Ask questions if you don’t understand a clinician’s advice, or utilize various resources to learn about a proposed treatment, drug or other intervention so the decision can be based on facts and the weighing of potential adverse outcomes.

Use this short guide to jumpstart taking charge of your health. After all, who better to take charge of your health, than you!

Grossman Wellness Center does offer comprehensive early detection, executive physicals and consultations. For more information, visit our website www.grossmanwellness.com

 

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