Oct 4, 2013

The Way of Eating I Recommend


I eat what I eat because of particular medical problems, many perhaps arising from a "leaky gut." I describe my individual way of eating here:
http://anti-itisdiet.blogspot.com/2010/07/what-do-i-eat.html

What I eat is a subset of the McDougall Program way of eating. That Program is the best therapeutic way of eating for some individuals who are ill—for example, with obesity:
http://www.drmcdougall.com/health/education/free-mcdougall-program/

Nutritionist Jeff Novick lists diet programs similar in their overall pattern: http://www.jeffnovick.com/RD/Articles/Entries/2013/12/5_The_Specturm_Of_Health__The_Evidence_For_A_Whole_Food_Plant_Base_Diet_-_Pt_1.html

Occasionally friends ask what diet I recommend for maintaining or enhancing health for a lifetime. The way of eating that I generally recommend is not what I eat. The diet I recommend is the one I learned forty years ago, at the age of 30, from the book, Live Longer Now: The First One Hundred Years of Your Life, by Nathan Pritikin and others. A few used, inexpensive paperback copies of the book are available: http://www.amazon.com/Live-Longer-Now-Prit/dp/0425086917

Some of the details in the book are probably out of date now, but details are not important here. The book is helpful but you do not need it to understand what I recommend based on my experience.

At age 30, I had clogged arteries around my heart, chest pains (especially when I was under physical or mental stress), pain on the inside of my left arm (under stress), and high blood pressure. I had been eating the Standard American Diet—high fat, high protein, and Calorie Rich and Processed foods (C.R.A.P.). By adopting the Pritikin diet, described below, I lost 75 pounds in 15 months and got rid of all my symptoms.

OUTLINE OF THE DIET. Following are the defining characteristics of the diet I adopted, adapted, and now recommend:

1. Mostly coarse plant foods. That means fruit, vegetables and starches. Eat the fruit raw or cooked; eat the vegs cooked usually; and eat the starches cooked almost always. Eat the fruit, vegs, and starches in variety. Example starches are sweet potatoes, potatoes, beans, peas, grains, and so forth. Eat your food intact or whole. Intact means you can see the original food. An apple is an intact food; applesauce is not intact, though it may still be a whole food, that is, nothing significant has been removed and no substances have been added. Avoid juices and "smoothies" unless you have severe dental problems.

2. Overall, very low fat, with roughly 10% or fewer of the calories coming from fat. You do not need to count calories or weigh foods. Eat the right intact/whole foods, in roughly the right proportions (see below), and you will naturally eat foods that are low in calories and high in nutrients.

3. Very small amounts of meat rich in Vitamin B12 and maybe Vitamin D, the only essential nutrients missing from plant foods. (Sunshine may not supply enough Vitamin D if you live in a cloudy climate, as I do.) My information sources say the meats richest in B12 are clams, oysters, chicken liver, beef liver, and perhaps red salmon; salmon apparently also supplies Vitamin D. One or two tablespoons of one of these per meal should be sufficient to get the tiny amounts of B12 and D we need. Eat the meats in wide variety, but in very small amounts: shellfish, fish, poultry, beef, sheep, and so forth. The key is small amounts and mostly from the highest sources of Vitamins B12 and D.

4. No added, isolated fat. This means no butter, margarine, olive oil, bacon grease, and so forth. Learn to boil, bake, and steam foods, not fry them. The fats we need are contained in the foods we eat. We do not need to add isolated fats. 

Except for step 3, this way of eating is the McDougall Program Regular Diet. I am suggesting adding only enough of four or five meats to get naturally Vitamin B12 and maybe D—not from pills.

PROPORTIONS. I suggest roughly these proportions:
60% starches—intact or whole. Examples are potatoes, yams, and rice.
25% vegetables—intact or whole. Examples are spinach and bell peppers.
10% fruit—intact or whole. Examples are blueberries and oranges.
5% meats high in B12 and maybe D—in very small quantities, such as 1 tablespoon per meal. Examples are clams, oysters, chicken liver, beef liver, and red salmon.

EXCLUSIONS. Avoid all dairy products (though Pritikin allowed them in small quantities if very low fat). Avoid all C.R.A.P. foods such as candy and ice cream. Exclude alcohol, coffee, and tobaccoYou may want to exclude wheat and soy, two foods that cause trouble for some individuals. Last, minimize salt. (Because I have a tendency to high blood pressure, my current, one-year experiment is to eliminate all salt. So far, my blood pressure is lower.)

EXAMPLE. An example meal is: A large bowl of rice, a mound of spinach on top, an oyster or two mixed into the rice for flavoring, and an apple. Season it as you want: soy sauce, hot sauce, or other very low or non-fat condiments. Chew thoroughly and eat slowly.

EXERCISE. Pritikin also recommended exercise, especially "roving," which means walking plus occasionally running a short distance within each walk, if running is appropriate to your medical condition. Other exercises may be suitable, but I would recommend not sitting down to exercise, especially if you sit while working or in your usual entertainment. The important point is to stand up and move daily. You might also work with light weights or do calisthenics in addition to a light aerobic routine. 

RESULTS. On the Pritikin Program, all my heart disease symptoms disappeared and I lost about one pound per week, on average, for 75 weeks—without trying to lose weight and without restricting the amount that I ate. Of course, most of the weight loss occurred at the start. I only wanted to be healthy. I succeeded. I am nearing 70.

LOSING TOO MUCH? If you lose too much weight following the four steps above, add processed foods such as whole-grain pancakes and noodles, as well as small amounts of high-fat foods (whole or intact) such as nuts, avocados, olives, and so forth.

SUMMARY. I consider my recommended way of eating to be "whole food, plant-based." The "base" of the way of eating is plants (whole or intact), though this way of eating is not exclusively plants. This way of eating was generally the Asian way of eating until Western foods began making Asians fat. Think of Chinese farmers one hundred years ago. They ate mostly rice and sweet potatoes, vegetables (such as greens and green beans), and some fruit, with just enough meat to flavor the starches.

P. S. — Nutritionist Jeff Novick, for whom I have a lot of respect, discusses the spectrum of generally healthy diets, including those that include small amounts of animal products. See his December 5, 2013 article on his website: http://www.jeffnovick.com/RD/Articles/Entries/2013/12/5_The_Specturm_Of_Health__The_Evidence_For_A_Whole_Food_Plant_Base_Diet_-_Pt_1.html 

Burgess Laughlin
Author, The Power and the Glory: The Key Ideas and Crusading Lives of Eight Debaters of Reason vs. Faith, described here.

Oct 3, 2013

Tachycardia, Arrhythmia

Last updated: April 18, 2014

This post summarizes my experiences with episodes of tachycardia and accompanying arrhythmia. My earlier posts, which partly were journals of events as they happened, were:
(1) March 30, 2011: http://www.anti-itisdiet.blogspot.com/2011/03/metoprolol.html
(2) January 25, 2011: http://www.anti-itisdiet.blogspot.com/2011/01/my-atrial-fibrillationflutter-adventure.html

EPISODES. Through the last twenty years, I have had five episodes of tachycardia (rapid heart rate). 

EPISODE 1. The first episode, in Portland, Oregon occurred around twenty years ago, after Christmas day, about thirty minutes after an extraordinarily large evening meal. I was out walking and bent over to retie my shoe laces. Emergency medical people said my rate was about 175 beats per minute (bpm). In an emergency room of a hospital, a doctor injected a substance (unknown to me now) that stopped the racing and restored my normal rate of about 65 bpm.

EPISODE 2. The second episode occurred about five years ago, in Auburn, Washington, shortly before Christmas day, about thirty minutes after a very large evening meal, while I was cleaning my kitchen. An emergency room doctor tried but failed to stop the racing heart by injecting a substance through a tube. Doctors there persuaded me to stay in the hospital to test the functions of my kidneys, liver, thyroid, and pancreas. All were operating normally. The doctors also checked my lungs for an embolism and found none. Likewise, a CAT scan revealed no brain tumors or other problems. Finally after three days of testing, the doctors said "cause unknown" for the racing heart and slight arrhythmia (either atrial fibrillation or flutter, but the diagnosis was not clear). About three months later, I underwent electrical cardioversion, a shock to the heart, and it succeeded in returning my rate to normal and without arrhythmia.

EPISODE 3. A year after the e-cardioversion success my heart rate again went into tachycardia. This was my third episode; it occurred in Shelton, Washington. This episode happened in early March while I was sleeping—after a very large evening meal. The emergency room doctor was unable to stop it. They released me (at 2 am) to return home. My rate was about 135 bpm. This episode ended after about six months of medication (described below) designed to lower the heart rate.

EPISODE 4. A fourth episode occurred, also in Shelton, about a year later, again in March (2013) and again in the evening after a large meal eaten hurriedly and without adequate chewing. This episode ended after about nine months of medication—and three months of taking Vitamin D3 (1000 IU three times weekly).

EPISODE 5. My fifth episode began, in April, 2014, after about four months of no tachycardia or irregularity (December 2013 to April 2014). The most likely trigger was returning to my old habit of following the news and consequently feeling anger and anxiety about events I cannot control. In particular, this episode began in my sleep after a nightmare in which someone I loved was threatened but I could not save her. Possibly dehydration contributed. I have resumed taking 50 mg of Metroprolol (time release, in the morning) and 0.125 mg Digoxin (at dinner).

In summary, there is a pattern: onset in the dark months of December through April; and often in the evening after hastily eating a large meal. Dehydration (not drinking enough during the day) is another possible element.

MEDICATIONS. In the first episode, the ER physician released me from the ER without prescribing any medications. In the second episode, while I was in the hospital for the long series of tests, the physician prescribed 100 mg of Metoprolol, taken daily, which is the standard dosage. (The range of dosage is now about 25 to 400 mg/day.) I said I preferred to start at the bottom of the range and work up if that amount was insufficient. (The purpose of Metoprolol is mainly to reduce the heart rate, although it also lowers blood pressure.) The doctor insisted on 100 mg that first day. That night, the hospital monitors sent an alarm to the head nurse because my heart rate down into the low thirties. The nurse said I might be a hyperresponder.) The doctor adjusted the dosage to 50 mg. That brought my heart rate down to the mid forties in the following night, but no lower. (Normally, without medication, the heart rate is lowest in the deepest part of sleep, typically about four or five in the morning.)

After leaving the hospital in the second episode, I began working with a non-interventionist cardiologist, Dr. VK. After long discussion, he recommended that I try the first step in the staircase of treatments available: electrical cardioversion. Preparation for that treatment was long: about 10 weeks of treatment with a variety of drugs designed to shape my heart's action. Dr. VK said my arrhythmia was difficult to diagnose. He was not sure whether it was atrial flutter or atrial fibrillation. After a treadmill and other tests, he decided on atrial fibrillation.

During this period of preparing for e-conversion, I took Pradaxa (an expensive, strong anti-coagulant), which I used reluctantly, Multaq (apparently designed to "shape" the rhythm of the heart beat), and Metoprolol (50 mg, time release). I took the Metoprolol at breakfast and the other pills at lunch and dinner. 

The time release version of Metoprolol, which is more expensive, is supposed to have a steady effect of lowering the heart rate throughout the day but loses its strength somewhat very late at night when the heart rate is normally lower already. Even the low dosage of 50 mg made me very sleepy after breakfast for about two hours. (Fortunately I am retired and do not need to drive, which would have been dangerous.) Another result for about one month was intestinal upset (gas, loose stools), but this diminished with time. I suspect that the Multaq (prescribed for only a month or so as preparation for e-conversion) and the Pradaxa also contributed to the upset.

After the successful e-conversion, ending my second episode of tachycardia, I took 50 mg of Metoprolol and an 81 mg aspirin daily. (The aspirin, like the Pradaxa, is designed to reduce the chance of a blood clot forming in the heart, when the heart is not operating properly; the clot can be expelled from the heart and into an artery, thus blocking the artery and causing a stroke.)

After the onset of my third episode, I again took 50 mg of Metoprolol. I had much less intestinal upset, and even that diminished within two weeks or so. The gut does seem to become accustomed to the Metoprolol.After my fourth episode has ended, I continued to take 50 mg of Metoprolol. I also continued to take Digoxin. One of my physicians recommended it as a way of addressing the slight atrial flutter that accompanied the fourth episode of tachycardia. 

The prescription for Digoxin for my fourth episode was for 0.25 mg. I started by taking it at dinner. (I always take these heart tablets in the middle of meals unless the doctor says otherwise.) It seemed to make me jumpy. Going to sleep in the evening was difficult, which was unusual for me. I switched to taking the Digoxin at lunch, and that ended the jumpiness and sleeplessness.

After about two months of taking 0.25 mg of Digoxin (an extract from Foxglove, the drug that painter Vincent Van Gogh was taking when he cut his ear off with a razor), I began having vision problems: bright lights seemed to flicker. I also felt a little disoriented and I was not able to walk straight. I cut the Digoxin tablets in half, and the problems went away. (Any pill that has a "score" down the middle can be cut in half.)

My cardiologist for my second episode, Dr. VK, convinced me that even if the tachycardia disappeared, I should continue taking the Metoprolol for the remainder of my life, as a way of reducing the chance of the problem returning. That is why now, after my fourth episode has ended (lasting six months), I continue to take it. For the moment, I will also continue the 0.125 mg of Digoxin. I may wean away from it in a month or so and judge the effect.

JOURNAL OF READINGS. I measure and record my heart rate and blood pressure at least once daily, usually about 30 minutes after breakfast. Meals make the rate go up. The lead up to a bowel movement makes the heart rate go up. Of course any other physical or emotional event (such as reading the news) can elevate the heart rate and blood pressure. 

USUAL CAUSES. According to what I have read and have been told by physicians, the usual trigger for tachycardia is one or more of these: surgery (and the anesthesia); overweight; severe long-term stress; liver problems; kidney problems; brain tumors; embolisms in the lung; alcohol; stimulants (such as strong coffee); thyroid problems. Most victims of tachycardia are old, overweight, and damaged through an unhealthy lifestyle. However, some victims of tachycardia are young athletes—such as basketball players and runners—who subject their heart to long-term physical stress.

I am old (69), but my first episode occurred 17 years ago. I have been lean or very lean (now Body Mass Index of 18) for most of my adult life. I have frequently pushed myself physically (running up the steepest hills for the challenge of it, for example), and pushing myself to work very long hours without adequate relaxation. I still do not know the long-term cause of my tachycardia episodes, but I suspect that the physical pressure of eating too much volume was probably the direct trigger in each case.

BEHAVIORAL CHANGES. Why has my fourth episode of tachycardia stopped? Possible causes are:

(1) Curative effect of taking Vitamin D3 for several months. I was taking a standard, low dose of 1000 IU three times weekly. This seems to me, a layman, to be the most likely cure. Inadequate Vitamin D intake was the most likely cause of the tachcardia: All four onsets began in the December to March period of the years, the time when my Vitamin D level would be lowest. On my diet, I take in no Vitamin D from food (no fish, for example) and I live in rain-forest country, where, even walking outside two hours daily, I receive little sunshine from September to May.

(2) A cumulating effect of the medications. Does the Metoprolol "train" the nerve to fire at a slower rate? I do not know.

(3) Stopping  "pushing" myself when I walk; I now still walk up steep hills, but I do so slowly, without accelerating my heart rate much. I continue to walk two hours daily, but I cover less distance.

(4) Avoiding stressful situations such as reading the news. I can do nothing about the events featured in the news. They make me angry or sad, but I have no way to correct them. Now, when eating, I read a novel instead of reading the news stream of mostly terrible events.

(5) Monitoring myself: Am I physically and mentally relaxed? Am I focused on one task? Being relaxed does not mean being unproductive or working less.

(6) Stretching more, especially before sleeping.

(7) Resting more. A short nap can reduce my heart rate by 20 bpm.

(8) Avoiding all stimulants, but still drinking sufficient liquid. I avoid coffee, black tea, green tea, and even herbal teas that might stimulate the heart rate. The only teas I drink at the moment are Lemon Balm and Mint and occasionally "Nighty Night," a mixture designed to encourage relaxation and sleep. By drinking one cup of herbal tea or water (with or without a squeeze of lemon) after each meal, I consume plenty of liquid. Plus, most of my meals are either potato stew or steamed rice (which absorbs a lot of water in cooking).

(8) Being objective, by which I mean focusing on objects directly in front of and not worrying about real or imaginary events occurring outside of my life. This focusing includes engaging in one task at a time and not multitasking. Often slower is faster.

(9) Chewing my food thoroughly and eating slowly, without stress.

Burgess Laughlin
Author of The Power and the Glory: The Key Ideas and Crusading Lives of Eight Debaters of Reason vs. Faith, described here

P.S. If you have successfully stopped your own tachycardia episodes, please comment below.

Dec 18, 2012

A Low-Sulphur Elimination Diet


Of all the inflammation problems I have had, my dermatitis is always the first to appear if I eat something inflammatory. I can begin to diagnose the problem by following my low-sulphur elimination diet. The term "elimination" refers to eliminating from the diet all foods that are known or suspected to cause inflammation. The few foods remaining are the Elimination Diet.

RATIONALE FOR A LOW-SULPHUR DIET AS A TEST. Why are the foods on my Elimination Diet low sulphur? Because, for me, the concentration of sulphur in a food is the best predictor of whether I will get an inflammation reaction. (I do not know whether sulphur is the cause of the inflammation or whether it is a "confounder," that is, something that is always present when the real cause is present.)

Example foods that are very high in sulphur are mustard and clams. All animal products, except isolated fats, are high in sulphur. Almost all nuts, beans, peas, and grains are high in sulphur. (There are exceptions.) Example foods that are very low in sulphur are yams, celery, and many fruits.

PROCEDURE. If I follow the low-sulphur elimination diet, with perfect compliance, for one to two weeks and see some improvement, then I suspect that I have eliminated something that was causing the problem. I can then begin the long process of adding eliminated foods back into my diet. 

The standard reintroduction test is to add one serving of the suspect food (for example, asparagus) per meal for six meals in a row (two days). If I start on Monday morning at breakfast, the reintroduction will be completed with the evening meal on Tuesday, and then I eat only the elimination diet foods while waiting for a reaction, if any. If there is no reaction by Sunday, then on Monday I will test the next food.

Even if no inflammation reaction appears after testing a food, it is important to wait the five days (Wednesday-Sunday) between tests— to give the body time to dispose of the test food and its effects.

GUIDE TO SULPHUR IN FOODS. I have not been able to find a recent, comprehensive list of foods ranked by their sulphur content (milligrams of sulphur in each 100 gram serving). The guide I am using is this old document, "The Sulphur Content of Foods," by Margery Masters and Robert Alexander McCance, now on pdf: ncbi.nlm.nih.gov/pmc/articles/PMC1264524/pdf/biochemj01022-0143.pdf 

So far, it has confirmed my earlier tests and worked perfectly as a predictor.

ALLOWED FOODS. To follow this diagnostic diet, I eat foods from the following list and no other foods, not even seasonings. All the listed foods are rated at less than 25 milligrams/100 gram serving. Numbers in parentheses are the amounts of sulphur, in mg/100 g serving. All the foods listed below should be either organic or pure (no additives of any kind, especially no sulphur-based preservatives). To save money, I buy pure foods, either frozen, fresh, or canned (in water or juice) and generally avoid organics, which are very expensive. (Fruits canned in syrup can be washed.)

In my personal Elimination Diet list, I have excluded some low-sulphur foods that have a reputation for causing inflammation problems in some individuals. Citrus fruits (grapefruit, oranges, and so forth) are examples, though I am not certain about them. I have included "nightshades" (eggplants, tomatoes, and potatoes). They cause no problems for me; but some other individuals report getting a reaction from them. If you are unsure of your reaction to citrus fruits and nightshades, then you might start by excluding them. You can use them as test foods, introducing one per week back into your diet. Be cautious about generalizing. I have a strong adverse reaction to grapefruit, but no reaction to lemons.

AMBIGUOUS RESULTS. In testing a food, you might get an ambiguous result. You might not be sure whether you are experiencing an inflammation reaction. My suggestion is to set that food aside. Test it again months later, and test it with a higher dose—for example, two servings per meal for six meals in a row.

ALLOWED FOODS. The following foods are the foods I know to be safe for me. They do not cause inflammation problems in my skin. I eat something from each of the first three categories at every meal.

1. STARCHES: celery root (9 mg/100 g); pumpkin, canned, pure (10); winter squash, such as acorn, fresh or in frozen blocks, pure (10); sweet potatoes (15); yams (15); parsnips (15); and Russet, red, or gold potatoes (boiled, peeled at dinner table, 23).

2. VEGETABLES: carrots (9 mg/100 g); beans, green ("French" or "string," 9); celery (9); eggplant (9); cucumber (11); artichoke hearts (16); beets (22).

3. FRUIT (including "salad fruit"); pineapple (3 mg/100 g); apples (4); plums (5); pears (5); peaches (6); apricots (6); cherries (7); honeydew and other melons (7-12); grapes (9); nectarines (10); tomatoes (10); blackberries (13); bananas (13); figs, green (13); strawberries (14); raspberries (18); prunes (19).

4. FLAVORINGS: honey (1); white cane sugar (14); vinegar (19); salt (23-35?).

Suggestion: If you want to be extra cautious, you might start with foods that are rated at 15 mg/serving or less, which would include yams and parsnips.

Burgess Laughlin

Nov 29, 2011

Low Sulphur Experiment is Successful

SULPHUR AS A SUSPECT. I have long suspected that sulphur (sulfur) might be the cause of my inflammation problems. Recently I finally found a list of foods evaluated for their sulphur content. I used that list as my guide in designing a low-sulphur diet.


A PROGRESSIVE EXPERIMENT. For six weeks, I have experimented with a low sulphur diet. At first I tried to eat only foods that contain less than 10 mg/100 g serving (about half a cup). Examples are celery (8 mg) and cherries (7 mg). Many fruits fit this category. Few vegetables fit it. No major starches, except pumpkin (9.5 mg) meet this requirement. I soon realized that I would have a lot of trouble getting enough protein. To do so, I raised my limit to 20 mg/100 g serving. Thus I was able to include sweet potatoes (yellow inside) and yams (orange inside), at 15 mg.

Since I had no problems with any food having up to 20 mg of sulphur, I lifted the bar again, to 30 mg. This expansion allowed me to add potatoes (22 mg), thus assuring me all the essential amino acids -- as well as a tasteful and filling meal.

I am now slowly and cautiously adding foods from an even higher level of sulphur. An example is asparagus (46 mg). So far I have had no adverse reaction.

SULPHUR VS. PRAL? Previously I used Potential Renal Acid Load as my guide for deciding which foods to eat. I avoided foods that tended to produce acidity in the kidneys after digestion; and I ate only foods that tended to produce an alkaline condition in the kidneys. The PRAL standard worked very well, reducing my inflammation problems by 99%. The low sulphur diet, however, is even more effective. It has wiped out the last 1% of the problems I have had intermittently for several years -- particularly the last of the eczema and occasional pain problems.

SULPHUR VS. SULPHUR-BEARING AMINO ACIDS? Have I actually identified sulphur, which is a natural chemical element, as the cause of my inflammation problems? I would say "no." Sulphur load might be only a proxy, confounder, or coincident indicator. The problem might be, not the element sulphur, but certain amino acids that contain a lot of sulphur, particularly cysteine and methionine. I do not know.

REMAINING PROBLEM. So far, I have been using only the amount of sulphur in each food as my guide. I have not been calculating the total amount of sulphur in a particular meal. I do not know which is more important. For the sake of simplicity, I will operate on the assumption that I should have only one higher-sulphur food per meal. That standard is easy to meet. I always eat fruit, which is very low in sulphur; I always eat roots or gourds, which are low in sulphur; and I always eat only about 1 C of vegetable, the one food I would consider at the higher sulphur levels. (I completely avoid all the highest sulphur foods: animal products and "seeds" of all kinds, such as grains, nuts, beans, peas, and especially seeds such as mustard, which has one of the highest sulphur ratings on the list.)

ACCEPTABLE FOODS. For an ever-growing list of acceptable, low-sulphur foods, see "What do I eat now?" -- originally posted on July 15, 2010. There is a link to it in the Key Posts list in the upper right corner of this page.

I will add to this post as I learn more.

Burgess Laughlin

Mar 30, 2011

Metoprolol

LAST UPDATED (Bottom) July 6, 2012

(This post is a diary. For a summary and overview of my tachycardia and arrhythmia experiences see the October 13, 2013 post here: http://www.anti-itisdiet.blogspot.com/2013/10/tachycardia-arrhythmia.html)

Cardio-version ended my second episode of atrial fibrillation, as described in the January 25, 2011 post here. My cardiologist recommended that I take 50 mg of time release Metoprolol every morning for the remainder of my life. The purpose of the Metoprolol is to suppress the heart rate. By preventing it from beating too fast (for example, under great stress), the Metoprolol helps prevent the sort of instability that might lead to atrial fibrillation.
My doctor expects the atrial fibrillation to return. (He said, "When, not if.") He said the most likely causes of reversion to afib are (1) alcohol (which I do not drink at all) and (2) general anesthesia (which I hope to avoid for many years).
This post summarizes information about Metoprolol that I have gained through the help of an associate. As a layman, I think the information I cite is reliable, but each person must decide for himself.
WHAT IS METOPROLOL? According to drugs.com, Metoprolol is a beta blocker, that is, a drug designed to block heart receptors. The drug blocks chemicals in the blood that stimulate heart beat. Metoprolol thus reduces heart rate and thereby improves efficiency of pumping and reduces blood pressure.
IS METOPROLOL SAFE? Though I prefer taking no drugs at all, I think Metoprolol (also known as Toprol XL) is a safe drug, compared to many others. Coincidence and correlation are not causation. No proof shows that Metoprolol always or generally causes any particular adverse conditions. However, as always, some users report one or more adverse conditions while taking Metoprolol. For most adverse conditions reported, the number of reports is very small compared to the much larger number of individuals taking the drug. Partial exceptions are sleepiness (10% of users), depression (5%), and intestinal upset (diarrhea or nausea, 5% each). I experienced all of those at one time, but the effects faded after a few weeks.
WHEN SHOULD I TAKE IT AND HOW? I should take my Metoprolol tablet ("Extended Release") at the same time every day, in the morning, with breakfast. I need to swallow it whole so that this time-release tablet dissolves slowly during the following 24 hours. (Thus, I am receiving the lowest dose at the very time when I need Metoprolol the least, which is during deep sleep, when the heart is naturally beating most slowly.)
IS 50 MG A LARGE DOSE? I read literature from my pharmacist that said the range available is 50 to 200 mg. (My doctor originally recommended 150 mg.) If that is accurate, then I am taking the smallest dose available as a whole time-release tablet. I am considering cutting each one in half, a procedure which is acceptable as long as I do not crush it and thus destroy its time-release capability.
UPDATE, April 30, 2011: Last week both my eyes became bloodshot. The left eye's right side was becoming dark red. Alarmed, I went to an urgent care clinic on Saturday morning. While giving me a routine preliminary examination, the nurse noticed that my bloodpressure was acceptable (115/65) but my heart rate was disturbingly low (40 BPM). Metoprolol is the most likely cause of both problems -- the bloodshot eyes and the excessively low heart rate. On the next day, and thereafter, I took half a dose, 25 mg, at breakfast. My eyes began clearing within 24 hours. My heart rate is closer to 50 BPM now (at around 10 am). I will continue at the half-dose while I consider ending my use of Metoprolol.
UPDATE, May 21, 2011: I have extended my dosage experiment by reducing the dosage of Metoprolol to 12.5 mg (cutting the tablet twice). So far, my blood pressure (typically 120/65 at 9 am) and my resting heart rate (typically 45-55) have remained low, even with a 75% reduction in dosage. My medication symptoms (somewhat loose stools, drowsiness, slight nausea between meals) are gone. I may dispense with the Metroprolol altogether.
UPDATE, August 26, 2011: A few days after the May 21 update, I increased the daily time-release Metoprolol back up to 25 mg and kept it there until August 25, when I stopped the Metoprolol completely. Now, on my second day, I am seeing a more positive mood, somewhat faster transit of food through my intestine, less drowsiness after breakfast, no more dry eye.
Unfortunately, my blood pressure rose (up by c. 10/10 to c. 130/80, averaged throughout the day) and my heart rate rose (up about 10 bpm, to around 65). (I was alarmed when my BP spiked mid-afternoon at c. 133/96, but then it declined into the evening. I will continue monitoring. If they do not go higher, I will continue avoiding the Metoprolol.
UPDATE, October 16, 2011: After returning to a 25 mg dose, shortly after Aug. 26, I continued for about a month and then once again took 12.5 mg daily until yesterday. Today is my first day trying again to live without Metoprolol. (I am now taking only a daily probiotic capsule and a twice-weekly Vitamin B12 tablet, 500 micrograms each.) In the days ahead, if my blood pressure and heart rate do not rise alarmingly, I will continue avoiding Metoprolol.
UPDATE, October 30, 2011: My blood pressure did rise alarmingly. Here are readings in the late afternoon two days after stopping: 122/87, 68 bpm at 405 pm; 116/86, 70 bpm at 408 pm; 121/88, 67 bpm at 430 pm; 142/96, 60 bpm at 530 pm. I have returned to taking 25 mg of Metoprolol every morning, probably for the rest of my life, as my cardiologist had suggested. A typical recent reading is: 126/74, 50 bpm at 810 pm.
UPDATE, November 28, 2011. OFF METOPROLOL! At the recommendation of a Physician's Assistant, at a new general practice clinic, I halved my dosage of Metoprolol for a week and then stopped taking it. So far, five days later, the readings are acceptable: E.g., 116/71 at 58 bpm and 128/72 also at 58 bpm. I learned that, at least at the new clinic (which has no cardiologists), cardiologists generally have a reputation for seeking a much lower heart rate than most primary care physicians would seek. I am now free of pharmaceuticals.
UPDATE, March 30, 2012. BACK ON METOPROLOL. On March 10, when I woke up, I had a very irregular heart beat and a very fast heart rate. It did not subside, even with deep breathing. I went to the local hospital. Diagnosis: tachycardia (cause unknown, but no thyroid problems), a slight anemia (cause unknown), and dehydration. The arrhythmia corrected itself. I was treated with intravenous water, with no improvement, and then with Ativan (valium), with no improvement. My heart rate was c. 120 bpm and blood pressure c. 140/90. Two days later, on Monday, at my doctor's office, my doctor and I agreed that returning to metoprolol was the safest, most sensible next step. I will take 50 mg, daily (time release), measure the results for 2 weeks, and then take my blood pressure and heart rate log to my doctor. In retrospect, I should not have stopped taking the Metoprolol.
In another visit to my doctor, I found that I am in "atrial flutter." I am waiting now to talk to a cardiologist who visits this small town. We will decide whether to simply continue suppressing the heart rate with Metoprolol or plan for another cardioversion to try to reset the rate and rhythm.
UPDATE, July 6, 2012. BACK TO NORMAL; REDUCED DOSAGE. I talked to the local cardiologist, a moderately aggressive interventionist. I rejected his suggestion to prepare for cardioversion. I chose instead to stay with 50 mg of Metoprolol to suppress the heart rate, and live with it. Around June 15, I noticed that I was no longer aware of my own rapid and irregular heart rate. I measure it daily, at the same time, for two weeks. The average rate was about 48 bpm, with blood pressure of about 120/65. The skips and pauses were gone, judging from what I could feel with my finger tips. I cut my Metoprolol dosage in half, to 25 mg/day, time release. On July 5, an EKG at my doctor's office confirmed those numbers and the proper rhythm as well. I will continue to take 25 mg daily, time release.
What might have caused reversion to a regular, though rather low rate? Possibly one of these changes: (1) I had increased by supplementation with Vitamin B12 to 50 micrograms, 5 days per week and 500 micrograms twice weekly, thus more than doubling the dosage; (2) I had started using salt again, thus reintroducing more iodine; (3) I had started eating one Brazil nut per meal (for selenium); and (4) I had stopped eating avocados (to which I might be allergic). How long will this last? We will see.

Comments are welcome, especially about your own experiences with Metoprolol.

Burgess Laughlin

Mar 17, 2011

BkRev: "Over-Diagnosed" by Dr. H. Gilbert Welch

H. Gilbert Welch, MD, Lisa Schwartz, MD, and Steven Woloshin, MD, Over-Diagnosed: Making People Sick in the Pursuit of Health, Boston, Beacon Press, 2011, 228 pages. http://www.amazon.com/dp/0807022004/

"So when I suggest," writes Dr. Gilbert Welch, "that we develop a healthy skepticism about early diagnosis, I am referring specifically to seeking diagnoses in the absence of symptoms, because that's when overdiagnosis can occur. ... I'm simply suggesting that we should be most cautious about early diagnosis in those who feel well" (p. 185).

"Some," Dr. Welch continues, " may prefer to pursue health: to focus on feeling healthy and minimize medical contact while they are well. They accept a slightly higher chance of death or disability to minimize the chance of medicalization, overdiagnosis, and overtreatment now. They prefer to reserve medical care for problems that are obvious to them. Others may want to pursue disease: do everything they can to be healthy in the future and to decrease their chances of experiencing death or disability -- even with the knowledge that they are more likely to be diagnosed with disease, more likely to be frequently exposed to medical care, and more likely to suffer harm" (p. 185)

Those two basic choices -- primarily pursue health or primarily pursue disease -- are the alternatives the author of Over-Diagnosed offers at the end of his book. To reach that end, the author clearly but in considerable detail examines the potential benefits and dangers of premature diagnosis, that is, diagnosis formed before symptoms lead a patient to seek a solution to emerging problems.

The author explains the principles of diagnosis and overdiagnosis as he proceeds through a list of common diseases that most people -- and usually their doctors -- fear enough to be medically tested even before symptoms of disease appear. Those common diseases are: diabetes, osteoporosis, gallstones, damaged knee cartilage, bulging discs, abdominal aortic aneurysms, blood clots, defective pregnancies, prostate cancer, breast cancer, and other cancers. He also considers markers which are not themselves diseases but which might be harbingers of later disease: high blood pressure, high cholesterol, and genetic defects.

Welch meticulously shows the dangers of screening, that is, of automatically testing everyone -- or at least everyone of a certain category -- for the presence of a disease, even if they have no symptoms. The evidence for and against screening or other forms of premature diagnoses is mixed, which is why making a decision is difficult -- as much for physicians as for patients.

The time to read this thoroughly documented book is now, not when a physician tells you that you should be screened periodically for disease X or that you "might" have cancer or other frightening disease. Then you can make your choice about which approach you want to take.

Burgess Laughlin
Author, The Power and the Glory: The Key Ideas and Crusading Lives of Eight Debaters of Reasn vs. Faith, http://www.reasonversusmysticism.com/

Jan 25, 2011

My atrial fibrillation adventure

(This post is a diary. For a summary and overview of my tachycardia and arrhythmia experiences see the October 13, 2013 post here: http://www.anti-itisdiet.blogspot.com/2013/10/tachycardia-arrhythmia.html)

This post is my "journal" for my most recent medical adventure, chronic atrial fibrillation. I will revise the post as events unfold. I am not asking for specific medical advice. I welcome any suggestions for topics that I should consider or reconsider.

CHRONOLOGY
1997: EPISODE OF AFIB. After a large dinner, I walked, stopped, bent over to retie my shoe laces -- and my heart began beating irregularly and about 170 beats per minute (as I heard later from the emergency medical technicians who examined me). A doctor in the emergency room administered a chemical intravenously. It restored the regular rate. I walked home from the hospital.

2010, Dec. 19-23: CHRONIC AFIB. After a large dinner, I experience a rapid, strong, and irregular heart rate. It continued that way, with some variation, for four days. (I have learned to avoid rushing into medical treatments.) At the end of that period, I called 911 because I was worried about the rate. The emergency technicians said it was spiking at about 170 beats per minute.

Chronic atrial fibrillation, in some forms, is dangerous long-term because of the possibility of (1) eventual deterioration of the heart muscles, and (2) stroke resulting from a blood clot forming in the atrium, being expelled into an artery, and then blocking an artery somewhere in the body. Besides the danger, "afib" is very uncomfortable in some forms and very distracting. (My productivity for any kind of intellectual work plunged.)

2010, Dec. 23-25: ER AND HOSPITALIZATION. I went to a local hospital's emergency room. The doctor in charge administered, through an intravenous tube, a drug designed to regulate the heart rate. It did not work. The medication did improve the beat regularity somewhat and did lower the rate to about 130 BPM. (A safe rate is less than 90 and an ideal rate is about 60 BPM.)

I was admitted to the hospital from the ER. I had tests of my heart (electrocardiogram and echocardiogram [ultrasound]), thyroid (no problem), lungs (CAT scan, no embolism), "heart protein" (meaning unclear, but no problem), blood (no problem with either fat levels or vitamin or mineral deficiencies). I also had no kidney or liver or other organ problems. (That was good news I attribute to my diet.) No one asked me about what I eat except that the hospital dietician asked if there are foods to which I am allergic.

Struggling against the standard hospital over-treatment, I rejected some of the drugs which hospitals automatically prescribe for every heart patient: stool softener (I eat a high-fiber diet!), antacid (I have had no acid reflux since adopting my "anti-itis" diet six years ago), pain reliever (I have had no chest pain), two of the three anticoagulants (I accepted only an aspirin daily). I did accept Metoprolol (which suppresses the rapid heart rate to a safe level) in the lowest dosage (12.5 mg, 2x daily). The official diagnosis was atrial fibrillation, with no identified cause. I was discharged on Dec. 25 with instructions to take Coumadin (Warfarin, an anticoagulant designed to reduce the chance of a blod clot forming in the atria).

2010, Dec. 26 - 2011, Jan. 1st week: OUT OF THE HOSPITAL: PHARMACEUTICALS. For about five days, I experienced oscillating mild chill and fever, but it faded away. I researched online for the nature and effects of Coumadin (Warfarin). I decided not to take it.

I was examined briefly by my new primary care physician, Dr. C, and he gave me a short list of local cardiologists. I found Dr. K, a non-intervention specialist. He prescribed a higher dose of Metoprolol, a beta-blocker, 35 mg, taken once daily in the morning with breakfast. (The lower dose that I had requested in the hospital, as a start, wasn't working when I was under stress -- e.g., in a doctor's office.) My Metoprolol is now a time-release medication; it works for 24 hours and is weakest at precisely the time of day when my heart rate is naturally lowest, thus avoiding the danger of over-medicating and slowing the heart rate too much.

Dr. K discontinued my aspirin. He prescribed Digoxin, another beta-blocker designed to suppress heart beat. Dr. K also prescribed a drug newly "approved" in the USA, Pradaxa, an anti-coagulant. He gave me enough free drug samples of the Pradaxa (normally about $250/month), to last me until a stress test in his office. At that point, Dr. K said, he might be able to offer a more definitive diagnosis and recommend either a treatment program (possibly continuing the Pradaxa) or acceptance that I will need to live with the problem and continue taking Metoprolol and Digoxin to suppress the racing heart.

Dr. K confirmed what I had read about risk. The hospital doctors told me that I was at "high risk" of stroke, but I found later (and confirmed by my cardiologist) that the actual risk of stroke for a 66 year old man with afib, without medication, is, say, only about a 2% chance per year. With medication, it drops to about 1% per year. (The exact numbers are unclear to me.) So, relatively there is a much higher risk (100%) of stroke with not taking an anticoagulant, but the absolute level of risk is fairly small. On the "CHADS" scoring system (0 for the lowest risk, 6 for the highest risk), I am in the 0 category. As usual, the hospital doctors were being (over) cautious, perhaps for legal or regulatory reasons as well as training.

The pharmaceuticals I am taking now (Metoprolol, Digoxin, and Pradaxa) caused diarrhea in the first week. That problem lessened after about five days and then ceased when I began adding a probiotic (over the counter, chewable tablet, one per meal, containing Lactobacillus Acidophilus and L. Bifidus). I take all medications in the middle of meals, but spaced apart.

I am taking at meals two nutraceuticals -- nonprescription nutritional supplements designed to address specific problems -- recommended by two cardio physicians whose books I have read (with serious doubts, in one case): cod liver oil (1 teaspoon/meal), Vitamin B12 (50 mcg, 2 x week), and magnesium oxide/gluconate (1/day, 250 mg, which is about 63% of the Recommended Daily Allowance). The largest sources of magnesium are animal products and "seeds" (grains, and so forth). I can eat no animal products (except fats) or "seeds" without bringing my "-itis" problems back. (See "Key Posts" in the upper right corner.)

Three circumstances now accelerate my heart rate disturbingly: sitting up or standing up too quickly; compression (for exmple, bending over to tie my shoelaces); and mental stress (for example, reading the news). Mental stress is the strongest cause and the most difficult for me to control, but I am learning. My quality of life might depend on it.

GENERAL OUTLOOK: As of Jan. 25, a month after leaving the hospital, I have fully recovered my strong appetite, energy level, and exercise schedule (light weights, stretching, and walking 2 hours/day). Although I don't expect to live as long as I had originally hoped (85), I am cautiously hopeful that I can continue to live well for more years without yet starting to slide down the pharmaceutical spiral of ever-more drugs that treat the destructive effects of earlier drugs. I have no fear of death or of dying. I hate the idea of becoming progressively sicker because of pharmaceuticals.

UPDATE, 2011, Jan. 31, 10 am stress test: I took the stress test and enjoyed it. The main conclusions Dr. K reached are: (1) I have no heart problems other than the atrial fibrillation, and even that is not major; my heart efficiency is low but not dangerously so. (2) The Metoprolol and Digoxin are indeed suppressing my heart rate. (3) I need to continue the anti-coagulant Pradaxa until I can make a decision (after one more tests in three weeks) whether to have cardioversion or continue with some combination of drugs. (4) I probably will be able to replace the Pradaxa with a daily aspirin, eventually. (5) I am still in the bottom, least-risk category of the ranking for stroke risk. (That is why an aspirin will be sufficient, long-term.)

The details are, so far, unclear, but apparently the next step is to begin an additional drug for a few weeks, and then I will have another EKG. Apparently the new drug is a mild form of cardio-version (turning the irregular heart beat back to normal) that is safe for outpatient use. (More serious electrical, chemical, or surgical cardio-version would require hospitalization because of the doctors' fear of a stroke from a blood clot released during the cardio-version process. Apparently, when I begin the new drug, I will continue taking the Digoxin and Metoprolol but at reduced levels. I may have more details after February 2.

UPDATE, Jan. 31, 5 pm and 11 pm: While preparing dinner, I injured one finger with a tiny cut. It bled a small amount, but continuously for 30 minutes, despite soaking in cold water and wrapping it in tissue.

UPDATE, Feb. 4: Today I received my new instructions, via my doctor's medical assistant/nurse. I will continue taking Metoprolol (1/day, but now at 25 mg, half the previous daily dose), for rate control, and Pradaxa (2/day), for anticoagulation. Replacing the Digoxin will be Multaq (dranedarone), 400 mg/tablet (2/day), for rhythm control, as a sort of out-patient cardioversion, apparently. I am also continuing my nutraceuticals: probiotic (1/2 per meal), magnesium (250 mg, 1/day), cod liver oil (1 t, 3/day), and B12 (50 mg, 2/week). I am scheduled for an EKG in my doctor's office on Feb. 17.

I have a growing list of questions about the drugs, especially the Multaq: what are its advantages over its competitors? Safer? More effective? Only one governmentally approved for outpatient cardioversion (as my doctor had suggested in the past)?

UPDATE, Feb. 17: An EKG in my doctor's office revealed that I do indeed still have atrial fibrillation and my heart rate, even under medication, remains high (78 bpm). The chemical treatment (Metoprolol, Multaq), which is therapy stage 1, failed to reset my heart rhythm or lower the rate enough.

I agree with my doctor that trying the next stage of therapy, stage 2, is worthwhile, though it is expensive and has a success rate of only about 65% of the cases. This stage 2 is "cardioversion," in which I will be sedated at the hospital and then given a painless shock to my heart. The purpose is mainly to restore proper rhythm, apparently. I don't know whether lowering the rate is also a goal of cardioversion. The brochure I received from my doctor speaks only of rhythm restoration. My understanding though is that if the rhythm is proper, the rate will follow naturally. (I will need to double-check that.)

If the treatment does not work, or if it works only for a few months, I will not repeat it. (The success rate of repeated treatment is very low.) Instead, I will use only one drug, Metoprolol (plus an aspirin as the anti-coagulant), to fully control the heart rate and thereby make the heart more efficient. This approach is similar to the one Dr. McDougall describes in his newsletter article on Coumadin: Suppress the high heart rate (which functionally is the key problem) and live with it.

UPDATE, Feb. 24: Today I had the cardioversion therapy. It worked! My heart is now back in a normal rhythm and rate range. The procedure was painless, thanks to the intravenous sedation. If you have the procedure done, don't drive or make any important decisions afterward! I could barely form a complete sentence. I came home and slept for three hours.

My doctor convinced me that, on the short-term, I need to continue the drugs in order to keep my heart in a narrow range of rate (Metoprolol) and rhythm (Multaq), as well as to protect myself from a clot expelled by my now more effective heart (Pradaxa).

UPDATE, March 8: I consulted with my cardiologist today. Here is the plan: (1) Stop taking Pradaxa, the anticoagulant. (Drop from two doses daily to 1 dose daily, for 3 days, then stop altogether.) (2) For the rest of my life, take an 81 mg aspirin tablet daily as an anticoagulant. (3) Stop taking the Multaq after one more week. (4) For the rest of my life, take Metoprolol, 50 mg, time release, every morning, to keep the heart beating in a low range, thus avoiding a higher range that might send it into fibrillation again. The two usual causes of returning to afib are: drinking alcohol and general anesthesia for surgery.

I have hired a nurse-researcher to help me gather information about metoprolol: What are the risks of long-term usage? (My doctor says there are no established cumulative adverse effects.)

UPDATE, March 19: I have returned to normal, almost. I am walking as quickly (3 mph) and as far (5-6 miles/day) now as I did before the afib episode. I have stopped taking the daily aspirin. I do not need any anti-coagulant, either in general or in particular for the former afib problem. Now I am taking only the Metoprolol, 50 mg, a low dosage, but one high enough to make me drowsy two hours after swallowing it with breakfast. I am considering experimenting with a half-dose. I am continuing to take 1 teaspoon of cod liver oil per meal, one magnesium tablet (250 mg, 60% of RDA) per day, and two 50 microgram Vit. B12 tablets per week. The oil and magnesium are recommended by some cardiologists, though in much higher doses than I am taking. I am also continuing to take half a probiotic wafer per meal.

UPDATE, May 5: I now take 25 mg of Metoprolol. (I am cutting the regular tablets in half.) I take no other medications: no aspirin, no magnesium, and no cod liver oil. I continue to take a probiotic and a Vitamin B12 tablet (50 micrograms twice weekly).

UPDATE, August 26: Yesterday I stopped taking the Metoprolol. My mood is more positive; food transit time is a little faster; and I am much less drowsy. My blood pressure and heart rate have risen (about 10/10 and 10, respectively). That increase -- if it goes no higher -- is not alarming, but it is worth watching.

UPDATE, April 24, 2012: In March, 2012, I went back into afib. The cardioversion worked for one year. I do not know what caused recurrence. In a local emergency room, the physician said I was dehydrated and "moderately low" anemic. The hospital found no other possible causes (as in the previous episode). I never noticed being particularly thirsty. Now I am wrestling again with trying to decide what to do: Continue with medication (Metoprolol, 50 mg) to control the rate (about 130 bpm without medication, about 80 with medication) and blood pressure (about 125/80 with, 150/90 without)? Or try cardioversion again, and if that doesn't work, try more invasive procedures? This time, I may choose to take the medication and just live (or die) with it. I will write more after I resolve some of the many issues.

UPDATE, September 15, 2012: After taking 50 mg of Metoprolol daily April-July, and after refusing a second cardioversion, my heart has returned to normal sinus rhythm. My physician confirmed that a few days ago, while I was taking 25 mg of Metoprolol. (Because my heart rate has been dropping as low as the 40s, I have begun taking 12.5 mg, half a 25 mg tablet.) I probably will continue the Metoprolol. I am monitoring my heart rate and blood pressure. I have discussed the possibility of substituting digoxin, but my physician and I have not yet made a decision. Possible causes of a return to normal rhythm are: (1) an increased dosage of Vitamin B12 (from c. 250 to 1250 micrograms/week) in the two weeks before; and (2) resumption of using salt (containing iodine). The afib has disappeared as "spontaneously" as it had appeared.

Burgess Laughlin
Author of The Power and the Glory: The Key Ideas and Crusading Lives of Eight Debaters of Reason vs. Faith