Pollen Power

My wife says I’m an optimist. But when it comes to the recent cold, wet weather we’ve been having, there really is a silver lining in all that gray — it’s keeping the pollen counts down, even during the peak of allergy season.

And allergy season is serious business. Since the ol’ Gipper (that would be President Reagan, for my younger readers) first declared it in 1984, the month of May has been known as National Allergy and Asthma Awareness Month.

Given the stupefying side-effects of antihistamines like benadryl, it’s also no wonder that the Zombie Research Society has also declared May to be Zombie Awareness Month. (Note: not an official presidential designation, despite the powerful zombie lobby.) Then again, given the fantastic number of presidential proclamations that are issued each year, who’s to say The White House could not have slipped it in when no one was paying attention.

Locals always claim the Willamette Valley is one of the worst allergy locations in the country. Yet somehow, Portland ranks among the least affected cities on the Asthma and Allergy Foundation of America’s “Allergy Capitals.” That’s right folks — Stumptown scored a low 89th out of 100 major US metropolitan areas.

My nose would beg to differ, but such is the injustice of composite scoring systems. Just ask the administrators of Reed College, who have been speaking out on the flaws of US News and World Report’s college ranking methodology for years now.

I realize your watering eyes may not be able to take much more of my digressions, so here are my top allergy treatment recommendations:

• Behavioral adaptations should always be first on the list. Exercise indoors, or outdoors only at times of low pollen (usually in the evening). Keep windows and doors shut at all times. Trimming fingernails short and showering after outdoor activity both help to keep pollens off your body.
• If you need allergy medication, the single most effective treatment is nasal steroid spray. I have found that controlling symptoms at the nose provides nice carryover benefits to eye and throat complaints as well. Choice of brand is up to you — they’re basically all the same. So go with the generic fluticasone (Flonase).
• Need more horsepower? Add a sedating antihistamine like diphenhydramine 25mg (generic benadryl) at night. Yes, it makes you sleepy, but you’re going to sleep anyway. And it’s far more effective than claritin or allegra — not to mention dirt-cheap.
• For eye symptoms, use zaditor drops. They’re even OTC to boot, so you don’t need a prescription.
• Still symptomatic? A nonsedating antihistamine like claritin or allegra during the day is my fourth-line recommendation. Your doctor can prescribe several additional medications like antihistamine nasal sprays (astelin), selective leukotriene receptor antagonists (singulair), and even oral steroids (prednisone) if necessary.
• Remember that treatment is additive, so if one medication is ineffective, you add to it a second drug, then a third, and so on.
• For those whom medication does not help, allergen injection immunotherapy (allergy shots) is a proven treatment (but time-consuming and expensive).
• Lastly, forget honey therapy. Honey was found to be ineffective in a well-done (though small) study of 36 allergy sufferers. Participants were randomized to a daily tablespoon of either local raw, nationally processed, or artificial honey supplements. There was no difference in patient-reported symptoms over a 180-day monitoring period.

Vitamin D and Colds: The Sequel

Some interesting and poorly-publicized developments regarding the benefits of vitamin D arrived at the end of the year. Specifically, the Institute of Medicine (IOM) released their long-awaited recommendations for supplemental D dosing, as well as their assessment of the growing body of vitamin D research. Commissioned by the US and Canadian governments, you can read the executive summary as well as view the table of doses by age group  – but don’t expect any wild conclusions.

A lot of folks were hoping the IOM would stretch the available data a little and create some controversial guidelines — imagine a Charlie Sheen/Lindsay Lohan hookup for the scientific community. But they played it much more Tom Hanks and Rita Wilson — solid, dependable, but let’s face it: nothing to make us race to the newsstands.

Vitamin D, as I mentioned in a previous post, has been touted as a preventive for everything from certain cancers to depression. As a result, some advisory groups recommend D in massive doses, with the goal of achieving high blood levels.

But a close review of the science shows most of these studies are associative at best. The New England Journal of Medicine, in an April 14, 2011 editorial, cautions:

“Association therefore cannot prove causation. Many micronutrients that seemed promising in observational studies (e.g., beta carotene, vitamins C and E, folic acid, and selenium) were not found to reduce cancer risk in randomized clinical trials, and some were found to cause harm at high doses.”

Until further data are available, steer clear of megadoses of vitamin D (those in excess of Institute of Medicine recommendations) and aim for a total 25(OH)D (also known as 25-hydroxyvitamin D) blood level of 20 ng/ml — despite what other groups might advise.

On to the common cold….

It’s still mighty chilly in Portland, and that means we’re all inside more and passing germs around with greater ease. If it makes you feel any better, not even your doctor has been spared. The Baskin household has been a rhinovirus revolving door since November.

A recently-published meta-analysis revived interest in zinc, the nutritional supplement that (in nasal form) was associated with numerous cases of anosmia a few years back. In response, the maker, Matrixx, pulled the formulation, while maintaining its safety.

But the oral form of zinc was never implicated, and remains on the market. The new study summarizes all available information since 1984 on zinc and colds, and offers the following conclusions:

• Zinc is an effective cold remedy in adults and children, shortening duration and severity of cold symptoms if taken within 24h of symptom onset.
• When used as a preventive in school-age children, zinc also reduces absenteeism associated with colds.
• If taken continuously for 5 months, zinc cuts cold frequency by about a third.
• No one knows how zinc works to fight cold viruses.
• Zinc causes mild-to-moderate side effects, including bad taste, nausea, constipation, diarrhea, abdominal pain, dry mouth and oral irritation.
• Studies used a wide variety of formulations (zinc gluconate or acetate lozenges, zinc sulfate syrup) and dose ranges (30 to 160 mg/day), so the optimal regimen is unknown.

This meta-analysis was conducted by the highly respected Cochrane Group, so I’m inclined to trust the methodology.

Whether it’s worth it to take a pill that tastes bad, causes a fair number of side effects and reduces cold duration by only a day is up to the consumer. For individuals who catch a lot of colds, that one-third reduction in cold frequency might be sufficient reward to suffer through preventive treatment for a season.

As for me, I’ll stick with chicken soup.

CPR – update

‘Tis The Season

You can’t hear the wheezes emanating from my chest right now, but I’m in the grips of a nasty cold. Whole family is under the weather, actually — and we’re short a humidifier. I always thought we were a two-humidifier family, but this week has proven me wrong.

The common cold is usually caused by one of the many rhinoviruses — a family of 110 distinct strains, though additional virus families, such as coronoviruses, bring the total to over 200 strains. Understanding this disease process is complicated by the fact that there is no good animal model for experiments. In other words, not many critters catch colds.

This has not stopped researchers from attempting to infect the usual suspects: mice, rats, hamsters, rabbits and the like. Further efforts with hedgehogs, voles, ferrets, and a variety of primates from the red patas monkey to the sooty mangabey failed as well, leaving researchers with no other option than to work with the often reluctant and unreliable homo sapiens sapiens. Trust me, they drive a much harder bargain than those capuchin monkeys who work for grapes.

Despite these setbacks, we do know a few secrets of the common cold:

• Colds are not caused by exposure to cold or wet weather.
• Children are a prime vector for cold transmission, probably because of their close contact in schools (and often suspect hand hygiene).
• Colds transmit better in close quarters, which may explain the seasonal spikes at the start of school and the onset of cold weather (both drive people inside).
• Cold viruses can live up to 3 hours on your skin. They can also survive up to 3 hours on objects such as telephones, stair railings, Legos, Thomas trains, and anything manufactured by Mattel. (I’m just kidding about those last three, but it’s probably true anyway.)

Let’s move on to treatment. The rows and rows of cold medications on display at any drugstore have such potential for toxicity (combined with limited clinical value) that the medical community increasingly recommends against their use in the most frequent group of cold sufferers — children. I would echo that recommendation for their parents, too. The stuff just doesn’t work.

Other generally ineffective “natural” remedies include vitamin C, echinacea, garlic, and a variety of Chinese herbs.  Three others deserve special mention:

• Airborne, that ubiquitous combination vitamin preparation, was sued by 32 attorneys general in 2008 (for comparison, 41 states sued the tobacco companies in the late 1990s) for false advertising.
• The makers of Emergen-C, wary of Airborne’s experience, have resorted to the highly unscientific gimmick of customer testimonials. You can read Meghann’s achingly vague claims of benefit here.
• zinc nasal preparations have been associated with permanent loss of smell, prompting the FDA to issue a warning against their use. Oral forms of zinc have also been researched and results are contradictory in the two most recent studies.

But I shouldn’t throw stones, since my own routine (chicken soup, ibuprofen, sinus rinsing, and a nighttime humidifier) is also largely unproven, with exception of the ibuprofen.

If you absolutely need medication for cough, only one thing works: hydrocodone. Unfortunately, hydrocodone has high abuse potential and has gained quite a following in certain circles (Purple Drank, anyone?). Side effects can also limit its effectiveness.

As for prevention, our weapons are few. Good handwashing is a must, but for heaven’s sake avoid those antibacterial soaps. Alcohol-based gels are effective when a sink is not available. There’s also evidence that insufficient sleep leads to more colds, so try and get at least 7.5 hours of sleep nightly. Which is why I am going to end this posting here, since it’s past midnight and I have to get up early tomorrow.

21st Century Sex

Not All Pictures are Worth 1000 Words (When X-rays are necessary)

The phrase “a picture is worth a thousand words” is distinctly American. According to The Phrase Finder, it was used widely and exclusively in the US media starting in 1911.

So it would make sense that Americans apply the same logic to medical imaging. Unfortunately, we are in a much grayer (read: charcoal) area when it comes to the diagnostic value of all those studies. Most medical imaging comes at a price: ionizing radiation, a known carcinogen. (Though for some reason, the US Department of Health and Human Services did not officially recognize radiation as carcinogenic until 2005 – go figure.)

We used to take a fairly casual approach to those nifty little waves of energy that pass right through you. My mom tells amazing stories of the Buster Brown “shoe fitter” — an actual fluoroscope that was deployed in stores to ensure a proper fit. Kids were so entertained by the devices they used to stand on them repeatedly, fascinated by the moving images of their tiny irradiated toes.

The amount of radiation exposure from, say, a chest CT scan (equivalent to about 70 conventional chest X-rays) really only becomes significant if patients are receiving lots of studies. But this happens more often than you might imagine. Yes, trauma patients get scanned a lot, but so do patients with less life-threatening problems like chronic abdominal pain.

How much radiation are we talking about? The National Council on Radiation Protection and Measurements, a federally chartered agency, has been pondering issues surrounding radiation exposure since 1964. Granted, this is the same federal government that was also doing above-ground nuclear testing with reckless abandon until 1963. Their motto then: “Strontium-90 — we’ve added it to your milk!” But I digress.

The NCRP publishes riveting titles like Report #154: Cesium-137 in the Environment: Radioecology and Approaches to Assessment and Management. But occasionally they hit the jackpot and get the kind of recognition all physicists long for. Report #160 was just such a document. Quite simply, it was the first time anyone had taken a systematic look at radiation exposure in the US in more than 25 years. Some highlights:

• Medical imaging now accounts for nearly half (48%) of total US resident radiation exposure, up from 15% in the 1980s.
• CT scans represent 50% of total medical radiation exposure, up from 3% in the 1980s.
• In 2006, US doctors performed CT scans at four times the rate in the UK.

And sadly, much of this testing has little or no medical justification. Explanations for increased imaging rates include:

• Financial (doctors who own their own imaging equipment order tests at rates up to 7 times that of doctors who are not owners)
• Laziness (doctors who order imaging may avoid conflict with patients and/or shorten appointment duration/complexity)
• Fear of malpractice
• Patient preference and direct-to-patient marketing (“whole body” CT scans and heart scans)

So the next time one of your providers suggests a quick trip through the scanner, ask him or her if it’s really necessary. Not only will you impress your doctor with your thoughtfulness, you might just save your body a little damage.

Vitamin Re(D)ux

After reviewing my first blog entry on vitamin D, I came across a riveting hour-long YouTube post from some budding videographers at The Centers for Disease Control. And while the editing and composition leave something to be desired, there were some useful pearls that I will reveal here (and save you the burden of having to watch it yourself).

Four points emerge from the presentation, given by experts from several branches of the National Institutes of Health:

• There are only two systematic reviews (from 2008 and 2010) of vitamin D and its benefits. Both conclude there are no data to prove or disprove claims that D can influence the course of heart disease, cancers, hypertension, pregnancy outcomes, or death rates in general (cheerfully referred to as “all-cause mortality”).
• The existing recommendations on D blood levels and intake come from an Institute of Medicine report from 1997. That’s OLD research. The recommendation of 27.5 nmol/L was only intended to prevent rickets and other severe deficiency states. Because of this, other organizations have stepped in with their own guidelines — some as high as 80 nmol/L — though no one is sure which is correct.
• Because no one knows what the correct blood level should be,  the scope of the deficiency problem cannot be defined. For example, if we use the 27.5 nmol/L level, less than 6% of the US population is deficient. But raise that to 80 nmol/L, and all of a sudden that figure rises to more than 70%.
• The assays to measure D levels have changed dramatically over the past 15 years, and no one is sure which one is the most accurate.

As the Director of the Office of Dietary Supplements, Dr. Paul Coates, succinctly stated:

“I don’t know what number to tell people to shoot for… oh, and I don’t know that that number is reliably measured. It may be, but I don’t know that.”

Donald Rumsfeld could not have spoken any more clearly.

For now, I think the most reasonable recommendations are:

• 400 IU daily in children
• 400-800 IU daily in men and women < age 50
• 800-1000 IU daily in men and women > age 50.

We’ll see what the next Institute of Medicine report advises. Try not to lose any sleep in the meantime.

Let’s Be Friends

I have a confession: I don’t know the names of my neighbors across the street. And they’ve been living there for over two years now. In my defense, I know the people who reside to the left and right of my house. But crossing that two-lane street seems an impossible divide for me right now. I’m too busy:

• running my medical practice
• raising my kids
• exercising
• eating right
• trying to get a good night’s sleep now and then.

A new study from a team of psychologists suggests it might be worth my time, from a health standpoint, to spend more time with the neighbors. This meta-analysis evaluated nearly 150 studies comprising over 300,000 participants, extracting the risk of death relative to the strength of each group’s social relationships. The results were surprisingly consistent and powerful: people with stronger social connections increased their likelihood of survival by 50%. Results were controlled for age, sex, and health status.

Like almost all behavioral studies, these results represent only an association between social relationships and risk of death. (This blog has discussed before the pitfalls of confusing association and causation.) Nevertheless, it’s an extremely powerful association, on par with smoking and risk of death. (That relationship has long since been proven causative.)

In other words, the health benefits of a strong social network are equivalent in benefit to stopping smoking — and exceed the value of medications to control high blood pressure or cholesterol.

Yet major health organizations largely ignore the importance of this unrecognized health risk factor. And it appears to be a worsening problem: over the past two decades, the core discussion networks of Americans have withered by a third, with the average person in the General Social Survey reporting three confidants in 1985 but only two confidants in 2005.

Theories abound as to why social connections are in decline. The Harvard political scientist Robert Putnam, in his book Bowling Alone, proposes a number of explanations, including

• increased TV viewing habits, and
•  loss of civic-mindedness born out of the First and Second World Wars.

Other social scientists have suggested

• loss of time due to increased job demands (two-career households and longer hours at work), and
•  impersonal urban design (car-based communities without sidewalks, front porches, or parks).

Of course, a big question is whether the wealth of electronic social networks like Facebook or Twitter will provide any counterweight to these forces. The most recent survey data available is for 2006, when Facebook and others similar ventures were still fairly embryonic.

Of greater interest is why, or how, do social connections confer such protective effects on individuals? One explanation is that friends help cushion the cruel blows of everyday life — whether they be serious (death of a spouse or child), or slight (insults of coworkers or classmates).

I’ll be knocking on my neighbors’ door tomorrow.

Vitamin D Stands for Dubious

Where will the health benefits of vitamin D end? Lately this supplement has been enjoying glowing coverage in the medical literature and popular press alike. Based on a recent trip to the vitamin section of my grocery, D appears to be muscling in on shelf space traditionally occupied by vitamin C, glucosamine and the grandaddy of all supplements, king calcium.

Trouble is, high-quality data are lacking as to vitamin D’s true value. In most D studies, researchers try to link intake of the vitamin with various health outcomes. Connecting the dots between two variables — say, vitamin D and the risk for colon cancer — is irresistibly tempting. But as any researcher will tell you, association does not ensure causation.

For example, estrogen was mistaken as a beneficial supplement for postmenopausal women back in the 1980s. Women who reported taking estrogen were found to exhibit lower incidences of heart disease, stroke, even dementia.

Sadly, these findings weren’t rigorously tested until 1991. The Women’s Health Initiative, a  series of studies involving more than 160,000 patients, gave one group of volunteers a sugar pill and the other an estrogen pill, then followed participants for more than five years. To everyone’s dismay, all the assumptions about estrogen’s benefits were found to be incorrect.

How did researchers get it so wrong? Turns out estrogen consumption was really only a “marker” for a healthier lifestyle. Despite attempts to control for other confounding variables (exercise or smoking rates, for example) a few were still missed. These unrecognized behaviors then drowned out the negative effects of estrogen, making the hormone look beneficial.

Could D end up overreaching as well? Some associations have already been disproven by randomized studies. The same Women’s Health Initiative tested the hypothesis that vitamin D and calcium supplementation could prevent colon cancer. Based on the study duration of seven years, vitamin D had no beneficial effect on colon cancer rates.

This doesn’t mean we should ignore all of D’s claims. Without vitamin D, for example, absorption of calcium is very difficult. And we know that calcium and vitamin D provide modest protection from hip fracture in women older than age 60.

Evaluating other commonly cited effects of vitamin D — reductions in heart attacks, improvements in mood and memory, and protection from prostate and pancreatic cancer — remains challenging. Until high-quality, randomized, prospective studies are completed, we are left with tantalizing clues that may prove nothing more than epidemiologic dead-ends.

So how do I advise my patients? It’s recommended to take a vitamin D supplement of 800-1000 units daily if you are a woman over the age of 60, based on results from the Women’s Health Initiative. Additionally, vitamin D does not appear to cause harm in other populations (such as men or women younger than 60), so there appears to be little downside for these groups.

If you do decide to supplement, though, do it in a safe fashion: get your D in a pill or from foods, not from the sun. There’s no safe dose of sunshine — but we’ll save that topic for another time.

The Three-Meal Wonder

These are the dark times. The holidays are over. The Ducks just lost. The weather is cold, wet, and generally nasty. The social calendar is as empty as a champagne glass after New Year’s. And no one wants to cook.

After entertaining for the past 6 weeks, I’m right there with you. Between Thanksgiving, Hanukkah, Christmas, Kwanzaa, and New Year’s Eve, most folks are pretty tired of the kitchen. But you gotta eat, as the saying goes. So I put the dedicated chefs of the Baskin Clinic Test Kitchens (pictured above) to work. They came up with a series of recipes even a child could complete. And the best part: you get three meals out of one quick trip to the grocery store.

DAY ONE: Roast Chicken (serves four)

• 2 young or roasting chickens, about 4-5lb each (we like Draper Valley, available at Trader Joe’s)
• 4 carrots, peeled and sliced into one-inch chunks
• 1 onion, diced
• 10 garlic cloves, whole, peeled
• chicken broth (we use Pacific Natural Foods), sufficient to cover the bottom of roasting pan to a depth of half an inch or so
• kosher salt
• freshly ground pepper

Preheat oven to 350 degrees. Cover bottom of roasting pan with sliced carrots, chopped onion, and garlic cloves. Add the chicken broth. Remove chickens from shrink wrap. Discard the neck and innards from cavity. Generously sprinkle the exterior of the bird with salt and ground pepper. Place chickens in the pan, breast side up, and bake on middle rack, uncovered, for about 90 minutes or so. The chicken is done when the center of the breast reaches 160 degrees, or thigh reaches 170 degrees on an instant read thermometer (we like the model from ThermoWorks the best). The USDA says no part of the bird should be under 165 degrees, but I think this overcooks the breast.

Remove pan from oven and place chickens on a plate to rest for 10 minutes, then carve.

IMPORTANT: save the chicken carcasses in a pot and refrigerate for DAY THREE.

Suggested Sides:

Steamed Rice (we like to top with the cooked carrot/onion/garlic mixture and some pan juices)

Roasted Brussels Sprouts (recipe follows)

• 12-15 Brussels sprouts, stems trimmed and any damaged outer leaves removed
• 2 tablespoons olive oil
• 1/2 teaspoon kosher salt
• freshly ground pepper
• lemon juice

Heat oven to 400 degrees. Cut Brussels sprouts in half along the long side (like you would do with a hard boiled egg). Add cut Brussels sprouts, oil, kosher salt and pepper to a large bowl and stir until well-coated. Place Brussels sprouts cut side down on a heavy baking sheet and roast on middle rack for 15 minutes or until cut side is lightly browned. Flip sprouts cut side up and continue cooking another 10 minutes or so until the other side is lightly browned and sprouts are tender. Toss sprouts in a bowl with a few squeezes of lemon juice and another dash of extra-virgin olive oil, then serve.

DAY TWO: Chicken Quesadillas (serves four)

• 3 cups leftover chicken meat, chopped (We use the breast as the dark meat is sometimes too fatty. Two chicken breasts are enough to serve four people.)
• 2 cups Cheddar cheese (Monterey Jack or Manchego work nicely too)
• Four 10″ (the large size) flour tortillas
• Optional items: sauteed/caramelized onion, roasted red bell peppers, jalapeno or chipotle peppers (seeds removed)

Heat a heavy-bottomed 12″ skillet over medium-high heat. Add two teaspoons neutral-tasting (not olive) oil like canola, safflower, or mixed vegetable oil.

• When the oil is shimmering, place a tortilla flat in the pan. Add one-half cup grated cheese across the entire surface. Add three-fourths cup chicken and any additional optional items to one-half of the tortilla. When the underside of the tortilla is spotted light brown and cheese is melted, fold the cheese side onto the meat side. Press down lightly to seal. Flip the tortilla over to brown evenly on both sides. Remove and place on a cooling rack. Repeat with the remaining tortillas, adding one teaspoon oil to skillet each time.

Suggested Sides:

Green Salad

Guacamole (recipe follows)

• 2 ripe avocados
• 1/4 teaspoon kosher salt or to taste
• 1 teaspoon freshly squeezed lime juice or to taste

Cut the avocados in half, remove pits and scoop flesh into a bowl. Mash to a chunky consistency. Add salt and lime juice and mix. Serve immediately or refrigerate tightly covered (plastic wrap on the surface of the guacamole to prevent discoloration).

DAY THREE: Chicken Soup (serves four)

• 2 chicken carcasses, saved from the Roast Chicken
• 1 onion, quartered
• 3 carrots, peeled and cut into two-inch chunks
• 3 celery ribs, cut into two-inch chunks
• 2 bay leaves
• salt to taste

Vegetables, to be added when broth is finished:

• 4 carrots, peeled and diced
• 4 celery stalks, diced
• 1 onion, diced

Place the carcasses in a large stock pot. Add onion, carrot, celery, bay leaves and water. Bring to a boil, uncovered, and skim any scum or foam that forms. Reduce heat to a low simmer (only a few bubbles regularly come to the surface). Simmer uncovered for four hours. Remove from heat and strain broth through a colander or mesh strainer, discarding solids and carcasses. Return broth to the stove and add diced vegetables. Simmer covered until vegetables are cooked, add salt to taste and serve.

Suggested Sides:

Green Salad

Focaccia (recipe follows)

• 1 two-pound pizza dough ball (we like Hot Lips Pizza)
• 4 tablespoons extra-virgin olive oil
• 1/2 teaspoon kosher salt

Preheat oven to 425 degrees. Allow the dough ball to come to room temperature (it will be easier to work with). Add two tablespoons olive oil to an 18 x 13 inch sheet pan (also known as a “half-sheet pan”). Place the dough ball in the sheet pan, flattening it with fingertips and pushing the dough into the corners (dough will fill about half the pan). Work the air bubbles out along the way. Pour remaining two tablespoons oil over the top and sprinkle with kosher salt. Bake until lightly browned on top, 20-25 minutes. Lift bread from pan with spatula and cool on a wire rack. Serve warm, with a dish of extra-virgin olive oil and balsamic vinegar for dipping.

Bon appetit and Happy New Year!