Q&A with Bill Harris, M.D.
Q. Dear Dr. Harris,
Thank you for listening. I had written veg source last week to ask how I could contact Dr. McDougall, but had not received any reply. I am a 48 year old single female veterinarian with a ten year history of veganism. 14 weeks ago I weighed 236 pounds and have been within ten pounds of this for several years, despite numerous attempts to lose weight. 14 weeks ago I started a weight loss plan with a hypnotist, and have lost 20 pounds over the last 14 weeks.
Dear Dr. Harris,
I became vegan after reading one of Dr. McDougall's books back in 1991. Unfortunately, I neglected to take a vitamin/mineral supplement and cut way back on protein, probably becoming deficient.
A. It's rather unlikely that you really were protein deficient although if you were eating mostly starches and grains it's possible.
I remained vegan until three months ago, when I undertook the weight loss program; it prohibited beans, wheat, and potatoes; because these were all primary sources of protein for me, I felt I needed to add meat, fish, dairy and eggs back to my diet or I would not have any protein at all! (I don't enjoy eating alternative grains or tofu on a regular basis, and the only carbohydrate allowed on the diet is rice)
I analysed 95 readily available vegetables and found that they averaged 25% of Calories from protein. You only need 10% and the WHO puts the figure at 4%. A good deal of your problem may be related to the flawed method of nutrient analysis employed by the USDA and most nutritionists who sort and preference foods by nutrient/weight ratio. By this method beans and tofu look like good protein sources whereas leafy greens are much better on a nutrient/Calorie basis. Since there is no RDA for weight in the human diet while there is an RDA for Calories I argue that much of the obesity in the US is due to the archaic system of nutrient/weight analysis which leads people to regard animal foods and suboptimal plant foods as good nutrient choices when they are really only good Calorie sources. This is a mathematical conundrum not immediately obvious unless you spend some time looking at the USDA nutrient database which, as it happens, is downloadable (as a rather large file) at : http://www.vegsource.com/harris/food_comp.htm
I am seeing a very caring physician who has been evaluating me for the last four or five years annually. She is well aware of the veganism. The annual exam has always included a CBC and chemistry and UA. This year's tests, done three weeks ago, showed that I have stage 3 iron deficiency anemia (low ferritin and hypochromia), and my urine had ketones in it. My doctor is worried that I may have GI blood loss, and has scheduled me for a visit with the gastroenterologist (I am seeing him tomorrow); she would like me to get both a gastroscopy and a colonoscopy. The ddx for upper GI blood loss would be gastric ulcer; I have had GARD for about fifteen years- two years ago, I had to go to the emergency room I was in so much pain- they diagnosed me as having a gallbladder attack, based on the presence of gallstones on an abdominal ultrasound, and I was told to get my gallbladder removed. However, since being started on Nexium
Here is some information on Nexium from the PDR. Adverse reactions: Gastrointestinal: bowel irregularity, constipation aggravated, dyspepsia, dysphagia, dysplasia GI, epigastric pain, eructation, esophageal disorder, frequent stools, gastroenteritis, GI hemorrhage, GI symptoms not otherwise specified, hiccup, melena, mouth disorder, pharynx disorder, rectal disorder, serum gastrin increased, tongue disorder, tongue edema, ulcerative stomatitis, vomiting; Hearing: earache, tinnitus; Hematologic: anemia, anemia hypochromic, cervical lymphoadenopathy, epistaxis, leukocytosis, leukopenia, thrombocytopenia;
I have had not a twinge of abdominal pain or heartburn and it has been two years now- so I think the gallstones were an incidental finding, and I was actually having a GARD attack and suffering from severe esophageal erosion pain. The ddx for lower GI blood loss is colonic polyps, of course- and my paternal grandmother died of colon cancer, so a screening colonoscopy is certainly a good idea. My question is, even though GI blood loss is the primary rule out for iron deficient anemia, doesn't being vegan (ie dietary deficiency) supercede this as the most likely cause?
This depends on what sort of vegan foods you're eating. A diet of potatoes, grains, and junk food could lead to inadequate intake of both iron and protein but if leafy greens are a major food source it's unlikely. The term "iron deficiency anemia" in my opinion is very misleading as it implies an inadequate intake of iron when in most cases it is the result of iron loss from chronic or occult bleeding or heavy menses.
If so, why did it take ten years to show up? ( I have stopped menstruating- my last period was May 1- and had no periods from January to June of 2001- therefore blood loss from menses is no longer a factor- but until 2001, I had regular monthly periods of moderate to heavy flow, and my CBC remained normal up until this year). Is it possible I only became anemic recently due to a combination of BOTH dietary lack of iron AND a recently aquired GI blood loss?
Yes, that is a possibility.
What is the significance of the ketones in my urine, if all the chemistry values were normal? My doctor seems to believe it is due to fasting overnight for the blood work and is not concerned-
That is also my first thought. Before you pay too much attention to it you should have the test repeated or get some dipsticks from a lab or your doctor and and test it yourself.
but I always fast overnight, and don't eat breakfast- and previous UA's did not show ketones. Could it be because of the weight loss diet?
Yes, particularly if it's a Dr. Atkins style high protein diet. That one depends on ketosis to cause the weight loss.
Could it be a sign of liver disease?
Yes, but not one of the likely first signs.
Yes, possibly related to your weight loss.
I have been working out a lot at a gym, circuit weight training and cycling 20-50 miles on weekends.
That's great! Keep it up.
I take glucosamine as a nutritional supplement ( I have severe patellar femoral pain syndrome).
That may be in part from carrying extra weight. The knees are the first to tell you about it. If glucosamine really has any value in osteoarthritis it's probably because it acts as a sulfur donor. MSM is probably as good.
I am also on Singulair, Claritin, and Nasonex, for allergies/asthma
I checked the PDR here. All three have adverse reactions but anemia was not among them. Although I am not an allergist I am personally allergic to everything in the known universe and have found over the years that the best strategy is to find out what you're allergic to and avoid it. That basically comes down to cleaning up your air and going on a whole food mostly raw vegan diet.
Zestoretic for hypertension
No pertinent adverse reactions here but weight loss, exercise, no added salt, and the same diet as above are the best solution to hypertension. My objective has always been to show patients how to modify their lifestyle so they can get off all drugs. If a drug has effects it will also have side effects and the more drugs you're on the greater the chance of adverse drug interactions.
and Wellbutrin for depression.
Wellbutrin: slight increase in cardiac arrhythmias 5.3 / 4.3
I was on Ditropan XL for several years until recently, when I had to stop it due to heart palpitations, and a one-time ten minute episode of taccycardia.
The following adverse events were reported by 2 to 5% of patients using DITROPAN XL® (5-30 mg/day) in all studies. General: abdominal pain, dry nasal and sinus mucous membranes, accidental injury, back pain, flu syndrome; Cardiovascular: hypertension, palpitation, vasodilatation; Digestive: flatulence, gastroesophageal reflux; Musculoskeletal: arthritis Nervous: insomnia, nervousness, confusion; Respiratory: upper respiratory tract infection, cough, sinusitis, bronchitis, pharyngitis; Skin: dry skin, rash; Urogenital: impaired urination (hesitancy), increased post void residual volume, urinary retention, cystitis.
Now I am wondering if this was induced by the combination of the drug, which is anti-cholinergic, and my anemia. The palpitations have stopped and I have had no other episodes of taccycarida since stopping the Ditropan. The ECG done during my recent check up was normal. Only one other significant finding on my history: I have a very large (grapefruit sized) uterine fibroid. I am getting a pelvic ultrasound in two weeks to evaluate that, as my doctor feels it may be contributing to my intermittent urinary urge incontinence and back pain.
The fibroid probably goes with your weight problem and if that's all it is it shouldn't be your first priority.
I would greatly appreciate your valued perspective, given your experience with veganism and vegan patients, and will pass along any feeback you may have to my own physician- or, if you prefer, I can let you speak to her directly. If you need to look at actual test results, please let me know, so I can get them for you.
It sounds like your physician is taking good care of you and I doubt if she would welcome a retired ER doc poking around in her records. However, getting down to normal weight would probably solve most of your problems and that breaks down to diet and exercise. If you burn more Calories than you absorb you will lose weight. Period.
If you have Microsoft Excel 97 or later (but not the Windows Millenium spreadsheet) I have put up what I hope is a useful downloadable diet questionnaire at: http://www.vegsource.com/harris/download.htm
You can use this to keep track of your Body Mass Index and to learn to make better food choices. Incidentally, if you can convince yourself that killing animals for food is an ethical error the transition to a vegan diet will be much easier. PETA, Peter Singer, and various URLs at www.vegsource.com have some good articles on the ethical problems of animal food consumption. Good luck!
-William Harris, M.D.