David L. Katz, MD, MPH, FACPM is Associate Clinical Professor of Epidemiology & Public Health, and Medicine, and Director of Medical Studies in Public Health at the Yale University School of Medicine. A board-certified specialist in both Internal Medicine and Preventive Medicine/Public Health, Katz has 15-years of clinical practice experience. Dr. Katz founded and is director of the CDC-funded Yale Prevention Research Center, where he serves as principal investigator for numerous studies related to cardiovascular risk modification, obesity prevention and control, nutrition effects on health, behavior change, and chronic disease prevention. He is also the founder and director of the Integrative Medicine Center in Derby, CT, a clinical facility in which conventional and naturopathic medicine are blended to offer patients the best of both, generally with a strong emphasis on nutrition and nutrient therapies.
Do you regularly see Chronic Fatigue Syndrome (CFS) and fibromyalgia (FM) patients? If so, do you have a standard treatment protocol you follow to help these patients manage (and hopefully resolve) their symptoms? Also, do you treat symptoms in any particular order?
Yes, I routinely see and treat patients with these conditions. I have the privilege of doing so in a unique context, an integrative medicine center I founded and direct in Derby, CT. In this center, our care is provided by four clinicians, two trained in conventional medicine, and two trained in naturopathic medicine. At least one clinician from both teams sees all of our patients. We then confer with one another, and provide treatment recommendations by consensus. This allows us to offer our patients treatment options spanning the widest possible spectrum. It also enables us to respect evidence, without being caged in by it. Many patients have exhausted all of the evidence-based treatment options for CFS and FMS by the time they come to us. In general, human need goes on long after evidence runs out. We go with our patients - carefully, but unashamedly - beyond the edge of evidence as needed, so they don’t have to go alone.
We offer highly individualized care. Often our treatments for these conditions include conventional elements - analgesics, good sleep hygiene, graduated exercise programs, possibly antidepressants. But we also use many nutritional supplements, mind-body interventions, homeopathy, and intravenous micronutrient therapy. This last treatment - something called the “Meyer’s Cocktail” - is popular in complementary/alternative medicine clinics around the country. But we were surprised to learn it has not undergone any rigorous study. We thus began to offer it to our patients - seemingly with good results - but also decided to study it. We are now running a placebo-controlled trial of this treatment, with funding from the National Institutes of Health.
As you know, there is much debate surrounding the causes of CFS and FM. What do you believe contributes to the onset and pathology of "mystery illnesses" such as Chronic Fatigue Syndrome and fibromyalgia?
I cannot pretend to know what is unknown. But I do have theories and informed opinions.
The cells in our bodies are marked with surface proteins used by the immune system to distinguish ‘self’ from ‘non-self.’ In essence, these proteins are our code. They tell the immune system, “this is self - let it be.” Unfortunately, the proteins carried on the surfaces of some viruses and bacteria closely resemble some of the proteins in this code. Those of us who have such proteins in our codes are susceptible to auto-immune disease if we happen to get an infection with a pathogen carrying the same or similar protein. Auto-immunity is when the immune system mistakes self for non-self, and attacks it.
Some auto-immune diseases are quite blatant, such as rheumatoid arthritis. But others are subtle - and I believe CFS and FMS are among these. These conditions are clear enough in terms of symptoms, but are subtle in their pathology, so that no lab test is decisively diagnostic.
I also believe psychology plays a big role. But not at all because these conditions are “all in the head.” Rather, emotions powerfully influence immune function. People taxed by depression or anxiety are much more likely to become ill at any given level of auto-immune activity, than people with good mental health. It is likely most of us have some degree of auto-immunity, but for many of us, there are no overt symptoms. It is the combination of cell surface code, exposure to the “right” infectious agents, and other aspects of health - both mental and physical - that determines whether a disease state develops or not. FMS and CFS are, in my opinion, such disease states.
You are the nutrition columnist for "O", Oprah's magazine, and you've written a book called "The Way to Eat." To what extent do you believe unhealthy eating or being overweight (or obese) contributes to chronic illness? Do you have a standard protocol for patients to follow to overcome their pain and fatigue through diet and nutrition?
The way we eat influences all aspects of our health. This is little more than self-evident. Food is, after all, the fuel that runs all aspects of our metabolism. Just as the fuel put into a machine influences its overall function, so with the food we choose. And in the modern world, our choices are unfortunate for the most part. Far too much fast food and highly-processed food. Too many calories, too much saturated and trans fat, too much sugar, refined starch and salt; and not nearly enough wholesome, natural, unprocessed foods, especially vegetables, fruits, and whole grains.
The modern diet is also unbalanced in a critical way that directly influences immune function. The balance between omega-3 and omega-6 fatty acids in the diet determines the balance between the body’s pro- and anti-inflammatory chemicals; the fatty acids are the precursors for these chemicals. Whereas our ancestors had a fairly even balance between these two varieties of essential fatty acid, the modern diet provides an enormous excess of pro-inflammatory omega-6s. Restoration of balance, through diet or use of a supplement, is very important to overall health, and can offer therapeutic benefit in inflammatory conditions, and auto-immune states.
We invariably address diet with all of our patients. We at times use elimination diets to remove food allergens. We work to achieve the right balance of various nutrients to optimize immune function. But mostly, we guide our patients toward a healthful diet as the foundation for all of our other interventions.
I do, of course, see many patients for weight control and dietary counseling specifically. My approach is reflected in ‘The Way to Eat,’ and on my website, www.thewaytoeat.net. in my opinion, we are not at all confused about ‘what’ constitutes a healthful diet; the trouble is getting there from here. My guidance is about the ‘how’ - and focuses on the needed skills and strategies for lifelong healthful eating and weight control, despite the constant challenges of the modern world.
In the case of severe fatigue (such as that seen in CFS) and a compromised immune system, how do you help patients raise their energy levels and strengthen their immune response through diet and nutrition? Do you recommend any particular nutritional supplements or vitamins?
Every patient is different. When the cause and treatment of a disease are very clearly established, therapy tends to be fairly uniform. The less we know about cause, or consistently effective treatment, the more care needs to be tailored-to find what works.
We look for prominent features, and prominent symptoms, in each of our patients. The sequence of treatment then varies to match. There are, however, common elements. We generally use a high-potency multivitamin; coenzyme q10; and fish oil. We provide concentrated antioxidants in supplement form, or in tea. We also use immune modifying nutrients, such as reishi mushroom. And we generally provide a course of intravenous micronutrients - a mix of B vitamins, magnesium, calcium, and vitamin C.
For overall muscle and tissue pain and soreness, how do you help
patients achieve maximum overall comfort and a healthy inflammatory
We use conventional anti-inflammatories, such as NSAIDs and COX-2 inhibitors at times. We use fish oil, and elimination diets. We use glucosamine. We may try SAM-e, MSM, or other supplements. Then we get creative as needed: acupuncture, massage therapy, osteopathy. Perhaps what’s most important is: we never give up. As long as our patients are dissatisfied with how they feel, we are dissatisfied with our treatment plan.
Brain fog and cognitive problems are very common among CFS and FM patients. Do you have any methods to help 'clear up the fog' and achieve increased mental sharpness and focus for these patients?
Many such symptoms can be confronted directly, or indirectly. “Direct” approaches to improving mental clarity include such things as meditation, yoga, and various supplements - including ginkgo, coenzyme q10, possibly ginseng, and essential fatty acids. The indirect approaches, however, may be as or more important, as or more effective. Sleep deprivation and pain both compromise mental clarity. Improving sleep by various means has an enormously beneficial effect on resolving brain fog, so we work hard to achieve a good sleep pattern. Reducing the distraction of pain confers a similar benefit, so this, too, is a priority. Regular physical activity also enhances mental clarity, so we may proceed through several steps:
-analgesics, various treatment modalities to control pain
-evaluate sleep pattern, and initiate a sleep hygiene program
-optimize diet, remove food allergens as indicated
-provide pertinent supplements
-add in meditation/yoga, counseling, or stress reduction training as indicated
-achieve the necessary degree of symptom relief to initiate a program of graduated physical activity.
By this time, there has usually been considerable progress. But the whole sequence is open-ended; you can keep cycling back through the various parts of it to respond to changes in an individual patient’s condition over time.
One of your focuses is on prevention medicine. For those patients who are beyond the prevention point, how do you help them conquer their most troubling symptoms (fatigue, pain, digestive issues) and regain a healthy state of being?
Much of this is discussed above. The philosophy of preventive medicine is that all of medicine is directed toward prevention. If there is good health, then prevention is primary: maintain health, and prevent any disease from starting. If there is early stage disease, the goal of prevention is to avoid progression. If there is advanced disease, the goal of prevention is to avoid functional decline, maintain quality of life.
There is a need in the delivery of preventive care to balance the present with the future. Thinking preventively naturally directs one’s attention toward the future, the time when something that otherwise would occur is going to be prevented by optimal care. But for someone with symptoms today, controlling those symptoms today may be more important than the long view. A balance needs to be struck between protecting health over time, and maximizing the quality of life today.
An example of this is pain management. Many clinicians worry too much about the potential harms of some pain treatments, neglecting to consider adequately the harm right now of pain that is not well controlled. Good preventive practice balances these priorities.
How do you help patients achieve restorative, restful sleep? This is a major issue with CFS and FM patients, and lack of healthy sleep of course stands in the way of healing and optimal functioning throughout the day and gets patients into a vicious cycle.
Absolutely. This requires highly individualized care. What is the actual sleep pattern? What is disturbing sleep - pain, anxiety, something else? Is there a bona fide sleep disorder? Under what circumstances does sleep improve?
We often turn to polysomnography to evaluate sleep pattern formally. Once we know our patient - and understand the sleep disturbance - we tailor therapy accordingly. It may include soporific supplements (valerian, matricaria nepeta) or teas; a course of medication; stress management training; meditation; treatment for sleep apnea; a course of instruction in improved sleep hygiene; dietary modification, etc.
With a tailored approach, sleep almost always improves. And this is absolutely vital for both physical and mental well-being.
Do you think CFS and FM can be overcome by most patients, or do you believe they must learn to live with their illnesses and manage their symptoms as well as they can?
Both. Learning to accept and deal with symptoms so that quality of life and function are intact is overcoming the condition! There is a difference between effective management and cure. We don’t yet understand these conditions well enough to speak in terms of cure; what, exactly, would we be curing? But there is much we can do to minimize the impact these conditions have on daily quality of life. If you feel well; if you can enjoy your day; if you can do the things you want to do - you may have a medical condition, but it’s not ruling your life. That is the key.
We tend to be a bit unrealistic about health. The human body is extraordinary, and extraordinarily complex. I recall distinctly at one point during medical school suddenly feeling quite overwhelmed and horrified! Understanding how phenomenally complicated human physiology is, I thought: how can this ever all possibly work right? How can anyone ever possibly be truly healthy?
Amazingly, we can be, and often are. But it’s no real surprise that many of us - indeed most - have some abnormalities in this vast and complex array of physiologic functions. The question becomes: can we compensate for them, and live well? If yes, we’re doing ok! An advantage of thinking this way is that it helps us all avoid feeling sorry for ourselves when something goes wrong with health. Part of what makes health problems so difficult to tolerate is the notion that others are free of them. But, in fact, most people have some health perturbation to contend with, perhaps trivial, perhaps severe. You may simply not know about it. As a primary care provider over the years, I have often been amazed at the health problems my patients had that no one in their lives would even have guessed at.
By respecting CFS and FMS, but not capitulating to them; by staying as positive as possible, and exploring the necessary options in treatment - yes, most patients can overcome these conditions. Maybe not enough to feel perfect; but at least enough to live the life they should be living!
Any parting advice for CFS and FM patients? Where can our readers learn more about you and your work - and where can they purchase your books?
You deserve a health care provider who respects the fact that any symptoms you report are real. You deserve a provider who takes a condition they don’t understand and can’t diagnose with a lab test as seriously as one they do/can. Respect yourself - and insist on this! These conditions are real - it’s not your fault if medicine has yet to understand them adequately.
Recognize that all illness involves mind, body, spirit. A condition need not be all in your head to affect your mental health. Be open to treatment directed toward all of you, not just a body part where a pain resides. And keep the faith! Health care encompasses an astonishing array of options, and is constantly adding more. Don’t believe everything you read, or be overeager to try every lotion or potion that comes along - but do your best to remain abreast of new opportunities. There is very likely some approach to treatment that will work well for you; it’s a matter of finding it.
That’s what a clinic like ours is all about; looking at the widest possible array of treatment options, and trying to match treatment plan to individual patient. We also believe that we should never stop working to improve a condition, no matter how challenging. Our patients’ problems are our problems, we are on the same team, we share the same challenges. I believe you should find a healthcare provider who isn’t satisfied until you are.
My website is www.thewaytoeat.net
; my books are posted there, as are a number of my essays, my nutrition program, my bio, and other links. The Integrative Medicine Center in Derby, CT is online at www.imc-griffin.org
; our center manager, Lauren Liberti, can be reached at 203-732-1370 to provide more information.
More about Dr. Katz: Dr. Katz’ work, and expert opinion, have been cited in O (the Oprah Magazine), Prevention Magazine, Modern Maturity, Remedy Magazine, The New York Times, The Washington Post, Child Magazine, and elsewhere. He serves as consulting nutrition expert and columnist to the Oprah Magazine. Dr. Katz has authored numerous scientific papers and chapters, and has authored or co-authored six books, including Epidemiology, Biostatistics & Preventive Medicine (W.B. Saunders, 2001); Clinical Epidemiology and Evidence-Based Medicine (Sage Publications, Inc., 2001) and Nutrition in Clinical Practice (Lippincott Williams & Wilkins, 2000), and The Way to Eat (Sourcebooks, Inc.; December, 2002).