Physicians/Practitioners

Target Audience: Physicians/Practitioners/All Health Professionals/Community

Instructor: Brian Bull, MD
Brian graduated from CME Class of ’61, and then took a residency in Clinical Pathology at the National Institutes of Health. While there he devised a method for counting blood platelets by machine. These were the early years of chemotherapy and his research saved medical technologists many hundreds of hours by making it unnecessary to count platelets manually. He took a postdoctoral fellowship under Sir John Dacie at the Royal Postgraduate Medical School in London, England. One disorder that mystified hematologists at that time was microangiopathic hemolytic anemia. Brian solved the problem by devising an experiment that allowed him to photograph a red cell being torn apart by a fibrin strand…. Photographs of this process have appeared on the cover of several hematology journals and in textbooks discussing this disease.

Brian returned to his Alma Mater in 1968 together with his wife Maureen (nee Huse) also a CME graduate class of ’57. These were the early years of open heart surgery and Brian quickly found himself involved with the cardiac surgery team at Loma Linda who had just acquired a new heart-lung machine. Dr. Wareham and Dr. Huse sought his help to provide safe anti-coagulation during by-pass. Together with his collaborators Brian wrote a paper entitled, “Heparin therapy during extracorporeal circulation. The use of a dose-response curve to individualize heparin and protamine dosage.” The technique described in this publication became widely used by other cardiac surgery teams throughout the country, and late in 2015, 47 years after publication it was designated as number 8 on the list of the 20 all-time “game changers” in cardiovascular anesthesia. This single paper is estimated to have cut the mortality rate from open-heart surgery by 50%.

During his years at Loma Linda Brian has authored over 250 research papers in peer-reviewed scientific papers, monographs, book chapters and books in hematopathology, mathematics, and blood analysis instrumentation. Two of his research papers achieved the notable status in the research literature as “Citation Classics” – these were papers quoted many times by other authors as a basis for their further research. For ten years Brian was Editor in Chief of an international research journal –Blood Cells from 1984 -1994. During these years he organized international symposia on various aspects of Hematology and invited world leaders in his field to present their latest work so it could be published in the journal he edited. Blood Cells aimed to publish “The New, the True and the Beautiful” in hematology.

For his life-saving and “game-changing” research contributions, Loma Linda University named Dr. Brian .S. Bull the recipient of the Distinguished Investigator award. Click here for Curriculum Vitae.

Presentation title: Corpulence & Coronary, the Crime and the Culprit

Part I​: When Cardiologists Become Dieticians – Bad Things May Result. ​Cholesterol is “of Concern” No Longer and Dietary Fat May be OK.

Synopsis: ​During the last 100 years coronary heart disease (CHD) has gone from being a rare diagnosis to become the single leading cause of death in the US; it now kills one in seven Americans. 100 years ago obesity was unknown (<1%), now two-thirds of us are overweight (BMI >25) or obese (BMI >30). It seems likely that food and exercise are intimately involved, possibly with some contribution from epigenetics.

The American Heart Association has, for the past 50 years, specified a “healthy diet”—low fat as well as low in cholesterol and saturated fat (think “Heart Healthy” stickers on food items in the local grocery).

Two years ago the Dietary Guidelines Advisory Committee (advisory to US Department of Agriculture) removed cholesterol from list of “Concern for Overconsumption” and a few months ago the European Society of Cardiology effectively removed dietary fat (by raising the recommended dietary saturated fat content and the dietary fat content (the PURE study)

So now, what? We all have a stake in this matter because we all must choose what to eat 3 times each day. Where do we turn when our “authorities” have, unmistakably, led us down the wrong path? Perhaps the path through the “forest” is wrong not because it is the wrong path but because it is a path in the “wrong forest”? That is a possibility we will consider carefully in the remaining four seminars.

Objectives:​ At the conclusion of the lecture the participant will be able to

• Define BMI, calculate it and explain what it means.
• Trace the history of the American Heart Association recommendations on diet over the past 40 years and detail the evidence obtained from several prospective, retrospective and observational dietary interventions.
  Similarly detail the contradictory evidence from the European Society of Cardiology (PURE) study.
• Account for the unsatisfactory quality of the available scientific evidence in nutritional matters and, as an example, explain why dietary cholesterol is no longer an “item of concern for over consumption”.

​References:

1. Lowering the Bar on the Low-Fat Diet, Ludwig DA, JAMA Vol 316, pp. 2087-88, 2016
2. Dietary Fats and Cardiovascular Disease-A Presidential Advisory from the American Heart Association, Circulation Jul 18;136(3), 2017
3. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study, Lancet. Nov 4;2050-2062, 2017

Part II: Diet and Exercise Are Our Only Hope for Obesity’s Cure Despite Apparent Failure at Present. Disentangling the Causes of Obesity.

​Synopsis: The annual chance of an obese person attaining normal body weight is 1 in 210 for men and 1 in 124 for women according to a study of UK health records. However, only half are trying so the odds improve a bit! Five to ten percent weight loss is much more achievable and confers major health benefits. Estimates of success at this threshold are 1 in 5. Diet and exercise are our only tools out there despite claims that they “are not effective in tackling obesity at population level”.

Proposed causes of the corpulence epidemic include automobiles, fast food, TV, processed food, even the 1992 food pyramid itself. Non-surgical solutions are numerous, but all involve diets and exercise.

Diets: more than 600 well-characterized diets ranging from the “Hallelujah” to the “Amen” have been published and evaluated.

Exercise: is a very useful adjunct to combating corpulence. However, it’s clear that “you cannot outrun a bad diet!”

Objectives: ​At the conclusion of the lecture the participant will be able to:

• Explore the role of exercise and diet in maintaining normal body weight and the role that each plays in the very difficult and very unlikely recovery from obesity.
• Evaluate the various diets on offer and identify which are possibly helpful, if not in long-term weight loss then in various special situations such as:
  • Breast cancer
  • Diverticulosis and diverticulitis
  • Elevated cholesterol as an isolated risk factor
  • Ingestion of emulsifiers
  • Begin the process of identifying and evaluating various proposed causes of obesity.

​References:

1. Probability of an Obese Person Attaining Normal Body Weight—Cohort Study Using Electronic Records, Fildes A. et al, Am J Pub Health, 105(9): p 54–59 2015
2. Change in Percentages of Adults with Overweight or Obesity Trying to Lose Weight, 1988-2014, Snook KS, Hansen AR, Duke CH et al., JAMA Vol 317, Number 9, p 973, 2017
3. Weight Loss Maintenance—Wing RR et al., Am J Clin Nutr p 222S, 2005
4. Complete List of Diets—Everydiet https://www.everydiet.org/diet

Part III: The Upper Gut Food Pyramid is Recognized & Respected. The Unheralded Lower Gut Pyramid has been Ravaged – Disastrous.

Synopsis: The “nutritive value” of food is expressed in terms of carbohydrates, proteins and fats. Digestive enzymes release these “nutrients” from “food” which are then absorbed in the small intestine (upper gut).

There are no equivalent “nutrients” for the lower gut. Lacking a descriptive term for “lower gut nutrients” it is difficult to remember that a lower gut “food pyramid” exists. What cannot be named is all too easily ignored and destroyed. We will spend this entire lecture addressing this oversight and we will start by giving the “nutrients” of the lower gut a name—Microbe Munchies!

Most “whole foods” contain microbe munchies along with carbohydrates, proteins and fats. All munchies are complex carbohydrates that humans digestive enzymes cannot break down. “Processed” foods are munchie-poor. Microbe munchies vary widely in form and are typically tasteless and odorless. They have disappeared from the food pyramid over the past 100 years. That disappearance has been largely unnoticed—that process must be reversed.

Two examples of microbe munchies are the vesicle membranes of citrus fruits, and inulin—the fructose oligosaccharide abundant in Jerusalem artichokes (sunchokes) and also present at lower concentrations in vegetables such as regular artichokes, asparagus and onions. Some microbe munchies are not fibrous at all such as the oligosaccharides in mother’s milk and the mucin that coats our entire digestive tract.

A healthy microbiome is far more important than we have heretofore acknowledged. We would be wise to do everything necessary to recover it.

Objectives: At the conclusion of the lecture the participant will be able to:

• Locate anatomically the “upper gut” and the “lower gut”. Define the foodstuffs that are metabolized and absorbed in each.
• Trace the history of manipulation of the food that makes up our food pyramid so that soluble fiber (microbe munchies) has virtually disappeared.
• Define terms such as oligosaccharides, inulin, pre-biotics and pro-biotics.
• Account for the recent increase in C. dificile infections and explain the concepts underlying fecal transplants.

References:

1. Increased Consumption of Refined Carbohydrates and the Epidemic of Type 2 Diabetes in the United States: an Ecologic
2. Assessment, Lee S Gross, et al. The American Journal of Clinical Nutrition, Volume 79, Issue 5, May 2004, P 774.
3. Dietary Fiber Intake and Mortality in the NIH-AARP Diet and Health Study Archives of internal medicine 171.12 (2011): 1061–1068. Park, Yikyung et al. PMC. Web. 31 Jan. 2018.

Part IV: The Ideal – A Microbiome Fed Quality Microbe Munchies; The Real – A Decimated Microbiome Fed Next to Nothing

Synopsis: When our lower gut microbes are fed “munchies” they produce Short Chain Fatty Acids (SCFAs) which we then utilize for energy (calories). At present our diets provide approximately 7 % of calories from this source. Lowland Gorillas, with an anatomically similar gut, get up to 55% from their lower-gut microbes. That difference may, in part, account for the obesity epidemic. One hundred years ago we were likely getting ~20 % of calories from SCFA. We were not obese then. How might taking in even more SCFA calories possibly assist in treating obesity? By two means: (1) SCFAs (particularly acetic acid) down-regulate appetite and (2) microbes produce a steady stream of SCFA throughout 24 hours. This constant input of calories maintains a baseline blood glucose level, helps retain insulin sensitivity and makes ‘snacking’ less likely—a chemical “aid-to-willpower”.

SCFAs, especially the 4 carbon variety (butyric acid) provide the vast majority, (70-80%) of the calories utilized by the lining cells of the colon. These cover an area half the size of a badminton court. They are the single layer of cells that separate (and protect) us from being overwhelmed by billions of gut microbes. Good gut microbes produce compounds that function as anti-breast cancer agents, anti-inflammatory agents and immune enhancing agents. They likely produce many additional beneficial compounds that we do not yet understand. A population of ‘bad’ microbes in the lower gut can be devastating—and it can kill. C. difficile colitis is a dramatic example—but less spectacular damage also occurs. A healthy microbiome more important than we have understood. We would be wise to do everything we can to ensure its continuing health.

Objectives: At the conclusion of the lecture the participant will be able to:

• Define and describe chemically the major short chain fatty acids and explain their relevance to the health of colonic lining cells.
• Detail why healthy colonic lining cells are so vital.
• Explore the statin-like effects of the SCFA propionic acid.
• Refer to the relevant literature on appetite suppressant drugs both endogenous and exogenous.
• Explicate how an increased percentage of daily calories from SCFA might assist in maintaining normal weight and recovering from obesity.

References:

1. The Western Lowland Gorilla Diet Has Implications for the Health of Humans and Other Hominoids. David G. Popovich, et al. The Journal of Nutrition, Vol 127, Issue 10, 1 October 1997, Pages 2000–2005. (https://doi.org/10.1093/jn/127.10.2000)
2. Fiber Is Good for You. Now Scientists May Know Why. Carl Zimmer. New York Times, Jan 1, 2018. (https://www.nytimes.com/2018/01/01/science/food-fiber-microbiome-inflammation.html)

Part V: A “Microbe Munchie” Rich Diet in the 21st Century World. The Crucial Role of Breakfast and Exercise.

​Synopsis: Grain milling changed dramatically in the 1890s, a big drop in microbe munchies resulted. Coronary heart disease (CHD) was first reported 30 years later coincident with a rise in cigarette smoking. Both are known to increase whole body inflammation, coronary arteritis, arteriosclerosis and coronary heart disease (CHD). CHD peaked in the 1960s and has since lessened (coinciding with a decrease in smoking) but the decrease in microbe munchies has accelerated massively. Vitamins (such as K-1 and K-2) and statin-like microbiome-produced factors have likely, decreased or disappeared as a result. This munchie drop was accelerated by a 1980 request to food processors from the US Dept. of Health and Human Services to increase to 5,000 items, foods that were low in total fat, saturated fat and cholesterol.

How then do we now plan, choose, prepare and consume three meals a day in a 21st-century world? We’ll begin with the top five sources of calories in the American diet: #1…grain-based deserts (pies, cakes, donuts, etc.), #2…yeast breads, #3…meat, #4…sugar-sweetened beverages—sodas and sports drinks, and #5… pizza.

Eating only whole wheat vegetarian pizza corrects #5; drinking only water #4. A vegetarian/vegan diet that trades tofu/beans for meat and meat dishes rectifies #3. Eating only whole grain yeast breads will remedy #2 but #1 almost always involves intake of enriched flour since some grain-based pies, cakes, donuts etc. are going to be eaten. This will require the introduction of compensatory grain-based ‘dessecorp’ foods. These are ‘processed’ foods—reverse-engineered—essential for those who are recovering from obesity–and need time to reset their ‘appestat’; and useful for all.

At breakfast ‘dessecorp’, whole grain cereals, rich in “munchies” can be most easily introduced—allowing for ‘token’ pies, cakes, pastries etc. later in the day. Remainder of diet? Whole foods; for these are typically upper/lower gut balanced. Adequate exercise (40 minutes a day) rounds out the 21st-century dietary program.

​Objectives: At the conclusion of the lecture the participant will be able to:

• Enumerate several options for incorporating dietary fiber into breakfast, lunch and/or dinner.
• Understand and be able to enumerate the five main sources of calories in the America diet.
• Detail several modifications that can be made to each of the five main dietary calorie sources so as to decrease calorie intake and, simultaneously, restore the lower gut food pyramid to its previously healthy state.

References:

1. What Americans Eat: Top ten sources of calories in the U.S. Diet, Harvard Health Publishing, Source: Report of the 2010 Dietary Guidelines Advisory Committee
2. Cardiovascular Disease Death Before Age 65 in 168 Countries Correlated Statistically with Biometrics, Socioeconomic Status, Tobacco, Gender, Exercise, Macronutrients, and Vitamin K, Cundiff DK, Agutter PS, Cureus 8(8) 2016

Instructor: Michael Liedke, DNP, ACNP-BC
Michael Liedke is a professor of the School of Nursing at Southern Adventist University. Michael A. Liedke is an acute care nurse practitioner and has worked in critical care and neurosurgery for 15 years. He completed his RN and BSN degrees from Southern Adventist University, his Acute Care Nurse Practitioner/MSN from Emory University, and most recently his Doctor of Nursing Practice with a focus on neurocritical care and neurophysiology from University of Alabama at Birmingham. He currently serves as an Assistant Professor for Southern Adventist University in the graduate and doctoral programs as well as Midlevel Coordinator and provider with the neurosurgery group in Chattanooga. Click here for Curriculum Vitae.

Presentation title: Neurophysiologic Benefits of Worship

Synopsis: Traditional Judeo-Christian worship conveys significant health benefits, such as a reduction in
stress and depression, while concurrently increasing empathy and hopefulness. Recent advances in imaging technology are beginning to explain the neuronal structures involved. Since the middle of the twentieth century there has been a growing interest in the Eastern religions of Buddism. Hinduism and Confucianism. Practices common to these religions include meditation and breathing techniques. These too have been shown to be beneficial in reducing stress and epression with similar improvement in hopefulness and empathy. Understanding this phenomena’s neurophysiologic mechanisms, beneficial effects and the philosophical implications will aid in the practical application of these benefits to care of patients.

Objectives: At the conclusion of the lecture the participant will be able to

• Identify the neuroanatomical structures involved with worship.
• Understand the neurophysiological/physiologic benefits of actively engaging in worship.
• Understand how worship helps to attenuate stress.
• Understand the differences between traditional Judeo-Christian worship and meditation related to beneficial effects.
• Identify ways to maximize and prolong the beneficial effects of worship.

​References:

1. Björklund, A. & Dunnett, S. (2007). Dopamine neuron systems in the brain: an update. Trends in Neurosciences. 30 (5): 194–202.
2. Newberg, A. (2003). Cerebral Blood Flow during Meditative Prayer: Preliminary Findings and Methodological Issues. Perception and Motor Skills, 97, 652-630.
3. Simão, T., Caldeira, S., & Campos de carvalho, E. (2016). The Effect of Prayer on Patients’ Health: Systematic Literature Review. Religions, 7(1). http://dx.doi.org/doi:10.3390/rel7010011.

CME Accreditation Statement:​ (7 Hours)
Accreditation Statement
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Loma Linda University School of Medicine and Southern Union Conference of Seventh-day Adventists. The Loma Linda University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
The Loma Linda University School of Medicine designates this Live Activity for a maximum of 14.5 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure Statement
This program has been planned and implemented in accordance with ACCME essentials and standards. The Loma Linda University School of Medicine Office of Continuing Medical Education relies on its CME faculty to provide program content that is free of commercial bias. Therefore, in accordance with ACCME standards, any faculty and/or provider industry relationships will be disclosed and resolved.

Statement of Purpose or Overall Objective
This program designed to provide current, concise information on a variety of topics that are relevant to physicians and other health care providers in all specialties. The attendee is informed of practices that will improve patient care and enhance risk management skills. In addition, a lecture on stress will provide an overview on the importance of the nature of psychological stress and will describe the mechanisms that link stress with disease and appropriate interventions.