In the news

The 2024 measles outbreak.

            There is a rising fear, especially in the media, about several cases of measles, primarily in Florida but also noted recently in several other states.

As someone who has seen scores of children with measles, I’m very much aware of the seriousness of this disease. Before we had a vaccine, we lost about one child for every one thousand who were infected and about one in 500 suffered from measles encephalitis that left them seriously impaired. Those children who seemed to be unscathed by the disease were not. About one half of children with measles had abnormal cells in the spinal fluid that revealed a low-grade inflammation of the brain. As evidence of this, it was common for teachers to note that their kids were just not performing as well as usual in the months following a measles outbreak.

In the recent outbreak more than 90 percent of the victims had not received the measles vaccine, a tragedy considering that the vaccine has an effectiveness rate of more than 95 percent and almost no side effects – and no serious ones in my experience nor in published studies involving tens of thousands of vaccine recipients.   

The media are reluctant to report the incidence of measles among recent immigrants, especially considering that the number of measles cases number in the hundreds of thousands in developing countries, and that measles is a leading cause of death and childhood blindness in those parts of the world.

If you wonder why the vaccine is “only” 95 percent effective, there are several reasons. We delay giving the MMR (Measles-Mumps-Rubella) vaccine until 12 to 15 months because women who have been naturally infected by these viruses can transmit antibody during pregnancy to the fetus that will interfere with the performance of the vaccine. Note, however, that infants over six months of age should receive the vaccine if they are exposed to a case of measles. The reason: a woman who has never had natural measles, but has only received the weaker vaccine virus, will not have enough of the transplacental antibody to protect her infant.

Some vaccine failures are due to improper storage of the vaccine, and there are some children whose immune system simply does not respond adequately to the vaccine.

The worst tragedy of all: vaccine resistance among parents. This was sparked by the totally discredited Andrew Wakefield in the early 1990s who blamed the MMR vaccine for autism. He bears the blame for hundreds, perhaps thousands, of children who have suffered from diseases that could have been prevented by childhood immunization.

Lifestyle

Ow! That hurts! But it doesn’t have to.

            We’re very fortunate that having a tooth pulled, getting a crown or even a simple filling isn’t the ordeal that it was before the advent of dental anesthesia. But WOW! – the pain of the lidocaine injection into the gum – or even worse, the palate – is the worst part of the procedure.

Did you know that you can reduce or even eliminate the pain of the needle? Thanks to Dr. Geoff Bell of Carlsbad, I learned a simple technique that really works. As the dentist asks you to open wide so that he or she can inject the anesthetic, raise one leg a few inches and rotate your foot in a circle until the medication has been administered. I know – it sounds like voodoo, but there’s a reason why it works. When you rotate your foot it sends an impulse to your brain that interferes with the pain pathway. Don’t ask me for the details. I’m a pediatrician, after all, not a neurologist.

You can use the same method to reduce the pain of a venipuncture the next time you give a blood sample at the laboratory or donate at the blood bank.

The changing world of diabetes

            In barely a century the disease known as diabetes has undergone seismic changes relative to its incidence, its treatment and quite recently, its very nature. The ancient Greeks knew only type 1 diabetes, a condition marked by a large outpouring of urine, so they gave it the Greek word for siphon. It occurs when the insulin-producing cells of the pancreas are wiped out by an aberrant immune response, and it usually occurs in persons below the age of thirty. Without insulin, victims rarely survived more than a few weeks until the Nobel Prize-winning discovery of insulin in the 1920s. Type 2 diabetes has a very different mechanism but that wasn’t recognized until the post-World War Two era, at which time it began its spectacular rise. Known at that time as adult-onset diabetes, it is caused by an excess intake of refined carbohydrates and a simultaneous marked reduction in physical activity. Diabetologists refer to it as an exercise-deficiency disease. The incidence has skyrocketed to the current figure of thirteen percent of Americans; it affects more than thirty percent among those over the age of sixty years. The CDC predicts that more than half of all Americans will have type 2 diabetes by 2050.

            Now we have another major shift in our understanding of type 2 diabetes. Some type 2 patients have an immune response similar to those with the juvenile (type 1) form, namely that they also have an altered immune response and produce antibodies to insulin, though at lower levels than type 1 patients.  

            Some persons with apparent type 2 diabetes have difficulty maintaining normal blood sugar levels. The patient usually gets the blame for this but in at least some cases, it’s because they have Latent Immune Diabetes of Adults (LADA), a relatively new entity that some refer to as type 1.5 diabetes, a label that is itself in some dispute. Adding to the confusion is that LADA is a variable condition, sometimes occurring in persons who do not have the usual risk factors for type 2 diabetes, such as being overweight or obese.

Although most physicians are probably aware of this previously unrecognized form of diabetes, which may affect roughly ten percent of patients that have been diagnosed with the type 2 form, there are numerous examples of individuals who did not receive appropriate, timely treatment for several years. Thus, my reason for posting this blog is to alert patients who have difficulty in managing their disease to discuss this issue with their physician. Considering that there are now more than forty million Americans who have been diagnosed with type 2 diabetes, it is certain that some are suffering from and struggling with LADA. I encourage readers to forward this message to anyone who has or is at risk of developing type 2 diabetes.

The Internet Trap

            The Internet can be a marvelous source of information on almost any subject, but it is also the source of a great deal of misinformation. But you already knew that. Things will only get worse as Artificial Intelligence becomes a major tool for the bad guys whose goal is to alarm, mislead or entrap us.

            A recent example of seeming ignorance of the subject matter is a photo calling attention to the recent outbreak of measles that showed a child not with the rash of measles, but of chickenpox. A simple error, probably not intentional.

            An article that raised alarm about bubonic plague as if it portended the return of the Black Death failed to point out that there are, on average, about seven cases per year of this illness in the United States and that a myriad of small animals, especially in the Southwest, carry the bacterium known as Yersinia pestis. A risk, to be sure, for persons hiking or camping in places such as our local Palomar Mountain area. Fortunately, the conditions that led to one of the most deadly pandemics in history simply do not exist in the First World. Even in Madagascar, an economic and political basket case if there ever was one, which has been experiencing a smoldering outbreak of bubonic plague since 2015, the cases are in the hundreds, not thousands.

            Since the first months of the COVID pandemic we have heard reports of the dangers of the recently developed vaccines, one strongly suggesting that “white clots” caused by the vaccines are killing people. It has been thoroughly debunked but like the aspartame hoax of thirty years ago (the Nancy Markle hoax) it continues to linger.

            A rule of thumb regarding health-related matters on the Internet: limit your searches to web sites associated with medical centers, universities or the CDC, using suffixes such as edu or gov. Regarding the CDC, whose reputation has been severely tarnished, keep in mind that mundane articles regarding the symptoms and signs of diseases, statistical information, treatment, etc., are produced by rank and file scientists, not the politically or financially motivated people at the top. These days it’s easy to verify almost anything by going to other trusted sites.

Help for migraineurs.

            Migraine headaches affect millions of persons but there has been a steady accumulation of evidence that nutritional factors, especially vitamins, can help to decrease their frequency and intensity. Considering that supplemental vitamins and minerals have minimal side effects if not taken in excess amounts and that all prescription medications have annoying, if not serious, side effects, promulgating this information is worth the effort.

            Certain B vitamins (B2, B6, B12 and folate – known as B9), reduce the formation of homocysteine, a well-studied trigger of migraine and a contributor to cardiovascular disease. Because the production of homocysteine has a genetic basis the results of prophylaxis with these vitamins have been spotty, and some persons may require high amounts of certain vitamins (Vitamin B2 for example) that are not usually recommended.

            Vitamin D is important for normal bone health and for a strong immune system but about half the U.S. population is deficient in this vitamin for at least part of the year. In an analysis of several studies, persons who took 50 micrograms (2,000 units) of vitamin D per day had fewer attacks and fewer “migraine days” per month than did control participants. Vitamin D supplements have no significant side effects, and you can ignore the pointless warnings in some lay publications that high doses of this vitamin can cause kidney disease. That is correct but “high” means more than 10,000 units per day for at least six months!

            Vitamin E is a kind of orphan vitamin, little studied compared to the others and deficiency of this vitamin is rare, or at least rarely recognized. However, it has been found to be an effective supplement for women who have menstrual migraine and menopausal migraine.

            Magnesium is another nutrient that is lacking in the diet of roughly half the population. It shouldn’t be. Leafy green vegetables, nuts and whole grains have an abundance of this mineral, but it is almost absent in the processed foods that have become so prevalent in the American diet. Along with the vitamins mentioned above, magnesium is a component of any quality multivitamin/multimineral supplement.

The bottom line.

            Migraine headaches will continue to vex millions of people and it’s not likely that there will be a breakthrough soon in this very complicated condition. However, sufferers should consider improving their diet to contain more leafy green vegetables, whole grains, nuts and fresh fruit, in addition to drastically lowering their intake of processed foods – that means just about everything at the grocery store that comes in a box or bag – and adding a quality multivitamin/multimineral to their daily diet. It ain’t rocket science!

In the News

It ain’t rocket science!

            For several years there has been a steady stream of articles that have unequivocally demonstrated that the dozen or so chronic diseases that shorten our lives have almost nothing to do with aging but are the result of poor dietary habits and the near-universal lack of sufficient physical activity. We have dealt with the latter in the last couple of posts but a recent article, Dietary nutrient intake and cognitive function in the Age-Related Eye Disease Studies 1 and 2, in the journal Alzheimer’s and Dementia, confirms what we have been promoting for decades: a diet that includes vitamins, minerals and omega-3 fats slows the loss of cognitive function while a diet high in processed foods and refined carbohydrates does the opposite. The studies of Dr. Dean Ornish clearly show that a mostly vegan diet not only prevents coronary artery disease and stroke, but if vigorously maintained can actually reverse those diseases.

            Is it really so complicated??

            The above-cited article refers to the value of the true Mediterranean diet, which includes little red meat, an abundance of fruits and vegetables, no refined flour or sugars – well, OK, maybe an occasional tiramisu – a daily dose of olive oil and perhaps a single glass of red wine! Not exactly a Spartan regimen.

            Why have the most advanced, knowledgeable and sophisticated countries of the world not adopted these simple lifestyle programs. Perhaps because we are inundated with highly processed foods that are just too tempting to resist. In a recent rip through two chain supermarkets, I was struck by seeing large displays at the entrance of the stores with dozens of counters filled with junk food, beautifully decorated and packaged and surrounded by tempting aromas.

            What will it take to turn things around? 42% of Americans are obese, 40% are overweight, 13 percent have type 2 diabetes and fewer than 25 percent of young Americans can pass the entrance physical for the armed forces. What will our population look like in 2050?

In the news

Get ready for the next big (medical) thing.

            Gene-editing treatment is here, and it’s more meaningful than most people can imagine. For the first time the FDA has approved two methods for the treatment of sickle cell disease, a genetic defect that affects primarily dark-skinned people and that leads to years of pain episodes, strokes and other complications, including early death.

            The Nobel Prize-winning discovery of the structure of DNA was reported in 1953, just five years before I entered medical school. Multiple advances in the science of genetics have finally led to the manipulation of genes that can reverse the abnormality that causes sickle cell disease. We now have the basic framework that will eventually lead to the cure of brain-destroying conditions like Tay-Sachs disease and Huntington disease, as well as common diseases such as cystic fibrosis and neurofibromatosis. There are scores more such diseases that are relatively rare but that are devastating for the families in which they occur.

            There are – and will be – challenges, of course. The cost is staggering — more than two million dollars per patient. Side effects are inevitable, and some may be fatal. It will always be thus with brand-new technologies.

            Early in my career I watched the explosion in the field of antibiotics. Penicillin got off to a slow start, in which producing it was so difficult that the urine of patients that were being treated was collected so that the precious substance could be recovered and re-administered. Within about fifteen years diseases such scarlet fever, pneumonia and meningitis were no longer highly fatal. We are going to see the same surge of advances in the treatment, cure and elimination of many more diseases.

Lifestyle

The value and the psychology of the push-up

            The simple push-up, with its few variations, is IMHO (In My Humble Opinion) the most valuable exercise that one can do without equipment. It involves every major muscle group: back, abdomen, shoulders, chest, arms and legs. It even helps to strengthen the muscles of the neck, and if you are eventually able to rest on your fingertips and not your palms – yes, Virginia, you will be able to do that someday – some of the smallest muscles in your body will become stronger.

            Most people (53 percent), according to a study reported last September, cannot do TEN push-ups. A third cannot do five! Considering how important those major muscle groups are in daily living, that is a dismal situation.

            But here’s the good news: if you start doing push-ups every day or even every other day, you will be amazed at how quickly your numbers will rise. Begin by doing only five on the first day, then add only one more at each session. I guarantee that by the end of the second week you’ll be doing ten with ease. From then on it’s a matter of how hard you want to push yourself and whether you’ll get satisfaction from doing 30, 50 or even 100 push-ups at a time. Remember that because so many muscles are involved no single group has to handle a large load.

            Some tips:

            If you are not exercising regularly, begin with modified push-ups by resting on your knees and not your toes.

            Instead of resting your hands on the floor, rest them on a small platform or cushion. It can be three feet high in the beginning, gradually making that platform/cushion lower until you are hands-on-the-floor.

            After the first session you might want to rest for a couple of days, for two reasons. One is that if you work any muscle hard after a long period of inactivity you will experience DOMS (Delayed Onset Muscle Soreness). It’s the pain that often sabotages the desire to get in shape. The second reason is that dormant muscles are filled with dormant blood vessels. When you begin to activate a muscle those small vessels need to be awakened so that they will adequately supply muscle fibers with nutrients and carry away waste products.

            Bragging rights

            How do you think you’ll feel the day that you have done 50 or 100 push-ups? (Don’t get too cocky. When I told my brother how many push-ups I was doing he said “Of course! You don’t have much to push up!”)

            A New Year’s resolution

            I hope that this column will motivate you to take advantage of the psychological phenomenon called A New Year’s Resolution – most of which have been discarded by Valentine’s Day. But I know that when you have been able to do more push-ups than half the population you’ll find psychological as well as physiological energy to make 2024 your healthiest year ever!

In the news

            Several studies over the past few years have shown that persons who receive the recommended adult vaccines – influenza, pneumonia, shingles – seem to be less likely to develop Alzheimer’s Disease. Now a large study involving more than 900,000 persons over a ten-year period has revealed that the reduction is significant: persons who received one or more influenza vaccinations were 40 percent less likely to develop Alzheimer’s disease during the ten-year study period.

            Influenza is not the only vaccine that provides such protection but the number of persons who receive the other adult vaccines is considerably smaller and the protective effect is harder to prove. Those who have received the adult versions of tetanus-pertussis-diphtheria vaccines also derive a protective effect. The tuberculosis vaccine known as BCG, seldom used in this country because of the very low incidence of tuberculosis in our population, is among those. In fact, a lower likelihood of Alzheimer’s Disease has even been observed in patients with bladder cancer who have received intra-bladder infusions of BCG.

            The mechanisms involved are not yet clear but researchers are closing in. We have known that some viral diseases such as influenza have effects on the brain, even if there are no symptoms that would suggest such involvement (unless we include the sometimes severe headache that occurs in some patients). One possibility is that the vaccine prevents the virus from exerting influence among brain cells. Another possibility is that the resemblance of an influenza virus protein to the beta-amyloid protein that appears to be the culprit in Alzheimer’s disease may be involved.

            It will probably be several years before scientists will tease out all the details but this is yet another reason for receiving ALL the vaccines that are recommended for persons beyond middle age, in whom influenza, pneumonia and shingles have a much greater incidence and fatality rate. It’s true that some persons experience significant, sometimes painful or debilitating side effects but you should keep in mind this salient fact: if you have a serious reaction to a mild version of one of these diseases, what do you think would happen if you were hit with the real thing?

Lifestyle

It’s hard to avoid partaking of the usual Christmas treats like cookies, candies and eggnog, and of course the inevitable increased intake of alcohol. They all have concentrated calories and it’s no wonder that many people find that slacks and skirts don’t fit the way they did in mid-November. The good news: there are some strategies that you can employ that will help you to enjoy holiday feasting without feeling like a martyr.

It starts with limiting your “downfall foods.” (Mine are those mini cream puffs from Costco.) Decide how many you will have at the party. It helps to save them for last, when your appetite has been fairly well satisfied.

Limiting alcohol at parties helps. After two drinks I switch to water or ginger ale. Nobody seems to notice, maybe because they haven’t made the switch.

Move across the room from the buffet table. The closer you are the easier it is to step over and pick up a little more to put on your plate.

It’s not politically correct for me to say this, but hang around with the skinniest folks in the room. They are less likely to grab those treats being passed around by the hostess, and that will make it easier for you to pass them up as well. (I know I’ll get mail for that one!)

Don’t be the first person in the buffet line. The hostess has taken great pains to make everything look pretty and appealing. It won’t look as tempting after a few other folks have helped themselves.

One more thing – your exercise routine is likely to take a hit with all the hustle and bustle of the holiday season. Make it a priority on your calendar, not something that gets squeezed in when time permits.

In the news

More evidence that vaccines save lives – and it’s not the COVID vaccine

            Sickle cell disease occurs when the hemoglobin  molecule that carries oxygen in the blood undergoes a mutation that distorts the shape of red blood cells into a curve that resembles a sickle – hence the obvious name. Unable to swish smoothy through small blood vessels, the cells pile up and lead to obstructions that cause pain in various parts of the body and can lead to stroke when those blood vessels happen to be in the brain. The condition is highly prevalent among those of African descent and often causes death in early childhood.

            These children are susceptible to infection by the pneumococcus, a bacterium that is a common cause of pneumonia – another obvious designation – and that causes overwhelming infection in sickle cell patients. The development of highly effective vaccines against the pneumococcus in the 1980s dramatically reduced the prevalence of these infections in the entire population but especially among persons with sickle cell disease.

            According to a study from Europe the relative frequency of disease caused by the pneumococcal strains contained in the current vaccines has diminished, so that another nasty germ, salmonella, has taken its place as the leading cause of infection among children with sickle cell disease. There is no widely available vaccine against salmonella.

            Only about 60 percent of affected children in Europe in this study had received the pneumococcal vaccine although it also reduces the risk of ear infection, pneumonia and meningitis caused by vaccine-associated strains. It’s clear that this vaccine, like almost all others, is effective. It’s also clear that too few children are receiving optimal medical care even in the developed world.

Lifestyle

Exercise doesn’t do much to help you lose weight, but do it anyway.

            It’s painful to watch them, severely overweight individuals slowly pedaling away on a stationary bike at the fitness center, or languidly performing exercises on a machine. Most of them have probably been told that they need to exercise in order to lose weight, but even sweat-producing exercise has little to do with weight loss. I have noticed that I seldom see those folks again after only about one week!

            Having said that, it is vitally important to engage in moderately intense physical activities while cutting calories – the most important step in getting rid of excess fat – but not for the reason that most people think. People who seriously cut back on food intake, a.k.a. calories, will lose weight, but as much as half of that lost weight comes from muscle tissue, not from fat. Exercising not only preserves muscle, but it may add some, so that you might (frustratingly) see little change on the bathroom scale but you will see your belly begin to shrink. Remember that your goal is to lose fat, not weight.

In the news

One less thing to worry about.

            You might have heard about a disease that has affected the deer population in most states – especially if you are a hunter – called Chronic Wasting Disease (CWD). Elk, caribou and moose are also affected. First described in the late 1960s, it has been found in 30 states and some areas of Canada; a few diseased animals have been found in Scandinavia.  Affected animals show gradual weight loss (hence the name), abnormal gait and behavior. The disease is caused by prions (pree-ons), unusual proteins that are not alive but yet are capable of being transmitted from one animal to another.

            If the term prion sounds familiar it harkens back to the 1980s when Mad Cow Disease (the medical term is Bovine Spongiform Encephalopathy, or BSE) terrorized the United Kingdom. About 200 Britons succumbed to a disease that was very similar to a very rare but fatal brain disease in humans. Only four cases of human CWD-related illness have been reported in the United states but all appear to have acquired the disease in other countries.

            My reason for writing about a disease to which humans do not appear to be susceptible is the growing awareness that many, perhaps most, infectious diseases of humans ultimately come from animals. COVID-19 is an example and has stimulated intense interest in zoonoses, diseases transmitted from animals to humans. There is speculation – irresponsible in my opinion – that CWD will mutate as viruses are known to do and will initiate a pandemic for which there is no known treatment.

            On the other hand, there is no need to tempt fate. BSE spread in the United Kingdom because farmers there fed their animals meat scraps from infected cows. That practice does not exist in this country. The worry is that deer or elk hunters may feast on their kill and thus acquire the deadly brain disease. After nearly half a century that hasn’t happened but hunters have been put on notice by health officials that they should not eat meat from animals that appear ill. There is, of course, no way that contaminated meat will find its way into your local supermarket.

            So there! You can stop worrying about prion diseases the next time you see a dramatic headline on the Internet warning us of the next animal-related pandemic.

Lifestyle

Which is healthier, white potatoes or sweet potatoes?

            During my lectures I discourage some kinds of potatoes. For instance, I define french fries as nutritional pornography. Unlike the other kind of pornography, it’s OK to enjoy french fries now and then. We all love baked potatoes but the stuff we put on them, like butter and sour cream, isn’t exactly health food. Further, those Idaho baking potatoes as well as the ones used to make French fries are bred to produce starch that is quickly broken down into sugar – which is why they taste sweet even while you’re still chewing them – a clever marketing ploy.

            According to Dr. Katrina Nguyen, a pediatric gastroenterologist, both white potatoes and sweet potatoes are considered healthy. White potatoes have more calories but sweet potatoes have lots more vitamin A – perhaps 1,000 times as much depending on the variety.

            What most laboratory-centered nutritionists seem to ignore is the eating habits of the average American. Most people eat the starchy stuff on the inside and leave the skin – where most of the vitamins, minerals and fiber are – in the garbage disposal. (I know – some of you are saying “Not me! I always eat the skin.” Forgive me, but that’s not what I see when I dine with family or friends.)

            The bottom line: except for the generous amount of vitamin A in the form of beta carotene in sweet potatoes, it’s pretty much a draw. But eat the skin!!