Animal research is starting to suggest some clues as to why weight loss is so difficult. Studies on a Mouse Hormone Bear on Fatness in Humans

New studies in mice suggest that the hormone leptin can fundamentally change the brain's circuitry in areas that control appetite. Leptin acts during a critical period early in life, possibly influencing how much animals eat as adults. And later in life, responding to how much fat is on an animal's body, it can again alter brain circuitry that controls how much is eaten.

Researchers say the findings, published today in the journal Science, are a surprise and add new clues to why weight control is so difficult in some humans.

Scientists knew that leptin is released by fat cells and tells the brain how much fat is on the body. They knew that animals lacking leptin become incredibly obese, as do a few humans who because of genetic mutations did not make the hormone. Leptin injections immediately made animals, and the patients with leptin deficiencies, lose their appetites. Their weight returned to normal.

But it was thought that leptin acted like most other hormones, attaching itself to brain cells and directly altering their activities.

Investigators did not anticipate that leptin could actually change connections in the brain, strengthening circuits that inhibit eating and weakening ones that spur appetite. And few considered the possibility that there might be a critical period early in life when the hormone shaped the brain's circuitry, possibly affecting appetite and obesity in adulthood.

Very interesting stuff, which may eventually help us better understand weight control.

I have read the comments. I have reconsidered the radical libertarian stand. As I absorb the hyperbole, sophistry and especially obfuscation which my debating opponents utilize, I will try to return to first principles. Primum, non nocere. - First, do no harm.

In this context, I believe that many medications, if sold over the counter, could do great harm. I am also certain that improper dosing and improper combinations of medications can do great harm.

Of course, we have pharmacists to help us prevent dangerous drug interactions - but would the libertarian position end the licensing of pharmacists. Why not sell HIV meds at the grocery store?

As I read the arguments for ending FDA controls and required physician prescribing, I see many straw men. I do not believe that one can extrapolate from many of the examples. But I will use this retort?

Should the government require a licensed engineering firm to design a bridge? Why not just let the construction company build the bridge from their experience?

Many drugs can reasonably make the transition to OTC. Many do. We better make those decisions once we have enough experience to know the safety profile of the drug. Many prescription drugs do cause problems, and are removed from the market.

We certainly can (and should) loosen restrictions on some drug classes. Other drug classes and diseases should require medical care and decision making. I do not worry about the compulsive intelligent consumer who might research his/her problem extensively and do self-dosing (although I have seen physicians cause harm to themselves with self prescribing). Those patients will at least think through the pros and cons of treating themselves (perhaps). I worry about the many patients who get advice from friends - oh, you must have CHF - try an ACE inhibitor - it worked for me.

Remember Primum non nocere should guide us. Following the radical libertarian approach would do harm to many, some of whom cannot understand the risks.

We all really know this. Talk to any smoker, and he/she will tell you that they always drink more in a bar. The physiology makes sense. Habits: A Smoke Much Sweeter

A new study has found that alcohol, even in very small amounts, appears to enhance the pleasurable effects of nicotine.

At the same time, the researchers say, nicotine may counteract some of the effects of alcohol, like drowsiness.

"It may be kind of a balancing act in the brain ? that you're taking one substance to balance the effects of another substance," said Dr. Jed E. Rose of the Nicotine Research Program at Duke University and the lead author of the study, which appears in the current issue of Nicotine & Tobacco Research.

The link between alcohol and tobacco is strong and complex. According to the researchers, as many as 90 percent of alcoholics smoke. And alcoholism is much more likely to occur among smokers than among nonsmokers, they said.

But while there has been a longstanding cultural marriage between drinking and smoking, scientists have had trouble explaining the physiological relationship. Some have theorized that alcohol lowers the ability of nicotine receptors in the brain to respond to the drug, creating a desire for more cigarettes.

While this may, in fact, occur in some receptors, the new study reports, over all, alcohol makes nicotine more pleasurable.

If researchers can better decipher this interaction, we might gain some treatment ideas. It does explain an interesting phenomenon, and provide some useful information for counseling patients.

As one commenter suggested, I have really enjoyed the comments on my paternalism rants. They have help inform my conceptualization about this subject.

If one takes a libertarian viewpoint in our society one must still understand that the limits of ones freedom end when another is harmed. The common shorthand expression - The freedom of your fist ends just short of my nose.

So the first test for restricting a medication must involve potential costs to society of improper use. Certainly all antimicrobials fit into that paradigm. The huge problem of MDR-TB (multidrug resistant tuberculosis) stems from unrestricted access and distribution of TB drugs. You may want to take your medications as you choose (or even think you have researched). However, your knowledge lack can lead to my worse illness. In fact, we take a very paternalistic view of TB in this country requiring DOT (directly observed therapy) give through public health departments.

One can certainly extend this concept to all antimicrobials - the good of many others should outweigh your desire to buy antibiotics without seeing a physician.

Admittedly, the philosophical position gets more complex when discussing cardiac medications. However, your illness improperly treated (because you chose your meds rather than having a trained physician choose those meds) costs society significant dollars - from hospitalizations, lost productivity, etc. That decision also has a significant impact on your loved ones.

Critics argue against licensing physicians and requiring proper training. I have a difficult time understanding that position. Medical care has advanced dramatically over the past 50 years. This care advances because of our training and research. We do need standards for the public good.

You can choose care from a non-physician - e.g. chiropractic care. That certainly gives you freedom. You can go to a health food store and self treat with supplements and herbs. That gives you freedom. In my opinion that also gives you substandard care.

Like many such arguments, one can take a highly controversial position and incite everyone. However, as I read the comments, that highly controversial position does not withstand careful scrutiny for our society.

Our current medical system is not perfect, but it is very good. We do improve the quality of lives. We do lengthen life spans. We cure many infections. I cannot believe that a call for anarchy will help society. Thus, your freedom to buy any medication that you desire without medical consultation could lead to societal harm. And that should be the main concern.

EKR at Educated Guesswork writes about my paternalism rant - When is paternalism justified?

I think DB is missing something important here. Sure, if you want high quality medical care and you're not medically sophisticated you want to be under the supervision of a doctor. The problem is that it's legally mandated. There's no law against me working on my own car, but when I have a transmission problem, I don't drop the tranny in my garage--I take it to a mechanic. (To tell the truth, I take it to a mechanic to have the wiper blades changed). So, I think if you want to have mandatory paternalism, you really have to explain why people aren't able to decide for themselves whether they want close monitoring. In my view, DB doesn't do that satisfactorily.

Let me try again. Many patients make their own decisions regardless of our recommendations (and remember, we prescribe we do not force feed medications). I guess a well educated patient might be able to figure out a complex medication regimen. But it really is unlikely. I guess I could treat myself - but we do have a saying about that - "The doctor who treats himself has a fool for patient".

So I must endorse this form of paternalism. Physicians have the training and experience to juggle the multiple conditions and disease manifestations. We should include the patient in our decision making - but we should recommend and recommend strongly a treatment course that best fits the available evidence. For that I do not apologize!

Paternalism In Medicine - Part II: Gatekeepers

Trent McBride writes a long rant about the influence of prescription drugs on the doctor patient relationship. First, I love the blog's title - I love renal physiology. Maybe I should rename my blog the Countercurrent Mechanism. Or that could be a great name for an alternative band!

Trent hypothesizes that making patients come to the doctor for prescriptions represents the ultimate form of paternalism. I will disagree to some extent on his proposed solutions.

Yes, prescribing medications is paternalistic. But then I do not assume that all medical paternalism is bad.

If you have congestive heart failure, I have a complex drug regimen to prescribe. Adjusting these medications requires repeated visits. I must understand the side-effects of each medicine, alone and in combination. I must consider your renal function, and your electrolytes. Finally, I must prescribe the medications with an understanding of your other medical problems (and few patients have CHF alone).

So to provide the highest quality care, I believe that I must be paternalistic. In that sense paternalism is not a bad attribute.

Narcotics might be the exception. I do not really know how much pain a patient suffers. How can I judge the best method for treating that pain? Should I worry about narcotic abuse? Wouldn't we be better off if we just let patients buy their own pain meds and suffer their own consequences?

Trent does mention antibiotics - and he is correct. But I will gladly argue that many conditions which I treat require complex decision making and adjusting of multiple medications. I accept that paternalism and I believe the great majority (>90%) of patients want that paternalism.

Caveat ahead - even when one must take a paternalistic stance, one should still discuss the rationale for each medication with the interested patient. When choices are available for treatment, we can and should discuss those choices with the patient.

So as usual, I am a bit wishy washy. I agree with some of the Tubule's argument. But I believe he goes overboard. But after all, that is what blogs are for - to stimulate our thinking and challenge accepted thinking. And therefore he succeeds.

A New Era in Treating Imaginary Ills

They make frequent doctors' appointments, demand unnecessary tests and can drive their friends and relatives — not to mention their physicians — to distraction with a seemingly endless search for reassurance. By some estimates, they may be responsible for 10 to 20 percent of the nation's staggering annual health care costs.

Yet how to deal with hypochondria, a disorder that afflicts one of every 20 Americans who visit doctors, has been one of the most stubborn puzzles in medicine. Where the patient sees physical illness, the doctor sees a psychological problem, and frustration rules on both sides of the examining room.

Recently, however, there has been a break in the impasse. New treatment strategies are offering the first hope since the ancient Greeks recognized hypochondria 24 centuries ago. Cognitive therapy, researchers reported last week, helps hypochondriacal patients evaluate and change their distorted thoughts about illness. After six 90-minute therapy sessions, the study found, 55 percent of the 102 participants were better able to do errands, drive and engage in social activities. Antidepressant medications, other studies indicate, are also proving effective.

"The hope is that with effective treatments, a diagnosis of hypochondriasis will become a more acceptable diagnosis and less a laughing matter or a cause for embarrassment," said Dr. Arthur J. Barsky, director of psychiatric research at Brigham and Women's Hospital in Boston and the lead author of the study on cognitive therapy, which appeared in the March 24 issue of The Journal of the American Medical Association.

If these patients do not induce "heart sink" then you are a different physician than me. These patient's name on your daily list causes anxiety, depression and thoughts of illness.

The biggest challenge is sorting out their hypochondriacal complaints from real disease, because even a hypochondriac can get sick.

I once had a patient who came to me after having 17 negative HIV tests. He had not had any sexual relations in over 6 months, yet thought he needed another test.

I saw this patient for around 9 months. My greatest feat was getting him back to see his psychiatrist, as he also had major depression. Over time with reassurance, calm, scheduled appoints and medication he was able to regain a productive life.

As I read the article this morning, I saw most of his personality and problems. We (physicians) would all like a consultant who wanted to see these patients, as most physicians and psychiatrists shun them. I certainly hope that these initial positive reports are confirmed.

Wow - sometimes research provides good news. FITNESS: Study finds no evidence stretching prevents injuries

People who stretched were no more or less likely to suffer injuries such as pulled muscles, which the increased flexibility that results from stretching is supposed to prevent, researchers found. And the injuries found in the study typically happened within the muscle's normal range of motion, so stretching them would not have made a difference, Thacker said.

Other research has found that warmups, which increase blood flow through the muscle and make it more ready to respond to exercise, can reduce the risk of injury, Thacker said. Being in good shape also helps. Strength and balance training reduced injuries as well, he said.

Sounds good - warm up, stay in shape, do not worry so much about stretching.

The Limits of Opening Arteries

Experts agree that artery-opening methods ? like bypass surgery, or insertion of a balloon to mash down plaque and a wire-cage stent to keep the channel open ? can alleviate crushing chest pain and save some lives. But patients should not assume that their cardiovascular problems are "fixed" by such procedures, and patients without symptoms whose arteries are narrowing should be wary about undergoing these procedures to ward off a potential heart attack. They may have hundreds of vulnerable plaques elsewhere that are more apt to burst and trigger a heart attack than are the more stable plaques in the narrow section. Most such patients might better be treated with drugs to lower their cholesterol levels, control their blood pressure and prevent blood clots, or should adopt a healthier life style by giving up smoking, eating heart-healthy foods and exercising.

What follows represents the implications of this essay and the accumulated data that I teach on rounds. I have tried to interpret the original data and read about the theories.

Procedures - CABG and stenting - are still very important in 2 scenarios. First, patients who have just had an acute coronary syndrome, especially a small heart attack (which we call either NSTEMI or non-Q wave MI), clearly benefit from immediate intervention. Second, patients who have extensive disease (usually 2 or 3 vessels with severe narrowing) and problematic symptoms have their symptoms improved with interventions. Choosing an intervention must take into account the lesions, their location and availability of good artery past the obstruction. One must also consider current cardiac function (e.g., 3 vessel disease with a decreased ejection fraction has better results from surgery).

One should not go looking for disease to "repair" in asymptomatic patients. One might want to diagnose disease in patients with mild or equivocal symptoms - but not to "repair" the disease.

Regardless of whether patients do need a procedure, they need good medical management. I have written often about this issue. To reiterate:

We clearly know that coronary artery disease patients benefit from 4 drug classes

• Platelet inhibitors - aspirin, clopidogrel (in certain circumstances)
• Beta blockers
• ACE inhibitors or ARBs
• Statins

So the article and this editorial describe the current thinking of coronary artery plaques as fragile changing lesions. Understanding the dynamic nature of plaques gives us a broader understanding. This concept explains much current clinical trial and epidemiologic data. It drives current therapy.

Most important it should give hope to patients. As patients we can take some responsibility for our hearts. Exercise, weight control, and - when indicated - medications can modify coronary artery plaques, leading to regression and stabilization. Patients can often prevent coronary artery disease, but when they cannot (bad genetics especially), physicians can help greatly by prescribing the right drugs. Of course, the responsibility quickly reverts to the patient who then must take those medications.