When I first received the letter welcoming me in, I thought it was “Another one” of those organizations that give doctors undeserved big titles in exchange for the doctors paying them.

Investigation of their web site (www.BestDoctors.com) revealed quite the contrary. In reality, to become a member of Best Doctors, you have to be nominated by a colleague and then letters of review are sent to many physicians in your area.  Many questions are asked of the doctors but the most important one is “if you as a physician or a member of your family had a medical problem in the area of expertise of this doctor, would you go to this doctor yourself?”

In light of this peer elected status, I am very honored to be chosen to be a member of this organization.

This organization sells its services to large Fortune 500 Companies. If a member of their company gets a difficult medical problem, the company contacts “Best Doctors” and they arrange for one of the best doctors in the country in the area of that particular person’s problem to do a consultation on the patient.

I have already written my first consultation in my specialty, which you all know is internal medicine/integrative medicine. It is a 69 year old man with atrial fibrillation who was totally into natural therapy and was wanting recommendations on integrating pharmaceutical medication with natural medication.

Of course, this is exactly my specialty and I received word from “Best Doctors” after reviewing my recommendations that my report was “superb” and they were very pleased with it. In exchange for my consultation I receive a nominal honorarium.

I look forward to helping many other people throughout the United States who are not my immediate patients.

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In order to help spread the word, I have written an article that was published on HuffingtonPost.com. I received great feedback from several other bloggers and entering the blogosphere is exciting for me as a physician!

In the best of all worlds, you will ask me to get a Vitamin D level (if I don’t bring it up) the next time you see me, and we can exactly define your correct Vitamin D dose and bring you up to optimal levels.
 

But in the meantime, until your next visit to me, please start yourself (if you are not already) on 1,000 International Units (IU) of Vitamin D per day, which you can get from our dispensary (or from the health food store).

Recent articles have shown that Vitamin D dramatically stimulates the expression of  anti-microbial peptides which are in our white cells as well as the cellular lining of our respiratory tract, where they play a major role in protecting the lungs from infection.  This study shows that Vitamin D either derived from sunlight or pills, reduces the incidence of respiratory infections.

In summary, please take your Vitamin D!

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We have always assumed that the reason people get sick when they fly is the concentration of people they are exposed to at the airport, and of course, on the airplane, including the person sitting next to them.

Now a new article has appeared in the medical literature entitled, "Management of Exposure to Aircraft Bleed Air Contaminants Among Airline Workers: A Guide for Healthcare Providers."

This article points out that the outside air supplied to the cabin/flight deck on commercial aircraft ("bleed air") may sometimes be contaminated with Pyrolyzed Engine Oil and/or Hydraulic Fluid.

The article goes on to state that "as a result of this contamination, airline workers and passengers may develop acute and/or chronic health effects."
 

The list of symptoms which the article reviews, the common symptoms that we see in patients who have flown, include eye, nose or throat irritation, wheezing, and cough.

However, the surprising thing is that other symptoms including neurological symptoms like headache, dizziness, memory impairment and concentration difficulties along with intestinal symptoms including nausea and vomiting and diarrhea, as well as psychiatric symptoms, such as anxiety, sleep disturbance and even PTSD, are also connected with exposure to contaminated bleed air! The article even goes on to say that chronic symptoms can result from exposure to contaminated bleed air.

The article also points out other causes of patient’s flying and getting sick. This includes ozone, insecticides including Piperonyl Butoxide, De-icing fluids, disinfectants and deodorizers and exhaust fumes from ground vehicles. All the list of symptoms can also be caused by these additional exposures on airplanes.

The interesting thing to me is that this article (referenced below), talks about the effects primarily as being on aircraft personnel. However, I know that a significant number of my patients fly more than the legal limit allowed for airline pilots per month! For me as your physician, this additional information is very helpful.

Of course when I see patients after an airplane ride, we must treat their acute symptoms, but sometimes their "unusual symptoms" including the neurological ones, are mystifying to me and the neurologists that I send them to.

What can we do about this?!  The bottom line, of course, is practically nothing. When we are sitting on an airplane, we are all breathing the same air.

However, this information further stimulates me to encourage all my patients to be on a "permanent detox program" in an effort to minimize the Total Body Burden that I so often talk with you about.

For further information on this, I refer you to the "Total Body Burden" article I wrote, which is downloadable from my website at www.khalsamedical.com 

I also refer you to Sherry Rogers’ book, "Detoxify or Die."

I look forward to talking with you about this when I see you in the office.

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With rare exception, taking antibiotics before your dental appointment or your surgical procedure is no longer required!

The rare exception would be somebody with severe mitral valve prolapse with significant mitral valve regurgitation. The few of you in my practice who have this are aware of who you are.

Things have come so far in the last 40 years with the issue of antibiotics in Mitral Valve prolapse patients. In 1970 it was two days of antibiotics before the dentist. About 1980 it was just one dose before and one dose after the dentist. Then about 1990 it reduced to one dose ONLY before the dentist, and now this good news of NO antibiotics before Dental work is most welcome by me and all my patients!

Prevention of Infective Endocarditis. Guidelines From the American Heart Association. A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.Prevention of Infective Endocarditis. Guidelines From the American Heart Association. A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Oct 9;116(15):1736-54. Epub 2007 Apr) 19.])

Click here for Reference

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Many of my patients have done this test (as have I), and over the last year, over a dozen of my patients have had cardiac interventions to prevent heart attacks because of the information from this test.

A few things have held patients back from getting this test.  The first understandable reservation was about the amount of radiation given on the coronary CT Angiogram.  It has been equal to approximately 50 current chest X-rays. 

The other consideration holding people back, understandably, was the cost, which is $1500.

I am happy to let everybody know that now through major technology improvements both Cedars Sinai Hospital and Cardiovascular Medical Group (CVMG ) have been able to drop the radiation dose by up to 90 per cent!

Below I have a summary of estimated radiation doses for the new vs. the old cardiac imaging studies which Dr. Daniel Berman and I put together. 

You can see that the amount of radiation with the new low dose coronary CT Angiogram is now approximately the same as a simple CT coronary calcium scan (also known as EBCT)! 

To me this is very exciting news as previously wanting to avoid the large dose of radiation with a CT Angiogram, we have been doing the simple CT coronary calcium scan (EBCT).  But because this only shows calcified plaque on the wall of the arteries, we have also had to do a treadmill test to make sure there is not an extreme amount of soft plaque which will be missed by the simple EBCT.
 

Now that we have the much lower-dose coronary CT Angiogram which shows the soft plaque on the inside of the artery walls as well as the hard plaque on the surface of the walls,  it seems obvious that this is the best test to do. Financial considerations must include the recognition that if you only get the EBCT you will also need to do a treadmill or Nuclear Treadmill or Stress Echo and those have significant costs as well. 

In addition, because this test is so thorough, if a patient comes out “completely clean or nearly clean”, they will not need another heart screening test for 2, 3, or 4 years! 

In summary, I am so happy that Cedars-Sinai Hospital and CVMG have developed this test and

I would be delighted to talk to you about the relevance of this test for you and your health at our next office visit.

Summary of Estimated Radiation Doses
for Cardiac & Chest Imaging Studies

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          For decades our society has assumed that calories are the name of the game; specifically, as long as you adjust the calories with the right ratio of protein, fat and carbohydrate percentages, there will be a favorable outcome.

          Now there comes an exciting study that shows the role of Nutrigenomics on our biochemistry and subsequently on our health in general.
          Nutrigenomics is the science that studies how our nutritional intake affects the expression of our genes. We learn in medical school, and many people still believe, that if you have a “certain gene” you are predestined to develop a certain health condition. The new science of genetics however shows us this is quite erroneous. Specific environmental factors –  which include the very nature of the food we eat and other nutrients we intake, as well as toxins in our environment — can turn on or off the genes that we have received from our parents. This is all to say, “there are many you’s within you."

The food we eat delivers information to our genes and thus affects how those genes express themselves. As the genes express themselves, so is our biochemistry.
 

The most recent public example of this information is Morgan Sperlock in his movie, “Super Size Me.” In this movie, Mr. Sperlock had more than just super-sizing of calories. “He also had super-sizing of bad information from toxic food that was inducing different gene expression patterns.” It was not just the calories in and of themselves that created the multiple effects he saw in his body, but the information in the particular calories that he consumed.

          Now in this exciting study from the Journal of Nutrition, we get an answer to the question, “What happens if you hold the percent of calories as protein, carbohydrate and fat comparable, but you change the information coming from the food between the two groups?” If you do this “Would there be a difference in outcome in the two groups?”

          The bottom-line results of this study showed such an overwhelming difference between the two groups, that no one can help but recognize the power of Nutrigenomics in our health.

          Specifically in this this study by Lukaszer, Bland, et al,  they took two groups of post-menopausal women at risk for coronary artery disease. (Cardiovascular disease, as everyone knows, is the leading cause of death in both women and men.)

          Half of the women in this study followed the American Heart Association’s proven diet program for weight loss. The other half of the group was put on a “low glycemic index” (LGID) diet which included protein powder containing soy isoflavones and phytosterols. All patients in the study were followed for 12 weeks.

          The study results showed that both groups lost about the same amount of weight, as would be expected from the American Heart Association Diet Guidelines. (AHAD)

          The results also showed that the American Heart Association diet group had an improvement in their total cholesterol and their triglycerides and their body composition. But, “these changes paled in comparison to the members of the LGID group, who had the same calorie intake and the same exercise, but had a different level of phytochemical intake and different diet persuasion. These individuals had a 46% reduction in their triglyceride to HDL cholesterol ratio and a significant reduction in total and LDL cholesterol.  They also had a significant reduction in their highly sensitive C-reactive protein (hsCRP), a significant reduction in fasting insulin” as well as another measurement that indicates tendencies toward diabetes or pre-diabetes.

          The degree of difference in improvement between the AHAD group and the LGID group was statistically significant at levels rarely seen in the medical literature. For example, on the LGID diet, there was a significant decrease of the total cholesterol/HDL cholesterol ratio at a p value less than 0.0001 level, as well as the triglyceride/HDL cholesterol ratio, also at the level of  p less than 0.0001.

          Of note, the total cholesterol to HDL cholesterol ratio did not significantly change at all for the AHAD group. The triglyceride/HDL cholesterol ratio approached, but did not reach, significance in this group, either.

          What this study tells us is the extreme power of Nutrigenomic tailoring that leads to our getting the right information sent to our genes to produce the improved outcome.

          Jeffry Bland, in his review of this article, went to the medical literature to ask what drugs the LGID group of patients would have needed to be on to produce the same effects. Dr. Bland concluded the results were equivalent to putting patients on three drugs: Statins (for cholesterol) , Metformin ( for blood sugar), and ACE Inhibitors( for blood pressure and other heart risk factors).

          As Dr. Bland comments, these results “represent the best medicine, not alternative medicine, not complementary medicine, not integrative medicine, but the best medicine.” This is very exciting information, indeed, and something I want all of my patients to be aware of!

          I would like to make a comment about the fact that some people talk about the “toxic effects of soy.”  This is surprising in light of the fact that “there are hundreds of clinical trials that are published in the medical literature that demonstrate the beneficial effects of moderate amounts of soy in the diet.” This study showed that with “appropriate intake of approximately 30 milligrams of soy isoflavones (part of the soy protein isolate that is found in the LGID beverage and in the context of an overall well balanced low glycemic-index diet which is rich in plant foods, there are no toxic effects” from soy.

          Quite the opposite, as the article shows: “there is a highly desirable effect on every lipid, glucose, insulin, inflammation connection that was studied.”

          This is the future of medicine. We are watching a transformation facilitated by our increasing knowledge about the roles of our environment and our diet in relation to our gene expression and the resultant outcome in our daily health.

          This study clearly shows that often the very best medicine is found in the particular nutrients that we put into our bodies on a daily basis, along with the information that they carry to our genes.

          I invite all of my patients to have a lively conversation with me about this most exciting development in medicine.

Reference

Lukaczer, D., J. L. Deann, et al. (2006). "Effect of a low glycemic index diet with soy protein and phytosterols on CVD risk factors in postmenopausal women." Nutrition 22(2): 104-13.

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I have been friends and colleagues with Jeff for over 25years. He is a brilliant biochemical-nutrition researcher and teacher and he always teaches me wonderful information that allows me to help my patients using Nutritional Therapies.

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However, in recent months, information on Vitamin D has been flooding the news media. Insufficient Vitamin D levels are linked to diseases as diverse as osteoporosis, diabetes, cancer, heart disease and multiple sclerosis. Simply stated, insufficient Vitamin D weakens the immune system.

Vitamin D is an unusual vitamin in that we do not get it from food (except as added by the food industry), but rather from direct sunlight onto our skin.  Prior to the Industrial Revolution, people had no trouble getting significant amounts of sunshine and therefore Vitamin D. Nowadays, with people working more indoors, and dermatologists recognizing the connection between excessive sun exposure and skin cancer, people are wearing sunblock every time they step out the front door. Sunblock is now even put into cosmetics that women use routinely.

A recent article in the American Journal of Clinical Nutrition speaks to the subject of dietary Vitamin D requirements during pregnancy and lactation.  It appears the current governmental recommendations of 200-400 International Units (IU’s)  per day are woefully inadequate; at least 1000 IU’s per day are required by a woman during her pregnancy to assure optimal nutrition for both her and her fetus. Some specialists are suggesting even higher doses are required during pregnancy.

          With regard to Vitamin D and cancer, Professor Michael Hollick from Tuft’s University is quoted in a recent interview as saying that in Europe an estimated 25% of women who die of breast cancer might not have died of their breast cancer if they would have maintained adequate Vitamin D levels throughout their life and had some sun exposure.  Dr. Hollick also linked inadequate Vitamin D to a higher risk of getting prostate cancer and colon cancer. This is congruent with the recent study published and widely circulated on international television that Vitamin D deficiency is a contributor to pancreatic cancer.

          In this same interview, Dr. Hollick also stated that there was some evidence that if young children are fortified with Vitamin D from the age of one year and on, it can  reduce by 80% their risk of getting Type I Diabetes. Dr. Hollick has also found high blood pressure can be responsive to Vitamin D.

          In the same interview, Professor Rebecca Mason noted that Vitamin D markedly increases cell survival and reduces the DNA damage in surviving cells. She also stated that her research shows cells treated with Vitamin D did much better after being exposed to ultraviolet light and that Vitamin D helps the body to kill cancer cells.

          In the same interview, Professor Terry Diamond pointed out that if you correct the Vitamin D deficiency in a population at higher risk for osteoporosis, you can reduce the risk of hip fractures by 25-40%.

          I attended a recent conference where Dr. Hollick spoke about how many patients diagnosed with fibromyalgia are sent to him. They almost always are deficient in Vitamin D. With Vitamin D replenishment the aches and pains, especially in the neck and shoulders, often disappear. Dr. Hollick points out that these patients have osteomalacia rather than fibromyalgia and Vitamin D corrects the osteomalacia. [What is osteomalacia?] I have observed that Vitamin D replacement has indeed had this same effect on many of my own patients.

          The question about adequacy of Vitamin D is compounded by the government’s current recommendations of normalcy. Most laboratories are still reporting a normal blood level of Vitamin D as greater than 20 ng/mL.  In point of fact, Dr. Hollick’s research indicates that a minimum level is approximately 30 ng/mL.

          In many holistic practices of medicine, including mine, when treating people with diseases which have a Vitamin D insufficiency connection, we will endeavor to get the Vitamin D level over 50 ng/mL.  Please note that safe levels go up to 100 ng/mL.

          Of note, many physicians are ordering the wrong Vitamin D test. The correct Vitamin D test to order is 25 Hydroxy Vitamin D and not 25 Di-Hydroxy Vitamin D.

          Because of the newly recognized critical importance of this vitamin, I now routinely check all new patients and all current patients at their annual physical, for a Vitamin D level, just as I would check their cholesterol and their blood sugar.

          So far in my practice, approximately 90% of all new patients are insufficient or deficient in Vitamin D.

          If you are my patient and have health risks in any of the medical areas  I have mentioned above, please ask me to check your Vitamin D level.  If you are  not my patient, please ask your primary care physician to appropriately check your levels and prescribe therapy as needed to correct any insufficiency or deficiency.

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Recently the Vitamin D Council has published a paper entitled, “Epidemic Influenza and Vitamin D” by Dr. John Cannell. In this article, Dr. Cannell and his colleagues propose that Vitamin D deficiency is the reason influenza is much more common in the winter than in the summer.

Vitamin D is the only vitamin made by the human body and for that reason it is called a Pro-Hormone. We need ultraviolet B radiation (UVB) from the sun, in order to allow the skin to manufacture Vitamin D for our body. In Northern climates, including most of the United States, we just don’t get enough sunshine and therefore not enough UVB to make adequate Vitamin D in the winter. In addition, ozone (for example, smog) blocks the UVB, so even those places like Southern California that are getting plenty of sunshine, have a reduced amount of UVB in the winter.

 In addition, sunblock, which most of my patients use on a regular basis, blocks the UVB and prevents the manufacture of Vitamin D by the skin.

 In my opinion, dermatologists have done a good job of teaching us that the sun can cause skin cancer, but they have lost track of the fact that we need at least a few minutes of sun without sunblock on our skin several times a week in order to manufacture Vitamin D.

 The whole situation is complicated by the persistence of the official recommendations of the United States government for normal blood levels. The government, for a long time, has maintained that 20ng/mL is sufficient in the blood.

Due to extensive research in the field of Vitamin D by Dr. Michael Holick and his colleagues, we now know that blood levels should be higher than 33ng/mL and can go up to 100ng/mL without harm. In addition, many of my colleagues and I feel that any patient with a health problem involving their immune system is best served by a Vitamin D level of 50ng/mL or above.

As a result of this new information and the connection of Vitamin D with the winter flu, I am aggressively getting Vitamin D blood tests in all of my patients to insure that they are above 33ng/mL. Otherwise we are replacing them with oral Vitamin D.

For those reading this article who are not my patients, please note that the correct blood test for Vitamin D is the 25 Hydroxy Vitamin D level, not the 1,25 dye Hydroxy Vitamin D, which we were taught in medical school.

In addition, the very best technology for evaluating the Vitamin D level is now available which is liquid Chromatography, Mass-Spec. At my office, we now exclusively use this test.

Vitamin D deficiency has so many adverse effects on our body that I plan to continue in the near future with an additional blog on the many full roles of Vitamin D in human health. If you are interested in learning more about Vitamin D I refer you to the Vitamin D Council website.

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What does it mean, and why is it important?

For years the gold standard for evaluating disease or plaque in the arteries of the heart, called coronary arteries, has been the angiogram. To do an angiogram, you are taken into an operating room at the hospital. An incision is made in your groin and a very long, approximately 36 inch catheter, is inserted into your groin up your aorta and into the heart arteries. Under x-ray fluoroscopy the doctor injects dyes through the catheter into your heart arteries and then takes Cine pictures. These pictures show plaque or blockage of the arteries and we can get an exact measurement of whether your arteries are completely open, 20% blocked, 50% blocked, 80% blocked, 95% blocked. Once an artery is over 90% blocked, there is significant risk for an immediate heart attack.

Because the traditional angiogram of this type is obviously very invasive and quite expensive, we have never been able to do this in a routine fashion.

Instead, over the last years, we have developed and now do an “indirect” test to evaluate if there is blockage in the coronary arteries. Specifically, tests that we have for this include the regular treadmill test, a stress echo test, and a nuclear stress test. Each of these tests attempts, through indirect measurements, to get an idea if there is a significant blockage in the arteries. However, each of these tests goes abnormal only when there is an approximately 70% or greater blockage of the artery. In other words, if you have a 60% blockage in an artery, these tests all look perfectly normal.

Obviously it would be very helpful to know if you have a 40, 50, 60, or 70% blockage, as it is a heads up that we must be more aggressive about medical management, including lowering cholesterol, so that the plaque does not progress to the point where invasive procedures or open heart by-pass surgery is required. However, the current level of technology until the recent CT Angiogram did not allow this information.

Approximately 7 years ago, the EBCT or Electronic Beam Computerized Tomography was developed, which was able to see calcified plaque in the coronary arteries. We have known all along that there are two types of plaque: the hard or calcified plaque and the soft plaque. We also know that the EBCT does not allow us to see the soft plaque at all, but this is the best test we have had and it allowed us to at least get a head’s up whether a person was significantly calcifying their arteries. People with high levels of plaque went on to more diagnostic studies to assure that they were not having a critical blockage, whether hard or soft plaque. But we were never able to get an estimate of the soft plaque because we could not see it with that technology.

Then within the last one year, new 64 bit computer technology, for the first time, has allowed us to actually get cross-sectional images of the coronary arteries. This shows both the hard and the soft plaque! Therefore with this CT angiogram, we are able to tell you if you have a 10, 20, 30, 50, 70, 80 or 90 plus percent blockage. This non-invasive technology correlates very highly with the hospital angiogram that I described above. The beauty of the new technology is that it is a minimally invasive test. Specifically, only an IV is started on your arm. Dye is then injected through the IV while you are under the scanner and the beautiful cardiac images showing all the coronary arteries in 3-dimensions emerge from the computer. The total time from when you first change your clothes at the doctor’s office until the time you put your clothes back on, is 30 minutes. At that time, you just go back to work. Results are usually available by the next day. Obviously this is a complete contrast to the hospitalization that is required (often with an overnight stay in the hospital) for a traditional angiogram. The time and expense involved in that is prohibitive for routine use.

Already this test has helped dramatically in the clinical care of my patients.

One 55 year old woman with a family history of heart disease (but absolutely no symptoms) underwent, on my suggestion, the CT Angiogram. To our shock it showed a 95% blockage in her left coronary artery. The next day we were able to take her into the hospital and open the 95% blockage with traditional angioplasty and stent placement and the patient was fine. Without this technology, this patient would have become a statistic, as sudden death was in her immediate future.

Another 48 year old entertainment executive came to me with chest pain. Clinically it seemed like musculo-skeletal, but given that it was going down his left arm, he was absolutely convinced it had to be cardiac. Once we did the tests to assure ourselves that it was not an acute heart attack, he underwent the CT Angiogram. Thirty minutes later we found his coronary arteries to be wide open. The amount of relief and happiness in his face and eyes on hearing this information was truly touching. By the next day, with a couple of Advils, his muscular-skeletal chest pain was resolved.

With all this information you can see why I am so excited about this new technology for helping my patients to get this critical information about the status of their heart. Since heart disease is the number one killer of men and women in America, I believe this test is the very best test we have for everybody over 50 and for those in their 40s with family histories of heart disease and high stress in their lives.

An additional benefit is if a person’s arteries show no significant blockage, they really don’t need any other diagnostic tests, such as treadmill tests for coronary artery disease, for some years. For all of these reasons, I highly recommend this test to my patients for whom it is relevant.

Insurance companies are starting to cover this test for people who have documented heart disease. Otherwise, patients must pay out of pocket. Please note that this test also includes the older Calcium Scan of the heart .

I also want all of my patients to know that the radiation from this test is equivalent to 100 chest x-rays. This sounds like a lot but in the scheme of things the benefit of knowing about your heart, in my opinion, far outweighs this radiation exposure.

I urge you to consider it for your individual situation.

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