Mammograms are going 3D

You thought that it was only blockbuster movies going 3D! Well, screening mammograms are now available in 3D. Instead of a traditional flat image, 3D mammography, otherwise known as tomosynthesis, provides multiple digital images of the breast in slices which are then reconstructed by a computer to generate a 3D image.
Until now, there has been little evidence that this new technology offers any advantage to regular film or 2D digital mammography.
We now have a study recently published in JAMA* that shows an increase in cancer detection rate, particularly for invasive breast cancers. Regular 2 D mammograms required 815 women to be screened to find 1 invasive breast cancer and 3D mammograms required 707 women to be screened. It also showed a decreased recall rate for additional images, 107 women versus 91.
The study was not done over a long enough period to determine if 3D mammograms actually improve outcomes for patients, i.e. less breast cancer deaths.
There are some downsides, chiefly a higher dose of radiation for women with large breasts and the possibility of over detection. When a screening test gets too good, it can pick up things that would never have actually become a problem. This can lead to unnecessary treatment and a whole lot of anxiety. Lastly, 3D mammography is more costly and some insurance companies are not covering it.
So who should get this new kind of screening? Most women will be fine with regular 2D, but for women who have dense breasts, a higher than average risk of breast cancer, or have had a lot of recalls in the past, 3D mammography may be better.

*JAMA,June 25, 2014, Vol 311, No. 24 

The Truth About Whole Grains

My husband absolutely detests whole wheat anything. He thinks it tastes like cardboard and has steadfastly refused to jump on the whole wheat bandwagon. Instead he just eats smaller portions of white bread and pasta less frequently. All my cajoling about whole wheat being healthier fell on deaf ears. Turns out that my non-physician husband with absolutely no formal nutrition training was absolutely right! Processed whole wheat is actually no better for you. So much for telling my patients to just eat the "brown" foods! When you take whole wheat, or any grain for that matter, and grind it into a meal or flour to make bread or pasta, you are increasing the surface area available for your digestive enzymes to break the carbohydrates down into sugars. Whole wheat bread has the same glycemic index (how much a food causes your blood sugar to rise) as white bread! Unfortunately, the Whole Grains Council considers a food to be a whole grain if it still contains the 3 components of a grain (bran, germ and endosperm)after processing. I found the Whole Grain Stamp on a package of Snyder's Multigrain Cheese Puffs whose only "grains" were corn meal and rice flour. Yet the label proclaimed "20 grams of whole grain per serving"! It drives me crazy that we are all being tricked into thinking we are making a healthier choice, when in reality we are being sold products that are no better for us than regular old Cheetos and Wonderbread. So, what can we do? Choose actual whole grains! Instead of instant oatmeal which is basically pulverized oats and sugar, make up a batch of slow cooked rolled oats. Brown rice, quinoa, millet, bulgur and spelt wheat can all be made into delicious side dishes or can form the basis of a whole meal. When it comes to bread and pasta,look for brands like Ezekiel or Mestemacher which use whole grains and sprouted grains instead of flour. Liana Krissoff's excellent "Whole Grains for a New Generation" cookbook offers loads of delicious ideas. And be like my husband, enjoy your white, refined flour products in moderation.

The Problem with Diet Books

I was on Amazon recently checking out diet books and the number was staggering. Atkins, South Beach, Paleo, Wheat Belly...the list goes on. They all seem to have 2 things in common. They all promise weight loss and to achieve this weight loss you must generally remove an entire food group from your diet (usually grains, although I did find one called The Carb Lovers Diet!). I have several problems with these diet books. Firstly, the word diet itself has so many negative connotations. Diets to me imply restriction and a certain level of misery! I would personally much rather focus on the foods I should be eating than the ones that I shouldn't. I recently completed a fitness challenge at work and I loved it that the weekly assignments were things like "eat 3 vegetables a day" and "eat lean protein with every meal" instead of "don't eat candy". I found that whenI was making healthy choices I was naturally making less unhealthy ones, but I felt a lot better about it! Secondly, diets are not sustainable. In my experience, people tend to follow a diet for a certain amount of time and when they have achieved their desired weight loss they slip back into old habits. I prefer to think in terms of lifestyle change instead of dieting because change implies permanancy and sustainability. Thirdly, many normal weight people also need help making healthier food choices and since most diet books emphasize weight loss, these books often seem inaccessible. Lastly and most importantly, most of these diet books are not based on good science. The current trend is to eliminate gluten, a protein contained mainly in wheat. There are few rigorous scientific studies to suggest that this is a healthy lifestyle change unless you have a medical condition like Celiac disease. I have seen patients come back after going gluten free unhealthier than they were before because a lot of gluten free products are based on corn and white rice which have a high glycemic index (i.e. raise the blood sugar). Following food fads can have dangerous consequences. 20 years ago fat was the boogie man and everything was marketed as low-fat. Our rates of diabetes skyrocketed because food manufacturers simply replaced fat with sugar. Instead of promoting the latest trendy diet, I would like to introduce you instead to the Mediterranean style of eating. It has been the most rigorously studied "diet" since the 1940s. In fact, just this year alone there have been 4 major medical studies showing its health benefits. The Mediterranean food pyramid is rich in whole grains, fruits and vegetables as well as fish along with dairy like greek yogurt and ricotta and mozarella cheeses. Nuts, olive and red wine feature prominently and red meat and sweets are eaten sparingly but are not completely forbidden. It is a nutritional approach that promotes moderation and emphasis is placed on physical activity and enjoying food with others. This style of eating can be modified to accomodate cultural food prefences and it works well for multiple chronic conditions like diabetes, high cholesterol, high blood pressure, etc. Oldways, a foundation promoting traditional diets has a wonderful section on Mediterranan eating. http://oldwayspt.org/resources/heritage-pyramids/mediterranean-pyramid/overview I would also recommend Dr. Ornish's wonderful book "The Spectrum" which addresses lifestyle changes for cardiovascular disease prevention and treatment and includes a section on nutrition, which he bases on the Mediterranean plan. As Michael Pollan said, the best way to eat can be summed up as "eat real food, but not too much and mostly plants"!

Welcome!

I have been occasionally blogging for my medical practice for the past couple of years and decided it was time to branch out and start my own blog. I am a family physician working in a primary care clinic and I am passionate about helping my patients make the lifestyle changes needed to prevent and reverse chronic illness. A recent study of 23,000 people showed that walking for just 30 minutes every day, not smoking, eating a reasonably healthy diet, and keeping a healthy weight prevented 93% of diabetes, 81% of heart attacks, 50% of strokes and 36% of all cancers. That's huge!! And all without more costly pills or risky procedures. Sadly, our medical system is still structured in such a way that I rarely have the time I need with my patients to discuss lifestyle changes. That's where I hope this blog will come in. I have called it "An Apple A Day" because I really hope that by adopting a healthier lifestyle, you will be able to keep the doctor away! (I'm okay with working myself out of a job:))