Nutrition has never been a topic stressed in medical schools.   Most doctors have little if any formal education in this area.   This is surprising, since so many people suffer from eating disorders.   Who then do you turn to when you need help with your nutritional needs? If it's not your personal physician, who then?   Do you simply follow the old adage, Trust me, I'm a Doctor. Physicians are taught, First do no harm?   But, people are more aware of their health in this new millennium. They are less trusting of doctors.   Instead they place their confidence in Herbalists and Alternative Medical Personnel for their needs, without the definite knowledge that these practices are safe.   Doctors must attain a higher level of training in the field of nutrition and wellness, so they can renew that relationship of trust and confidence with the people they care for.

 

Unfortunately there have not been many scientific studies assessing the efficacy and safety of Complementary Medicine.   For this reason many physicians shun these practices.   What they don't realize is that fully 50% of Conventional Medicine is NOT Evidence Based but rather just as anecdotal as Alternative Medicine.  Anecdotal means: based on casual observations or indications rather than rigorous or scientific analysis.   A compromise must be achieved and doctors must use the best available evidence for their care, be it Conventional or Alternative and to First do no harm?.

 

People are more aware of their health in the new millennium and they are less trusting of doctors.

 

Chinese Herbal Medicine has been around for over 3000 years.   This has been a very long time, and wealth of observations of efficacy has been made over these centuries.   Much of this wisdom has been banished as unscientific by modern medicine simply because it hasn't been studied yet.   I believe that this fund of knowledge should be utilized and studied.   One big problem is that modern medical research is very expensive.   It has actually come to a point that funding for this research must be derived predominately from large pharmaceutical agencies.   These companies often have a vested interest in the results of the studies that they fund.   Many times there is a conflict of interests.   Thus, it seems unlikely, unless the large corporations begin manufacturing Alternative products, that meaningful scientific studies of these agents will be performed.    I propose in this essay to present State of the Art evidence for the usage of Herbal and Botanical Medicines in the fields of Nutrition, Wellness and Preventive Medicine.

 

Nutrition

What constitutes a nutritious diet?   Luckily we have a ton of evidence regarding the optimal needs for both men and women in terms of calories, minerals and vitamins in both health and disease.   So how are we doing in the United States?   The answer is terribly, abysmally.   Only 12% of Americans have a good diet.   Our typical Junk Food Diet is high in saturated fat.   There is an epidemic of obesity, diabetes and heart disease in this country.   Likewise, this diet is deficient in micronutrients and vitamins.   Deficiency of vitamins such as folic acid, B₁₂, B₆, C, and E, iron, zinc and probably selenium are well documented.   Our western diet is also deficient in antioxidants.   Over 20% of the population manifests some or all of these deficiencies.   Upwards of 55% (some state 61%) of the people in the United States are overweight?    For the first time in history the number of overfed and overweight people rival the number of the underfed and underweight in the world.   But the fattest people eat the lowest amount of fruits and vegetables and have the greatest deficiencies and are therefore overfed but malnourished.

Only 12% of Americans have a good nutritious diet.

Interestingly, not only do these poor people have the highest incidence of those diseases mentioned above, but they also have double the cancer rate.   This is because the deficiencies allow cellular damage of DNA, not unlike that of radiation.   Mutations occur and this leads to cancer.   Free radicals are basically supercharged oxygen molecules, which also mutate and burn DNA.   Antioxidants combat the actions of free radicals.   The important thing is to get enough of the essential vitamins and nutrients, as too many are also dangerous.

 

Vitamin C (Ascorbic Acid) 

Did you know that too much of a good thing can be bad for you?   Most people do not know that, when it comes to nutritional supplements.   They reason that if a little is good then a lot must be better.   Vitamins are commonly abused in this fashion.   Linus Pauling was the son of a pharmacist and became a chemical engineer in the mid-twentieth century.   He basically was the founder of Molecular Biology.   He was an outspoken man and a political activist.   His research into the effects of very high doses of Vitamin C (Ascorbic Acid) on the common cold and some forms of cancer were very popular.   Many people followed his prescription of using mega-doses of Vitamin C for colds and flu.   Recent studies have looked at the role of Vitamin C in the common cold and concluded:  Long term daily supplementation with vitamin C in large doses daily does not appear to prevent colds. There appears to be a modest benefit in reducing duration of cold symptoms from ingestion of relatively high doses of vitamin C. The relation of dose to therapeutic benefit needs further exploration.  Yet, there are over 1 billion colds a year in the United States.   They are most prevalent amongst children.   Many people still remain convinced that high doses of Vitamin C are beneficial at both preventing and relieving this benign malady.    I should point out that despite the incredible popularity of mega-dose Vitamin C therapy, very few recent studies have been performed in humans regarding its use in the common cold.

Ascorbic acid and the common cold. Evaluation of its efficacy and toxicity. Journal of the American Medical Association 1975 Mar 10; 231(10): 1073-9  Dykes MH, Meier P. We reviewed the clinical data relating to the efficacy and safety of pharmacologic doses of ascorbic acid in the prevention and treatment of the common cold. Although one study tentatively supports the hypothesis that such doses of ascorbic acid may be efficacious, a second study by the same group did not confirm the significant findings, and no clear, reproducible pattern of efficacy has emerged from the review of all the evidence. Similarly, there is currently little adequate evidence on either the presence or the absence of serious adverse reactions to such doses of ascorbic acid, although many such reactions have been hypothesized. The unrestricted use of ascorbic acid for these purposes cannot be advocated on the basis of the evidence currently available.

This would be fine and good if they were only throwing their hard earned money away and basically depositing the excess dosage in the toilet bowl.   But there is well-defined toxicity with Vitamin C, especially in children and especially when taken over long periods of time.   too much vitamin C can cause severe diarrhea, a particular danger for elderly people and small children.  In addition, too much vitamin C distorts results of tests commonly used to measure the amount of glucose in urine and blood.   Combining oral anticoagulant drugs and excessive amounts of vitamin C can produce abnormal results in blood-clotting tests.?(http://www.niaid.nih.gov/factsheets/cold.htm)    Vitamin C also interferes with stool testing for occult blood.    It also affects blood tests for cholesterol.   The gastrointestinal side effects of Vitamin C, such as severe gas and diarrhea, occur predominately at dosages in excess of 3000 mg daily.

 

There have been concerns that high doses of Ascorbic Acid might increase Iron absorption and lead to Iron toxicity especially in those prone to Iron overloaded states such as Hemochromatosis, Thalassemia and Sickle Cell Anemia.   Recent literature has shown that this is not the case (High-dose vitamin C: a risk for persons with high iron stores? Int J Vitam Nutr Res 1999 Mar; 69(2): 67-82).     There is no question that Vitamin C is intimately involved in the production of toxic Iron associated free radicals especially in the setting of Iron excess.   It has been postulated that when there is a very high level of Ascorbic Acid (Vitamin C) in the body and the cells, Iron leaks from its storage protein molecule, Ferritin, and forms billion of these free radical scavengers.   You can think of free radicals as little energized oxygen enriched Pac-men which gobble up (and burn) proteins and molecules, resulting in cell death.    Vitamin C was proposed as a therapy in HIV and AIDS, as well as in cancer, since by itself it is a potent antioxidant (anti-free radical scavenger).   Interestingly, a recent study found that mega-dosages of Vitamin C (much higher than the recommended 250 ?1000 mg daily) severely suppressed immune function in white blood cells  (human T-Cells).  These authors cautioned against the use of mega therapy in HIV, AIDS and cancer (Sustained levels of ascorbic acid are toxic and immunosuppressive for human T cells. P R Health Sci J 1996 Mar; 15 (1): 21-6).    There has been anxiety in the medical community fearing that mega-dose Ascorbic Acid therapy might lead to oxalate kidney stone formation, high levels of uric acid in the urine, vitamin B-12 destruction, and mutations of chromosomes and DNA.   But the consensus now is that these adverse effects do not occur in healthy subjects ingesting large amounts of vitamin C.

One problem is that the optimal, best or even the correct dosage of Ascorbic Acid is not known.   The daily optimal intake of Vitamin C has been stated to be anywhere from 250 mg to 5000 mg daily.   We know that dosages in excess of 400 mg daily result in increased tissue levels.   Most species of plants and animals make their own Vitamin C, but we humans do not and we need to ingest it.    It is well known that when you are deficient in Vitamin C you can get very sick and even develop Scurvy.   Aching bones, joints, and muscles, loss of appetite, dry skin, fatigue, bleeding, skin thickening, listlessness, loose teeth, muscle cramps, infections, shortness of breath, sore and bleeding gums, and weakness commonly accompany Vitamin C deficiency.   This symptom complex or syndrome is Scurvy.   Ascorbic acid works primarily in the body to maintain the strength of our tissues and especially on the protein collagen.   When it is deficient, tissue weakness results in these signs and symptoms by affecting the joints, muscles, skin and gums to name just a few.    A poor dietary intake of Vitamin C, excessive stress, aging, alcohol abuse, leprosy, and cigarette smoking are all associated with this deficiency.    Scurvy is perhaps the oldest known deficiency disease.   The early Egyptians and Greeks described it.   It wasn't until the 18^th century though that James Lind established the association with a poor intake of fresh vegetables and fruits.

Having said all that, I must point out that in general Vitamin C is incredibly safe and well tolerated at most dosages.    In one large recent study the data from the 1998 Poison Control Centers' Toxic Exposure Surveillance System was reviewed.   Of 2650 total exposures, there were no major outcomes, and not a single death.   The vast number of these exposures actually occurred in children under the age of 6.   There is also good evidence that Vitamin C protects against cigarette induced pre-cancerous changes in the lung.   Evidence exists that Ascorbic Acid is protective against alcohol induced liver damage.   High doses of Vitamin C have been used with chemotherapy (Cisplatinum) for cancer and been found to prevent the toxicity and damage to blood cells such as platelets which prevent bleeding.    When used in concert with another chemotherapeutic drug, Adriamycin, Vitamin C may protect against heart damage.    Numerous epidemiological studies have pointed to the importance of dietary and supplemental ascorbate in the prevention of various types of cancer including bladder, breast, cervical, colorectal, esophageal, lung, pancreatic, prostate, salivary gland, stomach, leukemia, and non-Hodgkin's lymphoma (Ascorbic acid in the prevention and treatment of cancer. Altern Med Rev 1998 Jun; 3(3): 174-86).   Some have even found that very high doses of Ascorbic Acid is cytotoxic (kills cells) against cancer cell and propose the use of mega-dose Vitamin C as a form of actual chemotherapy (Intravenous ascorbate as a tumor cytotoxic chemotherapeutic agent. Med Hypotheses 1995 Mar; 44(3): 207-13).    Most studies show that people whose intake of vitamin C is adequate have a lower incidence of Coronary Heart Disease and Cancer.    Ascorbic Acid also appears to be effective in the treatment of Idiopathic Thrombotic Purpura (ITP). 

In my opinion Vitamin C is a very safe and effective agent.   When assessing the Risk to Benefit ratio of this therapy, I strongly support supplementation.   I do caution against massive dosages and I await further clinical trials to define the optimal dosage of it.   

 

Other Vitamins and Minerals

Over 100 million people in the United States use vitamins regularly.   They spend over six billion dollars yearly on them.    This practice has actually doubled in the past 6 years.   A very recent study documented that the Hispanic population on the US-Mexican border are the highest consumers of vitamins and of Complementary Medicine in the US (Pharmacotherapy 22(2): 256-264, 2002).    Often times, vitamins are consumed with minerals and the most common combination is with Iron.   Iron containing vitamins are the most dangerous and most toxic.   We also know that Fat Soluble vitamins such as Vitamins A (retinol), D (cholecalciferol), E (alpha-tocopherol) and K (phytonadione) are also very toxic when acutely taken in overdosage.  [Water-soluble vitamins include Vitamins C, B-1 (thiamine), B-2 (riboflavin), B-6 (pyridoxine), B-12 (cyano-cobalamin), Folate, B-3 (Niacin), Pantothenic Acid, and Biotin.]   Interestingly, the 1998 Poison Control Centers' Toxic Exposure Surveillance System found no deaths associated with over 49,709 exposures to multiple vitamins, multiple vitamins with Iron, multiple vitamins with fluoride, Vitamin A, Vitamin E, Vitamin C, Niacin, Pyridoxine, and other B-complex vitamins.   The only major outcomes occurred with adult multivitamins, adult multivitamins with Iron, and with Vitamin E.   Thus the morbidity (the rate of incidence of a disease) and the mortality (the number of deaths) associated with pure vitamin ingestion and overdosage are very rare.   In fact one other study of over 40,000 people found only 8 adverse outcomes and one death.

The same problem exists for these vitamins and minerals as was described for Ascorbic Acid.   People take too much sometimes of a good and essential thing.   Iron is perhaps the most dangerous mineral supplement.   Although acute overdose is dangerous but often not fatal, the syndrome of Iron Overload is dreaded.   Iron is everywhere.   It is contained in almost all foods.   Iron is not excreted (wasted) in the urine or stool, but is lost in the hair, fingernails and dead skin (1 mg daily).   Menstruating females lose 1.5 mgs of Iron on the average daily.   When you bleed, you lose Iron and what often results is an Iron Deficiency Anemia (Blood Loss Anemia).   Iron is an essential mineral and without it we would die.   On the other hand, too much iron can damage your body especially over a long period of time. 

As I mentioned above free Iron in your blood causes a massive release of toxic radicals, which destroy tissues.   It is felt by some that the only people who should take Iron supplements are those who have lost the ability to absorb this mineral due to surgery or disease involving the bowel.   Excess iron is stored in the liver, heart, brain, pancreas, skin and joints.   When you have too much Iron on board it basically overloads your entire body.   A syndrome of Bronze Diabetes can occur, which basically means that the skin becomes bronze in appearance and that the Iron has taken over the pancreas gland and interfered with insulin secretion causing diabetes.   Symptoms of heart disease, cancer, cirrhosis, diabetes, arthritis, sexual dysfunction and others can be completely prevented when based on iron overload alone, but only if recognized and treated early.   It is felt that maintaining low Iron levels actually improves immunity, making Iron unavailable to viruses, bacteria and cancer cells.   The most common of several Iron storage diseases is Hemochromatosis.  It is caused by the most frequently expressed genetic abnormality in any population and can result in the metabolic defect that leads to Iron overload.  It is estimated that 42 million Americans are at risk, including those with the double gene and those with the single gene.  The single mutation may result in enough excess Iron to cause heart attack or stroke, aside from full blown Hemochromatosis.   Iron therapy and thus supplementation is only indicated when a deficiency state exists.   When someone develops an Iron Deficiency Anemia and there is no cause for a failure to absorb Iron, doctors begin to look for a source of bleeding.   The most dreaded concern is a cancer of the gastrointestinal tract.

As far as the remainder of the vitamins, I will present a few highlights and caveats, but I will not cover each agent in great detail.   Vitamin E is a potent antioxidant and has been used in combination therapy with Vitamin C in many studies.   A high antioxidant status is associated in epidemiological studies with a low incidence of degenerative diseases.   Vitamin E has been shown to be very safe in multiple randomized double blind studies in humans and even at very high dosages.   Long-term studies are really not available.    (The potentially toxic dose is more than 3000 IU/d for 7-9 weeks.)    It has been found that at doses greater than 400 IU daily, Vitamin E decreases Low-Density Lipoprotein (LDL) Cholesterol.    Vitamin E must be avoided in people who have blood-clotting abnormalities associated with Vitamin K deficiency, as excessive bleeding may occur.

Vitamin K is essential for the formation of multiple blood-clotting factors (Serine Proteases).   When deficient, bleeding often occurs.   It is found in many green, leafy vegetables.    Vitamin K1 (phytonadione) is found in plants, while Vitamin K2 (menaquinones) is made by bacteria in the gut.   Coumadin (Warfarin Sodium) is a blood thinner which blocks the production of Vitamin K dependant clotting factors (Serine Proteases) in the liver.   It actually depletes Vitamin K in the liver and this leads to a deficiency of Vitamin K and the blood becomes thin (anticoagulated).    If someone on Coumadin takes Vitamin K or eats green, leafy vegetables, the blood thinning effect is reversed and blood clots can form again.   Vitamin K deficiency can also happen when there is an obstruction to bile flow, which is needed for Vitamin K to be absorbed in the bowel.      Antibiotics can cause a Vitamin K deficiency by killing the bacteria in the bowel that makes Vitamin K2.   A physician, therefore, should only prescribe Vitamin K in carefully measured dosages.

Vitamin A or Retinol is needed to maintain healthy hair, skin and mucus membranes (gums).   It is also needed for proper bone and tooth growth and reproduction.   Vitamin A also is important for night vision and seeing in dim lighting.   When taken together, Vitamin E will decrease the absorption of Vitamin A from the diet in the bowel.    A water-soluble form of Vitamin A is available which is absorbed more readily.   True form Vitamin A is called Retinol and is found in liver and fish oils.    Beta-carotene is Pro-vitamin A and is found in many vegetables (e.g. carrots).   Pro-vitamin A must be converted to Vitamin A in the liver, in the presence of fat and bile.   Retinol is also a potent antioxidant.   For adults, 5000 IU are the daily-recommended dosage (US RDA see medical calculators above) of Vitamin A.   Toxicity is rare while the acute toxic dose is 25,000 IU/kg, and the chronic toxic dose is 4000 IU/kg every day for 6-15 months.   There has been some controversy regarding Vitamin A in pregnancy.   It is now felt that up to 10,000 IU of Retinol daily is completely safe in any pregnant woman.   At doses in excess of 10,000 IU, there is a definite risk of fetal malformations (teratogenesis) and these high levels should definitely be avoided during pregnancy.   A pregnant mother should likewise not eat liver, which can be very high in Retinol, and it is of note that fish liver oil (e.g. Cod Liver Oil) may contain in excess of 180,000 IU of Vitamin A.   Beta-carotene (Pro-vitamin A) is not associated with any fetal malformations. 

Vitamin D not only exists in many foods (dairy and eggs) but can also be made by your body, which requires exposure to sunlight (ultraviolet light).    It is central in maintaining the minerals Calcium and Phosphorus and thus participates in bone health.    When deficient a condition called Rickets can occur in children and the bones become weak, brittle and deform.   Rickets had been considered a childhood disease of the past.   Interestingly there seems to be resurgence in Rickets in the UK, as there were 24 cases recently reported between May of 2000 and April of 2001.   In adults, a lack of Vitamin D results in Osteomalacia (softening of the bones).   In excess, Vitamin D results in high levels of calcium in your blood (hypercalcemia) which can be life threatening.   Adults should take about 400 IU units of Vitamin D daily.   This is especially important in those who have a limited exposure to sunlight.    The elderly are thought to have a higher incidence of Vitamin D deficiency, and people over 50 years of age should definitely take a supplement.  The chronic toxic dosage of Vitamin D is greater than 50,000 IU daily.    There may be a lower incidence of colon cancer in people taking Vitamin D and Calcium.   Calcium and Vitamin D are essential in both the treatment and prevention of Osteoporosis (decreased bone mass with increased fragility).   Calcium and Vitamin D may be protective against hip fractures as well.    A recent study has shown that in elderly women animal protein consumption was associated with improved bone density (April 1^st 2002 issue of the American Journal of Epidemiology). 

Calcium should be supplemented as follows:

Age	Intake
7 to 9 10 to 12 (boys) 10 to 12 (girls) 13 to 16 17 to 18 19 to 49 50+	700 mg 900 mg 1200-1400 mg 1200-1400 mg 1200 mg 1000 mg 1000-1500 mg

There really is no upper limit on the amount of calcium a person could take daily.  It used to be thought that too much calcium resulted in kidney stones, but this has been disproved.   Another current study out of New Zealand found that Calcium supplementation improved Lipid profiles in post-menopausal women (April 1st 2002 issue of The American Journal of Medicine).   One gram of Calcium Citrate was administered daily (in a placebo controlled double blind format) and HDL Cholesterol increased 7%.   More studies are needed to see if this data also applies to men.

Osteoporosis

Osteoporosis is an incredibly common disorder.   It is estimated that there are 6 million women and 2 million men with this malady (NHANES III).   Seventeen million women and 9 million men have Osteopenia (below). Osteoporosis occurs in all populations at all ages but is most prevalent in postmenopausal women.   In the other people who have it, besides postmenopausal females, it often is unrecognized.   It is said that anyone who suffers a fracture from a trivial injury such as a fall (e.g. not a high impact motor vehicle injury) probably has osteoporosis.   Osteoporosis is an important and serious disorder.   There are financial, psychosocial and physical consequences of it.   Fractures and pain accompany osteoporosis and with these recurrent problems comes debility and disability (see the medical calculators above).   Hip fractures are an important cause of death and functional dependence in the United States and worldwide.   There are about 350,000 hip fractures yearly in the US.   The death rate for persons in the U.S. Medicare population who fracture a hip is 7% at 1 month, 13% at 3 months and 24% at 12 months.   That means that over 120,000 people die yearly in the USA from hip fractures which result from osteoporosis. Advanced age, history of confusion and greater severity of other diseases are associated with higher morbidity and mortality.   Interestingly men who sustain hip fractures tend to have a higher rate of death than woman.   Common complications of these people include thrombophlebitis (blood clots in the leg veins), surgical wound infections, urinary tract infections, urinary retention, skin ulcers, heart complications and confusion (delirium).    Hip fracture is a well-recognized cause of death worldwide.

 

How do we approach and treat Osteoporosis?   First we have to be able to identify people who are at risk for the disease and this can be a difficult process sometimes.   Postmenopausal women are all at risk, but so are all people on long-term cortisone therapy, Inflammatory Bowel Disease such as Crohn's Disease and Ulcerative Colitis, Current cigarette smokers, Vitamin D deficiency, anyone with a trivial fracture, history of a fracture in a first degree relative, advanced age, Caucasian race, poor health and frailty, female sex, sedentary life style (no exercise), dementia, Estrogen deficiency as caused by early menopause or after surgical removal of both ovaries, life-long inadequate calcium intake, alcoholism, low body weight (less than 127 pounds), recurrent falls and impaired vision despite correction.   The items in bold and underlined are the most important risk factors besides being postmenopausal.   (Please see the Medical Calculators above.)

Now that we know who is at risk for Osteoporosis what do we do?   It is in these people that screening is indicated.   How do we screen?   We perform a Bone Mineral Density (BMD) test and there are many different types of these.   In general this test will tell us the status of the bone mineral content and when it is deficient, Osteoporosis is present.   Without going into a lot of detail about the scan, a T-score less than ?.5 (by World Health criteria) is significant for this diagnosis. [Osteopenia is defined byT-scores between -1 and -2.5 and these people are also at increased risk of fracture and disability, and many would argue should be treated preventively.]   "In a recent review of computerized records of 33,662 US women older than 50 years of age, BMD had been measured in fewer than 2% of women, and only 14% of all women had recently been dispensed a bone-protective agent." Therefore we are not doing too well either screening for, protecting against or treating Osteoporosis.

How do we treat Osteoporosis and Osteopenia?   The first concept in therapy is always prevention.   Therefore we must stress and address skeletal and bone health lifelong.   Cigarettes should be avoided completely!   In moderate smokers with low body weight ( less than 75 kg or less than 165 pounds), increased bone resorption occurs and this results in a decreased BMD and an increased prevalence of vertebral deformities and fractures.  In former smokers, bone resorption is not increased, but BMD remains lower compared with that in never-smokers (J Clin Endocrinol Metab 2002 Feb; 87(2): 666-74).   Next, we must stress supplementation.   Vitamin D and Calcium both must be provided in adequate amounts, keeping in mind that in general the US diet is deficient, but that the elderly are at particular risk for nutritional deficiencies and Osteoporosis and Osteopenia.   The currrent pharmacologic Standard of Care for both of these conditions is the Biphosphonates.    Alendronate was effective in reducing fracture risk in multiple studies.   In women often times Hormone Replacement Therapy (HRT) is recommended.   The most recent addition to pharmacologic therapy for these diseases is Parathyroid Hormone (and fragments). To my knowledge, Parathyroid Hormone is the only therapy which actually increases bone mass density by the formation of new bone.   

Before we leave the general nutrition, minerals, vitamins and antioxidant discussion, I'd like to comment on a very interesting study from the journal Nutrition and Cancer.   Despite the fairly specialized conclusions of this article, I want to highlight it as typical of the State of the Art for nutrition in Medicine.   In fact we are really only in our infancy when it comes to understanding the impact of nutrition on human health and disease.   The biochemistry is still slowly evolving.   The cellular mechanisms are only now becoming evident.   The genetics of nutrition really is the promise of the future.

 

 Diets and Dieting 

People don't and can't stick with fad diets.

What about all of those fad diets out there, are they properly balanced for optimal cellular nutrition?   Unfortunately, they are not.   Furthermore, most people who are successful losing a few pounds on one of them, typically rebound above their baseline weight when they stop the diet and have nowhere to turn except back to their old, bad habits.   People don't and can't stick with fad diets.   Calories are important to consider when eating but hard to consider when counting.   In general most women need about 2000 calories daily and most men require about 2500 calories.    One pound of fat is basically an extra 3500 calories consumed.   Despite emphasis on a low fat, low calorie, conventional diet, mixed with exercise on a daily basis; the fact remains that it is very hard for most people in our society to do this.   What results is an obese population, which is ever expanding.

 

What does modern medicine have to offer?   As I already mentioned, most primary care physicians are poorly educated in nutrition and dieting.   This is unfortunate, as they really should have a pivotal role here.   Perhaps a little counseling is offered and a tattered copy of an old diet handed out in a busy office setting with instructions to come back in a few months.   Maybe if you are lucky you might get an appointment with a hospital dietician.   Amphetamines used to be prescribed like candy for weight loss until their addictive potential was recognized and abuse was rampant.   Many untimely deaths occurred from these medications, which were often combined with sedatives to combat the insomnia that resulted.   That certainly wasn't, First do no harm?   It wasn't very long ago that the combination Phen-Fen became popular.   Unfortunately another rash of deaths from heart and lung disease occurred and this combination was discontinued in a flurry of headlines, controversy and law suits.   Now Meridia or Sibutramine is starting to have deaths associated with cardiac and pulmonary disease.   In some European countries it has been removed.   Orlistat is a novel agent, which decreases fat absorption up to 30%.   Unfortunately, diarrhea and unpredictable gas are frequent side effects especially if you eat your typical fatty meal.   Weight loss on Orlistat has been variable and you must maintain a low calorie diet to be successful.   Finally there are the heroic surgical procedures (Bariatric Surgery) usually reserved for the morbidly obese and especially those with serious coexisting disorders.   These procedures can now be done laparoscopically (meaning no large scar and faster recovery times.)   The stomach is basically cut down to a small remnant (pouch) and a variable amount of small bowel is bypassed to decrease absorption.

 

I conclude that modern medicine has little to offer the obese population to date.

 

There are many complications with these procedures.   After the surgery, you must eat a very specialized diet to maintain your health as well.    Profound results have been achieved with these procedures but they are clearly not for everyone.   Thus, I conclude that modern medicine has little to offer the obese population to date.   We may have to wait another 50 years while they unravel the genetics of the disease.   What do we do in the meantime?

 

I mentioned that so many people suffer from eating disorders that it is an epidemic.   By addressing a weight reduction program, I have been talking predominately about people who are overweight, obese or morbidly obese.   There are many other eating disorders which plague our society and I am not claiming that the program I am using is appropriate for all of these disorders.   Some of these people really require a multidisciplinary medical and psychosocial intervention.   I will discuss some of these topics now.

 

Obesity and Eating Disorders 

Overweight and obesity are by far the most frequent nutritional and eating disorders in the United States.   According to a recent article in The New England Journal of Medicine, "Overweight and obesity are the most common nutritional disorders in the United States, affecting the majority of adults in the country...The prevalence of obesity has increased by more than 75 percent since 1980...Health care professionals should be concerned about overweight and obesity because of the well-established relations between excess body weight and such medical conditions as type 2 diabetes, hypertension, and osteoarthritis...29 percent of the men in the United States and 44 percent of the women describe themselves as trying to lose weight."   (N Engl J Med, Vol. 346 February 21, 2002.)    Women who are overweight are at increased risk of developing breast cancer. Breast cancer involves 1 in every 8 women worldwide.   In addition, increased dietary fat intake is a risk as well.   These medical conditions are referred to as co-morbidities.

 

What does it mean to be overweight and how do you know if you are?     The question really is what is your Ideal Body Weight?   Unfortunately there is really no consensus on this question but the best evidence comes from large studies.   Your ideal body weight is based upon your age, sex, height and body frame.   There are many reference standards used.   Here is just one of them described in inches of height and pounds:

 

 US National Center for Health Statistics - Females

Height	18-24 Yrs.	25-34 Yrs.	35-44 Yrs.	45-54 Yrs.	55-64 Yrs.
4'10"	114	123	133	132	135
4'11"	118	126	136	136	138
5'00"	121	130	139	139	142
5'01"	124	133	141	143	145
5'02"	128	136	144	146	148
5'03"	131	139	146	150	151
5'04"	134	142	149	153	154
5'05"	137	146	151	157	157
5'06"	141	149	154	160	161
5'07"	144	152	156	164	164
5'08"	147	155	159	168	167

 

 

 

 

 

 

 

 

 

US National Center for Health Statistics - Male

Height	18-24 Yr.	25-34 Yrs.	35-44 Yrs.	45-54 Yrs.	55-64 Yrs.
5'02"	130	139	146	148	147
5'03"	135	145	149	154	151
5'04"	139	151	155	158	156
5'05"	143	155