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A Country Doctor Reads: January 13, 2019

The Making of the Picky Eater – The Wall Street Journal

Picky eaters are said to be a newish phenomenon among children. An article in The Wall Street Journal gives some interesting history, from children being fed scraps to medically suggested bland diets to letting children eat whatever they wanted:

Doc­tors scram­bled to find so­lu­tions. One of the most widely noted re­sponses came from the Cana­dian pe­di­a­tri­cian Clara Davis, who con­ducted a se­ries of ex­per­i-ments in the 1920s and ’30s to see what would hap­pen if small chil­dren, in­clud­ing ba­bies, were al­lowed to pick their own foods. For her study, Davis was able to round up 15 in­fants from in­di­gent teenage moms or wid­ows and su­per­vise all of their eat­ing for pe­ri­ods rang­ing from six months to 4½ years, ac­cord­ing to ar­ti­cles she pub­lished in 1928 and 1939 in the Cana­dian Med­ical As­so­ci­a­tion Jour­nal and a 2006 re-ex­am­i­na­tion of her work in the same pub­li­ca­tion.

The chil­dren were al­lowed to choose among 34 items, in­clud­ing milk, fruit, veg­eta­bles, whole grains and beef, both raw and cooked. They made some rather ec­cen­tric choices, in­clud­ing fist­fuls of salt, and most were ap­par­ently fond of brains and bone mar­row. Some-times they ate lit­tle, and some­times more than an adult (no­tably, six hard-boiled eggs on top of a full meal, or five ba­nanas in a sin­gle sit­ting). The tiny sub­jects var­ied widely in their self-cho­sen menus, but the idio­syn­crasies evened out over time, and each child, Davis re­ported, ended up eat­ing a bal­anced and com­plete diet.

Sickly and scrawny at the start of the study, they be­came healthy and well-nour­ished, she wrote, sup­port­ing a con­cept that was be­com­ing known at the time as body wis­dom. “For every diet dif­fered from every other diet, fif­teen dif­fer­ent pat­terns of taste be­ing pre­sented, and not one diet was the pre­dom­i­nantly ce­real and milk diet with smaller sup­ple­ments of fruit, eggs and meat that is com­monly thought proper for this age,” she wrote. “They achieved the goal, but by widely var­i­ous means, as Heaven may pre­sum­ably be reached by dif­fer­ent roads.”

https://www.wsj.com/articles/the-making-of-the-picky-eater-11547222243?emailToken=80100119fadefc742677f724403aa150cbvUY9r2u42phXe/xLqWogESDE2LVV9s63YhE1cBAjC76RZ3aiqGOnAdmPVYJfP2d8RZyN8IAkeUG6dOlgjOuw%3D%3D&reflink=article_email_share

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1626509/

The Grace of Denial – The New England Journal of Medicine

This week’s “Perspective” essay is by a physician who has sympathy for patients and families who fail to accept a terrible disease diagnosis until well after it should have been obvious. Dr. Heather Sher insisted and believed her father had Lyme Disease instead of Amyotrophic Lateral Sclerosis.

So yes, I am familiar with denial. When I see patients who cannot face the prospect of a terrible diagnosis, I understand their delay, their reluctance, their trepidation on a deep level — a level that perhaps only someone who has witnessed a loved one’s slow demise from a terminal illness can appreciate. In the face of a diagnosis for which there is no effective treatment and no cure, our denial allowed my family 6 months of relative peace before things became unbearable. We had a few extra months with my father without the constant awareness that his death was imminent. My medical inexperience, clouded clinical judgment, and desperate desire for more time with my dad extended our denial of medical reality for longer than is typical.

Today, when I hear detached descriptions of patients who’ve waited too long to address a devastating illness, I understand. “Denial helps us to pace our feelings of grief,” Elisabeth Kübler-Ross explained. “There is a grace in denial. It is nature’s way of letting in only as much as we can handle.”

https://www.nejm.org/doi/full/10.1056/NEJMp1810685

There Are Few Shortcuts to Health

People aged 70-90 who follow a Mediterranean diet, are physically active, have moderate alcohol use, and are nonsmokers have less than half the heart attack, cancer and overall death rate of people who eat an average Western diet and have more average habits. This was the remarkable conclusion of the 2004 HALE study, involving people from eleven countries.

And the 2014 PREDIMED study demonstrated a 35-50% reduction in cardiovascular events by simply consuming extra virgin olive oil.

But there’s little money to be made for the pharmaceutical and health care establishment by promoting healthy eating habits.

In this week’s New England Journal of Medicine, there are two articles with opposite results from the use of different omega-3 fatty acids.

The first one, sponsored by the pharmaceutical industry, showed a 25% risk reduction from a supplement with Eicosapentaenoic acid (EPA), naturally found in fatty fish like salmon.

“Among patients with elevated triglyceride levels despite the use of statins, the risk of ischemic events, including cardiovascular death, was significantly [25%] lower among those who received 2 g of icosapent ethyl twice daily than among those who received placebo. (Funded by Amarin Pharma; REDUCE-IT ClinicalTrials.gov number, NCT01492361.)”

I remember reading about this substance way back in Barry Sears book, The Zone.

The second article showed no benefit from generic omega-3 fatty acids:

Supplementation with n−3 fatty acids did not result in a lower incidence of major cardiovascular events or cancer than placebo. (Funded by the National Institutes of Health and others; VITAL ClinicalTrials.gov number, NCT01169259.)

Conclusion: Good food and good clean living reduces risk by 50+%, branded supplements by 25% and generic supplements possibly not at all.

Is anybody surprised?

Curiosity, Antidote to Burnout

A patient with chronic pain who had tried CBD oil brightened up my ten hour workday on New Year’s Eve.

The cannabis derived product, free from the classic mind altering THC, has a sketchy record as a treatment for pain. But this woman described something that made me think, and Google for answers.

“It took away all that stinging, burning pain I have had everywhere, but it made me notice my hip and knee pains more”, she explained.

I instantly formulated my question: Does CBD affect signaling in the slow nerve fibers associated with the diffuse pain of fibromyalgia and opiate induced hyperalgesia, thereby making her more aware of the rapid transmission pain messages from her arthritic hips and knees?

“It’s as if your body was like an old fashioned radio and you adjusted the tuning so that the static decreased and now you can hear the actual broadcast more clearly…”, I said.

“Yes, exactly!” Her eyes lit up.

I thought for a moment.

“I would think that is a good thing, empowering, in that your arthritis pain makes more sense and may be more predictable than your fibromyalgia pain. This new state may make you more able to gauge how much you can do before you overdo it in terms of the arthritis.”

She agreed, and promised to keep me posted.

New Year’s Day I read an article on the BBC website that made me think again of my patient’s observation and how it fired up my curiosity. Titled “The secrets of the ‘high potential’ personality“, (https://www.bbc.com/worklife/article/20180508-the-secrets-of-the-high-potential-personality) it described curiosity as an antidote to burnout and one of several predictors of professional success that the authors claim to be better predictors than the Myers-Briggs Personality Types.

“Compared to our other mental traits, curiosity has been somewhat neglected by psychologists. Yet recent research shows that an inherent interest in new ideas brings many advantages to the workplace: it may mean that you are more creative and flexible in the procedures you use, help you to learn more easily, increases your overall job satisfaction and protects you from burnout.”

The six traits are:

    Conscientiousness
    Adjustment (ability to reframe stressful situations)
    Ambiguity acceptance
    Curiosity
    Risk approach/Courage
    Competitiveness

At the beginning of my day, my mind had been wandering back to New Year’s Eves away from the office, trudging through the snow in the Swedish countryside or dancing at Chateau Frontenac in Quebec.

As my workday ended, I wished my Suboxone group Happy New Year and thought about the literature search I wanted to do on my day off.

May I never lose my curiosity…

Medicalization and Demedicalization in US Healthcare

“Admission Diagnosis: Causa Socialis”

In my training in Sweden it was not unusual to admit patients to the hospital for social reasons: An elderly person who could no longer manage at home, a person whose social network fell apart, and so on.

“Social reasons”, Causa Socialis, was a legitimate diagnosis (Swedes used more Latin than Americans, at least back then). And it was used with only mild grumbling. There was a clear understanding that the hospital was an important part of the social safety net. And, after all, it was ultimately tax dollars that paid for both medical and social services in the community.

In this country, these two types of services have little to do with each other. That is a problem.

For issues that could be either medical or not, Americans have a Newspeak vocabulary. I write frequently about “medicalization”, where for example more or less normal aging processes (wrinkles, osteopenia, low testosterone) become diseases.

The New England Journal of Medicine recently published a piece about the opposite term, “demedicalization”, exampled by a homeless, mentally ill patient who came to harm because he didn’t have a medically appropriate admission diagnosis.

Demedicalization

Demedicalization is the transformation of problems formerly understood to be medical in nature into problems understood to be nonmedical.

Like its opposite, medicalization, demedicalization occurs at multiple levels, ranging from the conceptualization of etiology to the understanding of whether interventions for problems are appropriately medical or nonmedical.

Many disadvantaged people still view modern hospitals as safe havens, like mountaintop monasteries or old fashioned charity hospitals, but they really aren’t anymore.

My thoughts often return to the unsettling, upsetting if you will, fact that societal, cultural, public health or general life problems are “medicalized” when there is money to be made and “demedicalized” when there is not. Do the megahospitals really have tighter operating margins than the two older kinds of institutions they replaced?

Will Technology Keep Us From Thinking?

The New York Times quotes Plato’s play Phaedrus to make a point about Facebook’s use of data. They make the claim that “Technology promises to make easy things that, by their intrinsic nature, have to be hard”.

In the play, a wise king, Thamus, is offered the art of writing by the god Theuth.

The art of writing, Theuth said, “will make the Egyptians wiser and give them better memories; it is a specific both for the memory and for the wit.”

But Thamus rebuffed him. “O most ingenious Theuth,” he said, “the parent or inventor of an art is not always the best judge of the utility or inutility of his own inventions to the users of them.”

The king continued: “For this discovery of yours will create forgetfulness in the learners’ souls, because they will not use their memories; they will trust to the external written characters and not remember themselves.”

It struck me how this analogy is also perfectly applicable to the new technologies entering the field of medicine, from EMRs with “Decision Support” to Artificial Intelligence.

Just like there are store clerks who can’t make change (for customers who still pay with money) or school children who can’t multiply without a calculator, will the doctors of the future be helpless if dislocated from the propping up we are now starting to expect should they ever have to practice in a natural disaster, remote area or mass computer hacking situation?

(P.S. This reminds me of something I read in The Lancet years ago. They tried to coin McCoy’s Syndrome for when Star Trek like doctors rely too much on technology.)


I just realized none of the posts show on an iPad or a computer, but they do show on an iPhone. WordPress is working on this. In the meantime, please visit my Substack.

 

 

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

 

BOOKS BY HANS DUVEFELT, MD

CONDITIONS, Chapter 1: An Old, New Diagnosis

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