Water is bad, coffee is good … wait, what?

Sometimes I don’t know whether to laugh or cry when I read stuff on the internet.  Take, for example, the article on news.com.au today about the long-held notion that drinking eight glasses of water a day is good for you.

The article centered around comments made by a lecturer at La Trobe University, Spero Tsindos, that you didn’t need to drink eight glasses of water a day to maintain your fluid balance, and that continuing to make such a statement to the public was just perpetuating a myth.

Stripped of its context, such comments make Tsindos sound like a douche bag, though what offended me more was the layer upon layer of arrogance and ignorance that followed in the comments section.  Some of the comments were from people that were genuinely confused by the disparity between what the article appeared to say and what their personal trainer keeps telling them.  Others were just plain stupid, or perpetuated hysterical mistruths from people that probably should have known better, which just made it all the worse for the people suffering from genuine confusion.

So while it may not be ever be appreciated by the readers of news.com.au, if I don’t try to rectify the myriad of mistruths ensuing from this article, I’ll spontaneously combust.

First of all, lets add some context to the comments made by Mr Tsindos.  The poor guy was just engaging in a robust intellectual debate with other public health academics, in a peer-reviewed forum, considered the most appropriate vehicle for such debate.  He was not making a statement to the press, or writing something for the lay public.  His letter was probably part of a whole series of debate for and against the idea that eight glasses of water a day is mandatory for good health.  Intellectual debate in journals takes a lot longer than posting to facebook, but unfortunately the general public has an attention span shorter than the average goldfish and can only process one paragraph at a time, so the notion of intellectual debate is lost on them.

And for the record, Mr Tsindos is correct in that whatever we put in our mouths contributes to our fluid balance since most of the food we eat contains a lot of water.  So do all fluids, be they water, milk, juices or soft drinks.  Even coffee adds to your fluid balance, despite the caffeine, but we will get to that later.  He was talking about our fluid balance not our overall health.  Unfortunately, again due to our collective attention deficit disorder and our affinity for jumping to conclusions, that was lost on most people.

The comments ranged from the reasonable, “Isn’t coffee a diuretic, so wouldn’t drinking lots of coffee dehydrate you” to the ignorant pseudo-experts, “Everyone should be taught to interpret the colour of their urine properly to see if they are adequately hydrated.”  And from the plain hysterical, “Coffee is pure acid.  Coffee taxes the liver”, to the ridiculously hysterical, “It’s all a conspiracy from juice/coffee companies to deceive you.  Just like evil doctors that push vaccinations full of mercury, that all cause autism.”

First of all, caffeine is a weak diuretic.  Diuretics are drugs that make your kidneys produce more urine.  People who are not used to caffeine will get a diuresis from coffee.  But unless you drink nothing but espressos, there is usually more fluid in the coffee than the small increase in urine output from the caffeine.  And like all drugs, your body develops a tolerance for the diuretic effect of caffeine after a while, so habitual coffee drinkers will get a reduced effect, increasing the fluid contribution from coffee.  You will not dehydrate if you drink nothing but coffee.

And the suggestion that coffee is taxing to your liver and leads to health problems is a myth still held dear by alternative practitioners and overzealous nutritionists.  Broad population studies that follow hundreds of thousands of coffee drinkers for decades have shown that coffee drinkers live longer than non-coffee drinkers, especially chronic habitual coffee drinkers who drink over four cups a day.

Back to the notion that you need to drink 8 glasses of water to be healthy.  Broad generalisations are like one-size-fits-all clothing … they usually don’t fit anyone properly.  The same goes for the idea about the number of glasses of water that you should drink.  You drink the water that you need to drink.  How do you know how much?  The human body has been pre-equipped with the ability to determine exactly how much water we need in a day, and it has nothing to do with eight glasses or the colour of our urine.  It is thirst.  If you are thirsty, drink some water.  If you are not thirsty, don’t drink water.  It’s not that complicated, is it?

The point with the eight-glasses-of-water dictum is that water is beneficial and we don’t drink enough of it.  On this point, I agree with Tsindos, the eight glasses rule should be discarded.  Rather, all we need to say is, “drink more water”.  When you are thirsty, choose to drink water instead of soft drinks or fruit juice.  It’s that simple.

When I have more time I will write a blog about all the virtues of water, because if a drug-company could, they would patent it, such is the overall health benefits of water.  But for now, just remember to drink more water in line with your thirst.

Oh, and lets cut Mr Tsindos some slack.

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Placebo therapy is fraud

I’ve often had discussions with friends and patients that go something like:

Friend/relative/patient: “I went to [blah blah] alternative therapy the other day.  I feel great.  You should recommend [blah blah] alternative therapy to all your patients.”
Me: “But [blah blah] natural therapy is a sham.  There’s no good quality evidence to prove that it’s better than a placebo.”
Friend/relative/patient: “But I feel better, and so does Jo Bloggs who lives two doors down.  She said it cured her bad back that she’s had for twenty years.”
Me: “Well, that’s great for Jo Bloggs.  It still doesn’t mean that it’s any better than a placebo.”
Friend/relative/patient: “I don’t care whether there is any evidence for [blah blah] alternative therapy.  I feel better.  That’s all the evidence that I need.”

As they walk away from this conversation, most people think I’m an arrogant unsympathetic retard because I didn’t gush with enthusiasm for their miracle cure.  I’m not unhappy for them.  But placebo therapy is a pet hate of mine that tends to overshadow any deeper joy.

A placebo is any medical treatment that is inert or inactive.  Around one third of people who take placebos will experience an end to their symptoms. This is called the placebo effect.

Placebo therapy is my own description for any treatment which is marketed as having amazing healing properties, but in reality, the only healing it provides is through the placebo effect.  To me, profiting from such therapies is tantamount to fraud.

Some would disagree.  After all, the pillars of medical ethics are, “First, do no harm” and, “Do good.”  If the therapy they offer does no harm, and does some good, then what’s the problem?  The end goal was to make the patient feel better, and if they do, what does it matter that it was the treatment or the placebo effect?

Here’s a hypothetical.  Imagine if I go into a hardware store and ask for a hammer so that I can make some minor repairs to my house.  The store only had baseball-sized rocks, and sold one to me.  I could use the rock to knock out some walls, nail some bits of wood together.  It just so happened to help me.  But it isn’t a hammer.  It’s barely even a tool.  To sell it as a tool or specifically a hammer would still be fraud, despite the eventual outcome.

What if a drug company were to market a sugar pill, claiming a medicinal benefit.  The placebo effect would guarantee that one third of the people who used it would feel better for it, but it would still be fraud.  Our community would be outraged.  Imagine the scathing media reports and the indignation from political and community leaders.  There would be calls for jail time for the executives who profited by misleading the public, and rightly so.

The market for herbal supplements in Australia alone is worth billions of dollars.  Yet there is a paucity of rigorous scientific trials of these herbs.  I could count on one hand the number of herbs that have evidence that they’re better than a placebo.  The other thousand or so unproven herbal supplements are no better than mass-marketed sugar pills.

Any herb, supplement or other treatment needs to show that it has a better outcome than a placebo before it can claim to be therapeutic.  To claim otherwise is fraudulent, and even though I may seem like an arrogant unsympathetic retard, I think people deserve better than being mislead by claims that can not be fully substantiated.

More information on the placebo effect can be found here – http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Placebo_effect?open

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Dieting. Is it worth it?

In an opinion column on the Brisbane Times news site, Kasey Edwards wrote about the recent struggles that weight loss company Jenny Craig have had finding celebrities to endorse their product.

Edwards cited Australian actor Magda Szubanski, and Kirstie Alley before her, as typifying the difficulties that dieters have. She also stated that over the last 50 years of research, dieting has a typical success rate of only 5%.

Her source was unstated, but if it’s correct, then it’s somewhat disheartening. She said, “With such damning rates it is extraordinary that we still blame individuals for ”failing” at weight loss programs rather than accusing the diet companies of selling snake oil. Can you imagine buying any other product with a 95 per cent failure rate and then blaming yourself when it didn’t deliver on its promise?”

The question is then, “Do all diets suffer from the same failure rate, or are there one or two really successful diets who’s success is diluted by the failure of others?” The answer, not really. It depends on how long you measure for.

From the eMedicine article on obesity, “The results of most weight-loss programs are dismal. On average, participants in the best programs lose approximately 10% of their body weight, but people generally regain two thirds of the weight lost within a year. When defined as sustained weight loss over a 5-year follow-up period, the success of even the best medical weight-loss programs is next to nil. Most available data indicate that, irrespective of the method of medical intervention, 90-95% of the weight lost is regained in 5 years.” (Reference)

So, you can invest thousands of hours, and hundreds of dollars into a program, and the end result is most likely the same, nothing.

That sounds depressing. So what’s the point? Perhaps we should just quit while we’re ahead.

You could, but I think there is a solution. Dieting is not the answer, but I think making healthy lifestyle choices is.

That’s for another post.

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Being a Resistance Fighter

On ANZAC Day, it’s important to remember the price our past generations of soldiers and their families paid for our freedom.  While we may not experience the ravages of war in Australia, we still face a bleak future as a result of a war that we fight every day, and on the front line, GP’s and pharmacists who every day, battle with the tide of sniffling masses  pleading, “Can I please have some antibiotics for this cold.”

We all know how it feels.  Your muscles ache, your nose feels like it is flowing like Niagara Falls.  Your throat is on fire.  You lurch between shivering under four blankets to sweating like you were in a sauna.  You would do anything to feel better.

A significant proportion of the population head to the pharmacist or naturopath and try whatever herbal treatment was last recommended by their facebook friends or the pharmacy assistant (which are usually unproven, or have been shown to be no better than placebo, but that’s another blog).  I see the people who feel that their cure lies in the miracle of antibiotics.

Antibiotics don’t seem like a miracle anymore.  But even as recently as the 1950’s, bacterial infections caused severe illness, and deaths were common.  With the discovery and adoption of penicillin, and the subsequent development of the armory of antimicrobials, we now see bacterial infections as trivial.  Antibiotics have become common place and they tend to be used as a panacea.

According to the Australia’s National Prescribing Service, the use of antibiotics in Australia is one of the highest per capita in the developed world.  The NPS says that “overuse and misuse of antibiotics has made it harder and harder to treat many bacterial infections. Antibiotics are losing their power against illness-causing bacteria.”

The NPS have recently launched a campaign to raise awareness of the growing concern of Antibiotic Resistance, which the WHO recently declared as ‘one of the greatest threats to human health today’.

While the ad is a bit pithy, the message is not.  You don’t need antibiotics for coughs and colds, which are usually caused by viruses.

The NPS says:

  • Understand that antibiotics are only effective against bacteria and not viruses — colds, flu and most coughs are caused by viruses and will get better on their own.
  • Treat your flu and cold symptoms and let your immune system fight the virus — antibiotics will not help you get better quickly, and may give you side effects such as diarrhoea and thrush.
  • Don’t ask for antibiotics — instead ask your doctor about the best way to treat your symptoms.
  • If you are prescribed antibiotics ask your doctor about the risks and benefits and always take them exactly as prescribed.
  • Don’t take someone else’s antibiotics.
  • Spread knowledge, not infections — encourage other people to join the fight against antibiotic resistance.

If you aren’t sure if you have an infection caused by a virus or a bacteria then see your GP.  They are the health professionals that are in the best position to examine you and advise the best course of action.  It may mean a script of antibiotics.  But nine times out of ten, all you’ll need will be a medical certificate, and a trip to the supermarket to get some paracetamol or ibuprofen.  If you have a favorite cold remedy, feel free to post a comment.

If you want more information on the NPS campaign to become a resistance fighter, you can get it here: http://www.nps.org.au/bemedicinewise/antibiotic_resistance

If you want to follow the NPS on Facebook, click here: Facebook

See the video: http://youtu.be/H1wwdE5abLk

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Why Diet Zealots Are Usually Wrong

I hate Diet Zealots.

You know, those people who tell you, “I lost blah blah pounds on the blah blah diet.  If only everyone was on the blah blah diet, then we wouldn’t have an obesity crisis.”  The also add when they see my generously rotund abdomen, “Why don’t you try it?” Grrrrr.

Its hard to argue against these people.  They hold unshakably to the belief in whichever diet worked for them because of their own attentional bias.  Usually they have tried for years to lose weight and have consistently failed.  So it is only natural that when they finally lose weight, their attention and belief systems are immovably focussed on their path to enlightenment.  It doesn’t help that some have the scientific acumen of a lab rat.  But of the many Diet Zealots that have come across my path, even the ones that have some scientific training find it hard to move beyond their cognitive anchoring to the program that finally worked for them.

But no matter what the French physician says in his book, or the woman who lost 200 pounds says on the TV, there is no magic ingredient or silver bullet in any of their diets.  If any diet brings about weight loss, there is only one fundamental reason.  It brings about a calorie imbalance, where more calories were used than consumed.  Nothing else.

The key point isn’t whether a diet can induce weight loss.  I can show you examples of people doing the dumbest things and still losing weight.  One guy ate nothing but potatoes for 60 days and in the process lost 21 pounds.  Even the cabbage-soup advocates say that you can lose 10 pounds in seven days.  Although I think I’d rather remain five kilos heavier than live on cabbage soup for a week.

The foundation to any diet is that it has to be healthy.  Because isn’t that the point, you go on a diet for your health.  There are a number of diets which sound good on the surface, and the guy selling his book will point to the thousands of people who may have genuinely lost weight on it.  But if it contributes to heart disease or colon cancer, then all it means is that you will fit better into your coffin.

The other consideration is whether the diet contributes to long term loss of fat.  Short term weight loss is always water weight and intracellular carbohydrates, then proteins from your muscle and bones.  Losing most of the weight in the first two weeks and then plateauing is actually going to be bad for you in the end.  Slow gradual weight loss over months to years is the best form of weight loss, because that usually represents fat loss, the sort of weight that you want to lose.  If you lose about two kilograms a month (or four to five pounds in the imperial) then you are on the right track.

Next time you meet a Diet Zealot, be happy for them.  It’s hard to lose weight, no matter which diet they might be on, so congratulate them on their achievement.  But don’t feel you have to be converted.  Find what works for you, which is likely to be something a lot more simple than what the Diet Zealot has done.

(If you would like to compare the pros and cons of a number of the popular diets, I found this website in my research: http://health.usnews.com/best-diet/best-overall-diets I don’t know who their expert panel was, whether they were experts, or whether they were paid off.  But it’s the best comparison I have seen so far on the web.  If you have come across one better, let me know in the comments.)

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Land of the Free – Chapter 4: There’s no place like home

Well, we’ve made it. I have now stepped foot in my living room, after completing a 30,000km round trip to the other side of the earth. The memories are many, but because of my early onset dementia, they are fading fast. But it was a really full on 17 days.

When one travels overseas, one receives the gift of perspective – I have been reminded about the good and bad things about living in Australia. For one, the coffee. Every day, every Australian should rise from their beds and thank God that we consume some of the best coffee in the world. American coffee is awful. I believe it’s made from silt dredged up from the bottom of a secret swamp, deep in the heart of southern Florida, mixed with a number of bitter herbs and goats urine, and boiled for 24 hours. The only reason I can think why Americans drink it is that it has healing properties. Anything tasting that bad must be good for you.

The other thing that I value is the feeling of (relative) safety here in Australia. LA gives me the creeps. Away from the tourist strips, I always had this foreboding, that someone was about to mug me for my wallet and my kidneys. It’s natural that one would have some anxiety when negotiating a new area, and if I was to settle somewhere in the US, that would probably pass. But since there is very little social security in the USA, and even worse health care if you don’t have insurance, the destitution seems a lot more visible.

It has also allowed me to see just how much Australians are subject to price gouging and taxation. The prices of almost everything in the US were ridiculously low compared to Australia. They were moaning in Hawaii that their gas prices were 445 US cents per gallon. Apparently their gas prices are expensive compared to the US mainland. And yet, 445 cents per gallon is equivalent to 117 cents per litre. In the taxi on the way home, I saw petrol prices at about 160 cents per litre near my house, and that is pre-carbon tax which is going to increase the price more. As I noted in my previous post, their alcohol is cheaper by a factor of 300%. The other product which I can compare directly with home was the price of a meal at McDonalds, known in finance circles as “the Big-Mac Index”. It was about $1 cheaper for a standard meal in the US, which is larger compared to the same meal in Australia.

The other thing about the US is tipping. I’m mixed on the whole tipping thing. It seems like a rort on the surface, a way for the service industry to make a couple of hundred dollars in tax-free cash a week. But on the other hand, it offers a way of direct reward for good service. I stayed in four different hotels on my travels. The three in the US had people there that were falling over themselves to help you. Carry your bags, get taxis for you, offer information. Sure, you would need to tip them, but I appreciated the service. When I arrived at the Holiday Inn at Sydney Airport, the front counter was like a ghost town. There was one person manning the front desk. No concierge, no people to help with the luggage. The one other person that was there when the taxi driver was dumping our bags in the middle of their driveway disappeared as soon as he saw 4 large suitcases that he might have to help with. Might as well put a big banner up at the airport: “Welcome to Australia, where we don’t give a sh*t.”

Griping aside, there are some other great benefits from being away from my office. The weather was fantastic. Other than the first day in LA with it’s cloudiness and sub-zero temperatures, the rest of the holiday was sunny and warm. I spend two weeks in blazing sunshine, which has been fantastic for my rickets. I think I’ve also lost about 5kg from all the walking that I had to do. So overall, a good break.

Well, I hope that these blogs haven’t bored you all to tears. You’ll have to wait until I save up enough money for my next holiday before you get any more, so a welcome break I’m sure. Until then, enjoy life, and God Bless America.

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Land of the Free, Chapter 3 – Aloha!

Hawaii. A little cluster of eight islands in the middle of the north Pacific Ocean.  It is an eclectic mix of bustling US city complete with its clogged freeway system and homeless people, and of tropical island paradise with white beaches, palm trees and clear oceans that reflect the skies magnificent azure hue.

It has a rich polynesian heritage.  The local polynesian dialect is still spoken regularly, like an unofficial first language, and everyone greets you with a hearty “Aloha”.  I always thought that the whole aloha thing was just one of those annoying tourism gimmicks (like the nauseating “Have a magical day” that Disney people irritate you with).  But everyone says it – from the checkout chick at the supermarket to the guy serving at Maccas.

The kids had a little bit of trouble with the pronunciation though.

Me: “Aloha boys.”

Mr 7: “Hello-ha.”

Me: “What is the name of the island we’re on?”

Mr 5: “We’re staying at … Haw … ah … Ha-wee-wee.”

Me: “And the name of the city?”

Mr 7: “Hallelu-lu.”

Hawaii is truly a beautiful place, with some absolutely stunning natural features.  The beach at Waikiki is a pale, clean sandy beach where the clear shallow water reveals the schools of small fish swimming around your feet, and further out, the shoals of coral reef.  The clear water gradually gives way to the most amazing ocean, which looks like someone took a swatch of the most amazing shades of blue, then bled and blended them like a water colour, all the way to the cloudless horizon.

Turn around, and the mountain range looms above you, its sides covered with a lush carpet of rainforest, and its sharp ridges disappearing into the cumulus clouds that remain perpetually attracted to it.

The main artery of Waikiki is Kalakaua Avenue, which is a clean, vibrant, high-end restaurant and retail strip.  Louis Vuitton, Victorias Secret, Prada … there are a lot of different ways in which you can spend your money.  If you keep going west, you will eventually end up in Ala Moana, which is a very very large, open-air shopping centre with many of the same brands.

If you would prefer cheap alcohol, cigarettes and souvenirs then head to the nearest ABC store.  You won’t have far to go.  The ABC stores are everywhere.  There are literally 60 or 70 of them in the mile or so around Waikiki.  They outnumber McDonalds about 30 to 1.  They stock almost everything.  Groceries, snack foods, lots and lots of souvenirs, tacky Hawaiian shirts, and really really cheap alcohol and cigarettes.  Like, 1.75L bottles of Smirnoff Vodka for $US25.  In Australia, that same volume of spirits would cost about $70.   The story from the tour guides is that the chain is owned buy a japanese family, who named it ABC as an abbreviation for “A Better Convenience”.  The locals have a number of other possible abbreviations – Aloha Brings Customers, Alcohol Bric-a-brac Cigarettes, Another Bottle of Cognac, A Bunch of Crap, just to name a few.

The Hawaiian diet is unique.  This little island consumes the largest amount of spam in the world.  They serve spam with breakfast in McDonalds.  They have cook books entirely  dedicated to spam.  They have macadamia nuts with spam flavored coating.  The tour guide said they even have a festival where they close part of the main street of Waikiki for a festival of spam cooking.  If they ever took Iron Chef to Hawaii, their key ingredient would be spam.  Cue Monty Python sketch here.

The other key ingredient to combine with the spam is, not surprisingly, pineapple.  Again, they like to serve everything with pineapple, or pineapple juice.  Every time I ordered a meal from McDonalds, they gave me a cup of pineapple pieces with it.  Mr 5 ate a couple of them, but I had four left over in the fridge when I left.  I must admit, it does go well in Mai Tais, but other than that, I really didn’t share their pineapple fetish.

The dress code is pretty much anything you feel like.  High end restaurants will let you in wearing T-shirts, shorts and sandals.  Gaudy Hawaiian shirts are the standard uniform for everyone in hotels, transportation and tours.  On the beach, as long as you have some form of material covering your delicate parts, no one cares.  There are exceptions of course.  One middle aged, unattractive Indian lady decided to wear a white, relatively see-through G-string Bikini.  When she emerged from the water, there wasn’t much left to the imagination.  And worse yet, she sauntered up the beach, blithely oblivious to the wave of nausea that she was creating, found her towel, and then bent over for about five minutes while she scrounged around in her handbag looking for her sunglasses.  Oh please madam, put it away, this is a family beach.  Now, I have seen my fair share of buttocks in my time as a doctor, from the aesthetically pleasing to the downright ugly.  Even so, there was something particularly hideous about this view, and yet, like a doe staring into the headlights of the on-coming semi-trailer, I strangely couldn’t look away.  I should have.  I’m now scarred for life.

Over all, I enjoyed Hawaii so much more than the rest of the trip.  We did pay through the nose to get high end accommodation, a condo 35 floors above and directly across from the beach at Waikiki, but having a bedroom and bathroom to ourselves was absolute gold.  We will definitely be coming back – to explore the rest of Oahu, and to try and get across to Maui or the big island of Hawaii.

I’d recommend coming if you can.  Before I came to Hawaii I thought it would be just like the Gold Coast. While there are definitely some similar elements, the Gold Coast doesn’t come with a stunning mountain range just behind the beach, coral or the clear water that allows you to see it, and it certainly doesn’t come with magnificent sunsets over the ocean that I witnessed at a Luau the other night.

I might come back to the keyboard when I get home, to sum up a few things but for now, mahalo, aloha, and God bless America.

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