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Know your Numbers / How Statistics Can Be Misleading

April 2016

A recently published study in the New England Journal Medicine, The Hope-3, looked at the benefit of statin drugs to lower cardiovascular disease.  The study was funded in part by AstraZeneca, a company that makes statin drugs.  The idea is that perhaps healthy people should be given a low dose statin alone or would a mixture of a statin with a mild blood pressure medicine help to lower risk of heart attack or stroke.  Essentially, should ALL of us over 50 be on these drugs?  Turns out that the statin alone worked better than with a combination of a blood pressure medication.  

But that’s not what I found interesting.

What I found interesting is that the presentation of these numbers is a perfect example of how numbers are used to manipulate or confuse the truth, not about just medicines but EVERYTHING.

The study included 12,000 people; that’s a lot of people.  Good.  Some were given a statin alone. Some were given the combo pill, and some were given placebo.  Of the people who got placebo in the study, 4.8% had a heart attack or stroke.  The people who got the statin drug, 3.7% had a cardiovascular event.  The author noted that this represented “a statisically significant 24% reduction in risk."  (Actually the article came up with 24% but the math is 23% to my way of calculation.)

Here’s the math:  4.8 - 3.7 = 1.1

                            1.1 / 4.8 = .2292  or rounding, 23%

SOUNDS IMPRESSIVE!  Doesn’t it?  “A 24% reduction of risk.”

But the author is leaving out a very important qualifier; he should have use the term “relative risk.”  And to my mind, relative risk is often meaningless.

Let’s look at the numbers again:

4.8% of the people on placebo had an event.  This means that for every 100 people on placebo, not quite 5 individuals had a heart attack.  For every 100 people on the statin, 3.7 or about 4 people had an event. So 

5 - 4 = 1  So, for every 100 people on the drug, only 1 heart attack was prevented.

ONLY ONE!

This is the difference between relative risk and absolute risk.  Relative risk is reduced by 23%; absolute risk was reduced by 1%.

By example, let’s say that there is a 1 in a million risk for a rare cancer. But! Hooray for medical science!  If one were to take a drug, that may cause liver problems or be assoicated with memory problems, or increase your risk for diabetes, (i.e. statins),  the risk becomes 1 in 2 million.  That represents a whopping 50% reduction in risk.  THAT would be the headline.  But is it wise to take a drug with known risks just to help with a 1 in a million chance?  Probably not.

I am not suggesting people stop taking their statin drugs, especially if they have already had a heart attack or if their cholesterol is astromically high (because their risk is much higher than the 4.8%.)  But I do call to question how risks and benefits are presented to the public.  Know your numbers.  I don’t think the author was trying to dupe the public, but it does demonstrate how statistics can be used to confuse the truth, from medicine to especially politics. 

Statistics play a role in my practice.  When one’s intra-ocular pressure (IOP) reaches 26, roughly 50% of people will develop optic nerve damage, which is the definition of glaucoma.  (There are more risk factors which should be considered however, increasing or decreasing risk; so this number of 26 is rather simplistic).  But at any rate, at a pressure of 26, I often offer treatment to the patient to lower their risk.  But I am careful to explain that if I put 10 people with a IOP of 26 on drugs, I am OVER TREATING 5 of them!  I then let them decide.  

Only when people are given the true meaning of numbers can good decisions be made.  





Lens Materials: A Guide to different lens materials

In the “old days” glasses’ lenses were made out of crown glass, hence the term glasses.  Glass lenses are still available today, and a few of my patients still insist on glass, but very few.  Glass has some advantages though, namely they don’t scratch easily.  Glass has excellent optics.  But, glass has major disadvanages: glass can shatter, and glass is heavy.  So in terms of safety and comfort, glass has  largly been replaced by newer materials.  To put this in perspective, I probably order 3 to 5 glass lenses in a year’s time.

Refractive Index: Simply means: how much does the material bend light.  The higher the index, the more it bends light which translates to thinner lenses.

ABBE Value: Means how the material “splits” light into different colors, the higher the number the better.  Technically, it means the material refracts (or bends) different colors differently, which is not good.  The effect is that one color, say, blue light is refracted more than red, thus spliting your vision into a rainbow of colors.  Ideally, you want all your colors focused at the same place.

Plastic Lenses (CR-39)

Plastic lenses remain the most popular lens material today.  It has excellent optics.  It’s less expensive than any of the materials.  It’s about half the weight of glass.  With the introduction of scratch coatings, plastic rivals the scratch resistence of glass.  Of course it’s much safer than glass.  It CAN shatter though.  It’s a great material.

Advantages of Plastic:

     Least expensive of the materials. It’s lighter than glass.  It has good optics.  It lasts forever (yes, lenses do age).  Has the highest ABBE value, ie good.  Trivia:  It’s great for welders; sparks tend to bounce off plastic but tend to bury into glass.)  If you are a welder or work around welders, plastic is for you.  Also plastic can withstand practically any solvent (you might think this is not important until your paint solvent turns your lenses opaque.)

Disadvantages of Plastic: Thicker than any of the other materials.   Can Shatter.  Does filter UV radiation but now all.

Polycarbonate

“Poly” was introduced in the 1970’s.  It’s primary advantage over plastic is strength, weight, and it’s thinner than plastic.  It’s used in safety glasses.  

Advantages of Poly:

    Highter refractive index than plastic.  Roughly half the weight of plastic.  Filters all UV radiation.  Very tough.  I’ve never heard of it shattering but can chip and crack.  Of the “thinner” hi-index lenses, poly is the least expensive of the “high index” lenses.

Disadvantages of Poly:

    Less than ideal optics.  A small percentage of people just hate it.  It has a lower ABBE value so it spits color more.  The solvent acetone will melt poly (i.e. nail polish remover)

Trivex

Trivex is one of the newest materials on the market.  It’s main advantage is that is even tougher than poly.  It won’t chip.  It’s the toughest of the materials. 

Advantages of Trivex :

     About the same index as poly, i.e. it’s about the same thickness as poly.  But, it’s even lighter in weight than poly.  It has crisper optics than poly with a higher (better) ABBE value.  So better durability and optics than poly.  I use Trivex in drill mount frames as I’ve never seen it chip.  it filters 100% of UV radiation.

Disadvantages of Trivex

     Not many. It’s simply more expensive than poly.  It’s slightly thicker than poly by about 10%.  So think, slightly thicker but lighter than poly but tougher with crisper optics.

1.67 Plastic

     1.67 Plastic is a high index plastic.  it is thinner than poly and Trivex.  If you want the thinnest lens, 1.67 is for you.

Advantages of 1.67 Plastic

     It’s thin.  There is 1.74 index plastic, which technically is thinner but not by much, but it’s ridiculously expensive.  For a thinnest lens, 1.67 is the best value.

Disadvantages of 1.67 Plastic

     Not as durable as Poly or Trivex.  It’s surface can “craze” leaving a crackled surface.  Optics are not so good.  You will likely see rainbows as it splits colors into a rainbow.

Conclusion

For most prescriptions, good ol’ plastic is the way to go, but if your presription is high with thick edges, or if you need lenses which won’t shatter or break, then you might consider the alternatives.



  







Dry Eye and What To Do About It: The Importance of Lid Hygiene

This is a boring subject but an important one.  Dry eye is likely the single most common complaint an eye doctor encounters. It affects millions of people and can be debilitating. Eyes get dry.  So what?  Well tears are important.

Your tears are:

1) The refractive surface of the eye, which provide the glass smooth surface upon which refracts light is focused.  Insufficient tears means a hazy, out of focus vision.  Have you been reading and all of a sudden the print fades away?  Now you see it; now you don’t?  Dry eye.

2) Highly antimicrobial.  Tears kill many bacteria on contact.  Less tears means more eye infections.

3) Bathe and support the cornea.  Bad tears mean the cornea becomes inflamed which translates into pain.

_____________________________________

“Doc, it feels like there is grit in my eye.  I look in the mirror but I don’t see anything.”

“Doc, I can be reading and all of a sudden, the print fades away.”  (My favorite: “The letters grow fur.”

“Doc, my eyes burn and feel tired all the time.”

“Doc, it feels like there’s a hair in my eye.”

(I like being called Doc, by the way, casual yet respectful.)…………………

If I hear these symptoms, especially the “letters growing fur” comment, I think dry eye.

If you’ve been to my practice with these complaints, then no doubt, you will have watched me put this paper loaded with yellow stuff in your eye.  Flourescein is a water soluble dye which is fluorescent.  So when I apply the blue light on it, it glows.  So I can “see” your tear film, which means I can see your tears.  I can tell if your tears cover your eyes and how long.  Fluorescein also is absorbed by damaged cells; so if cells have died, they absorb the dye and GLOW!   Commonly I see dead cells scattered all over the cornea.  OUCH, which explains, “Doc, my eyes are red and irritated; it feels like grit in my eyes; my vision comes and goes, and when I read, the letters grow fur!”

The science so far:

Tears are made up of three layers: a mucus layer, a watery layer, and an oil layer.  The mucus acts to bind the tears to the surface of the eye so the tears can “flow.”  The watery layer keeps the eye wet of course, and the oil layer helps prevent evaporation.  It is now believed that most dry eye cases are caused by a lack of the oil layer, causing  the tears to simply dry up faster than is being produced.  The oil is produced by huge oil glands called meibomian glands.  Dry eye is usually caused by inflammation of these glands.  Bacteria enter the glands and metabolize the oil and transform it into a whitest goo, much like cottage cheese.  If you apply pressure to the gland, clear oil should come out.  As the disease progresses the oil goes from clear to milky to cheesy.  This is called meibomianitis.  Finally, the oil becomes plugged and the oil production stops.  Also, as you might imagine, the gooey, milky oil is full of toxins which when spilled into the eye causes inflammation on the cornea, and the tears evaporate quickly so the individual is left with a dry, inflamed cornea.

meibomianitis.jpeg

Meibomianitis

Sometimes the watery layer is missing.  In this case, a drug called Restasis is helpful.  It causes tear cells to multiply and can be amazingly effective. I used to prescribe it often and for some it helped immensely but for most it was ineffective.  

So what to do?

First off, to get quick relief, use an over the counter tear drop, Systane Balance or Systane Ultra are good.  Not only do tear drops provide instant moisture to the eye, they also serve to wash away toxins, which reduces inflammation.  The best tear drops are “preservative free” because preservatives can irritate the cornea, especially with long term use.

But the long-term better course is:

Hot Compresses and Lid Massage to clean out those oil glands !!!

                                                           (recall, I did say it was a boring subject)

 The more fundamental treatment is we need to get to the root of the problem, which is ususally but not always the oil (meibomian) glands.  Heat thins out the cheesy material so that massage, i.e. pressure, can express i.e. squeeze it out.

Hot compress and message/expression:

Apply heat to the lids.  It can be a hot shower on your face, or a hot wash cloth.  Apply heat for a minute or so. Then apply pressure to the lashes because that is where the meibomian glands are.  Apply pressure and hold; the excretions are thick, they ooze, so pressure and time is important.

Do  this every day.  In several weeks, symptoms are likely to improve.

There is another treatment, called LipiFlow.  LipiFlow is a device which your lids fit in like a glove into the treatment device  With the lids held in place, heat and pressure is automatically applied to facilitate the meibomian expression.  I hear that the cost of this device is around $100,000, so I don’t own one.  Duke has one, as does Carolina Eye Associates (Southern Pines); and there are many more locations.

Although expression of the glands is the first line of defense, antibiotics also can play a role.  Doxycycline taken orally is very useful.  Doxycycline, in addition to being antimicrobial, also has anti-inflammatory properties.   It is used in dermatology for the treatment of  ache, and not surprisingly is also used to treat lid disease.  When presented with true cottage cheese or toothpaste like excretions, I prescribe this antibiotic.

Update June 2014

Since really stressing to patients the importance of lid hygiene, I have observed many positive effects.  Even when the patient doesn’t have dry eye per se by having lots of tears, the hot compress/expression treatment improves a host of symptoms.  I have observed less irritation of the cornea, less irritation of the lids themselves, and generally more comfortable eyes.  So I now recommend this treatment be done even without obvious dry eye symptoms.  It just seems to improve everything.  So even if your eyes feel fine now, go a head and hot compress and express, you may feel better but more importantly doing so will prevent problems down the road.  We brush out teeth to prevent oral disease; lid hygiene works the same way.

Punctal Plugs.

Every time we blink, our lids literally pump tears down the drainage system of the eye and into the nose.  So if one’s eyes are dry, then tears are being drained away that we would like to keep.  Simply, these plugs plug the opening to the drainage system (the puncta).  For some these plugs can be very helpful.  They are simple to insert and can be removed. There are also temporary collagen plugs which when inserted will plug the duct for about 3 days; they slowly dissolve on their own. This allow people to experience having their puncta plugged but without the expense of the permanent plugs.  In general plugs are converged by insurance.  


The Physiology of Fat Metabolism, the Abridged Version

Often at the office I am asked about questions of diet.  I found myself repeating the same material over and over again so I have decided to write it all down.  So you want to loose weight?  You want to better control your diabetes?  Read on.  This article is really too long to hold interest for most people, and I know that, but I didn't want to skim over anything.

To understand weight loss and especially diabetes, one needs to know a few things about physiology, the study of how your body works.

Hormones: Hormones are compounds which is secreted by one part of the body which affects other parts of the body.  They regulate things.  Usually they work by acting as a key which inserts into a “lock.”  The lock is called a receptor.  Metabolism is a general term which refers to biological transformation in living things.  So fat metabolism refers to either the making of or burning of fat.  Glucose is the type of sugar in the blood, known as blood sugar.

Food, as defined by containing energy, consists of three sources. There are only three: carbohydrates, proteins, and fats.   All foods regardless of whether it consists of a carb or fat or protein; all food eventually is converted into glucose by the body.  A carbohydrate is basically sugar or starch.   A starch is nothing more than individual sugar molecules linked together in chains.  Sugars are quickly metabolized because they are already in the basic chemical form used by the body.  Potato, rice and corn starch is primarily consists of glucose starch, which means they raise blood sugar the fastest because no conversion is required.  Other starches with different associated sugars are converted by the liver into glucose, which is done relatively quickly.  Fats consist of long carbon chains.  The only difference between a fat and an oil is an oil is a liquid at room temperature whereas a fat is a solid at room temperature.  Fats are converted into the blood sugar relatively slowly with no blood sugar spike.

There is another concept that I think is important.  It is the 1st Law of Thermodynamics.  Although there is a technical definition, the basic law is this:  Energy cannot be created or destroyed, but it can be converted.  So a gallon of gasoline contains a lot of potential energy.  When it is burned in a car, the energy stored in the gas is converted into heat and motion (kinetic energy).  It is converted but it is never destroyed.  This is a simply a physical fact, more on this later.

The key to understanding weight loss or weight gain is understanding the hormone called insulin.  Now it is generally known that insulin lowers blood sugar.  When insulin is secreted by the pancreas or when injected by a needle, the amount of glucose, blood sugar goes down.  It works like this:  Generally, when we eat, the level of glucose in the blood rises,  the body senses this and in response, the pancreas releases insulin.  Insulin travels throughout the body and bathes each cell, be it brain cell, muscle, fat, etc.  Each cell has insulin receptors; the insulin attaches to the receptor, which tells that cell to turn on the glucose pumps, causing that individual cell to pump glucose from the blood into the body of the cell.  In mass, with trillions of cells having their glucose pumps turned on, the glucose is pumped from the  blood and transported into each cell.  Accordingly, the level of glucose in the blood goes down, and the amount of glucose in the cells goes up.

Insulin, however, has another important function.  The amount of glucose in the blood determines how the body metabolizes fat.  Insulin decides, literally, is fat going to be converted into glucose to be metabolized (i.e. “burned”) , or, will fat be produced instead.  This is another unavoidable fact.  It is insulin, along with a hormone called glucagon, which determines fat gain or fat loss.  If insulin is high, fat is being made; if it is low, fat is burned.  This cannot be overstated.  Insulin high then gain weight; insulin low, then losing weight becomes possible.  It’s just that simple.

The process to convert fats or proteins into blood sugar is a relatively long, complicated, slow process.  And whereas all foods are converted into glucose eventually, carbs are converted quickly; fats and proteins are converted slowly.  This means that whereas fat contains a lot of calories, gram for gram, because it is converted to glucose slowly it does not raise blood sugar appreciably, nor do proteins.  The point here is that foods high in calories (i.e. fats) do not necessarily raise blood sugar levels appreciably.  The opposite is true for carbohydrates.  Carbs are converted into blood sugar quickly which can spike the blood sugar.  If high blood sugar then higher insulin.  If higher insulin then weight gain.  It’s just that simple.  Eating carbs equals increased blood sugar which means increased insulin which means fat production.  This is an unfortunate metabolic fact.  Your favorite foods are making you fat because everyone’s favorite foods are carbs, and carbs are addicting.

Insulin Resistance

To thoroughly understand weight loss, one must understand weight gain and the important term, insulin resistance.  When I was growing up, our household had all the junk food.  My parents bought into all the stuff advertised on TV.  We had Ho Ho’s.  We had Twinkies, cookies, cokes.  We had big plates of spaghetti.  We made milk shakes.  I had ice cream constantly.  I loved french fries.  Breakfast often consisted of cereal upon which I added extra sugar.  I was constantly bombarding my body with sugar, which meant my body was constantly cranking out insulin.  As a teenager I remained thin, and if I wanted to lose some weight after the holiday season, all I had to do was just skip the cookies.  Then seemingly over night in my mid 20’s, I was putting on weight and I had to seriously diet, with mixed results.  I had become insulin resistant.  By my mid 30’s, I was in a constant battle over weight; I was running 4 miles several times a week; nothing worked.  What was wrong?   The answer lies in how I ate in my childhood and teen years.  By eating carbs and sugar constantly and mixed with my genetics, my insulin levels were constantly high.   Recall that insulin acts on insulin receptors to pull blood glucose down, well, what happens is the receptors became resistant to my own insulin, ie they just didn’t work.  The insulin receptors had been damaged by constant stimulation of elevated insulin for years on end.  So as one becomes insulin resistant, the pancreas puts out insulin as usual but the receptor just doesn’t respond. So it goes like this: eat food which causes blood sugar levels to rise which causes the pancreas to put out insulin and then ... nothing happens; the blood level does NOT fall as it should.  The body will try to control blood sugar above all else so it responds by cranking out more insulin and perhaps even more until finally the blood sugar falls.  So at this point, the person has normal blood sugar but abnormally high insulin levels.  Recall that insulin causes the body to put on weight.  So the switch had been switched; I was in fat making mode.  When the insulin is high, you are a fat making machine.

So in simple terms, insulin resistance means the person is walking around with elevated insulin levels which causes them to gain weight.  There is another term for a constellation of harmful risk factors for heart disease called Metabolic Syndrome.  It’s very similar to insulin resistance but also includes being overweight, hypertension, large waistline, etc.  To me though insulin resistence is the root of all of it; so if you see metabolic syndrome, think insulin resistence. 

Insulin resistance is directly related to Type II diabetes.  What is type 2 diabetes?  People who have type 2 diabetes are people whose somatic cells are so insulin resistant that simply their pancreas cannot produce enough insulin to pull the blood sugar down.  So insulin resistance and diabetes are one in the same.  It’s all a matter of degree.  Now, technically speaking in the latter course of the disease, the pancreas, trying to churn out more and more insulin, and in combination with diabetic drugs which force the pancreas to produce more and more insulin, burns itself out, and insulin production finally stops.  Now these poor individuals are type 2 and insulin dependent.  At this point diabetes is not reversible.

Insulin resistance also has another negative consequence; unless you understand your disease (I consider insulin resistance a disease) it is very difficult to eat less or skip a meal in order to lose weight.  Why?  Recall that insulin resistance means that the person is in a constant state of elevated insulin (hyperinsulinemia).  When the person stops eating or eats significantly less, the blood sugar falls, but the insulin doesn’t.  This is critical to understand.  When our blood sugar falls, insulin should fall too, but in this case, it doesn’t.  Recall that low insulin stimulates the conversion of fat into glucose and that high insulin turns this system off.  So when the person skips a meal, the blood sugar falls, insulin does not, and the person now experiences low blood sugar (hypoglycemia) because the ability to raise the blood sugar back up to normal has been turned off.  Low blood sugar is not pleasant.  Our muscle cells can burn fats directly, but our brains cannot.  The brain can burn glucose or ketones (ketones are created as a bi-product of fat metabolism), and when its glucose supply is low, alarm bells go off.  The brain is literally starving.  The person may feel jittery; often times anxious, weak, difficulty concentrating, low energy, sometimes panicky and hungry.  Low blood sugar stimulates hunger.  So the person, desperate to feel better, is forced to eat, and they eat carbs in order to raise their blood sugar back up.  Ahhhh, that’s better.   This is why people get stuck in a pattern of eating all the time; if they try to eat less, all these symptoms appear, forcing them to eat more, even though they are trying to eat less.  And over time, they equate eating carbs with pleasure so they don’t even try anymore.   I had a patient once who was complaining about her weight.  “Well,” I said stupidly, “try skipping a meal once a day.”  She became angry, literally angry, exclaiming, “I CANNOT SKIP A MEAL!”  Apparently she tried it, and the symptoms were just too overwhelming.  I dropped the subject.  Dear Reader, if you can't skip a meal without feeling anxious or panicky or overwhelmed by whatever symptoms, that should be a big clue for you that something is seriously wrong.

There are different degrees of insulin resistance of course, severe or mild.  If you are simply gaining weight and can skip a meal without too much distress then I guess you’re mild.  If you get the jitters, likely moderate; if you are labeled “pre-diabetic” then more severe.  Regardless, whether mild or severe, the good news is insulin resistance is reversible.  But it isn’t easy.  

Oh before I go on, I should point out one more thing.  If you’ve ever read about the science of dieting, and especially if the information was written 20 years ago or so, you would have learned that when people lose weight, a large percentage of the weight they lose is muscle mass.  I don’t remember the numbers, but they are big, like for every 10 lbs of weight loss, say, 3 lbs of it is muscle and maybe 7 lbs is fat.  How depressing!  Before I knew what I was doing and I simply starved myself to lose weight, I noticed that I looked worse as I lost weight and looked better when being so miserable that I started eating again and started to gain weight.  What was happening was that I was losing my muscle on my arms and chest but kept my belly fat so I looked more pear shaped on the way down.  When I gave up and started eating again, I was able to put muscle back on and actually looked better overall, chubby but better.  And it didn’t make sense to me.  Lions and predators go without food for days; they don’t burn their muscle before fat, the very means by which to acquire more food; that would lessen the chances for survival.  But humans do.  What gives?  The answer is, once more the disease state, insulin resistance.   So yet again, you eat less, the blood sugar falls; insulin should fall but it doesn’t; fat is not burned fast enough to supply the brain with adequate glucose, but our intrepid dieter perseveres!  What is the body to do?  Answer, the body desperate for glucose literally digests muscle into glucose.  Rather than burn fat as the body should, muscle is converted into blood sugar.   (Don’t believe me?  Look it up.)  If insulin is low, then the body correctly burns fat instead of muscle.  So the key to burning fat and not muscle is to keep insulin normal to low.

How to lose weight

You must go on a low carb diet.  You might ask, “Why didn’t you just say so in the first place?”  The answer is unless you really understand your physiology and the insulin connection, you won’t be presented with the choice of really knowing what to do.  Also the media and advertisements bombard the population with bogus material and outright lies.  If you really understand what is going on, then you can better determine fact from fiction.  Finally, you have the knowledge to make choices and understand them.  Losing weight becomes a choice, and for once, you actually know why.  Losing weight becomes a choice without suffering.  It’s one thing to give up a pleasure, it’s another to suffer.  To lose weight you give up a pleasure, but you don’t suffer.  That’s a huge difference.  And for many it’s not worth it.  That’s ok, but for me it means that no one can say “I can’t!”  Now they can only say, “I choose not to.”

Lose Weight by eating low carb.

If you want to, you can just go low carb from the get go.  What you are really doing is substituting proteins and fats for fuel instead of carbs.  It goes like this.  You eat a meal; it contains protein, but little carbs.  As a result, the blood sugar does not spike; the insulin does not spike, your blood sugar stabilizes.  Without feeding yourself sugar, the blood sugar will fall, but because you have eating protein, it won’t go too low.  If you are insulin resistant, you might not be able to burn your fat yet, but you can burn that dietary protein, saving your own muscle.  As your blood sugar drops, eventually, your insulin will fall in turn.  Once the insulin is low enough you start burning fat very quickly.  Even so stopping eating sugar and carbs is difficult because.

Sugar is Addicting

It may seem wild and implausible, but sugar is physically addicting.  In our brains we have “pleasure centers” or “reward centers.”  When these centers are stimulated; we feel good.  Unfortunately, when we eat sugar the area of our brain called the VTA (ventral tegmental area) is stimulated; this leads to dopamine produced and the nucleus accumbens is stimulated, and when that happens, we experience pleasure.  This is the site of the brain where addition occurs.  This is the same area of the brain that cocaine and amphetamines stimulate.   Using PET scan studies, scientists can see which areas of the brain become active when different stimulai are introduced.  You guessed it; sugar lights up the Nucleus Accumbens.  

Fructose is the Worst form of Sugar

Glucose will spike a blood sugar, but fructose is FAR worse for you in the long term.  Fructose is in everything.  It is the sugar of fruits.  It is cane sugar.  It is in sodas in the form of high fructose corn syrup.  When high fructose corn syrup was introduced in 1983, obsesity skyrocketed.  Fructose is metabolized as a fat; 30% ends up as fat.  And, fructose is a hepatotoxin, meaning it is a toxin to the liver, just as alcohol is.  (This is why some overweight people get the disease state "fatty liver"; alcohol can cause it but so can excessive sugar.)  Translation? Stop all sodas. Stop drinking fruit juice.  I am not saying you should not eat fruit however; I am saying eat the fruit but not the juice.  Fruit juice is basically sugar water.  Fruit itself has fiber in it; you have to chew it etc.  You would not eat 5 oranges in one sitting would you?  But that’s what you are doing when you drink a glass of juice.  Drinking orange juice in the morning was a marketing triumph, but it is BAD for you. Period.  Fructose has been directly implicated in metabolic syndrome (insulin resistance), meaning it makes you fat, leads to heart disease and can damage your liver.

Baby Steps

Some people are so insulin resistant that their bodies have literally forgotten how to burn fat and, or they are addicted to sugar.  For them, eating low carb even in the presence of protein causes them to suffer all the symptoms of low blood sugar.  They can’t seem to do it.  What do they do?  Answer: start a food diary.  Simply write down everything you eat for say a week.  Don’t lie to yourself.  Then you figure out how many carbs you eat per day.  Let’s say you take in 500 or 600 carbs a day, doesn’t matter.  Once you know what you are doing, then you know where to begin.  Simply cut your carbs from whence you came.   Number one is sodas.  Especially cut sugary drinks, including orange juice and sweet tea.  This isn’t easy but you must break the addiction.  Do that a week then cut more until you are in fact low carb, say 50 to 80 carbs a day.  That’s low.  Nutritionist will say you need an x amount of carb per day; this is bogus.  You goal is to eat high nutritious but low carb meals; this means lots of vegetables and meats and fish.  I won’t go into which foods to eat; there is mountains of material of low carb out there.   Also low carb does not mean you can eat in any quantity.  A friend of mine was over one day; he was on a low carb diet and was complaining that it wasn’t working any more, but while we were talking, he ate a whole jar of planters peanuts.  The whole thing! Friends, you just can’t eat massive amounts of food and lose weight, even low carb; he probably swallowed 2000 calories in one sitting.   

Understanding Ketosis

When eating low carb after years of eating high carb, you will burn fat very quickly but you will be craving and going through withdrawel. So at first, if asked, you would say you feel fine, your energy levels are up, you are not hungry, but you would die for a piece of bread.  You are craving.  Expect it.  You are missing that happy feeling when your brain is bathed in sugar.  It will pass.  Now, at first, when starting low carb for the first time, if you are strict, you will be burning fat VERY quickly, so quickly that you will enter ketosis.  What is ketosis?  When fat is burned, it produces something called a ketone body.  A ketone body has caloric value; i.e. it contains calories.  Interestingly, the brain besides using glucose as fuel happily burns these ketones.  Since normally fat is burned slowly, these ketones are recycled and in turn themselves burned.  But when initiating low carb, fat is being burned so quickly and the associated ketones are being produced so fast that they cannot be recycled; instead they are discarded, via  breath and urine.  Literally you are urinating calories away, and you have bad breath.  Ketosis is normal and is as natural as sweating.  (I say this because I read a diet article, likely backed by the ag industry, attemping to convince readers that low carb was bad for you because of the dreaded ketosis. Nonesense.)  So, for the first several months, you will lose weight extremely quickly.  The cravings subside and you may think you have reached diet nirvana.  But like most things in life, it can’t go on forever.  The body will adjust.  We, as humans, are not designed to throw calories away; we are designed to survive.  So the metabolism adjusts again.  One day, low carb will cease to cause automatic weight loss because the ketosis will stop.  At this point, you must, if you want to lose weight further, you must actually restrict calorie intake.    This is another unfortunate fact.  Before we leave ketosis, I should mention ketoacidosis for clarification.  Ketosis is normal and likely all people enter ketosis without knowing it; ketoacidosis on the other hand is a life threatening condition.  The two should not be confused.  Ketoacidosis occurs when a diabetic patient’s insulin falls so low that the body is thrown into burning fat so fast that the ketones are produced to such an extent that the pH balance of the blood becomes acidic.  This is a medical emergency and has nothing to do with the normal ketosis.

Calorie Restriction

Did you know that if you overfeed a rat, it doesn’t gain weight?  (There are fat rats, but these are genetic mutants.)  Why not?  Because the rat has the ability to raise its body temperature to shed excess calories.  We humans do not have this ability.  If we intake more calories than necessary then we gain weight, even while eating low carb.  And of course, if we do not eat enough calories then we lose weight by burning our fat reserves (or muscle).  So ultimately, reduction of fat requires calorie restriction.  You might ask, then what’s the point of low carb?  By now you should know this, but I think I need to spell it out.  Without low carb, you would remain insulin resistant and when you attempted calorie restriction, your blood sugar would go too low, you would not burn fat, you would burn your muscle instead and you would be miserable and give up.  The necessity of low carb is that your body will have learned how to burn fat again, so that when you give up a meal, you quickly switch over to converting fat into glucose so that you don’t experience low blood sugar symptoms.  Also, by burning fat you produce ketones which not only helps you lose weight quickly but also provides the brain with an ample energy source.

Exercise

What about exercise?  Is it important to lose weight?  The answer is yes. Exercise is important, but few people understand why.  It turns out an average man running a mile only burns about 100 calories.  There are 3300 calories in a pound of fat.  So to run off a pound of fat, he would have to run 33 miles!  And, that assumes he doesn’t pig out at the end of the run, which is unlikely.  If you run 2 miles or so, a more realistic situation, you've earned yourself one Ruby Tuesdays’s large crab cake (sadly as of 2014 crab cakes are not longer offered at Ruby’s and they took away the  guacamole too, very annoying) which is good but unless you limit calorie intake, exercise just cant make up for the ingested calories. This explains why people kill themselves at the gym and never lose weight.  Unless you are a farmer of days of old when they walked behind a mule all day, you can’t exercise your fat loss away; at least and hold on to your day job at the office.  The role of exercise is that it drops insulin.  In other words, when you exercise, your insulin falls; lower insulin means faster fat conversion which mean faster weight loss.  Therefore the combination of exercise, low carb, and calorie restriction is the true “fat buster.”  Not fun, but that’s the way it is.  Off subject but exercise improves everything: mood, memory, bones, immune system; you name it; exercise improves it. Does a low carb diet enhance athletic performance?  Answer: No.  Athletes need carbohydrate for quick energy, especially endurance exercises.  Also, contrary to popular opinion, you really don’t need to eat after exercise; no, your muscles will not waste away.  This has been thoroughly studied.  Now if you are a professional body builder or a professional athelete, and want to max your strength to the max, that’s one thing, but for the rest of us, we don’t need to eat after exercise.  In fact, studies show that fasting up to 3 days does not waste muscle, IF, you engage in resistence training, ie lift weights.  The body preserves the muscle you use, which makes sense because there was a time thousands of years ago when we went without food for days.  We would not have survived had our bodies burned muscle before fat.  

And one more bit of advice: Get some sleep.  People who lack sleep typically eat more in an attempt to increase their energy levels.  Also, lack of sleep is a major stressor on the body.  As the result of stress your body will crank out cortisol, the major stress hormone.  Cortisol makes your blood sugar increase. So: increased stress leads to increased cortisol which leads to increased blood sugar which increases your insulin, and which leads to weight gain.

Finally, at the beginning of “my little blog,” I mentioned the 1st Law of Thermodynamics, that energy can neither be created nor destroyed.  As stated earlier, this is simply a fact.  Energy has to go somewhere; it can’t go nowhere.  Which means fat can’t melt.  I say this because I am constantly dismayed by the horrible advice given in magazines about the next miracle diet.  I was on yahoo the other day and read about how to lose cellulite.  Oh God!  It contained the usual nonsense.  “Eat whole grains … " eat so many portions of this or that.  She would have you wrap you legs in some sort of seaweed.   Then there’s the next new discovery about some magical herb that when taken and without dieting causes one to shed dozens of pounds.  Or the stuff that you sprinkle on your food and lo’ the pounds melt away! (Update March 2014: the FDA put an end to this company making false, misleading claims. Hmmm!)  Ladies and gentlemen, one must ask “Where did the fat go?”  Was it burned?  Ok, burned into what?  If 10 pounds were lost, where did the 33,000 calories go?  Or where did the fat move to?  You can’t urinate fat away; that would be quite odd.  You can’t defecate it out.   No.  It’s either burned directly (muscles can do this; brain cannot) or it’s transported to the liver where it is converted into glucose.   If it’s converted to glucose, then, oh yea, your blood sugar has to go up (because the sugar has to go somewhere), then your insulin goes up, then your fat production increases, and it ends up right back where it started from in the first place, on your thighs. You might say the muscles do it.  But if the muscles are not expending the energy by moving and performing work, then where does all that energy go?  It has to go somewhere.  Not by shedding heat like the rats; we can’t do this.  (Technically speaking, we do produce heat to maintain our body temperature via something called brown fat, but if we were to lose weight this way, we would all be running fevers, but we don’t because we can’t.)  As Margaret Thatcher once said, “Facts, facts, stubborn facts that’s the rub…”  In other words, it is what it is.  When the advertisment says "clinically proven" you should think it's a lie.  

The only way an herb or medication can work is if it causes the individual to eat less, which is possible.  That’s why research is being done on satiety, the feeling of feeling full and not needing to eat.  There are hormones which produce a feeling of feeling full and content.  Research is being done to emulate these, but until they do, you just have to do it on your own.  Diet (speed) pills work by giving the person so much energy that they eat less and are likely simply more active.  The Fen Fen drug, which was taken off the market because it killed people, did work.  It worked by taking away people’s appetite; they ate less.  There are fat blockers and then there is that fake fat that can’t be digested.  But, 1st Law remember.  Fat contains a lot of calories; what happens to it?  Answer: it is converted into methane by bacteria in the gut.  Once more, energy is conserved, in this case by converting fat into methane gas which is, well, expelled and not always in a pleasant manner.   

When if comes to losing weight, I think you should remember that all those women’s and men’s magazines and TV shows are driven by money.  I don’t care if Dr. Oz isn’t financially directly compensated by the products he advocates; he’s in the bizz.  He needs an audience, to attract advertisers, to sell products.  He doesn’t care if you get the products he talks about or not; he just wants you to watch his show so that you buy his advertisers products.  And, watch you do.  [Update January 2015: the FDA just fined the makers of White Bean extract 9 million dollars for false advertising and fraud for their product endorsed by and promoted by Dr. Oz as a miracle weight loss product.] The magazines must sell so that advertisers will spend money so that you will buy their products.  There are billions of dollars to be made by selling hope.  Are they willing to lie?  Yes.  I’m sorry.  The science is done.  “Men’s Health” magazine front cover is almost ALWAYS the same, “How to get those ripped abs!”  Apparently, men want ripped abs, well so do I; the problem is you can’t spot reduce.  So if you work your abdominal muscles, they do get stronger but the overlying fat remains unchanged because ... it has nowhere to go.  Men, ripped abs is a function of percent body fat. Period.  You want ripped abs?  Get down to about 13 percent body fat.  End of story, but they won’t tell you that because if they do, there isn’t much more to say.  Women, want less cellulite?  Well, you can’t make it go away entirely because it represents fat pockets trapped in connective tissue, but you can reduce it by lowering body fat percentage.  Wrapping your legs in sea weed is, well frankly, idiotic.  The point here is that you can’t trust magazines for good health advice because if the magazine ran articles stating that protein bars have too many carbs or that whole grains are not good for you, then advertisers would stop putting ads in the magazines.  The information is tainted by the money of advertising.

My Editorial Rant   (you can skip the next paragraph if you want to)

I would like to close by saying Dr. Atkins was right.  I just have a need to defend him.  He might not have gotten everything exactly right, but he was primarily right.  He was belittled, ridiculed, called a quack, suffered insults etc.  Only now years later is the medical community finally recognizing the dangers of the low fat diet, i.e. obesity and diabetes and the benefits of a low carb diet. The medical community still doesn't understand the dangers of eating grains yet, but eventually they will.  I watched 60 Minutes TV show where they highlighted research done on the west coast.  It was a beautiful study where participants were fed a low carb diet of meats and veggies in a controlled setting; blood work was done with whatever associated health markers were measured.  Then these same volunteers where put on a high carb diet of pasta and sugary drinks, etc.  Blood work revealed their health markers went down.  The conclusion?  Sugar is bad for you.  Holy cow!  We’ve know this for ages.  News?  No offense, but the medical community is the last to know.  Years ago, I couseled my diabetic patients to go low carb.  At the time, they were advised to go low fat.  I explained, "Well, if you don't eat fat, then that limits your meats, and that only leaves you starches, the very food which raises your blood sugar."   I told them I knew I didn't have a nutrition degree and that I am only a little eye doctor in North Carolina but that the advice they were receiving from their physician or nutritionist was wrong.  I annoyed a physican or two for my meddling with this advise.   But, I was right, and they were wrong.  I was listening to an interview on NPR where a researcher was looking at low carb vs. high carbs diets and concluded that low card was safer and better.  The interviewer then asked, “So Dr. Atkins was right?”  The guy hesitated and side tracked the question; he just couldn’t admit it.  Shame on him!  Dr. Atkins was right, but the researcher was too much a coward to admit it.   Atkins didn't advocate eating nothing but meat by the way.  And to this day, people lie about him.  Why?  I don’t know.  The lie is he died a great big obese man of a heart attack.  Wrong.  He was thin and in his eighties and was actively working at his clinic in New York.  He slipped on ice and was killed when his head struck the curb.   I mean if the man was right, he was right.  A little intellectual honesty is deserved here.

This blog is not the end all of nutrition and is not meant to be.  It merely explains the physiology of fat and insulin resistance.  It didn’t delve into various types of beneficial fats or oil, or nutritional products or the role of inflammation to produce disease.   Research is being done on gut flora affecting fat gain or loss.  Who knew?  I made reference to sugar being highly addictive but stopped there.  There is a lot to know and learn, but this blog entry is way too long anyway.  I hope is a good start for you the reader, as you, I hope, take responsibility for your health.  Your body truly is your most precious possession; I hope you have the courage and purpose to take care of it. 


“New ideas pass through three periods: 1) It can’t be done. 2) It probably can be done, but it’s not worth doing. 3) I knew it was a good idea all along!”

                                                                        Arthur C. Clarke

 So, so true.


Frequently Asked Question:

Q. Can i eat brown rice instead of white rice rice?  (The questioner pleading for an out to the harsh realities of giving up his or her favorite foods).  Answer: No. Rice is rice.  They have the same glycemic index.

Q. Can I eat whole wheat bread?  Answer: Not and be low carb, no.  Although fiber does slow digestion down a little, it can't make up for a person chowing down on a lot of bread.  You must look at the label and see how many carbs it is.  Besides grains are not good for you.  (If enterested in grains, read the best selling book "Grain Brain" by David Perlmutter, MD)

Q. Is sweet potato better than white potato?  Answer: Yes.  It contains roughly half the carbs that white potatoes do.

Q. Is it true that if you skip breakfast that your metabolism slows?  Answer: No.  Studies indicate that eating a breakfast does not help lose weight.  In fact skipping breakfast might be beneficial because doing so helps stabalize blood sugar longer (i.e. less insulin).  Also if you eat a carb laden breakfast, you'll tend to be hungrier earlier in the morning and therefore tend to snack more.

Q. Is it true fasting or calorie restricted diets slow metabolism?  Answer: No.  This has been thoroughly researched; calorie restriction does not slow metabolism.  Starvation does, but if you are 10 lbs overweight then by definition you are not starving.  Fasting drops insulin far more than a low carb diet does, and fasting turns on a system call autophage which is basically your body being put in “clean up” mode.  Eating turns this system off.  Simply, our bodies were not designed to have something in our stomachs 24-7 for years on end.  Being well fed is not the same as being constantly fed, a modern phenominon.

Ok, I’m done.  If you would like to read more about this subject. Here is my recommended reading list.

"The Zone Diet" by Barry Sears. This basically talks about the same stuff I did but in more detail.  It’s boring but good.  He has a wacky confusing portion sizing, but he explains the science well.  Also it explains the benefits of fish oil and something called eicosanoids.  He also has a book, "The Age-Free Zone" which reviews the various theories of aging.

"Eat Stop Eat", an e-book which can be downloaded.  It reviews much of the scientific research done on humans fasting with references to the research.  It changed my eating patterns, as now I am not afraid to stop eating as I once was.   Turns out fasting is good for you.  Link: www.eatstopeat.com

The web site link: www.mercola.com.  It’s free and he nicely presents research being done on dieting and health.

The app “My Fitness Pal” available online or on a smart phone is basically a food diary.  It is easy to use and is useful to learn portion sizes.  

“Grain Brain” by David Perlmutter, MD.  Dr. Perlmutter explains the role of sugar and grains and a possible link to Alzheimer’s Disease.

I invested in a food scale so that I could learn for example, what is 6 oz of steak anyway?  

Contact Lens Complications

Serious Corneal Complications Associated with Contact Lenses

The most serious contact lens complication is a central corneal ulcer.  A corneal ulcer involves a bacterial infection of the eye in which the bacterium penetrates the protective outer layer of the eye (the epithelium).  Few bacteria can penetrate an intact epithelium but when this happens the bacteria can enter the the interior of the cornea (stroma), producing a crater, like a pot hole, in the cornea.  This produces scarring and therefore vision loss.  


corneal-ulcer


This is a stock image and not one of my patients.  It looks fungal to me.

Notice with whips strands emanating from the central lesion. This patient will have permanent vision loss.


Rarely, the bacteria manages to eat all the way through and into the eye; when this happens, it’s usual all over.  You’ve lost an eye.  As of this writing, in all my years as a eye doctor, every corneal ulcer I’ve seen, except for one, (and by the way, a corneal ulcer can’t be missed) occurred with the patients wearing contact lenses.  So this brings up some obvious questions.  What can be done to reduce the risk of getting this severe, vision threatening disease?  And, do some brands of contacts afford increased safety for ulcers?  The most basic answer is to not wear contacts at all, but that’s no fun.  So what else can be done?  Answer:  Don’t sleep in your contacts.  Or if you do, don’t sleep in them often.  Studies show a direct relationship between the number of consecutive days of wearing contacts and the risk of an ulcer.  So removing nightly is best, weekly is a little riskier and monthly is even more risky.  Wearing your contacts non stop for more than a month is quite frankly kinda nutty.  Many people do it and don’t get ulcers, but it’s risky.  Complicating all this is the fact that there are two brands of contact lenses approved by the FDA for 30 day continuous wear.  These are the Ciba Air Optix Night and Day and the Baush and Lomb Purevision.  These are made from a class of contact lens material called a silicone hydrogels.  Silicone hydrogels provide 5 or 6 times the oxygen to the cornea that the older materials do.  Both these contacts are excellent contacts; with the added oxygen, there is less redness of and eye and reduced or no corneal swelling.  They’re great lenses, but: they don’t reduce the risk for corneal ulcers.  And the reason they do not I suppose is that corneal ulcers are not caused by lack of oxygen.  So the main point here is that one should not be lulled into believing that just because the contact lens is FDA approved, that it’s perfectly safe, because it’s not.  Of course many, many of my patients sleep in their contact, and that’s fine.  It’s just safer if they didn’t.  So the answer is regardless of brand of contact lens, to lower risk, don't sleep in your contacts

Another type of ulcer is called a marginal ulcer.  This ulcer is located close to the edge of the cornea and therefore has less risk of permanent vision loss.  The way this works is this:  We all have staph bacteria growing on us, and this “normal flora” secretes toxins.  The toxins get trapped under the contact lens and or gets stuck to the contact lens and are held against the cornea.  This causes an immune response which causes white, inflammatory cells to migrate into the cornea where they coalesce  and produce a white dot.  The white dot represents millions of white cells so many that they can be seen with the naked eye.  The problem is white cells, when angered, secrete digestive enzymes which literally digest the cornea.  So the white inflammatory cells are fighting something which really isn’t there.  Treatment is a combination of antibiotics and topical steroids.  Although usually not vision threatening, the condition is painful and is no fun.  If this happens, you are doing something wrong.  Remove your contacts at night.  Use a disinfectant solution.  Use good hygiene and throw away your contacts according to your doctor’s instructions.

                            <<<<<<<  WASH BY RUBBING YOUR CONTACT LENS CASE ONCE A WEEK >>>>>>>

Why wash your case?  It looks clean?  Well, it turns out that bacteria can produce a “biofilm”.  Essentially, the bacteria produce a shield-like film under which the bacteria live.  The biofilm reduces the amount of disinfectant solution reaching the bacteria underneath.  So even though the case looks clean, it still has bacteria in it.  A study used a blue stain which stains bacteria.   The stain was applied to a new case: case remains white.  Then the stain was applied one month out: it was pale blue.  Then the stain was  applied to a case 3 months out; it was noticably blue.  Then again at 6 months out; the case looked like it was painted with blue.  The images were striking.  This might explain why some of my contact lens patients seem to be prone to infections.  Washing your case by rubbing it will strip off the biofilm, reducing the risk of infection.   


Diabetic Retinopathy

Several years back a diabetic man walks in my door.  He had been diabetic for years but hadn't taken his meds for years.  Deciding he didn't want to die, he started taking his medications again and came in for an eye examination. When I dilated him and looked into his eyes, this is what I saw:

Sutton James labels


Ok, this is a great photo of diabetic retinopathy.  He's got it all.  Look just below the label neovascularization.  You will see some squiggly blood vessles.  These are "new" blood vessels which have grown in an effort to supply the retina with more oxygen.  Unfortunately, this newly grown blood vessels leak fluid which enters the retina and causes the retina to swell.  Our retinas are composed of neurons (brain cells) so when the retina swells these connections between neurons are torn apart which of course leads to blindness.  Left untreated, eventually, the blood vessels will break and bleed and ultimatley scar down.  The specks just below that are exudate; exudates are crystaized deposits caused by the fluid in the retina.  Fluid enters the retina which elevated the photoreceptors off of the blood supply of the eye (choroid), eventually without a good blood supply, the photoreceptors wither and die.   The cotton wool spot, the white puffy areas, are produced by hypoxia (lack of oxygen).  It turns out that neurons have little organelles and travel up and down the length of the cell.  Well, it takes energy to transport and if an area has little or no oxygen, the transport system stops.  The white puffy areas represent a log jam of intracellular material which in mass have gotton stuck and can be seen as these puffy spots. This man's vision was headed south.

Naturally, I referred him to a retina specialist for treatment. I hadn't seen him for a years, but eventually he came back to my office.  When I dilated him, this is what I saw:


sutton keel hem


Now, looks bad doesn't it?  But actually it's a vast improvement.  The little circular whitish dots are laser burns which the retina specialist laid down.  Where a laser burn is, the retina is dead.  A dead retina doesn't use oxygen.  So a treated retina doesn't need as much oxygen, leaving more oxygen available for the remainder.  Notice the neovascularization is receding.  The exudates are drying up.  The cotton wool is less pronounced.  The large hemorrhage is called a keel boat hemorrhage because of its shape.  This occurred because the newly grown blood vessels, while vastly improved, were still present, and an old one broke.  This eventually will clear.

As of this writing, this patient is seeing very well, considering what his eyes went through.

Edit: December 13, 2016. Sadly my friend passed away.  His zany humor will be missed.


© Richard Randolph 2012