Letter from the Publisher

December 2016

Generation Zika

Reading about the connection between a mosquito transmitting the Zika virus and microcephalic babies in Brazil last Christmas seemed like some weird front-page story from Star magazine. Unfortunately, while the story was bizarre, the reports continued to appear in the Wall Street Journal, the New York Times, and NPR. Despite disbelief that this virus alone could be responsible for causing an “epidemic” of deformed infants, that epidemiology remains the most persuasive cause of microcephaly. Over the course of the past 9 months, the Aedes aegypti mosquito thought to be the primary vector for transmitting Zika is dramatically increasing geographically. Zika testing in Puerto Rico has determined that thousands of women who are pregnant or of childbearing age are now infected. The Zika-carrying mosquito has turned up in neighborhoods of Miami and much of the Caribbean. Despite efforts to eradicate mosquitoes, their population has hardly been impacted. Although some public health authorities have discussed the possibility of breeding a “neutered” male as a means of “sterilizing” Aedes mosquitoes, no community has embarked on such a program. In other words, the likelihood that Zika infection will dramatically increase in 2017 is very high.

While the media focus on efforts taken to control the mosquito and worry about pregnant women acquiring Zika, little attention is being paid to the microcephalic children. Early reports indicate that the infants who have Zika-based microcephaly differ neurologically from non-Zika microcephaly cases. The cost of specialty care and medical treatment for each patient is estimated to exceed $10 million over a lifetime. However, the possibility that a Zika-infected baby who does not develop microcephaly will develop instead a major neurologic or psychiatric disorder is only beginning to be appreciated. A higher prevalence among Zika infants of autism, ADHD, other behavioral disorders, as well as psychiatric disorders such as schizophrenia and bipolar disorder, is very worrisome. Furthermore, Zika-exposed infants are expected to face a greater frequency of Parkinson’s and Alzheimer’s as adults. Because the virus targets neuron stem cells, the potential for neurologic degeneration is vastly increased.

To date there is no effective drug agent that treats Zika virus. However, even if it is controlled, there is little likelihood that an infant would be able to reverse the damage. The best strategy for approaching Zika is the development of a vaccine program. Despite the worry about potential adverse effects from vaccination, benefits greatly outweigh the risks in this situation. Effective vaccine programs have been developed for yellow fever and Japanese encephalitis, viruses similar to Zika. A vaccine for Zika should be relatively inexpensive to develop and implement compared to the treatment of neurologically impaired Generation Zika.¹

The Ultimate Anti-Aging Medicine: Bariatric Surgery

While participating at a pharmacology course at the University of Washington Medical School a few years back, I was not shocked to hear faculty speakers berate nutritional therapies, vitamin and mineral supplements, and unapproved treatments. At a certain point, discussion turned to weight management and dieting. There was little disagreement among the clinicians that obesity and metabolic syndrome were rampant and patients needed to be encouraged to partake in exercise and dietary programs. Indeed, the attitude was emphatic that obese patients had little justification for medical treatment unaccompanied by vigorous dieting. Still, the course faculty recognized that long-term dieting was fraught with failure and time-consuming daily exercise unlikely to be complied with. They were not impressed with the panoply of drugs that had been used in the past to assist weight loss, and newer drug agents were not enthusiastically supported. Then one of the clinicians broached the use of human chorionic gonadotropin (HCG,), accompanied by a very low-calorie diet. Here there was a moment of sarcastic repartee by the professor dismissing the huckster aspect of doctors prescribing HCG as a bariatric treatment. With little but anecdotal data, he stated that HCG was useless in weight loss and whatever loss occurred was achieved by “starvation.” Since the patient would be unable to maintain the calorie deprivation, any weight lost would be rapidly regained.

Listening to this degradation of HCG, as a member of the audience I felt a mixture of outrage and a need to wring the professor’s neck. Of course, I did not want to “out” myself as an HCG doctor and kept quiet; there is little to be gained in such a setting by identifying oneself as a “quack.” My experience with injectable HCG and low-calorie diet has been remarkable. In fact, it has been one of the more gratifying treatment protocols that I have advised to patients. First, HCG injectable is a prescription that is easy to administer, accompanied by no side effects, and relatively inexpensive. Given that this is the hormone of pregnancy, it would make sense that there are no adverse effects. HCG is administered in relatively low doses, approximately 200 IU s.q. daily, less than 5% of what circulates in the pregnant woman. The patient is asked to eat two meals daily of approximately 250 calories each consisting of about 4 ounces of animal protein, a vegetable, and small fruit portion. HCG appears to modify the ghrelin response on brain receptors, dramatically decreasing hunger. Patients need little encouragement to adapt to the HCG injections and low-calorie diets. After 6 weeks of HCG injections, the program requires for a modest increase in calories without HCG for the next 6 weeks. It is not unexpected in 12 weeks to lose 20 to 30 pounds. Ideally, patients maintain a prudent diet of approximately 1200 to 1500 calories thereafter and there is long-term persistent weight loss. Of course, if the patient were to return to former dietary habits, it would not be unexpected to regain weight over the ensuing year. Certainly, many individuals do not want to be confined to a low-calorie diet; without compliance the HCG program would fail. However, for those individuals who are motivated, the HCG protocol not only provides modest and ongoing weight loss but can be repeated, and weight loss can be maintained. Compared with other weight loss programs, the HCG diet has been more helpful than other approaches. Hence, I was dismissive of the faculty member’s critique of the HCG diet.

Admittedly, there are many who are not willing to abide by HCG injections and diet. For those who are obese, the opportunity to do a surgical procedure to successfully manage the condition is very attractive. Gastric lap-band surgery has become the primary bariatric surgery over the past two decades. Governor Chris Christie had modest results undergoing lap-band surgery two years earlier. The surgery is done easily in outpatient surgery with a laparoscopic approach. While the concept is sound, limiting food ingestion by impeding the stomach opening, there remains a need to follow a prudent reduction in calories. Additionally, the band is subject to breaking, mitigating any benefit from the procedure. For those who have done that surgery, three other bariatric surgery procedures have been perfected: sleeve gastrectomy, gastric bypass, and biliopancreatic diversion, all major procedures with attendant risks but likely long-term benefit. In a article in the New Yorker, a physician reporter follows an obese individual having a sleeve gastrectomy at Beth Israel Medical Center in New York City.²

In 1995 bariatric surgeons did approximately 20,000 surgeries to treat obesity; in 2014, 200,000 procedures were done, and the number is stabilizing. William Anabnet, MD, at Beth Israel is one of the surgeons who developed the sleeve gastrectomy. It is not unusual for this procedure to follow a failed lap-band surgery. Hence, the initial part of sleeve gastrectomy is cleaning up the adhesions residual from the earlier surgery. Bariatric surgery is now performed through laparoscopic robotic procedures –surgeons appear to be operating video-game joysticks that control robotic arms cutting and stapling a majority of the stomach until it has been reduced to a “sleeve”-like tube. The reduced stomach lessens the body of the organ, inhibiting the amount of food ingested. Additionally, the gastric tissue gland cells responsible for producing ghrelin, the hunger hormone, are dramatically reduced. The outpatient procedure is very straightforward, and patients immediately experience a change in their eating habits. Weight loss achieved through the procedure is usually half of the patient’s excess weight. Not unexpectedly, many patients achieve major improvements in diabetes and metabolic syndrome, and sleep apnea, as well as related improvements in their cardiovascular status. Given the overwhelmingly positive benefits, it is not surprising that the procedure is covered by most insurance companies and Medicaid; surgical procedures to eliminate excess skin brought about by major weight loss are considered cosmetic and not covered by insurance.

Given the obesity epidemic in the US, bariatric surgery should be considered an important part of anti-aging medicine, since the surgery is very successful and highly likely to provide long-lasting improvements in metabolic and cardiovascular status.

British National Health Service Defunds Reimbursement for Homeopathic Prescriptions

On Oct. 6, 2016, the National Health Service defunded reimbursement for homeopathic prescriptions in the northern part of the UK. Only London and Bristol continue to fund homeopathic prescriptions.³ The defunding was ordered by the Wirral Clinical Commissioning Group, a local governing body for the NHS. The British Humanist Association has campaigned for many years for the NHS to defund homeopathy; its president cheered the cessation of homeopathic funding. Because the NHS is under pressure to slash budgets for medical treatment, there has been an outcry by the British Humanist Association to allocate the $10 million spent on homeopathic prescriptions for conventional medical care and medication. Additionally, the Good Thinking Society has also called for defunding homeopathy. The society stated that “by reinvesting these funds in patient care, staff time, and the availability of proven medicines and treatments, commissioning groups across the North of England have set a very strong example to the rest of the country by favouring evidence-based medicine over woo, superstition, and snake oil.”

On the day after this decision was rendered, I found myself reading the comments of anti-homeopathic advocates on social media. When I attempted to argue about the evidence and virtues of homeopathy with these individuals, I was scorned, belittled, dismissed, and ultimately called an “arse.” Of course, debating these people was futile, and it was clear that, despite their emphatic positions, not a one had the slightest experience with either using or researching homeopathy.

In this issue Dana Ullman, MPH, CCH, tackles the great divide that exists between the homeopathy oppositionists and proponents. Unfortunately, that divide is as wide as the Grand Canyon, and the oppositionists offer no open-mindedness to consider the evidence. Of particular concern is the position that Wikipedia takes on homeopathic medicine. According to the Washington Post, the Wikipedia articles on homeopathy and Jesus Christ are considered its two most controversial entries. Ullman examines, indeed dissects, the Wikipedia article on homeopathy, critiquing its abject bias. The Wikipedia article conveniently includes negative meta-analyses about homeopathy but ignores positive ones. Wikipedia includes negative non-peer-reviewed magazine articles about homeopathy but refuses to cite pro-homeopathic journal articles.

When my secretary treated her dog that becomes agitated by fireworks with a homeopathic calming remedy, the dog promptly settled down and took a brief nap despite the explosions. As the anti-homeopaths quipped to me on social media, that is an anecdote and placebo effect. Doggies respond to placebo – who knew?

One other agency took action against homeopathy in October. In the US, the FDA put out a warning that seizures have been reported in toddlers using homeopathic teething medicine. Hyland’s teething tablets contains Calcarea Phosphorica, Chamomilla, Coffea Cruda, and Belladonna. Hyland emphatically disputes any risk associated with its product.

Recently I have been focusing on food allergies, sensitivities, and intolerances. While there has been a backlash among media columnists and late-night comedians about gluten sensitivity, the issue is real and sadly underappreciated by medicine. It is not uncommon to be evaluating new patients with a myriad of symptoms and conditions, treated with polypharmacy, using extensive supplementation, but not restricting gluten or other foods. Food antibody testing for allergy and sensitivity has been criticized as well, despite the fact that the allergist’s pinprick food allergy testing is generally replete with falsely negative results. It should be noted that there has been innovation in food allergy testing, including the ALCAT procedure that assesses leukocyte reactivity to food as compared to IgG and IgE antibody testing. When a patient is found to be sensitive to gluten, dairy, and other foods, it is an easy matter for the practitioner to recommend avoidance of these foods; it is no easy time for the patient to comply. For the family member who loves to prepare new recipes, a food avoidance program or rotational diet may not be problematic. For the person who cooks simply or prefers prepared meals, gluten and dairy restriction is a major undertaking.

Of course, there are numerous gluten-free recipes compiled on websites and in cookbooks. The question is whether these recipes are easy to prepare, tasty to eat, and kid-friendly, use inexpensive ingredients that are easy to shop for, and make complying with food restrictions fun rather than a chore.

Enter Theresa Nicassio, PhD, a clinical psychologist, who developed health problems while in her 30s that led her to rethink her diet. She discovered that, like many others, she was sensitive to gluten and dairy. When she began to explore what was available to guide her in modifying her diet, she was dismayed that most recipes were arduous to make, not very palatable, and not fulfilling for the appetite or soul. Worse, when she put the meals on the table, her husband and daughter reacted with a grimace. Theresa always enjoyed cooking and she became inspired that she could do a better job on a gluten- and dairy-free meal. At first she would tinker with the recipes that she could find, but eventually she found herself stepping out of the box, bringing together ingredients in unique ways that would emphasize taste and meet muster with her harshest critic, her 12-year old daughter. It didn’t take long for Theresa to engage her older daughter, Alex, in her nutrition adventure as well as her husband. In 2013 Alex and Theresa embarked on more formal training in preparing cuisine, attending the Living Light International Culinary Institute in California. Both became raw food chefs and were certified as nutrition educators. The result is that Theresa, Alex, her family, and other collaborators developed dozens of recipes that not only satisfy a gluten-free and dairy-free diet, but are also mostly sugar, egg, and potato free. Some recipes are vegan as well. The recipes are compiled in her book, YUM, and Theresa updates them on her YUM website. The one distinguishing aspect of the recipes is that Theresa writes them with a social consciousness – how will the meals make the family feel? For Theresa, living on a restricted diet not only should heal the body but also empower the planet, and most of all it should be fun.

Here is YUM’s “Raw Kale & Avocado Salad,” reprinted from the book:

The ingredients are: 4 cups chopped baby or de-stemmed kale; 1/2 cup chopped chives; 1 cup diced tomatoes; 1/2-1 red pepper, thinly sliced; 1 avocado, chopped in small pieces; juice from 1 lemon or 2-4 tbsp apple cider vinegar, to taste; 1 tbsp extra virgin olive oil; 1 tbsp nutritional yeast; Himalayan salt and black pepper to taste.

Here’s a perfect version of a kale salad we have been making for years. An important trick when working with fresh kale is to “cook” by massaging it with your hands in the oil (in this case, olive oil combined with fresh avocado) and acid (lemon juice or vinegar), squeezing the kale as you do so. This process not only helps to make the kale softer, but also improves its taste—a fun method that most people have never heard of. It can take you back to your days of finger-painting in schools. Kids will love this process too, and it’s a great way to turn them on to eating this incredibly nutritious food. I used to think that kale was boring and didn’t taste very good. It was this recipe and method that changed my mind forever, and it’s been a great transformer for many others as well. Avocado-massaged kale – YUM! Serves 2-3.

Directions: Toss together the kale, chives, tomato and red bell pepper, then add and massage with the avocado, lemon juice or vinegar, olive oil, nutritional yeast, salt and black pepper. Serve immediately with the garnish of your choice.

Teresa’s Tip: I know these ingredients sound weird. But as you massage in all these ingredients you are, in effect, creating the dressing for the salad. The tomatoes break down and break down with the avocado and other items, resulting in an amazingly delicious creation!

Thierry Hertoghe, MD, and Testosterone Hormone Replacement Treatment

If any treatment personifies the face of anti-aging medicine, perhaps testosterone hormone replacement treatment best fits that role. Undoubtedly, one of the chief proponents and teachers of male HRT is Thierry Hertoghe, MD, president of the International Hormone Society. For the male who has symptoms and physical signs of testosterone deficiency, together with laboratory tests confirming the diagnosis, Hertoghe believes that testosterone replacement is mandatory.

But what is the optimal testosterone level? How does one diagnose testosterone deficiency? What are the typical complaints and physical signs of male hormone deficiency? What are best laboratory tests for diagnosing it and how does one interpret these tests? What are the different treatment modalities for optimizing testosterone levels and how are they best utilized? Finally, what considerations are needed to ensure testosterone safety?

In this issue, Hertoghe examines testosterone deficiency, its diagnosis and treatment. Hertoghe and colleagues offer advanced education on hormone diagnosis and treatment at the A4M meeting this December in Las Vegas.

Alan McDaniel, MD, and 5-Alpha-Reductase

Readers should be familiar with Dr. McDaniel, who graces this issue’s cover: in April 2016, he penned an important clinical article on fungal hypersensitivity. (If you missed that article please take a gander on our website, townsendletter.com.) I love Alan’s clinical style: he presents cases and dissects the pertinent pathology, physiology, and laboratory relevant to evaluate and treat the patient. McDaniel likes to challenge our clinical acumen, presenting clinical symptomatology and lab data indicating lack of progress or relapse, asking what we should do next. He charts date sequential hormone laboratory data together with therapeutic interventions; this makes for an intelligent way to evaluate hormone replacement therapy. I think that McDaniel’s hormone charting should be included in university endocrinology fellowships.

In this issue McDaniel tackles the clinical importance of 5-alpha-reductase (5alpha-R) and male testosterone hormone replacement therapy. In a word, 5alpha-R is the enzyme responsible for converting testosterone to 5-alpha-dihydroxytestosterone (DHT). The problem in testosterone HRT is that if there is excess 5alpha-R activity, too much testosterone is converted to DHT. As McDaniel explains, this excess conversion of testosterone of DHT causes men to not experience the touted benefits of testosterone treatment. One of the chief problems of testosterone replacement is that prescription gels and compounded creams applied to the skin are subject to increased 5alpha-R activity due to the skin’s increased enzyme activity. Not unexpectedly, intramuscular injections of testosterone obviate this problem. McDaniel’s article is a must-read for testosterone prescribers.

Notes

1. Lipkin W. The coming trials of generation Zika. Wall Street Journal. Sept. 7, 2016. Pg. A15.

2. Galchen R. Keeping it off: for obesity, diet and exercise rarely work. Increasingly the solution is surgical. New Yorker. Sept. 26, 2016:32–37.

3. Dhaliwal P. State-funded homeopathy no longer available in the North of England. British Humanist Association. Oct. 6, 2016.