Sunday, April 6, 2014

More on the Gut-Brain Connection

I'm still in the midst of reviewing a ton of literature on psychobiotics in time for the APA Annual Meeting in New York City this year. Our Evolutionary Psychiatry talk has been moved from two to three pm on Monday May 5th, as the Vice President will be speaking at 2pm. (Attendees can watch the VP on close caption so you can run to our room to beat the crowds ;-)

Anyway, I've written a layperson's version of my portion of the talk on the Gut and Brain, probiotics, etc. which I just put up over at Psychology Today. My academic talk will have a lot more details about the immunological effects, cytokines, hormonal regulation, etc.

New Music: Cherub: Doses and Mimosas (not exactly my usual style, but catchy, particularly the chorus.)

Head of a pinworm, major immune system regulator. From wikimedia commons.

Sunday, March 30, 2014

Tylenol in Pregnancy and ADHD in Offspring

Excuses, excuses...haven't blogged in a while. The kids keep me busy, and I've been working on some personal projects that make me happy, not to mention some major work going on with the practice, which, since it pays the bills, takes a good deal of my attention.

However, I do have a new article up at Psychology Today, about the recent JAMA Pediatrics article linking acetaminophen use and the risk of ADHD in offspring. It's an observational study, but the best sort of observational study. However let me warn you, I'm biased against acetaminophen from my experience working the ERs and ICUs. I do feel for pregnant women suffering pain or inflammation...what are they to use? If aspirin, other NSAIDs, and acetaminophen are all off the table... 

I've been hiding from conferences since AHS last August, but I'll be at PaleoFx (briefly) in mid April, on the Thrive Show (a google hangout) with Jennifer Brea (producer of what looks to be an amazing film called Canary in a Coal Mine) on April 22nd, and doing a couple presentations at the American Psychiatric Association Annual Meeting in New York City the first weekend in May. I'm teaming up with Drew Ramsey that Sunday to do a practical workshop for the practicing clinician on Food and Mood, and then Georgia Ede will join us on Monday for a full three hour symposium on Evolutionary Psychiatry. I'm very excited about both these presentations, and not just because Georgia and Drew are some of my favorite psychiatrists and people in general. 

The Evolutionary Psychiatry symposium will include sections on the gut/brain connection, all the latest data about the micorbiota and parasites, the immune system, and psychiatric disorders, but also reviews of minerals and hormesis/fasting and ketosis. If you are going to the APA, be sure to come out to see us, and come early, because last year our workshop was filled to the brim with some folks refused entry. We are planning exciting, interactive presentations that may be a little different from the typical dry academic talk, but still on point and evidence-based, of course. 

I will have a few more blog articles coming out at Psychology keep on checking back!

Sunday, February 16, 2014

Here We Go Again: Vegetarian Diets and Mental Health

One of the primary messages out of public health agencies and nutrition gurus from Walter Willett to Michael Pollan is to eat more plants. And, indeed, in many studies, vegetarian* diets are associated with better cardiovascular health, lower BMI, and better health behaviors (less likely to smoke, drink, and participate in shady Rock and Roll activities).

*In most of these studies, vegetarian does not mean vegan, but usually includes the addition of dairy and eggs, and in some cases, also fish and chicken. Many of these studies use the metric of what people self-identify as, rather than what people actually eat. And the large ones are cross-sectional observational studies, which don't give us causation.

Studies have mostly (but not always) shown that vegetarian diets are associated with poorer mental health, particularly when it comes to anxiety, eating disorders, and depression (See You're A Vegetarian. Have You Lost Your Mind?). This correlation makes sense due to the particular nutrients mostly vegetarian diets are low in (B12, long chain omega 3s, choline, and zinc among others) are particularly important to the brain and nervous system. Mediterranean diets, on the other hand, rich in fruits, vegetables, and whole grains, but also in fish and poultry, are associated with better mental health, and a randomized trial of men with type II diabetes assigned to a Mediterranean diet for several years had lower incidence of depression than controls (1). 

In the face of a lot of messy data, Austrian researchers took a cross section of the population to learn more about self-reported diet and health. The paper is free full text and available here:

I tweeted the paper yesterday, proving that there's nothing a paleo-leaning audience loves more than a study inconsistent with the notion that vegetarian diets are the elixir of eternal health and happiness, at least for humans.

There was also a little twitter skirmish of vegetarian protest. "Correlation doesn't mean causation" one told me. (Yes indeedy! That's why I used the word 'correlates'). Another accused me of being misleading #shame:

I'm happy to let each of you in the twitterverse determine how misleading I am. It would be too cumbersome to define each verb each and every time I use them in 140 characters. Let me qualify that I'm sure there are happy and healthy vegetarians out there, and all my best to continued health and happiness; be sure to get your B12 from somewhere!

Anyway, the researchers did a decent job of getting a nice cross section of people in Austria from all levels of health and socioeconomic classes. Then they pulled out all 343 "vegetarians" (which were vegans, lacto-ovo vegetarians, and lacto-ovo-pescatarians) and matched them with folks from three other self-identified groups that we shall call the virtuous carnivores (lots of fruits and veggies + meat), the carnivores who eat less meat, and the shameless meat-eaters. Then the researchers measured (or asked about) a lot of health factors using trained interviewers. Body mass index, smoking, alcohol use, how many times a person visited the doctor, whether they got their preventative health care, and what sort of medical conditions and health complains they had.

After a lot of number-crunching, the results were as follows: Self-identified vegetarians had poorer mental health (defined as depression and anxiety), poorer overall health, and poorer quality of life. The other finding was that BMI correlated linearly with the consumption of animal fat (with the shameless carnivores having the highest BMI, the vegetarians the lowest). 

What can we learn from this study? Are vegetarians are more likely to be neurotic sick people looking for dietary cures for what ails them, thus come out of the study looking more skinny, unhappy, and unsatisfied? Or are vegetarian diets nutritionally bereft leading to health problems, mental health problems in particular? We will never be able to get that answer from a study of this design.

The Mediterranean diet, as always, has more consistent data for positive benefits for mental and physical health. I tend to think that the diet with a bit of variety and the least processed food will be the healthiest and simplest to explain.

Wednesday, February 5, 2014

New Directions in Autism

Last Sunday I put out yet another new post on Psychology Today, but failed to link it here. It is a discussion of a very interesting long term cohort study in Crete, where the researchers used a sifting haystack approach to find some metabolic problems that might be causing the symptoms, then, in certain cases, presumptively treating the problem, leading to two successful remissions of severe autistic symptoms. While the methods are too cumbersome and there isn't enough data to use the approach on everyone, I can't help but think we are looking at the next iteration of the future of medicine. Better knowledge of what different organic acids mean when found in the urine, and how different metabolites present in the blood after a fast or a glucose bolus tell us something about the overall functioning of the metabolism…then a tailored approach. Those who had trouble with fat metabolism were on high carb diets and reported decreased symptoms. Those who had trouble with glucose metabolism went on ketogenic diets…etc. etc. It's a smart and forward-thinking approach that makes sense in research and in these devastating conditions for which there is no treatment or cure. (Yet more data would be nice!)

Song: Big Data, Dangerous

But when does the needle in a haystack approach go to far? It's common for someone to go to a naturopath and get full blood, urine organic acids, and stool samples for fatigue, poor skin, lack of ability to lose weight, or constipation (or insert other chronic difficult to treat condition here.) In the case of the naturopath, the patient is paying out of pocket for this sort of treatment and that's free market health care. In the case of large population medicine and insurance/medicare/medicaid, there are not the resources for such an approach. Also, the most bang for the buck in the general population has to come from cheaper, more generic approaches, such as education and motivational interviewing about exercise, proper eating, and sleep…then if everything is more or less ship shape (or if the problem is disastrous), more investigation is warranted. My bias tends to be toward *less* testing and more listening, common sense, and empirical treatment (with the caveat that you don't want to miss the life-threatening condition, for example, my first break psychosis patients will get directed toward that MRI, low yield though it may be, so as not to miss the occasional brain tumor).

With no further ado:

Targeted Diet Interventions in Autistic Spectrum Disorders

And via Paul Whiteley: Autism, Treating the Whole Person

Saturday, February 1, 2014

Raise a Glass to Mutual Trust

Today I took the youngest to a preschool friend's birthday party. It was at a gymnastics center, and even after an hour of bouncing and running around, the eager children began doing laps of the table after the happy birthday/cupcake portion of the celebration. Yet there is still a lack of appreciation of exactly how acutely diet can actively affect behavior. A recent, fascinatiing study (forwarded to me by Dallas Hartwig of Whole9Life) shows how dietary manipulation of tryptophan (and therefore central nervous system serotonin levels) can affect mutual trust when it comes to money (brand new article over at Psychology Today):

The Drink of Trust

I'd be interested to see the results of similar studies with intranasal oxytocin or orally administered Jack Daniels.

Other pertinent articles:

Sunlight, Sugar, and Serotonin

The Anger Drink

Dopamine Primer

Do Carbs Make You Crazy?

Do Carbs Keep You Sane?

In the mean time, eat whole foods and consider your behaviors with care :-)

Sunday, January 26, 2014

Spirituality, Depression, and Recent Events

A brand new post is up over at Psychology Today: Brains, Spirituality, and Depression. It discusses the links between…well, guess. There are some interesting anatomical findings in the brain that correlate with both increased spirituality and a reduced risk of depression, but go read to find out more.

Thanks for comments and donations! I've not always been on top of the comments situation, and given the vagaries of gmail, I can't have my comment-approval gmail open at work…sometimes it takes me a week or two to approve a comment, and some get missed in the avalanche of spam. Excuses excuses…

I'm on track to writing more, though new article/science stuff will probably end up on Psychology Today first to be a more effective use of my time, because I have to blog monthly over there to get paid. :-). Other recent activities include freezing, hiking, a lovely Brazilian steakhouse dinner with Chris Kresser, Mat Lalonde, Sarah Johnson, and Diana Rogers and registering the youngest for…gasp…kindergarten.

Chris Kresser's book is out, btw! Great addition to the paleo book menagerie. And you might find the author of the Foreward to be familiar.

Too cold unless you are these guys

Meltwater on the ice-covered pond at Stony Brook

Wednesday, January 1, 2014

Man of Steel

Hello 2014! This blog post probably makes more sense if you have seen Man of Steel. Seriously, spend $1.50 at redbox. It’s awesome. Though perhaps ethically disappointing

I know it has been a long time. Suffice it to say that between some unexpected illnesses and deaths in the extended family, along with the normal life of a family with two working parents and two very active little girls, there was simply no extra time or energy for a little while. There was also a little stutter in my sense of purpose, trying to figure out what it is I am trying to do here. There is a lot more attention from my fellow psychiatrists (the president of the APA follows me on twitter, so all the sudden I feel a little awkward sharing my 140 character opinions and links on the Hunger Games). Far more importantly, I’ve been honored to be selected for a three hour symposium on Evolutionary Psychiatry at the next APA annual meeting in New York City, which is the major meeting of psychiatrists in North America, if not the world.  It’s all very academic and serious. 

Yet the underpinnings of what I am trying to say (and, in this blogosphere, trying to pick out the truth) are so simple it often feels as if there is nothing left. Sleep well. Eat well. Take a break. Be merry-ish. I am not temperamentally designed for ambivalence (except as an appropriate therapy tool), but after three and a half years of blogging the basics are settled, and the tougher subtleties come to the fore. The blog is coming out of infancy and becoming self-aware. A separate consciouness dogging me, and mocking, sometimes. Is there no way to make a difference without being outrageous and unconscionable?

There is a community now, of doctors and people looking for common sense and an active role in their own care. Yet the publicity is centered on the straw-man paleo critics and the ridiculous purveyors of “paleo” brownies and doughnuts. I do see a use for these on some level and I don’t begrudge anyone the right to make a living by selling grain-free garbage, just not with that smarmy stamp of “health” across the top. It’s no better than the American Heart Association approval across the top of cheerios or whatever stupid processed cereal product they decide to endorse (shoot, even the AHA is ambivalent about the grocery store, as I can’t get their grocery store heart check products list to even load at the moment).

 It’s like Christopher Nolan took over my blog and replaced the shining optimism of a summer blockbuster with the dark semi-antihero superhero (spoiler!) who breaks General Zod’s neck in front of the sobbing families in Grand Central Station or the Metropolis equivalent. Yet life is really positive and wonderful, and the kids are doing well, and business is booming.

The ultimate child-like medical journal (no grumpy, scene-stealing, genetically engineered to be two-dimentional Krytponian General Zods allowed) is Medical Hypothesis. The staid and serious need not apply. No question that the glorious and insane ideas unleashed there could spark a revolution in medical treatment. The next generation is inspired, unplanned, and is blessed with the looks of Henry Cavill (he is training at Gym Jones for the MOS sequel, can you confirm this, Dallas?). Maybe. Or maybe it’s all an optimistic waste of time or craziness. You never know until the battle to the death that makes it all clear at the end of the summer blockbuster.  Victoria Prince (with her shiny new MD and PhD in addition to her native awesomeness, not unlike like Natalie Portman in Thor) sent me an article from there about OCD and the gut microbiome.

OCD I’ve always considered to be one of the more “organic” of mental disorders. More neurology, less psychology. Let’s not confuse it with obsessive compulsive tendencies that have led many a med student to success. No, OCD is a heart-breaking disorder, where people get stuck with unwelcome, repetitive, ego-dystonic thoughts and engage in uncomfortable compulsions to relieve the anxiety of those thoughts. Typical thoughts include pedophilia in a teacher who would never dream of harming students, or killing your own children, or stealing, or running over someone, or being contaminated by germs. (Hoarding is thought of as a variant of OCD, but is more responsive to treatments such as stimulants, which typically make OCD worse). Worsening OCD symptoms tend to be caused by pregnancy (even typical post-partum depression symptoms are OCD in nature, worries about the harming the baby, germophobia, etc.) and other stressful life events. It’s horrible but, in my experience, typically amenable to the standard treatment, therapy with an OCD specialist and high doses of SSRIs. Hardly paleo but neither is an appendectomy. Seriously, I’ve had patients who have led shadow lives for decades, bothered by these intrusive thoughts, who tried therapy after therapy, finally convinced to take an appropriate dose of medication who are suddenly free of the obsessions, the compulsions, and the constant mental torture. It’s an awakening. Sol to the native-born Kryptonian. Stretched the metaphor too far? Sorry, you are reading the wrong blog.

But I’ve been interested in the microbiome for a long time. 90% of our personhood are these “other” cells who inhabit us. They communicate with our brain, serve as a major part of our immunity, and regulate our immune response. Right up until the 20th century (more specifically mostly before 1975) we co-evolved with parasites, certain commensal bacterial, and pseudocommensals. The major autoimmune diseases, such as multiple sclerosis, rheumatoid arthritis, asthma, etc. have increased in incidence and prevalence in the last thirty years (though peaking, in some instances, around 2000, prior to more aggressive anti-autoimmune medical care instituted early). OCD has long been considered a variant of an autoimmune disease (while most of my patients were affected in childhood, I do have a few who became symptomatic in adulthood after infection with lyme disease, herpes, or other neurologic pathogen, plausibly leading to an autoimmune attack on the brain causing chronic OCD symptoms.)

So what does Medical Hypothesis have to say about all this speculation? Both dietary and emotional stress are known to affect the microbial population. And the PANDAS associated with OCD might not be the problem…perhaps it is the antibiotics given to treat the strep infection? Let’s not forget that before antibiotics, people died right and left of scarlet fever and all sorts of bad things. Henry Cavill also struggles with throwing the baby out with the bathwater. Do I reveal myself and save the school bus full of children? [SPOILER] Does Kevin Costner really want me to let those children drown? Good thing the tornado takes away his crazy moral equivalency…

The Medical Hypothesis article calls for the trials of probiotics that we all deserve, except that everyone knows the only hard core way to permanently affect the gut microbiome is via helminth therapy (yes, introducing parasitic worms) or fecal transplant. If we are going to be radical, let’s go radical in a scientific and controlled and meaningful way.

I’m impatient sometimes. And no one wants to wait for everyone to wear blue-blocking glasses, get some general daily activity in already, and save the magic paleo cookies for a few special occasions a year. People want sensibility, convenience, beauty, and fresh air. A glorious man in Antarctica who can fly with his red cape in the light of our young sun. Coconut milk. Roast beast. Fermentation. They want a grumpy, two-dimensional villain, like Zod, or Carbsane, or the Medical Establishment, or the flu vaccine.

I get so many emails that break my heart. Can you help me, I’m sick, my relative is sick.

I have no magic elixirs. I am no Henry Cavill. I can barely keep myself operating sometimes with all the souls currently assigned to my watch. I couldn’t save my young cousin from sarcoma. I can’t save anyone. You have to save yourself.