Dr Ralph Ryback


I have learned, as have all of you, the positive and negative interactions of physical, mental and financial health and security. A close friend of mine quipped "money doesn't make you happy, it just makes it easier". It is a powerful truism that without health we have little. In what follows I will briefly discuss a few pertinent health related issues including the areas of bowels, bones and brains.

Each of us in our own microcosmic way reflects the development of our modern species which is thought to have trudged out of the plains of Africa 40 to 50,000 years ago. Their biological and psychological selves experienced many "revolutions" including more recently agricultural, industrial, digital, cyber, etc. Each caused and continues to cause psychological and physiological stress, or exposure to adverse situations over which we perceive or we have little or no control, on a biological system, the vessel of our body and brain, numerous times older. Understanding these relationships is vital to our present and future health.

This delicate balance between stress and biochemistry can be characterized bio-chemically from our inceptions as constant struggle to maintain a balance between oxidative damage from the formation of free radicals called pro-oxidants and their consumption by antioxidants. Steady supplies of antioxidants are necessary to maintain this balance or oxidative damage accumulates, with resulting disruption of normal physiology (e.g. damage to DNA, lipids, and proteins) and then overt disease. Sleep is a necessary part of the repair processes and that is why I call "sleep the center of sanity", that is, the center of our physical and mental sanity. During deep sleep reparative processes take place including and involving the release of growth hormone. The "stress system" or the hypothalamic-pituitary-adrenal axis, is thought to be involved in sleep and mood regulation. Accordingly, improving sleep is of concern to many members of our community since insomnia is an exceedingly common problem.

Some have suggested that the life long damage by free radicals accompanies and is part of aging when the bodies repair processes and antioxidant defenses can no longer keep up with the assault of the many different types of free radicals produced by life in our body and in this world (our environment). In response to these suggestions, high ORAC (i.e. oxygen radical absorbance capacity) supplements and nutritional products have been created and foods identified suggesting incremental benefits. Dr. Ron Prior, the director of the U.S. Department of Agriculture Research Service and the Arkansas Children's Nutrition Center, with whom I have talked several times, and others, have demonstrated there is a limitation to the amount of ORAC nutrients the body can assimilate. Moreover, whether more is actually harmful has not been ascertained. This delicate balance of nutrition and health is open to inquiry by members of our community in the quest to separate substance from sales pitch.

Free radicals are actually produced by the metabolism of what we eat. This is why the actually consumption of food has toxic qualities not only related to what we eat (e.g. saturated and transfat, processed foods, sugars, additives, preservatives, etc) but how much we eat. We are familiar with the concept that overloading a motor will burn it out, and the shutting it off so it can cool down may prevent this but we rarely think this way about ourselves. Fasting is in fact the closest we get to this in our present and past dietary lives when we didn't have a supermarket a phone call away now making fasting an unusual experience. Fasting, food restriction, and resveratrol (in red wines and the alleged explanation of the French paradox, that is, fatty food consumption with relativity low morbidity) all turn on the same enzymatic systems and all have been shown to prolong life in many animal species. However, the quality of life is of central importance.

Obesity is a very close second behind smoking as a preventable cause of morbidity and mortality. Obviously, you have to burn more calories than you consume to lose weight and will power and exercise are often considered the path to weight loss even for stress eaters. However, recent information in the physiology and bio-chemistry of appetite had revealed new opportunities for successful intervention including ghrelin, cholescytokinin, (CCK) and leptin. When ghrelin the "hunger hormone" becomes elevated the brain is signaled to find food. It decreases usually after a meal and CCK levels increase as part of a hormonal cascade along with leptin produced in the body fat related to feeling full and sated. There are now a number of natural products to successfully increase CCK and leptin with statistically significant reductions in weight.

Yes, we are what we eat, but what we eat can also reduce our appetite. Soluble (now called prebiotic- oat and glucomannan have been studied) and nonsoluble fiber have been studied, including psyllium husk, increase the speed of food transport, thus decreasing fat absorption. Both can decrease appetite and increase satiety. Resistant starch found in for example, bananas and barley can decrease glucose and insulin levels after the present and the next meal. It is felt that this occurs in part by changing the colonization in our intestinal tract in a manner that affects absorption and metabolism favorably. Moreover, pure protein such as whey and casein consumed before meals decrease appetite and can elevate CCK. (I happen to also mix in brewers yeast because of its balanced nutritional composition) With age, the intricate architecture of the intestine tract changes (often with a decrease in intrinsic factors to absorb vitamin B12) making fiber even more important to avoid constipation and diminish weight gain. Extremely large members of our society only had until recently, the very difficult partial gastrectomy procedure to decrease their weight. That has changed with the outpatient two hour laparoscopic adjustable band surgery.

Our bones are our supporting framework since in many ways we are a sophisticated sack of water. Among the problems we face are back pain, slipped discs, osteoarthritis (called wear and tear), rheumatoid arthritis (autoimmune) and spinal stenosis. Many of these problems begin with the way we carry ourselves and sit. For example: if you sit, leaning slightly over a desk, stand up without moving your upper torso, you will find yourself erect and leaning forward with the slow development of weaker back and stomach muscles. This results in a leaning forward posture as we age. It also puts unequal pressure on the anterior facets of most vertebrae (i.e. spinal column) increasing the likelihood of slipped discs or the "itis" or inflammatory process when bones are unevenly stressed. I have to tell too many of my patients to walk looking at the horizon. Even orthopedic surgeons are beginning to realize the benefits of Pilates to prevent or partially remedy these problems. Pilates results in the strengthening of core musculature and stretching of muscles in both directions helping to realign the body and its bones.

The brain is the vessel of our mind and some would say, somewhere therein of our soul. A few squander it early in life such as a recent 24 year male patient former Merit Scholar who had a math scholarship to a major university, did with inhalants or "huffing". Slowly with proper diagnosis of attention deficit disorder, paranoia, depression and treatment his thinking has become less disjointed and his ability to play the piano is improving. Yet more pertinent to the members of our community is the presumed cognitive decline with age. It is clear that in some individuals reasoning, memory and other brain functions worsen with the most extreme being Alzheimer's dementia. I remember when a brilliant president and chairman of the board of a large corporation was forced out because of Alzheimer's (85%of dementia) as might have occurred with President Reagan who many protected during his last years in Washington. Despite an industry has jumped to the fore with Mind Fit, Brain age, Brain Trainer, crossword puzzles, etc., there is lack of clinical support for mental exercises slowing decline. However, it is also documented that the period of greatest creativity for many is between 50 and 75 years of age. How can one reconcile this? It has been shown that novelty and especially attention are necessary prerequisites for the brain rewiring itself or what is called plasticity. Are you paying attention? Plasticity is absolutely necessary for the acquisition of skills. This is why the brain games noted eventually fail because they become routine or hardwired instead of plastic or flexible like "thinking outside of the box". Moreover, with age, and without illness, the brain cells that we have actually become more efficient and we usually acquire a larger data base or our repertoire. Accordingly, if we stay focused and are willing to accept novelty we can maintain our psychological plasticity.

If you remind yourself that more than 70% of your brain is dedicated to your body's muscles and their integration including those of the heart, diaphragm, stomach, and intestinal tract, it is not surprising that a 2003 review of 18 studies found aerobics and strength training maintain remembering, planning, multitasking or executive function, at a high level. My experience with the Man Orbiting Laboratory research more than 40 years ago supports and reinforces these more recent studies.

In some of those studies, initially young airmen ages 18 to 21, were put on complete bed rest for 8 weeks. They had TV's, a novelty in those days, and regular daytime visits by young WACS, female airwomen. They were carried to the bathrooms. By the fourth week their mental acuity including memory and mood decreased which became more evident and severe by week eight. These effects could be stopped and reversed by exercise. On a historical note, the benevolent asylums of the 19th century regularly used exercise, even forced exercise, as a treatment for depression. However, how much exercise is necessary is up for debate but recent studies have clearly shown that the amount suggested in many publications including the book "Younger Next Year" are misleading.

In medicine we are almost always treating symptoms instead of root causes. "Inflammation" at the cellular wall of each cell and specific cells could help us understand the possible relationship and similarity between depression, anxiety, cardiovascular disease, cancer, diabetes, arthritis, etc. To be simplistic, the cell walls are double or bilayered, made up of water, protein, fats including cholesterol and omega 3 fatty acids, etc. with pumps and channels creating an electrical gradient which is essential for life and utilizes 75% of all the energy we consume. Our immune system is intimately and precisely familiar with all of this at birth or shortly thereafter. If any of these intricate arrangements change, an inflammatory response begins and if it progresses the immune system can decide it is a foreign invader and attacks. If you put coal tar on a rodent's skin, it will become inflamed. If you continue to do so for several weeks, the skin cells will undergo change and eventually become cancerous. If an individual is predisposed genetically to psoriasis, rheumatoid or psoriatic arthritis and they are stressed psychologically or physically (e.g. cold), their illness will be expressed and the actual cellular composition biochemically of their synovial living (i.e. lining of the joints) and their skin with psoriasis, will have changed. One of the oldest treatments is steroids which are anti-inflammatory agents. With diabetes there is little now to practically separate between type I (inherited) and type II (acquired) when a large number of adolescents have diabetes which was rare only 60 years ago. However, developmentally we didn't evolve to consume more than 80 lbs of sugar per year affecting the vasculature of our entire body which underlies diabetes since at its core among other things it is a vasculitis or inflammation of vessels, and elevated blood sugar is its most obvious late symptom. In our past history honey was a rare treat.

Some of you may think that I'm over the edge to suggest depression and anxiety are inflammatory processes. Briefly, both are signals of stress and stressors in and of themselves. Suffice it to say that depression and anxiety in heart disease patients raises the risk of deterioration and death and if you are depressed or highly anxious you are more likely to have a heart attack. In one 10 year study of 740 healthy men overall anxiety independently and strongly predicted the incidence of myocardial infarction (MI) even after controlling for age, education, blood pressure, weight, marital status, smoking, drinking, caloric intake, cholesterol, and glucose. Most remarkable, the incidence of MI and anxiety were directly related. Stress (e.g. "this job is killing me") releases pro-inflammatory cytokines including tumor necroses factor-alpha, interleukin 1and 6, while most anti-depressants have a negative immune regulatory effect which may explain part of their efficacy. As we age the organizational arrangements of our cell walls and cellular proteins change with an increasing incidence of cancers, hypertension, immune and metabolic disorders such as diabetes, dementias, etc. In Alzheimers, a protein called tau becomes changed because of hyperphosphorylation and tau can no longer form microtubules necessary for transport (or the subway tunnels) in our nerve cells. This leads to the breakdown of communications between cells, nerve cell death, amyloid beta accumulation which is toxic and inflammatory, with consequent plaques and neurofibrillary tangles or the pathological sinequanon of Alzheimers. There are experimental but not yet clinical ways, except perhaps omega 3 fatty acids, to inhibit the hyperphorphorylation of tau protein which is a protein inflammatory change. Into this fray the more than 20 billion dollar a year supplement industry has jumped with many physicians claiming science cashing in.

Supplements as stated are supposed to be supplements to normal nutrition which is becoming rarer with processed and engineered foods. Our bodies have not evolved on supplements but whole organic foods and are not prepared to assimilate most supplements in a complete or healthy manner. For example, vitamin E when taken in more than 200 IU per day is associated with a higher incidence of stroke, probably related to easier bleeding. If 400 IU of vitamin E is taken alone, on an empty stomach less is absorbed than 60 IU in a breakfast cereal because of the fat in the cereal improves absorption. Some supplement and vitamins are more poorly absorbed because they are chemical fabricated rather than organically derived. We generally don't know what is really in a supplement because it is generally not independently laboratory tested. We don't know how supplements interact with each other in our bodies or which might cause subtle damage to for example, the mitochondrial function or the power plants of our cells. Most of the good studies are coming out of Germany where their government supports this research. However, large double blind human placebo controlled studies which cost 50 to 100 million dollars required by the FDA of the pharmaceutical industry are lacking. This could change with federally supported research.

The FDA agrees that cold water fish oil (i.e. EPA and DHA) for the heart and the brain are good and why not. It is a molecularly distilled natural product (i.e. without mercury, or other pollutants) which decreases the risk of poor memory and health in humans and in mice. Even when given (i.e. omega 3 DHA) to older mice brain amyloid beta accumulation and oxidative brain damage decreased along with improved cognitive function. Of course I'm never sure what a mouse knows. The Framingham Heart 9 year study of 899 people of 76 years of age on average who were in top 25% of DHA blood levels (i.e. average 3 servings of fish per week) had a 47% decrease in the development of poor memory. Yes, you can teach an old dog new tricks if you feed him fish regularly or give him optimally 2,000mg of omega 3 DHA and EPA (not the fish oils). EPA is more beneficial to the heart. I also use a group of natural supplements to regularly lower cholesterol in some of my patients with better results than they had with statins.

I want to make it clear that I am not against the supplement or nutritional or any type of capital producing treatment or technological industry rather I want with you to have critical inquiry and information exchange. Two technologies will be briefly discussed, personalized medicine with pharmacogenomics and computed tomography (CT) screening. Personalized medicine by metabolic profiling through genotype analysis has the potential of predicting what drug to prescribe as well as predict a patient's response to a given medication. This approach has already proven useful for several drugs in medicine (e.g. warfarin anticoagulant action and several cancer treatments).

The CAT scan industry has helped medicine progress in a limited manner and in the U.S.A. whether real or not, a perceived necessity to avoid malpractice suits as well as propels income. The most recent iteration is the promoted suggestion that CT scanning can provide earlier diagnosis and treatment and have more favorable outcome with the extreme offer being full body CT screening. A study of CT screening and lung cancer outcomes in current and former smokers published in the Journal of American Medical Association in March 2007was of 3246 asymptomatic individuals with CT repeated 3 or 4 times over 4 years. In short, it demonstrated that repeated low-dose CT increased the rate of lung cancer diagnosis and treatment (i.e. 144 individuals diagnosed with lung cancer compared to 44.5 expected cases), but did not reduce the rate of lung cancer or death from lung cancer. It did result in a 10-fold increase in lung cancer surgeries with subsequent hospitalization and illness. The post-operative mortality rate following resection of lung cancer averages 5% in the United States. These findings with CT scan are no different than prior randomized studies of lung cancer screening with chest X-ray done in the late 1970's and in the 1980's in the United States. But Why? The "positive response" is to suggest the tumor was too small or had already metastasized. However, what about the procedure? Radiation is an inflammatory carcinogenic insult. In the 1940's shoe stores had fluroscopic x-ray machine to look at your feet until a large spike in the incidence of foot cancer was noted. Why do x-ray technicians leave the room when doing even routine chest x-rays? Some physicians have laughingly said that repeated, even low dose, CT scanning is like being 4 or 5 miles from the epicenter of Hiroshima. Remember radiation is a cumulative poison. Just look at what the sun has done to the back side of your hands and face and compare it to your derriere. Sadly like in quantum physics the observer may be affecting what is being observed.

There is a different form of personalized medicine about which many of you have heard and in which you may be participating. This is called "concierge medicine". It is supposed to provide a better higher quality of health care. It evolved in part due to declining Medicare revenues in physicians who wanted to limit their practice. Like the French gatekeeper there is a fee to enter ranging from hundreds to thousands of dollars for the individual and somewhat more for the couple. There is usually a more rapid response to calls, more follow up at the hospital when necessary, and an extensive yearly physical examination with a large battery of tests. Some groups have begun to give parties for their group members, offer informational talks and actively encourage referrals. What is missing in this is an "accurate" assessment of the participating physician and how the "market" slowly gravitates to excellence.

More than 30 years ago I was a participant on a "premanaged" care meeting where the Medical Director of Kaiser Aluminum made a presentation claiming 25% decrease in costs and a 35% improvement in outcome. He went on to explain that he had done this over a period of several years monitoring hospital lengths of stay, days out sick for various illnesses, length of outpatient treatment, patient's and spouse's assessments of improvement, etc. and matching the physician and other caregivers to the best outcomes. He then directed his employees to that pool of caregivers regardless of what they charged (many charge a regular or lower fee than average) and they became his comprehensive treatment team of excellence. Each of you knows at least one caregiver of excellence and why you feel they are that way. What might evolve is a Cap Net X comprehensive treatment team of excellence without borders.

When estate planning is begun or new job opportunities offered, various assets are discussed except the most important which is you. That part is taken for granted with the possible exception of physical health. Yet, we live and function in our mind where reasoning, concentration, judgment and memory are essential to making good decisions for ourselves, our family and our company. If you were able to assess these and other cognitive functions in the privacy of your own home with repeat testing and results available for you to see by yourself, you could make an informed judgment early and make appropriate plans for the future. Over time you can see whether you are at risk, put plans together and develop organizational habits which take the fear out of self evaluation and allows a higher quality of life. I will be teaming with a psychologist with 30 years experience in this field to develop this and other types of confidential computerized testing and follow up treatment intervention as requested.

Contact Ralph Ryback
Tel: 239799-5933

Ralph Ryback, Psychiatrist Naples Florida

"My advice to you is not to inquire why or whither, but just to enjoy your ice cream while it's on your plate - that's my philosphy "
~ Thornton Wilder

"Knowledge comes, but wisdom lingers." - Alfred Lord Tennyson