Drugs, Diets and Doctors

By Dr. Jim Ferguson

It’s that time of the year when resolutions fly. No, not Congressional resolutions, but vows to exercise more, eat better and lose the bounty of the Holidays preventing buttoning of pants and skirts. We live in a land of plenty, and without some restraint won’t be able to fit into an airline coach seat.

Since this is not a tabloid column I’m not going to talk about the Kim Kardashian diet. Actually, Ms. K’s diet has been around since the 1950s and is known as the Atkin’s Diet. It is a diet low in carbohydrates and, if rigorously adhered to, promotes a change in metabolism and the production of mild ketosis as fats are converted to glucose to fuel the brain and vital systems.

I tried the low carb/high fat diet once just to see what it was like. Actually, I love bacon and consider it one of the food groups along with bread, cheese, olives and wine. However, I only lasted three days on a steady diet of fatty foods. The French have a saying, “You are what you eat.” I felt like a grease ball on the Atkins diet. Entrepreneur that she is, Ms. Kardashian is being paid by the Atkin’s Company, I assume, for her name.

I’ve written before on various diets including the paleo diet. However, a recent review of the low-fat diet in JAMA (Journal of the American Medical Association) caught my eye. The author chronicles the low fat diet craze that swept America beginning in the 1960s and 70s. The author blames research done by the sugar industry which duped our government and nutritional societies to recommend diets low in fat, and making up calorie deficits with a high intake of carbohydrates and starches. Apparently, no one is responsible for independent thinking or common sense and the big bad corporations duped our noble “gub-ment” officials and nutritional “experts.” As a result, our country now suffers from an epidemic of obesity and diabetes. Who would have thought a diet of Cheetos and Twinkies would be harmful?

There are three energy components in food: protein, fats and carbohydrates/starch. Examples of each are animal flesh, butter and potatoes. When metabolized (burned), fats have twice the calories (energy) as proteins and carbohydrates. Sixty years ago Americans got 40% of their calories from fat and we used whole milk. Today, experts recommend 30% of our calories come from fat. Unfortunately, the calorie loss is too often made up with potato chips since these are more affordable and palatable than many of the items on the food pyramid proffered in 1992. The real lesson here is: eat sensibly and less, walk/exercise daily and be wary of politicians who know very little and experts who think they know more than everyone else.

I’m often asked about Tylenol, Motrin and Aleve for the treatment of fever or aches and pains. Tylenol is the brand name acetaminophen (paracetamol) and lowers fever by altering the brain’s heat-regulating center. And it lessens pain by blocking pain impulse generation.

Motrin is brand name ibuprofen, and Aleve is the brand name for naproxen. Like aspirin, these drugs are known as NSAIDs (non steroid antiinflammatory drugs), and work by inhibiting prostaglandin production. Prostaglandins are produced when there is tissue injury or inflammation, and modulate the injury and healing process. Prostaglandins also regulate blood flow in the intestinal lining and the kidney.

Ideally, you’d like a medication that safely relieves aches and pains, and cools a feverish brow. Acetaminophen (Tylenol) doesn’t cause stomach ulcers or impair kidney function, and is therefore safer, unless you’re getting liquored up every evening! Acetaminophen (Tylenol) has the potential for liver toxicity which increases markedly with the concomitant use of alcohol. I often advise patients that if their joints are stiff and sore, but aren’t red, hot or inflamed, acetaminophen (Tylenol) may work just fine and is generally safer than NSAIDs, especially in older folks. However, NSAIDs are generally superior for broken bones, injuries and swollen joints.

The reason NSAIDs seem better in injury and inflammation is because these agents inhibit the production of inflammatory prostaglandins which are released from injured cells or rheumatoid joints. Short courses of aspirin, ibuprofen (Motrin) or naproxen (Aleve) are helpful with booboos and are generally safe. However, with continued use of NSAIDs the risk of complications increases.

An important clinical study (PRECISION) was recently published in the NEJM (New England Journal of Medicine) comparing the long term toxicity of ibuprofen, naproxen and another NSAID celecoxib or Celebrex. Science has shown that prostaglandin production is mediated by two isoforms of the cyclooxygenase (COX) enzyme. COX-1 is associated with local blood flow in the intestinal lining and kidneys, whereas COX-2 seems preferentially activated in inflammation. Aspirin, ibuprofen and naproxen inhibit both COX systems, whereas celecoxib (Celebrex) seems to preferentially work to inhibit COX-2. It was hoped celecoxib would cause less side effects and work as well as the older NSAIDs. This large study helps to assure doctors that celecoxib is as effective as the other drugs and seems safer for long term use, sometimes justifying prescription cost.

Life is complicated and so is medicine. We doctors think of ourselves as experts who advise our patients from science, compassion and experience. For years we’ve advised folks with heart disease to use a baby aspirin a day because this drug binds to platelets and keeps platelets from sticking to ragged plaques in vessel walls. Unfortunately, medications like ibuprofen (Motrin) may hinder aspirin’s platelet effects, and have been associated with an increased risk of heart attacks in heart patients. Interestingly, studies have not shown increased cardiovascular risk with naproxen (Aleve). Now, the PRECISION study has shown cardiovascular safety with celecoxib (Celebrex).

Science is a methodical system of observation reality. Individual doctors might eventually figure out that patients do better on some medications through trial and error, but clinical trials with large numbers of patients using rigorous statistical analysis is a more powerful observational tool.

They say nothing is for sure except death and taxes. This goes for medications as well. One of my axioms is “any medicine can do anything to anybody.” However, be wary of any expert who challenges your common sense. Remember the consequences of low fat diets recommended by experts. And beware of blindly following so-called “experts” –  persons fifty miles from their home with a powerpoint presentation!

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