Plant-Based Diets Are Not Nutritionally Deficient

[Letter]. Perm J 2013 Fall;17(4);93

http://dx.doi.org/10.7812/TPP/13-111

Re: Tuso PJ, Ismail MH, Ha BP, Bartolotto C. Nutritional update for physicians: plant-based diets. Perm J 2013 Spring;17(2):61-66. DOI: http://dx.doi.org/10.7812/TPP/12-085

Dear Editor,

We would like to thank Phillip Tuso, MD, and associates for their comprehensive review of the evidence supporting the value of plant-based diets for preventing and curing the epidemic of diseases caused by overnutrition that are sickening millions of people in the US and crippling our nation’s economy. However, counterproductive to the authors’ goal that "physicians should consider recommending a plant-based diet to all of their patients" is the authors’ dedication of a substantial portion of their article to the possibility of deficiencies of selected nutrients. In our experience of treating more than 5000 patients with a low-fat, whole foods, plant-based (vegan) diet, with follow-up lasting as long as 28 years, we have not seen any deficiencies of protein, iron, calcium, or essential fatty acids. (We do recommend to our patients a vitamin B12 supplement and adequate sunshine for vitamin D.)

Tuso et al characterize the risk of these deficiencies as low, but deserving of monitoring. The risks are so low that illnesses because of the lack of any of these essential nutrients, including protein,1 have not been reported to occur on any natural human diet (as long as calorie intake is sufficient). Dietary manipulation or supplementation to improve the overall quality, or to increase the absolute quantity, of protein, iron, calcium, or fatty acids has not been found to be beneficial. To the contrary, excess protein is a major contributor to bone loss,2 kidney stones, and kidney failure.3 Although iron stores may be lower in vegetarians, there is no reported increase in incidence of iron deficiency anemia.4 Data supporting the benefits of calcium supplementation to improve bone health is lacking, and adverse effects, such as an increased risk of fracture5 and myocardial infarction6 from supplementation have been reported.Plasma levels of essential fatty acids can be lower in vegetarians, but there has been no reported clinical consequence of this laboratory finding.7 In addition, randomized placebo controlled trials for the primary8 and secondary9 prevention of cardiovascular disease with omega-3 supplements have been disappointing as of late. Furthermore, there is concern that these "good fats" may increase the risk of common cancers, including prostate cancer.10

More than a half-century of creative marketing by the meat, dairy, egg, and fish industries has produced fears surrounding nonexistent deficiencies, which in clinical practice need no patient monitoring by physicians and dietitians. Hopefully our concerns for overemphasizing the importance of largely theoretical risk will remove an unnecessary hindrance to the acceptance and practice of scientifically sound plant-based diets as recommended by Tuso and associates.

Craig McDougall, MD
Northwest Permanente, Portland, OR

John McDougall, MD
The McDougall Program, Santa Rosa, CA

References
1. Millward DJ. Meat or wheat for the next millennium? Plenary lecture. The nutritional value of plant-based diets in relation to human amino acid and protein requirements. Proceedings of the Nutrition Society 1999 May;58(2):249-60. DOI: http://dx.doi.org/10.1017/S0029665199000348
2. Frassetto LA, Sebastian A. Commentary to accompany the paper entitled ‘Nutritional disturbance in acid-base balance and osteoporosis: a hypothesis that disregards the essential homeostatic role of the kidney’, by Jean-Philippe Bonjour. Br J Nutr 2013 Jun 17:1-3. DOI: http://dx.doi.org/10.1017/S0007114513001499
3. Adeva MM, Souto G. Diet-induced metabolic acidosis. Clin Nutr 2011 Aug;30(4):416-21. DOI: http://dx.doi.org/10.1016/j.clnu.2011.03.008
4. Hunt JR. Bioavailability of iron, zinc, and other trace minerals from vegetarian diets. Am J Clin Nutr 2003 Sep;78(3 Suppl):633S-639S.
5. Seeman E. Evidence that calcium supplements reduce fracture risk is lacking. Clin J Am Soc Nephrol 2010 Jan;5 Suppl 1:S3-11. DOI: http://dx.doi.org/10.2215/CJN.06160809
6. Bolland MJ, Avenell A, Baron JA, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 2010 Jul 29;341:c3691. DOI: http://dx.doi.org/10.1136/bmj.c3691
7. Sanders TA. DHA status of vegetarians. Prostaglandins Leukot Essent Fatty Acids 2009 Aug-Sep;81(2-3):137-41. DOI: http://dx.doi.org/10.1016/j.plefa.2009.05.013
8. Risk and Prevention Study Collaborative Group; Roncaglioni MC, Tombesi M, Avanzini F, et al. n-3 fatty acids in patients with multiple cardiovascular risk factors. N Engl J Med 2013 May 9;368(19):1800-8. DOI: http://dx.doi.org/10.1056/NEJMoa1205409
9. Galan P, Kesse-Guyot E, Czernichow S, Briancon S, Blacher J, Hercberg S; SU.FOL.OM3 Collaborative Group. Effect of B vitamins and omega 3 fatty acids on cardiovascular diseases: a randomised placebo controlled trial. BMJ 2010 Nov 29;341:c6273. DOI: http://dx.doi.org/10.1136/bmj.c6273
10. Brasky TM, Darke AK, Song X, et al. Plasma phospholipid fatty acids and prostate cancer risk in the SELECT trial. J Natl Cancer Inst 2013 Aug 7;105(15):1132-41. DOI: http://dx.doi.org/10.1093/jnci/djt174

Response to Drs Craig and John McDougall

We thank Drs John and Craig McDougall for their interest in our article. Although we understand their point of view, from a clinical perspective, we are obligated to inform physicians of potential concerns, even if the risk for harm is low.

It may be true that eating a healthy, plant-based diet can offer the optimal amount of most nutrients needed to support health. Not every person however, will follow a quality diet, so it is important for physicians to understand what these potential concerns might be.

Phillip Tuso, MD
Mohamed Ismail, MD
Benjamin Ha, MD
Carole Bartolotto, MA, RD

 

 

More from this Journal section

Letters to the Editor - Obesity
Monday, 30 August 2010
Winter 2011 - Volume 15 Number 1 Original Letter Dear Editors and Readers, I thank the editors for this opportunity to respond to Vincent Felitti, MD’s comments on our article: Effects of 12- and 24-Week Multimodal Interventions on Physical Activity, Nutritional Behaviors, and Body Mass Index and its Psychological Predictors in Severely Obese Adolescents at Risk for Diabetes,1 for which I was the primary author. Although I wholeheartedly agree with Dr Felitti that providing basic education, alone, has not made even a dent in the obesity problem, I also have concerns with several of his statements made in his Letter to the Editor, which appeared in the Fall 2010 issue. Some issues may have their basis in my being a behavioral scientist (focused on health behavior change) within the emerging field of health psychology. For example, his concern that we, “and with many others,” lack focus on “Why these children became obese …” seems to be indicative of a common criticism of behaviorists who, admittedly, are more concerned with obtaining sustained behavioral changes than dwelling on possible underlying psychological factors. Many within our discipline believe that, in our quest for large-scale changes in health behaviors (within an epidemic of obesity and sedentarism), it is an inefficient use of our resources to seek out nuanced personal psychosocial factors that may or may not lead us to effecting changes. Rather, we seek to uncover meaningful patterns in psychological variables that may be used to reliably advance desired behavioral changes, with an eye on disseminating evidence-based treatments based on those findings to the many, rather than a few. In the real world, such interventions may best be delivered through referrals to trusted community organizations (eg, YMCAs), considering the reality of time restrictions that physicians are under. Dr Felitti also stated that we “avoid exploration” of constructs such as “self-concept, general self, and overall mood,” but just the opposite is true. This article is just one of dozens of peer-reviewed reports that I have authored in which we used established behavioral models (here, social cognitive theory as developed by Albert Bandura) to derive treatments that focus on predictors of sustained improvements.2-6 Other researchers skillfully continue this quest through similar scientific means. For example, behavioral theory (specifically, self-efficacy theory) suggests that individuals feel an improved sense of accomplishment, self-concept, and self-efficacy when they perceive that they can make meaningful progress while applying themselves to a task they see as worthwhile. This leads to sustained health behavior changes. Thus, treatments following self-efficacy theory may incorporate systems where long-term goals are broken down to short-term goals. As a reasonable plan of action is facilitated and adhered to, and incremental progress is documented, feelings of self-efficacy emerge. Unfortunately, left on their own, people typically set lofty goals, get disappointed by slow progress, and relapse to their original behaviors. Although it is true that we have little knowledge of “Why” one person complies while most do not, we have been able to systematically empower the skills needed for sustained change—and that’s quite worthwhile. Another example of this is when we teach self-regulatory skills such as positive self-talk, cognitive restructuring, and thought stopping. Although we do not know why negative self-statements emerge and undermine progress, we feel that a primary focus should be to teach how to realign self-talk when it becomes unproductive. In the treatment referred to in our article, a computer program was used to help in the large scale dissemination of these and other behavioral methods. I hope that this letter serves to clarify our perspective in designing the research and interpreting its findings. It is true that although the behavioral methods used succeeded in increasing the severely obese adolescents’ physical activity levels (just as theory predicted), the nutrition education portion failed to obtain much change. As mentioned in the Discussion section, we are preparing to better apply behavioral theory to the nutritional portion of the treatment in the future. In fact, through studies such as the one focused on here, we recently found that, when administered properly, A) exercise-induced mood change is associated with reduced emotional eating, B) self-regulation skills learned in an exercise context “generalize” to self-management for controlled eating, and C) self-efficacy derived from persistence with an exercise program carry over to confidence in sustaining improved eating. It stands to reason that our future weight management efforts build upon these findings. Such is the nature of applied research. I hope that, ultimately, behavioral science will gain the trust of the medical community so that, as a team, we may contribute to the large-scale prevention and treatment of physical inactivity and overeating behaviors. To be of best service to society, we must efficiently use our resources, effectively incorporate the most current knowledge base of our fields, and accept the responsibility to facilitate meaningful health behavior changes. James J Annesi, PhD, FAAHB Director of Wellness Advancement YMCA of Metropolitan Atlanta, GA References 1.    Annesi JJ, Walsh AM, Smith AE. Effects of 12- and 24-week multimodal interventions on physical activity, nutritional behaviors, and body mass index and its psychological predictors in severely obese adolescents at risk for diabetes. Perm J 2010 Fall;14(3):29-37. 2.    Annesi JJ, Gorjala S. Changes in theory-based psychological factors predict weight loss in women with Class III obesity initiating supported exercise. J Obes 2010:2010. pii:171957. Epub 2010 Jun 2. 3.    Annesi JJ. Relationship of physical activity and weight loss in women with Class II and Class III obesity: Mediation of exercise-induced changes in tension and depression. Int J Clin Health Psychol 2010 Sep;10(3):435-44. 4.    Annesi JJ, Whitaker AC. Psychological factors discriminating between successful and unsuccessful weight loss in a behavioral exercise and nutrition education treatment. Int J Behav Med 2010 Sep;17(3):168-75. 5.    Annesi JJ, Whitaker AC. Psychological factors associated with weight loss in obese and severely obese women in a behavioral physical activity intervention. Health Educ Behav 2010 Aug;37(4):593-606. 6.    Annesi JJ. Relations of mood with body mass index changes in severely obese women enrolled in a supported physical activity treatment. Obes Facts 2008;1(2):88-92.   July 2010 Dear Editor, I am writing in support of the article in the Spring 2010 issue1 by Felitti et al summarizing their work over the last 25 years running the Kaiser Positive Choice Weight Loss program, which details the struggles and successes of treating obesity using supplemented absolute fasting in conjunction with weekly group therapy. For the last five years, I have been naively prescribing my obese patients a formula that goes something like this: to lose weight, calculate your basal metabolic rate, add on an activity factor and then eat 500 calories less than that each day. Using this formula, they would lose one pound a week and in time, they would shed the weight. In theory this is true. My paradigm was recently broken when I read Dr Felitti’s recent article. Out of curiosity, I drove down to their San Diego clinic and visited the group. I met with Dr Felitti, Dr Ray, and Kathy Jakstis who lead the clinic and also sat in on a prospective member orientation and a group that had been meeting for more than 12 weeks. The following findings particularly struck me: As Dr Felitti points out, obesity is not a disease. It is a sign, similar to tachycardia or jaundice. Then what is the cause? Well, rarely are people born obese. This was shown in Dr Felitti’s interview of 2000 obese patients with only one individual having been born obese. The only aspects of obesity that are genetic are a person’s distribution of fat (ie, do they hold excess weight in their abdomen, buttocks, thighs) and the maximal weight the human frame can hold (approximately 1100 lbs for men and 850 lbs for women). In addition, rarely do people gain weight in a linear fashion. It usually occurs in an abrupt fashion following a specific event in life. If that is the case, then in obese patients, we have to ask two fundamental questions—what caused them to gain weight and what keeps the weight on. To answer the first question, obese patients appear to be using the psychoactive benefits of food to heal past traumas. Thus, food is the “solution” and obesity is the result of too much of that “solution.” However, there are other ways to respond to past traumas. We as humans exert free will and thus the stimulus-response equation is different in all of us—some negative (nicotine, gambling, alcohol, high-risk sexual behavior, overeating), some positive (medications when appropriate, meditation, counseling). This explains why not all patients who have experienced traumatic events respond by becoming obese. Only those who choose to medicate themselves with food would travel this route. Easy access to food is also a necessity, explaining why those who suffer severe trauma cannot always use food to medicate these wounds if the food simply does not exist (ie, concentration camp victims, prisoners). To answer the second question, obese patients appear to maintain the weight gain because it is beneficial to them socially, physically, and sexually. Sexually, because it wards off the unwanted attention of others; physically, because it provides a means of intimidation and power, and socially, because people tend to expect less from you. When comparing the obese population to the lifelong slender population, the obese have more than double the rates of family discord, ie loss of a parent in childhood, at least one alcoholic parent, the suicide of a family member, current marital dysfunction, personal history of divorce.2 This program appears to be successful although longer-term follow-up data are clearly needed. At present, at 18 months, half of the participants keep off more than 60% of the weight lost. Standard weight loss programs report weight loss of 5% to 10% of initial weight at 12 months.3 Patients who have undergone bariatric surgery lose an average of 25% of their initial weight at 12 months and this weight loss appears to hold at greater than 48 months4 although tracking these patients is difficult. Medically supervised absolute supplemented fasting is safe, effective, and surprisingly well tolerated by patients. But that is not in dispute—if you take in fewer calories than you expend, you will lose weight. Maintaining the weight lost is the difficult part. Many methods exist and have been studied.5 Dr Felitti’s approach of accompanying weight loss with ongoing counseling to reveal the underlying psychological need to use the psychoactive benefits of food to medicate oneself, and to address the benefits of keeping that weight on appears to be an effective strategy, at least within 18 months. Finally, the immediate change in my practice is that I now ask my obese patients “at what point in your life did you become obese” and “what life event happened during this time.” The above observations have changed my understanding and approach to obese patients. I am in favor of the above approach and hope that as obesity becomes one of Kaiser Permanente’s top clinical goals, this program will achieve widespread adoption throughout the Kaiser Permanente system and beyond. Amal L Puswella, MD Lakewood Medical Center Anaheim, CA References 1.    Felitti VJ, Jakstis K, Pepper V, Ray A. Obesity: problem, solution, or both? Perm J 2010 Spring;14(1):24-30. 2.    Felitti VJ. Childhood sexual abuse, depression, and family dysfunction in adult obese patients: a case control study. South Med J 1993 Jul;86(7):732-6. 3.    Franz MJ, VanWormer JJ, Crain AL, et al. Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc 2007 Oct;107(10):1755-67. 4.    Five year outcomes of laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass in a comprehensive bariatric surgery program in Canada. Can J Surg 2009 Dec;52(6):E249-58. 5.    Turk MW, Yang K, Hravnak M, Sereika SM, Ewing LF, Burke LE. Randomized clinical trials of weight loss maintenance: a review. J Cardiovasc Nurs 2009 Jan-Feb;24(1):58-80.
Letters to the Editor - Obesity
Monday, 30 August 2010
Fall 2010 - Volume 14 Number 3 Effects of 12- and 24-Week Multimodal Interventions on Physical Activity, Nutritional Behaviors, and Body Mass Index  and Its Psychological Predictors in Severely Obese Adolescents at Risk for Diabetes Fall 2010 Dear Editors and Readers, The approach taken in the current obesity article by James J Annesi, MD; Ann M Walsh, MS, RD; and Alice E Smith, MS, MBA, RD is so different than our observations gleaned from a quarter-century of experience treating obesity that some useful insight might be gained by comparison. Their essential conclusion from their carefully described and well-executed study is that a major treatment effort focusing on diet and exercise as the key treatment modalities failed to reduce weight meaningfully in a group of morbidly obese adolescents. Because the concepts of diet and exercise reflect conventional thinking about a problem whose treatment is rife with difficulty, we propose that they are describing a treatment approach whose basic premise is flawed. The concept that obesity is the result of nutritional ignorance, while appealing, has no more demonstrable validity than does the supposition that poverty results from an inability to count money. Each, however, provides the comforting opportunity to busy ourselves in teaching rather than in understanding a more disturbing causality. It is axiomatic in medicine that etiologic diagnosis is antecedent to treatment. Otherwise, we end up treating cough instead of Gram-positive bacterial pneumonia, or do not differentiate the shortness of breath of pulmonary embolism from that of anxiety. The question not addressed by Annesi et al (and by many others) is Why these children became obese, understanding that this is not to be confused with How they became obese. In what ways do their obese patients differ from demographically similar adolescents who do not significantly overeat? As we point out in our article in the Spring 2010 issue of The Permanente Journal (TPJ),1 with very rare exception, no one is born fat. Thus, the age at which weight gain first begins is a useful start in the differential diagnosis of the physical sign of obesity. Family history is also important, not because of genetics, but because it allows us to see how others in the same household have responded to life’s stresses, whether internal to the family or external to it. In a number of places Annesi et al hint at these stresses (“… self-concept, general self, and overall mood” and “Physical activity has also been shown to improve low mood, which is associated with obesity in adolescents”) but avoid exploration. Their conclusion thus rings particularly true: “… and attention to participants’ self-concept and mood may be important treatment considerations.” Indeed, the psychoactive benefits of eating for the treatment of various levels of depression are profound. These benefits underlie the fact that almost every single “diet pill” has been a stimulant that has had antidepressant activity. So too, physical activity has antidepressant properties, just as inactivity is a commonplace marker for depression. It is not our intent to engage in a polemic, sportive though that is in topics of difficulty and uncertainty. Rather, we propose that readers interested in the origins and treatment of obesity go to the TPJ Web site and review the Pre-Program Questionnaire (www.thepermanentejournal.org/files/Obesity/PreprogramQuestionnaire.pdf) that we have developed and used in San Diego during the past quarter-century. Having a few obese patients fill out that questionnaire at home will provide the information base underlying the needed new direction of our approach to obesity. Nutrition and arithmetic are both important subjects, but the one is no more relevant to the treatment of obesity than the other is to the resolution of poverty. The change in direction that we propose will undoubtedly be resisted because it significantly raises the performance bar for those choosing to be involved. The article by Annesi et al has merit because it illustrates the ineffectiveness of the usual approach to obesity. Hopefully, it will lead to explorations of other possible treatment approaches for obesity that incorporate awareness of the benefits of overeating in unconsciously treating problems that are unrecognized, often distant, and almost never explored. Additionally, those approaches must incorporate an understanding of the benefits of obesity, which are not at all in conflict with the manifest risks of obesity. Indeed, in biological systems, the simultaneous existence of varying levels of opposing forces is the norm of all our control systems. Vincent J Felitti, MD, FACP Retired Internist from the Department of Preventive Medicine, Clairemont Mesa Medical Office, San Diego, CA; Senior Editor for The Permanente Journal Reference 1.    Felitti VJ, Jakstis K, Pepper V, Ray A. Obesity: problem, solution, or both? Perm J 2010 Spring;14(1):24-30. Click here to read the response letter.   Dear Editor, Congratulations to Dr Felitti and colleagues for publication of the article “Obesity: Problem, Solution, or Both”1 in the Spring 2010 issue of The Permanente Journal (TPJ) as well as continued success for their weight loss program in San Diego. I believe that readers of TPJ and individuals contemplating participation in similar programs might appreciate a different perspective, evidence, and context regarding the use of Very Low Calorie Diets (VLCD) for weight management. Caloric restriction strategies for weight loss using less than 1000-1200 calories daily should only be undertaken with supervision of a physician or other clinician with significant expertise.  Marked fluid and electrolyte shifts can occur and result in complications such as potentially life-threatening arrhythmias, syncope and hypotension. Many individuals will experience side effects such as fatigue, constipation, and cold intolerance. Evidence-based practice guidelines from the National Institutes of Health2 discourage use of diets providing less than 800 calories daily.  Studies comparing diets of 800 calories daily or more to diets of less than 800 calories daily show that sustained weight-loss outcomes are similar, though risk and side effect profile are increased with diets using less than 800 calories daily.3 Metanalysis of VLCD meal replacement programs indicate mean weight loss of 17.9 kg (16%) at six months,4 significantly lower than that reported in this study. Recent work has elucidated counterregulatory biologic mechanisms that decrease weight loss accrued from caloric restriction over time. Weight regain after use of VLCD and similar programs are rapid and substantial. More than 50% of accrued weight loss is likely to be regained within two years after program participation.3,4 Individuals contemplating these programs need to understand the high likelihood of weight regain, and that long-term participation in behavioral group treatment, continued use of meal replacements, and high levels of physical activity are the best strategies to mitigate this risk. Overall costs and “cost per pound lost” is much higher in VLCD program as compared to other noninvasive strategies for weight loss.5 This is because of the need for medical supervision, laboratory monitoring, and purchases of food products, all services generally excluded (whether appropriately or not) from health insurance benefit packages.   Keith Bachman, MD Clinical Lead for Kaiser Permanente’s Care Management Institute Weight Management Initiative References 1.    Felitti VJ, Jakstis K, Pepper V, Ray A. Obesity: problem, solution, or both? Perm J 2010 Spring;14(1):24-30. 2.    Practical guide: Identification, evaluation, treatment of obesity and overweight in adults [monograph on the Internet]. NIH Publication No. 00-4084. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute, North American Association for the Study of Obesity: 2000 Oct [cited 2010 Jul 28]. Available from: www.nhlbi.nih.gov/guidelines/obesity/prctgd_b.pdf. 3.    Tsai AG, Wadden TA . The evolution of very-low-calorie diets: an update and meta-analysis. Obesity (Silver Spring) 2006 Aug;14(8):1283-93. 4.    Franz MJ, VanWormer JJ, Crain AL, et al. Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc 2007 Oct;107(10):1755-67. 5.    Tsai AG, Wadden TA.  Systematic review: an evaluation of major commercial weight loss programs in the United States. Ann Intern Med. 2005 Jan 4;142(1):56-66. Response: We are pleased to respond to Keith Bachman, MD’s comments on our recent description of our extensive experience with treating obesity in the Southern California Permanente Medical Group San Diego area. Dr Bachman’s comments represent the usual views about treating obesity, a serious problem that is generally not handled easily or well. There is no question that unsupervised Very Low Calorie Diets (VLCDs) are dangerous, which is the point we made with our example of the Irish Hunger Strikers. Indeed, Optifast is not even available by prescription, but only in physician-supervised programs. Because we actively supplement with potassium, and monitor weekly, our impression is that our patients on an absolute fast supplemented with Optifast have fewer electrolyte problems than patients taking prescription diuretics. As separate and minor issues, distinctly fewer bowel movements are the natural consequence of not eating. Cold intolerance and fatigue will be experienced by a few as commonplace stress responses to not being able to de-stress by eating, but most patients report increased energy levels and reduced asthma attacks and other allergic processes. The psychophysiology of this improvement has not yet been described. Our San Diego Positive Choice Program, developed as the result of many years experience, differs markedly from the program supplied by the manufacturer of Optifast. That program, although safe and well intentioned in our opinion, does not adequately pursue the psychological underpinnings of obesity, thus needlessly limiting the effectiveness of their product. Dr Bachman accurately notes this limitation in his Point 3. Considering the approach usually given to treating obesity, the National Institutes of Health caution is appropriate to most of these circumstances. However, with capable medical supervision of electrolyte balance and related biomedical matters, risk is not an issue, as we have illustrated in our 30,000 cases. Our experience with treating these patients over 25 years demonstrated that maintaining weight loss has nothing to do with calorie intake in the weight-loss phase. Maintenance is totally a function of what is accomplished or not accomplished in the accompanying program, which needs to be psychodynamically (not nutritionally) oriented. This point has further been demonstrated by those patients who have been able to eat their way out of bariatric surgery, as we illustrated by the quote in our article, “The antidote [sic] to bariatric surgery is Karo Syrup.”1 The whole point of our article centers on our having outcomes better than usual. That said, weight loss in any program is a function of patient compliance, which is a function of the support provided by the program. This, in turn, will be a function of how well the issues underlying any given patient’s obesity are understood, by the program and the patient. This is not an easy concept to grasp if one persists in misunderstanding the caloric origins of excess poundage as the crux of the problem. That misconception mistakes mechanism for cause, a common error. We believe that our better-than-normal outcomes are the result of the support from our program, in conjunction with the VLCD. Indeed, rapid regain sometimes occurs, and is a blight in some programs, just as it sometimes occurs after bariatric surgery. The question is why does it occur in these instances? How do these individuals differ from those who do not regain? The answer to this question has absolutely nothing to do with calorie intake in the weight-loss phase, a point made clear in our article. It is the program that is the key determinant of long-term outcomes. Our program has been slow in development because we repeatedly tripped over counterintuitive aspects of obesity, such as the hidden benefits of obesity and the consequent threat of major weight loss to many individuals. This statement does not incorporate the cost savings to our patients in not buying any food or caloric beverages for 5 months. Thus, while our cost-neutral charge to the patient is approximately $2500 for the Program, including Optifast for 5 months and the Maintenance Program for the next 12 months, when corrected for food not purchased and dinners not eaten out, the actual net cost for most people will be only a few hundred dollars for a 17-month Program. On the other hand, to the degree that a person on a VLCD is also eating on the side, the economic costs of failure will indeed be high. The major reduction in office visits that we documented during and in the year subsequent to the Program are an additional benefit, either to the patient or to the health care system. Beyond this, the details of insurance programs other than Kaiser Foundation Health Plan were not examined. Although we believe we made these points clearly, we also understand that they lie sufficiently outside conventional thinking about obesity that they perhaps need re-statement in different ways. To that end, one of us (AR) has extended an offer to Dr Bachman to again visit the San Diego Positive Choice Program to see in action what we are describing. Any major revision of commonly held ideas is difficult, uncomfortable, and sometimes threatening. The philosopher, Eric Hoffer, explored this problem well in his small monograph, The Ordeal of Change.2 In that regard, The Permanente Journal offers us all in Kaiser Permanente an important sounding board for the introduction of new thinking into an old problem that is obviously getting worse in the face of usual approaches, even though those approaches are supported by august governmental agencies.   Vincent J Felitti, MD, FACP; Kathy Jakstis; Victoria Pepper, RD; Albert Ray, MD References 1.    Felitti VJ, Jakstis K, Pepper V, Ray A. Obesity: problem, solution, or both? Perm J 2010 Spring;14(1):24-30. 2.    Hoffer E. The ordeal of change. New York: Harper and Co; 1952.
Letters to the Editor - Gastric antral vascular ectasia (watermelon stomach)
Wednesday, 23 February 2011
Spring 2011 - Volume 15 Number 2 Dear Editors, This letter is in regard to the article, “Gastric antral vascular ectasia (watermelon stomach)—an enigmatic and often-overlooked cause of gastrointestinal bleeding in the elderly” published in The Permanente Journal by Nguyen et al.1 We share our experience managing a patient who mimicked as gastric antral vascular ectasia (GAVE). A Caucasian male, age 83 years, was referred to our gastrointestinal clinic for iron deficiency anemia. On his six-month routine follow-up, his primary care physician incidentally noticed that his hemoglobin dropped from 14.1g/dL to 12.4g/dL. He denied any complaints of epigastric or abdominal pain, hematemesis, rectal bleeding, melena, or weight loss. He had no history of nonsteroidal anti-inflammatory drug use. His iron studies showed iron level of 43µ/dL, total iron binding capacity 462µ/dL; iron saturation 9% and serum ferritin 13.2ng/mL. His mean corpuscular volume (MCV), vitamin B-12, renal functions, and liver functions were within the normal range. His colonoscopy, performed in June of 2003, was negative. His past medical history was positive for hypertension and hyperlipidemia. There was no liver or spleen enlargement on his physical examination. Because of his anemia, esophagogastroduodenoscopy was done. This revealed mucosal inflammation with erosion in the gastric antrum, suggesting GAVE (Figure 1). However, the biopsy indicated, Helicobacter pylori gastritis with Warthin-Starry stain showing Helicobacter pylori. He was treated with antibiotics for Helicobacter pylori and given iron supplements. On six-month follow-up, the patient was doing fine with hemoglobin level of 13.8g/dL. The majority of GAVE patients present with iron-deficiency anemia secondary to occult blood loss. GAVE has an appearance similar to the dark stripes on the surface of a watermelon, thus the name “watermelon stomach” is commonly used.2 GAVE is diagnosed by the classic endoscopic appearance and may also be confirmed with endoscopic biopsy, endoscopic ultrasound, tagged red blood cell scan, or computed tomography scan.2-3 We agree with Nguyen et al that GAVE is an often-overlooked cause of gastrointestinal bleeding in the elderly.1 Our case is unique in the sense that apparently it looked like GAVE on esophagogastroduodenoscopy, but pathology was different. It is interesting to note that our patient had no history of cirrhosis of liver, autoimmune diseases, atrophic gastritis, CREST syndrome and/or bone marrow transplant. As we do not know the exact pathogenesis of GAVE,1 if more cases like this are reported, one ponders if Helicobacter pylori also has some role in GAVE syndrome. Khurram Abbass, MD Dayton Veterans Affairs Medical Center, Dayton, OH; Wright State University, Boonshoft School of Medicine, Dayton, OH. E-mail: drkhuramabbass@gmail.com Waheed Gul, MD Wright State University, Boonshoft School of Medicine, Dayton, OH Salma Akram, MD Dayton Veterans Affairs Medical Center, Dayton, OH; Wright State University, Boonshoft School of Medicine, Dayton, OH References 1.    Nguyen H, Le C, Nguyen H. Gastric antral vascular ectasia (watermelon stomach)—an enigmatic and often-overlooked cause of gastrointestinal bleeding in the elderly. Perm J 2009 Fall;13(4):46-9. 2    Abbass K, Akram S, Gul W. An unusual cause of upper GI bleeding: gastric antral vascular ectasia. J Ark Med Soc 2010 Nov;107(6):108, 110. 3.    Herman BE, Vargo JJ, Baum S, Silverman ED, Eisold J. Gastric antral vascular ectasia: a case report and review of the literature. J Nucl Med 1996 May;37(5):854–6.
A Father’s Letter to His Graduating Daughter: Advice to the Medical School Class of 2013 as They Go Forth Into Uncharted Waters
Thursday, 11 April 2013
Lee Jacobs, MD Perm J 2013 Spring; 17(2):e111 http://dx.doi.org/10.7812/TPP/13-064 Online Only Introduction On March 15th, 16,390 American medical school seniors successfully matched to first-year residency positions in the National Resident Matching Program.1 The more than 40,000 registrants made it the largest resident match in the program’s history. In many ways, these first-year residents will be facing a rapidly changing health care world, probably with much more uncertainty than when I graduated from medical school in 1973, and possibly even more than when my father graduated in 1944. My daughter, Julie, is one of these medical school graduates. The following is a letter I wrote to her to provide encouragement and some direction as she goes forth into uncharted waters. I’m presenting it here in The Permanente Journal with the hope that a few of her 16,000 classmates might benefit from the advice. — Lee D Jacobs, MD, Associate Editor-in-Chief Dear Julie, I want to tell you how proud your mother and I are of you. You have worked hard and endured a tough journey. I’m certain that you’ll always look back on graduating from medical school as one of the major accomplishments in your life. You did it! As you venture out from medical school to start a residency, I want to provide some suggestions that may help you, your colleagues, and, most importantly, your patients over the next few years. First of all, you will be entering a health care environment in a state of flux, a condition that will probably remain for years to come. Regardless of the array of complexities—and there are many—people will continue to be patients. People not too much different than the people your grandfather cared for in northern Vermont in the 40s and 50s. In light of the MD after your name, people will believe in you and will trust that you will meet their needs. With that in mind, here are a few imperatives that definitely have not changed with time: Your patients will continue to want you to listen to them—that is how they define respect. Empathy is an essential element of quality communication with patients.2 If patients believe you understand their situation and empathize with them, you will be taking great strides to gaining their trust. It is all about their history! If you have not arrived at a likely diagnosis after listening to your patients, start asking questions all over again. Most frequently the diagnosis is discovered from the patient’s history rather than from the physical examination. Your medical license is like a new car—there is no telling where the vehicle will take you and what horizons will be opened to you over the years. Family, friends, and neighbors will all know you have skills and knowledge that might help them with their health concerns. Here is a philosophy that I have found important in my medical life: Be generous. You have earned a special gift—use it freely. Locally, there will always be a need for health care clinics for the homeless, the uninsured and the underinsured. As a primary care and emergency room pediatrician, volunteer your time as you have in the past. Ask your specialty care colleagues to open their office schedules to care for a few of these patients in need. Just think of the impact if each of the 16,000 graduates in the class of 2013 provided free community care in the future! There are also meaningful opportunities to serve around the world. As you know and have experienced, the need worldwide is great and involvement in medical missions can be life changing. This will instill a sense of hope in their lives. In conclusion, my daughter, I want to again congratulate you on an amazing accomplishment and wish you many wonderful years as you care for those in need. Your loving father. References 1.    www.nrmp.org [home page on the Internet]. Washington, DC: National Resident Matching Program; updated 2013 Mar 27 [cited 2013 Apr 1]. Available from: www.nrmp.org.2.    Halpern J. Gathering the patient’s story and clinical empathy. Perm J 2012 Winter;16(1):52-4. DOI: http://dx.doi.org/10.7812/TPP/11-107B
Letters to the Editor - Alternate Model for Medical Education
Wednesday, 23 February 2011
Spring 2011 - Volume 15 Number 2 Dear Editors and Readers, The article by Eichbaum, et al (An Alternate Model for Medical Education: Longitudinal Medical Education Within an Integrated Health Care Organization—A Vision of a Model for the Future? In: The Permanente Journal 2010 Fall;14(3):44-9) outlines an innovative proposal of a medical school program housed within Kaiser Permanente (KP). The authors suggest that the program be modular and longitudinal, with self-paced learning. The model proposed envisions a “lifetime medical school,” where students could progress through both undergraduate and graduate medical education within the same health care organization, allowing for streamlined and less-costly application processes for medical school and residency, student-centered learning, possible reduced tuition and debt for students, and possibly enhanced patient care due to continuity experiences with physicians-in-training over time. We write to inform you of what may be the first step in such a medical school program, or a hybrid that allows students training in university medical schools while experiencing the benefits of working in a progressive, integrated health system such as KP. Beginning in April of 2011, eight third-year medical students from the University of California, San Francisco will embark on a yearlong longitudinal integrated clerkship (LIC) housed at KP East Bay (including Oakland and Richmond campuses) called KLIC (Kaiser Longitudinal Integrated Clerkship). The current experience of clinical medical students may not be an optimal way to structure a basic clinical education. Patients have shortened inpatient stays and care has shifted more to the ambulatory setting. Additionally, inpatient attendings switch with increasing frequency and residents battle duty hours, leading to less longitudinal oversight of students’ competencies and reduced opportunity for meaningful feedback. In response to such a fragmented experience, LICs have been implemented, both nationally and internationally.1 LICs are based upon principles of continuity with faculty, patients, populations, and a health care system. The students experience their clinical education as patient-centered and student-centered, as they progress through all seven of their core clerkships simultaneously with one faculty preceptor in each discipline, primarily based in the outpatient setting. They also experience a developmentally progressive curriculum, created to help organize their learning tasks with sequentially increasing complexity and a focus on individual pace and learning styles.1 As recommended in the recent Carnegie Foundation report,2 medical education’s key challenges include individualization, integration and insistence on excellence. We believe that by incorporating an LIC at KP we will expose clerkship students not only to the fundamental principles of continuity within an LIC, but also to improve habits of inquiry and improvement, engaging learners in a system dedicated to patient-centered care, population health and health promotion. Moving clinical learning to a health care system where quality patient care is delivered may allow students to “participate authentically in inquiry, innovation, and improvement of care” as the Carnegie report authors suggest. It is our hope that students trained in this model will obtain not only outstanding clinical experiences, but a glimpse of a progressive health care management organization. The lessons and experiences they obtain at KP may pave the way for them to become future KP leaders, or leaders in the changing landscape of health care and health care reform. The KLIC model may be adapted to other KP sites, or into the model of a KP School of Medicine that the Eichbaum, et al article suggests. Lindsay A Mazotti, MD Program Director, Kaiser Longitudinal Integrated Clerkship, Kaiser Permanente Oakland E-mail: lindsay.a.mazotti@kp.org Juan Guerra, MD Assistant Program Director, Kaiser Longitudinal Integrated Clerkship, Kaiser Permanente Oakland E-mail: Juan.J.Guerra@kp.org Reference 1.    Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Acad Med. 2007 Apr;82(4):397-404. 2.    Cooke M, Irby DM, O’Brien BC. Educating physicians: A call for reform of medical school and residency. San Francisco: Jossey-Bass; 2010.
Volunteerism and Homeless Health Care
Friday, 08 April 2011
Summer 2007 - Volume 11 Number 3 Dear Dr Jacobs, Thanks for writing an article about volunteerism, and homeless health care, and for encouraging physicians of all specialties, and their families, to get involved. (Jacobs L. Looking for an opportunity to serve your community? Suggestions on volunteering at a homeless medical clinic. Perm J 2007 Winter;11(1):70-1.) The homeless represent a diverse group of people that includes some vulnerable patient populations, with special needs. Some of these needs include mental health, care of developmental disabilities, and substance abuse. I would refer you to American Family Physician's recently published review in: The Homeless in America: Adapting Your Practice1 and editorial: Health care for the homeless in America.2
Letters to the Editor
Tuesday, 05 April 2011
Fall 2007 - Volume 11 Number 4 Dear Editor, My name is Dr Richard Sattilaro. My cousin, who was president of Methodist Hospital in Philadelphia, wrote a book Recalled By Life [referenced in J Horowitz, M Tomita. The Macrobiotic Diet as treatment for cancer: review of the evidence. Perm J 2002 Fall;6(4):34-7]. He was diagnosed with metastatic cancer. In desperation he tried macrobiotics and had a remission. In his sincere enthusiasm he wrote the above book and appeared on several TV shows. His book has been proffered as a ‘bible” to many cancer victims who have, as a consequence, forsaken traditional treatment. His remission was short lived. He died from his cancer not very long after the book was published. Thousands of copies of his book are still “hawked” to make a buck. To repeat: he died from the same cancer he thought was “cured” by holistic medicine and/or macrobiotics. You should make this clear on your Web site. Richard F Sattilaro, MD

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