The Management of Chronic Diseases via Different Therapeutic Modalities with Peptic Ulcer Disease as an Example

Following two experiences I published here in this blog only last night, a few hours ago on my chronic neck pains and how I managed it with almost instant relief without the use of drugs, and analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) here: 

A https://scientificlogic.blogspot.com/2023/04/an-almost-instant-cure-for-neck-to.htmln 

 I promised I would produce two different opinions on how peptic ulcer disease (PUD) is managed.

The first part is how a medical doctor who depends solely on conventional drug-based medicine to treat PUD looks at it, and the second part also by a medical doctor who uses an integrated approach in medicine to much better improve the therapeutic outcome in the management of PUD.

This is also to compare two different systems of medicine: one a more broad-spectrum, more holistic approach using natural and or a more integrated therapeutic modalities combined in the practice of medicine.

 https://www.tiktok.com/@natsolphc/video/7138152476045266219

There is also another video presentation by Dr. Peter Glidden sent to me by a medical colleague and friend of mine on conventional drug-based allopathic medicine.  

https://www.bitchute.com/video/e7JzINEL47ov/

However, I need to stress that all systems of medicine have their strengths and shortcomings. For instance, I need to emphasize that a lot of drugs used in emergency situations and for the management of acute and life-threatening diseases are absolutely necessary and lifesaving. For example about emergency drugs I wrote here published on Saturday, March 4, 2023.

https://scientificlogic.blogspot.com/search?q=emergency+drugs

Unfortunately drug-based conventional treatment for most chronic diseases, especially lifestyle diseases failed miserably with an integrated approach where the root causes need to be first addressed and the patient needs to be educated.

There are of course tens of hundreds of diseases that we need to discuss and write here, but this would run into dozens of volumes of textbooks on medicine, and alternative / complementary medicine each volume containing at least 1,500 pages. This is far, far beyond the scope of this article from the views of two MD doctors who would best write all of them separately. We will only reproduce two views, one using just solely drug-based approach, and the other using a more holistic and integrated approach on the management of peptic ulcer disease (PUD).

Part One: 

Petic Ulcer Disease. A Drug-based Approach: 

  

Petic ulcers disease (PUD) are mucosal defects in the in the gastroduodenal mucosa whose regenerative properties have been overcome by increased hydrochloric acid production or prostaglandin depletion by Non-Steroidal Anti-inflammatory Drugs (NSAIDs). Risk factors include cigarette use, alcoholism, NSAID use, familial history, gastric outlet obstruction, infection with Helicobacter pylori, CPD, hepatic cirrhosis, and renal failure.

Clinical features:

Peptic ulcer disease classically presents with burning epigastric pain 1 to 3 hours after meal, often awakening the patient at night. Although the patient may relate relief with food, more classical is relief with antacids or vomiting. Elderly patients or those using NSAIDs tend to have less pain associated with their ulcers. History may provide confirming clues, such as tobacco use, NSAIDs or alcohol consumption, or familial predisposition to ulcers.

A history of frequent vomiting, weight loss, early satiety, or nausea should suggest gastric outlet obstruction. Hemodynamic instability, hematemesis or melena all confirm hemorrhagic complications. Although bleeding is not common, perforation will usually present with severe pain or peritoneal signs.

 Diagnosis and Differential Diagnosis:

Typically, the diagnosis of peptic ulcer disorder is based on history and examination. The patient may have very mild epigastric tenderness. A succussion splash in the presence of excessive vomiting suggests gastric outlet obstruction. Directed laboratory work may confirm associated illness and can include blood cell count, creatinine, and calcium. Rectal examination and possible nasogastric aspiration may aid in diagnosing bleeding complications. in the presence of bleeding complications. In the presence of bleeding, one should consider clotting studies and, perhaps, liver function tests. A nasogastric tube may aid in the diagnosis of perforation by allowing the instillation of 250 ml air prior to an upright chest radiograph, specifically checking for air under the diaphragm. Definitive diagnosis of peptic ulcer disorder can only be made with an GI series using barium or by gastro endoscopy through direct vision, such tests can be reserved for patients with severe pain or bleeding. Serological tests for H. pylori and a serum gastrin may be useful in cases of persistent or recurrent peptic ulcer.

Many disorders can mimic peptic ulcers in pattern and location of pain. Pancreatitis is usually associated with worse pain and more commonly radiates to the back. With gastroesophageal reflux the patient may relate positional pain originating substernally.   Clues to biliary colic include a history of fatty food intolerance rather than pain with food in middle-aged obese females. The most serious diagnosis confused with peptic ulcer is myocardial ischemia or infarction, which should be considered in any patient over 40 or with cardiac risk factors.

Conventinal Management:

Treatment is primarily done on an outpatient basis unless complications exist.

1. Pain can be relieved with liquid antacids such as aluminum hydroxide gel, 30 – 60 ml to be continued 1 hour and 3 hours after each meal, and at bedtime.
2. Peptic ulcers are most conveniently treated with H₂ receptor antagonists such as cimetidine, 300 mg IV or 400 mg po bid, ranitidine, 50 mg IV or 150 mg po bid; famotidine, 20 mg IV or 40 mg po qhs (; and nizatidine, 150 to 300 mg po qhs. More recently the use of proton pump inhibitors such as Omeprazole, Esomeprazole (Nexium) is indicated for persistent peptic ulcers. This works by blocking an enzyme called H+/K+ ATPase to inhibit the production of acid in the stomach. Sucralfate and misoprostol are secondary drugs that may be considered.
3. Dietary modification should be the mainstay of the treatment.

 with the avoidance of caffeine, alcohol, and NSAIDs.

 Patients who demonstrate any complication of peptic ulcer disorders should be stabilized and admitted to a hospital. For haemorrhage, this includes intravenous fluids (RL or NS) with packed red blood cells (PRBC’s) and fresh frozen plasma (FFP) as clinically indicated. Gastric lavage with room temperature water will help assess extent of bleeding and prepare the patient for both diagnostic and therapeutic gastro-endoscopy. Perforation requires nasogastric suction, broad-spectrum antibiotics, KIV surgical intervention. Pyloric stenosis requires correction of fluid and electrolyte abnormalities, with referral for surgical management.

Part Two: 

An Integrative Medical Approach for PUD: Nutrition and Other Therapeutic Modalities : 

Pathophysiology:

PUD is one of the most common diseases clinicians see regularly. Many of them are undiagnosed. PUD is caused by disturbances in the gastrointestinal mucosa. These disturbances are due to the loss of protective elements and / or damaging insults that result in mucosal erosions, most commonly located in the duodenum or stomach. People with PUD commonly complain of epigastric pain particularly a few hours after meals, bloating, nausea, early satiety, altered bowel habits and heartburns.

Pain is usually improved with food or antacids. PUD may also occur without symptoms, particularly in older adults. Peptic ulcers may cause GI bleeding, which is a potentially life-threatening emergency necessitating urgent endoscopy and intensive care unit consideration. Ulcers may rarely perforate leading to intense pain and acute peritonitis, which is a surgical emergency. Patients with significant weight loss and PUD symptoms should undergo endoscopy to investigate potential malignant diseases.

The loss of gastrointestinal mucosal integrity is typically multifactorial, with diminished protective elements predominantly decreased acid buffering, reduced immune system functioning, and slowed wound healing. And insults primarily Helicobacter pylori infection, the use of nonsteroidal anti-inflammatory drugs (NSAIDs), increased acidity, and inflammation. Treatment efforts are focussed on restoring protective factors and reducing harmful affronts.

 Peptic ulcers may occur at any time in life, although the incidence gradually increases with age. In the early twentieth century, PUD was diagnosed in men at twice the rate as in women. However, PUD is now nearly equally distributed between genders, although gastric ulcers tend to be more common in women and duodenal ulcers more common in men.

 Historically, investigators were aware that smoking, stress, use of NSAIDs, caffeine, and family history increases risk three times with an afflicted first-degree relative contributing to peptic ulcer formation. However, prior to the late 1970s, allopathic medicine (as already discussed above) had limited success in treating PUD until the arrival of two revolutionary developments: the intervention of pharmaceuticals that reduced the amounts of acids the stomach produced such as the use of proton pump inhibitors (PPIs) like Omeprazole / Esomeprazole (Nexium) as already discussed above, and the discovery of the Heliobacter pylori bacterium.

 The development of gastric acid-suppressing medications, with the advent of histamine-2 receptors antagonists (H₂ blockers) in the late 1970s and proton pump inhibitors in the 1980s heralded a new chapter in conventional allopathic treatment of PUD. Previous efforts had focussed on reducing risk factors, administering acid buffers such as calcium carbonate for symptom relief, and surgery associated with significant morbidity and mortality. With the invention and administration of acid-reducing medication, the majority of the cases of PUD are quickly attenuated. The approach has drastically reduced the need of surgery and the increased the role of pharmaceuticals in PUD therapy.

 H. pylori was identified in 1982, a discovery for which Dr J. Robin Warren and Dr Barry J. Marshell won the Nobel Prize for medicine in 2005. The more the medical world learns about this unique bacterium, the more our thinking about PUD treatment evolves. H. pylori infection has been shown to increase the incidence of PUD by at least four-fold. Rates of H. pylori infection vary worldwide according to age and economic status. Younger, more affluent individuals have rates as low as 20 %, whereas up to 60 % of all individuals in the developing world, and 50 % of individuals older than 60 years are colonized by this bacterium. Living in harsh acidic environment of the human stomach, H. pylori appears to increase the risk of PUD by directly damaging the protective mucus lining of the GI tract and allowing for increased acidic damage. H. pylori also triggers an immune response that causes damaging inflammation. Besides PUD, H. pylori has been linked to increased rates of gastric cancer, dyspepsia, vitamin B₁₂ deficiency, iron deficiency, and idiopathic thrombocytopenia (ITP). H. pylori may not be without benefits, with some studies indicating a correlation between H. pylori colonization and decreased rates of asthma, allergies, gastroesophageal reflux disorder (GERD), obesity, and oesophageal cancer. Whether H. pylori is predominantly a symbiotic bacterium that has been with humanity for millions of years, occasionally running amok and causing PUD and stomach cancer, or strictly a pathogen that has an increasing niche in the modern world warranting global. The pending answer to this question will likely guide approaches to PUD treatment in the decades to come. 

 Although there have been promising H. pylori vaccines studies in animal models, indicating vaccines may eventually become the most powerful tool for treating PUD, successful clinical vaccine trials have yet to be reported. Even with a potential vaccine, complete global eradication of H. pylori is logistically challenging, despite H. pylori exclusively residing in humans, because there are currently an estimated 5 billion people infected worldwide.  Further, only 10 % to 20 % of H. pylori-infected

 Individuals develop PUD. Thus, current treatment screening of asymptomatic individuals for H. pylori is not advised. H. pylori and NSAIDs, in combination with other risk factors, account for the majority of the cases of PUD. The remaining cases are attributable to other independent risk factors and a few clinical “zebras”, such as Zollinger-Ellison tumours, carcinoid syndrome, other drugs, radiation, cytomegalovirus, and systemic mastocytosis.

 Pharmaceutical acid suppression, the discovery and subsequent antibiotic treatment of H. pylori, resulted in optimism that PUD was on the verge of elimination at the end of the 21^st century. However, due to increasing antibiotic resistance, increasing knowledge of the harm of long-term pharmaceutical acid suppression, in addition to evidence of the potential benefits of H. pylori infection, there is now a requirement for more judicious use of antibiotics and the incorporation of more integrative approaches to PUD management in the years and decades ahead.

Diagnosis:

The overlapping constellation of PUD symptoms with other diseases, such as gastritis, irritable bowel syndrome, gastroesophageal reflux disease, Crohn’s disease, pancreatitis, gallstones, and malignancy, makes the initial diagnosis of PUD challenging, particularly because endoscopy which is invasive and expensive for current standard diagnostic testing. The next best tool is the barium GI series that has radiation risk, cost and potential inaccuracy. A study reported that the physical examination finding of epigastric tenderness decreases the likelihood of PUD. Thus, it is not surprising that many clinicians, and patients without signs of serious disease such as bleeding or weight loss, hesitate in electing to pursue these invasive diagnostic measures. Accordingly, the majority of PUD may never be diagnosed with certainty. H. pylori testing in symptomatic patients increases the number of people diagnosed with H. pylori infection, but a positive test result indicates only a bacterial infection and cannot differentiate between conditions such as gastritis and more serious PUD. although initial management is largely the same. There are various tests for H. pylori, but the stool antigen and urea breath tests are consistently the best for determining active infection.

Once a diagnosis of PUD is established, recurrence is reported in up to 74 % of patients. PUD management therefore focuses on the prevention and symptomatic treatment, a good fit for an integrative approach in medicine not just using pharmaceuticals.

 Dietary constituents were linked to PUD long before the discovery of H. pylori infection. Accordingly, nutrition is considered a key component of ulcer prevention and symptom management.

Meal timing influences PUD, with skipping breakfast and consuming large meals shortly before bedtime shown to increase the risk of PUD.

Fruits and vegetable intake reduces the risk of developing ulcers, with epidemiological studies demonstrating that a diet high in plant-based fiber and vitamin A, especially carrots, spinach, mango, sweet potatoes, and apricots helps protect against PUD. Flavonoids, compounds found throughout the plant kingdom have been found to be protective against H. pylori infection and are present in concentrated amounts in citrus, berries, onions, parsley, green tea, red wine, and dark chocolate. Sulforaphanes, which are phytochemicals found in vegetables such as brussels sprouts, broccoli, cabbage, cauliflower, bok choy, turnips, and radishes, are also protective against H. pylori infection.

Studies have specifically shown that virgin olive oil (30 g daily for 2 weeks) or broccoli (70 g a day for 8 weeks) have the ability to decrease and potentially eliminate H. pylori. Foods containing capsaicin (chili) have been shown to be protective against ulcers. Other common foods demonstrating protective effects against P. pylori include banana, honey, garlic, ginger, okra, pomegranate, and apple. There is likely a synergy in consuming combinations of these beneficial foods as ‘let food be thy medicine’.

However, milk increases PUD risk, likely due to the increased stimulation of acid production. However, fermented milk products such as yogurt, aged cheese, and sauerkraut that have probiotics have been demonstrated to have a protective action against H. pylori. Although there is no evidence that caffeine and coffee are risk factors for PUD, the evidence is lacking, although there are risk factors for reflux disease.

Physical Activity:

Numerous studies have shown that regular exercise and physical activities compared to sedentary lifestyles is more protective against PUD One study particularly showed that the risk of duodenal ulcers was 62 % less in men who cumulatively walked or ran more than 10 miles a week. Routine exercise should be recommended for almost all patients, especially those who have a previous history of PUD.

Stress Reduction:

The relationship between stress and PUD is a classic example of the need for clinicians to keep in mind the social determinants of health, over which our patients have varying degrees of control. Stress is largely a product of the social and environmental milieu, and convincing evidence indicates that stress plays a role in PUD. It is well known that people with stressful jobs such as directors, managers, executives, doctors among others are more prone to suffer from PUD than others. When the discovery of H. pylori linked to PUD was discovered they dismissed stress as one of the causes by putting this bacterium solely to be blamed. However, immunologists know that stress compromises the immune system by allowing the H. pylori and other infectious agents to take hold. The connection between stress and PUD is established early in life. Childhood stress in the form of traumatic events, such as an illness or death in a family, financial strains, or family conflict and relationship is shown to be associated with nearly 50 % higher rates of PUD in adulthood. Studies have also shown that the GI ulceration increases with both chronic stress and in times of acute stress, such as during an earthquake or war. A multipronged approach to stress reduction, in comparison with any single method, appears to provide more protection against PUD. As a clinician, recommending individually tailored stress reduction programmes, including yoga, tai chi, meditation and other coordinated movements inclusive of focussed breathing and any other culturally applicable relation techniques will likely be beneficial.

Sleep:

Inadequate sleep is a risk factor for PUD, likely the result of increased stress levels causing immune dysfunction and impaired lifestyle decisions. Maintaining good sleep hygiene is an important component of ulcer avoidance.

Cigarette Smoking:

Smoking increases rates of PUD up to four times when compared with non-smokers, likely due to decreased wound healing. According, smoking cessation is essential in addressing PUD.

Alcohol Avoidance or in Moderation:

Alcohol in large amounts has also been shown to be linked to PUD, probably due to mucosal damage. One epidemiological study showed that those who consumed more than 42 drinks per week had a greater than four-fold increase in the incidence of bleeding ulcers compared to those who consumed one or less than one drink per week. However red wine was reported to be protective against H. pylori infection possibly due to the presence of bioactive substances such as flavonoids. Avoidance of alcohol especially in high doses and in frequency is prudent for those with a history of PUD or its symptoms whereas a moderate consumption of red wine may be useful.

Nonsteroidal Anti-Inflammatory Drugs:

There is evidence that the use of NSAIDs increases the risk of PUD by up to 5 times and the risk of bleeding ulcers associated with conformed PUD up to five times also. NSAIDs inhibits prostaglandin production, and such an event compromises the protective muco-protective coats in the GI tract. However, there is evidence that medications such as sucralfate or misoprostol together with NSAIDs can relieve the symptoms of PUD and prevent its recurrence NSAIDs should be avoided as much as possible in patients with PUD or with patients with a history of PUD. However more than 80 % of patients on NSAIDs never develop PUD and may not be necessarily harmful to those with asymptomatic PUD or with a history of peptic ulcers. 

Nutritional Supplements:

Certain useful microorganisms have been shown to be useful in the management of PUD. The use of probiotics for instance, has been shown to decrease the recurrence of peptic ulcers. There is a straight-line correlation between higher intake of probiotics and lower incidences of H. pylori infection. Its mechanism is unclear, probably due to increased GI mucus production, competition for mucosal binding sites as bacterial competitors and the production of compounds unsuitable for H. pylori. Results of studies in animal models showed probiotics decrease the inflammatory response to H. pylori. The majority of the studies were conducted using Lactobacillus strains commonly found in yoghurt but other strains of probiotics are also useful. We believe that the incorporation of yogurt and other probiotic rich foods regularly into the diet may be useful in PUD prevention and its recurrence. Many clinical studies have confirmed that probiotics like Lactobacillus and Saccharomyces boulardii have synergy with antibiotic therapy for H. pylori eradication and can decrease antibiotic-related side effects such as diarrhoea, bloating nausea and abdominal pains. There are some evidences showing probiotics alone with antibiotics can improve PUD symptoms and perhaps suppress or eradicate H. pylori infection

Vitamin C:

Vitamin C or ascorbic acid has also been shown to have an effect on the eradication of H. pylori. There is one study demonstrating a 10 % eradication rate with 2 weeks daily dose of 1000 mg of vitamin C. Additionally, vitamin C enhances the effect of antibiotics regimens against H. pylori eradication. This has been shown in at least two studies. There was a 5-year Japanese study demonstrating lower rates of PUD in groups taking vitamin C supplementation. A constant intake of dietary intake of vitamin C is recommended for individuals with symptoms of PUD, a previous history or family history of PUD, or other risk factors associated with PUD,

Zinc:

A clinical trial has reported zinc accelerates the healing of peptic ulcers up to three times compared to placebo groups. This observation was strengthened in animal model studies. The role of zinc may be due to its ability to enhance tissue repair. Zinc supplementation has been used in Europe and East Asia among other countries for PUD and was found to be effective in numerous other studies.

There are also many other nutrients and nutritional adjuncts such as polyunsaturated fatty acids, glutamine, as well as botanical medicines such as Curcuma longa (turmeric), De glycyrrhizinate  Liquorice  (Glycyrrhiza glabra), mastic (Pistacia lentiscus), cabbage (Brassica oleracea), chili (Capsaicin), cranberry (Vaccinium  oxycoccos), neem (Azadirachta indica) and hundreds of other botanical medicines among them just to name a few more like peppermint, wormwood, cinnamon, chamomile, gingko, nutmeg, hops, sage, green tea, red ginseng. Aloe, fenugreek, and mugwort among many, many more far too long to list them here, let alone discuss their scientific studies, mode of action in phytotherapy (pharmacognosy) and their therapeutic role in the prevention and relief of symptoms of peptic ulcer disease.  

Conventional approaches use acid-suppressing drugs, antacids, sucralfate.

Others: 

Other alternative / complementary medicine against PUD includes acupuncture, massage, Traditional Chinese Medicine and osteopathy.

All studies and references quoted above, please refer online to:

ExpertConsult.com

 

Which is the Most Challenging Field in Medicine and Health Care?

 

  

  I received a question from the mother of a doctor in Singapore. She posted her question under this article:

“The Management of Chronic Diseases via Different Therapeutic Modalities with Peptic Ulcer Disease as an Example”

https://scientificlogic.blogspot.com/search?q=the+management+of+peptic+ulcers

Greetings Dr. Lim,

My name is Shanzey, a Malaysian working in Singapore. My daughter and myself have been reading all your articles with great interest especially on health and medicine. My daughter is a doctor here in Singapore who intends to specialize but she is unsure which area would be easiest, and which would be hardest, and which area in medicine can earn her better money. The area should not take too long to study, but more importantly not too tough especially with diagnosis. We solicit your expert advice and thank you in anticipation.

 

My question is:

Which field of medicine is most challenging, time consuming but with better income?

--------------------------------------------

 

Thank you for your question, Shanzey.

You have asked me a very tough question. If your daughter cannot decide, how am I to know? I can’t decide for her. The study or the practice of medicine, like everything else in life, is very personal. All depends on individual taste.

Some like to study a certain field to be an expert on it in their working life, others not.  It all depends on individual taste, interest and aims in life.  affordability, economic and social circumstances and other environmental and influencing issues, outcome and dynamics. There is no one sure answer that suit all.

If your daughter is thinking about earning capacity, I think an area such as cardiac and liver surgery can be very specialized and technically very challenging, besides good income as there are not many doctors around who are good in this area. She may not need any other specialist doctors to help out, except in surgery with teamwork effort from supporting staff such as the anaesthesiologist, perfusionist, haematologist, immunologists and theatre nurses.

But this does not mean other areas in medicine or surgery are less important, less difficult, less in demand with less earning outcome. I should say, all health-care professions are equally important, and all are in demand.

However, if your daughter intends to go into private practice, there are only two areas I strongly would not advise her, or any doctor for that matter.  Never go for emergency medicine and forensic medicine. The reason is obvious. If you are in private practice, who would send an emergency case, say a serious trauma case in the streets or in a shopping mall, or someone who is already dead as in forensic medicine to your private clinic?

A Good Samaritan, say who saw a street accident, or someone with a heart attack in the office, or anywhere, even at home, would straight away call an ambulance to dispatch a casualty to the emergency department of a government or public hospital.

He is not going to send him or her to your private clinic or to a private hospital and pay for it. Neither would any sensible person send a person who is already dead to your private practice. He will send him straight away to a mortuary and call the police. He or she will never send a dead person to your private clinic or to a private hospital and pay the private doctor to “treat” a dead person. He will of course straight away send the body to a government hospital and ask them to deal with it. It is a police case. So don’t touch these two extreme areas in medicine unless your daughter intends to stay in government service where she will be paid whether the patient is dead or alive.  

Emergency medicine, which I am more familiar with, is very dramatic and lifesaving, but in terms of income and earning capacity it is almost zero. A doctor specializing in this area in private practice can wait for all eternity, and not get even one patient sent to him or her. It is the same with forensic medicine. It is a dead medicine. Both are at the extreme ends, one highly dramatic sent to the triage red zone in a public or government hospital, the other on the extreme end, into the black or white zone (mortuary). Never, never go into these two extreme areas of specialization if your daughter is thinking of going into specialized private practice later.

I should say, choose something in between where there is a demand such as general medicine meant for all, or O & G for female doctors, paediatrics for families with young children. General medicine probably is the best because all patients generally go to an ordinary GP or a physician first because patients normally would not know what ailments are troubling them, except some symptoms they suffer. So, they will see their doctor or a GP first as front-line healthcare professionals to have it sorted out. I should say, most cases are medical in nature rather than surgical. Once a general doctor or a GP sort this out, he or she will refer the case to an appropriate specialist who may be anyone from a cardiologist, oncologist, rheumatologist, haematologist, psychiatrist, ENT, cardiac, neuro, orthopedic, eye surgeon all the way down from A to Z in specialty. All are relevant with good income in private practice.

As far as length of study and technical difficulty to your question is concerned, I think all are lengthy and challenging to study and to specialize. It takes at least another 4 years from a basic MBBS or an ordinary MD degree to get a master’s degree in a field of specialization. A general medical doctor will have to study all the basic medical sciences such as anatomy, physiology, biochemistry, pharmacology, bacteriology or microbiology, histology, pathology, cellular biology, genetics and basic molecular biology all over again especially if it was for the UK MRCP or MRCS Part 1 before going into the area of specialization where they need to pass the examinations on these subjects before going to Part II examination of the Royal College of Physicians or Surgeons or in other disciplines. It is a long ladder to climb.

Furthermore, in order for a doctor to specialize he or she has to be in permanent post for at least 3 years in a specialized department of a government hospital (not private hospital which is not recognized) for teaching and training purposes, experience and exposure in that area the doctor is interested in. He or she will have to work under the supervision of a specialist or a consultant. So that is another ladder to climb.

 The doctor cannot afford to be a contract doctor with no permanent position and is posted here and there especially to a small hospital or in a rural area where he or she is a stand-alone doctor where every little complication needs to be referred or sent by ambulance elsewhere. He or she can never specialize in any field of medicine or surgery. He / she has to be in a big, tertiary or in a teaching hospital for teaching, experience and exposure purposes first.  

As far as your question on technicality and difficulty on diagnosis is concerned, straight away I should emphasize the diagnosis of malnutrition and nutritional disorders. This is the most difficult and most technically challenging branch of medicine for any doctor or even for an expert nutritionist.

First of all, the word “malnutrition” actually means “bad nutrition” to mean “mal” “bad,” “wrongful,” “ill,” from French word “malapert” such as we say “malpractice, malodorous, malformation, malformed, maladjustment, and so on.

Malnutrition does NOT mean only undernutrition as most people, including even specialist physicians think. It technically includes those who are also over-nourished with excessive nutrition from overeating. Overnutrition too is bad or malnutrition. Does that surprise you? I am more than sure you do, including all medical doctors who thinks that malnutrition means only those suffering from nutritional deficiency diseases such as marasmus, kwashiorkor, beriberi, pellagra, rickets and hypocalcaemia, osteomalacia, vitamin K deficiency, xerophthalmia, anaemia and iron deficiency...all the way down to over 350 different types of nutrition deficiency diseases.

 Unfortunately, most doctors are not familiar with them. They tend to misdiagnose them as something else and prescribe them chemical drugs instead.

For instance, a person who is underweight and always feels tired and lethargic should be a suspect of caloric undernutrition. This is because of the body’s innate response to converse energy rather than to lose body mass. So, he or she feels tired and lethargic most of the time to need rest. This has nothing to do with an under thyroid function and needs to do a thyroid function test with all those T3 T4 and all those unnecessary stuffs.

 On the extreme end, over nutrition is the root cause of most of the chronic and degenerative diseases such as cardiovascular, diabetes, endocrine and metabolic syndromes, gout, arthritis, renal, liver, cancers and neoplastic diseases. All these are mainly caused by malnutrition, either under or over nutrition afflicting mankind today due to affluence and overeating and lifestyles. None of these can be “cured” by any chemical drugs that only mask them into other emerging linked diseases. The only way is dietary and lifestyle modifications which is best treated by a dietician. As clinicians and nutritionists, we are very clear on this.

One of the most difficult challenges in diagnosing malnutrition for a doctor or for a nutritionist whether under or over nutrition is, that their presentations (clinical signs and symptoms and even blood tests) do not show up. Most of them are subclinical without signs and symptoms which would be riskier unlike a heart attack, a fever, pain, nausea, vomiting where tell-tales signs are very clear which we can differential diagnose by asking questions, looking for signs and symptoms, taking medical history, clinical examination, blood tests, radiology and imaging and so on. These are not the slightest problems to do or observe. But not with malnutrition which is a disease that can be fatal leading chronic and degeneration of all body systems if not corrected with dietary and lifestyle modification. None of these nutritional diseases, whether under or over nutritional, can be “cured” by prescribing all sorts of drugs, or rather chemicals. That is more than sure. That makes diagnosis, management and compliance extremely difficult for both the doctor and the patient.  

For instance, if you were to ask me if you are malnourished, meaning either undernourished or over nourished, I would not know. You may appear well-fed and healthy physically in appearance and none of any blood tests would show anything. They would all appear as negative with no abnormality shown unless I perform what we call a saturation  test (British) or loading test (American) on you to look at your water-soluble vitamin such as thiamine, riboflavin or ascorbic acid or Vitamin B₆, (nicotinamide) status where we dose you a certain amount of the water soluble vitamins and see how much is been retained by the body, and how much excreted into the urine.

A person may look perfectly well and healthy but in truth his / her health is below optimal, and optimal health depends so much on optimal nutrition. But what then is optimal health and optimal nutrition? The answer is, we do not know as it varies from individual to individual depending on his / her daily nutritional needs which again depends on gender, age, physical activities, physiological requirements, perhaps race, environmental temperatures, body weights among other internal and external influences such as lifestyles. These problems are very complicated to sort out, and we can only take an average from large population studies of apparently healthy people. That is the reason why every country has their recommended daily allowance for various nutrients according to age, sex, pregnant and nursing mothers, heights, weights, physical activities among other factors to be considered. There is no standard dose for any nutrients so unlike drugs which are standardized. This is the reason why the practice of nutrition is so much more complicated than the practice of medicine where the dose is almost fixed and easy to titrate.

In nutrition variations in physiological and biochemical needs are so wide that no one can give a definitive answer. That is why if you were to ask me if you are eating the optimal requirements for your needs, or for the prevention of any disease I would not be able to tell you with certainty even though I am a nutritionist and clinician. You may only look every fit, healthy and well-fed, but within you, lies latent dietary and lifestyle diseases like metabolic syndrome like diabetes, cardiovascular, stroke and even cancers awaiting you in the years ahead. On the other end of malnutrition (undernutrition) you may suffer subclinical kwashiorkor (protein malnutrition), marasmus (caloric deficiency), beriberi (thiamine deficiency), scurvy (vitamin C / ascorbic deficiency), signs such as sore throat, lesions of the lips and mucosa of the mouth, glossitis, conjunctivitis, seborrheic dermatitis, and normochromic-normocytic anaemia (riboflavin or B2 deficiency), iron deficiency  anaemia, together with vitamin B12 deficiency resulting in Addisonian and pernicious anaemias.

Other nutritional deficiency diseases to name a few are, pellagra (niacin or vitamin B3 deficiency causing delusions or mental confusion, diarrhoea, photo-sensitive dermatitis, angular stomatitis, cheilosis, lacrimation, photophobia, Casal collar…etc, etc without you realizing them.

Most of them may be sub-clinical and do not show up. You may feel well, fit and healthy, but in fact you are not. That makes diagnosis exceedingly difficult. They don't even show up on any blood and biochemical examination unless very serve where certain metabolites appear in the blood due to incomplete metabolisms where these vitamins are needed. One example is erythrocyte transketolase activity coefficient (ETKAC) assay for thiamine (vitamin B1) status.  

Else the assessment of nutritional status is exceedingly difficult even for large populations, let alone for individuals based only on clinical examination alone or some blood tests.

 Please see link below how the assessment of nutrition status is done by the coordinated efforts from a team of nutritional, medical and other health professionals.

In fact, the diagnosis of malnutrition is more difficult even for an expert well-qualified nutritionist let alone for a doctor who knows very little on nutrition unless the clinician specialises in nutrition at post graduate level with a master’s degree in this area.

When I was doing my postgraduate in nutrition at Queen Elizabeth College, University of London we were all retrained by the University on the procedures in assessing nutritional status and how to diagnose clinically cases of acute or sub nutritional diseases. There were a number of us in our postgraduate course. They came from various countries. We were all there at London as students, all medical doctors, plus one biochemist from the University of Manchester and a Master degree holder in pharmacology from St Andrews University, one doctor from the University of Singapore, and one Dr Jason ST Teoh from the Faculty of Medicine, University of Malaya, who later began the Head of the Department of Social and Preventive Medicine, and later became a  Professor and Dean of the  Faculty of Medicine at the  University of Malaya. Unfortunately, Professor ST Teoh has since passed away.

One was a gynaecologist from Oslo, Norway, one doctor from Canada, another from Nigeria, one from Hong Kong, the rest of the doctors from the UK itself.  We were very, very well trained, over and over again by London University on how to recognize, diagnose and also how to assess the nutritional status of a community using all means available to us, not just clinically, using blood or urine tests.

Just to give readers a glimpse how this is done, we need teamwork effort from other experts and specialists such as physicians, nutritionists, anthropologists, sociologists, behavioural scientists, statisticians, medical lab technologists, nurses, and general workers to work together, and not just the doctor or the nutritionist alone.

A nutritionist is a very well-qualified professional who underwent a 4-year degree broad-based training course in a good university. A medical course is just one year extra at 5 years. A student in nutrition too has to study all the basic medical sciences such as anatomy, biochemistry, physiology, pathology, microbiology, etc, plus basic medicine just like any medical student. He carries these subjects in great technical detail in the first 2 years before studying applied nutrition and their practices. 

Nutritionists like dieticians are licensed professionals with protected titles by law in Malaysia as in most countries. Not everyone in recent years can call themselves a nutritionist or a dietician. Both are protected professions, and they must be qualified and licensed for practice. A nutritionist can diagnose malnutrition whether under or over or assess nutritional status far more qualified and much more expertly than a medical doctor or a clinician or a physician who has to deal also with other diseases. Normally a medical doctor will refer cases of nutritional deficiency diseases or nutritional-related disorders to a nutritionist for assessment and diagnosis. 

A dietician prescribes the proper diet for a patient especially for all those with dietary and lifestyle diseases, but a doctor prescribes drugs instead that unfortunately do not cure any nutritional or lifestyle disease. That’s the difference between these two healthcare professionals. But drugs too are very lifesaving in a medical emergency, not to say they are not good.

In most cases especially for modern lifestyle and dietary diseases a very difficult change for proper nutrition is the only medicine but are we willing and compliant. 

"Let Food be thy Medicine" (Hippocrates), and NOT let medicine be thy food as pharmaceutical companies would promote. 

However, drugs too are useful, especially fast-acting ones in a medical emergency.

See my explanation on fast-acting emergency drugs that can be lifesaving here: 

 

https://scientificlogic.blogspot.com/search?q=emergency+drugs

 

Having briefly explained all that, should you insist in asking me again since both, sub-nutrition and overnutrition are mal or bad nutrition, and you insist of which between the devil and the deep blue sea would be the worse, I would say overeating and over nutrition is the greater devil since as far back as in1935 Clive McCay at Cornell University has clearly shown that food restriction especially caloric restriction prolongs life span. Subsequently, over 100 studies done on literally all animals showed the same, not just longevity, but disease-free longevity. I think there is a lot of gospel truth in all these findings since McCay’s time since overeating and over nourishment generates a lot of harmful metabolites, especially damaging free radicals the body, especially the liver and kidneys have to deal with, besides not giving a chance for any bowel and body system rest. It is like churching our food waste and garbage 24 hours a day for clearance with excessive food being thrown out into the streets as garbage.

Which would we choose, under or over nutrition since both are classified as bad or malnutrition  

"Mal" means "bad". 

Explaining further, let us give ourselves an example of normal distribution curve.

In a normal distribution curve there is a minmium on both sides, with a peak somewhere in the middle. The peak is the average or the medial where the cluster of the data is highest. Clustering around the medial are the rest of the data with its Standard Deviation at the tail ends of the the distribution curve. 

Assuming this peak represents the optimal nutrition which we may also represent as optimal health.

Anything on the left of the left of the curse is sub-optimal. Let this be undernutrition. 

Anything on the right of this peak is also sub-optimal, representing excessive and overnutrition. 

Anything on either side of this optimal (maximum) peak is either under or over optimal. Since we are unable to define or determine which would be under or over nutrition for an individual, which side of the curve would we choose to advise an individual how much he or she to take at least to get as close as possible to reach the peak of optimal health? Bear in mind all recommended nutrient intake is based on very large population studies who are in apparent good health through food consumption studies, clinical, anthropometric measurements, age, heights and weight, gender, occupation, physical activities, biochemical, social, economic studies, food supply and food balance sheets among other parameters.  Now we are in hot soup between the deep blue sea and the devil. We cannot answer this with certainty since our nutritional needs are so personal and individualized. We can only  rely on Recommended Daily Allowance based on food consumption studies in large population studies.

As a research nutritionist and food scientist I would not be able to give any specific advice to any individual on his specific nutritional requirements because of vast individual variations. 

This is so unlike the practice of medicine where we can prescribe  the exact dosage of a medicine to a patient. This make the practice of medicine far, far easier than the practice of nutrition for sure. The practice of medicine is quite standard plus or minus a little bit, but not in nutrition because of vast biological needs. 

But if you were to force me for an answer, I would choose the deep blue sea of undernutrition for the simple reason I have explained that there are now over 100 studies both in humans and all animals without exception that under nutrition, specifically caloric restriction greatly prolongs life, not just longevity but disease-free long life. 

I have already proposed a few logical theories to explain this. It is up to nutritionists, nutrition scientists,  and other biomedical scientists to accept these hypothesis and use them as a springboard to work on them further. 

Under nutrition in very severe cases only such as marasmus, kwashiorkor, scurvy, night blindness, beriberi, riboflavin deficiency, pellagra, iron deficiencies...etc, etc can easily be corrected within days, but not chronic degenerative diseases such as diabetes, metabolic syndrome, cardiovascular and stroke, renal, liver diseases due to overnutrition. 

So make your choice between the deep blue sea which can be rescued and the devil that is permanently taken away 

This is just one of the reasons. But I think if we look at this from the evolutionary perspective it is just the way Nature wants any living animal, us included, to adapt to drastic changes in food supply and in harsh environments so that we can become hardier and able to survive with minimum nutritional needs. In a nutshell, the body conserves energy without sacrificing its body mass loss due to caloric restriction to thrive better and longer disease-free. It just merely obeys the biological laws of “survival of the fittest” by being more adaptable to changes in nutritional needs with lesser calories available by being less physically active in order not to lose body mass (body weight) so that it can survive longer.

This theory of mine why we may live not just longer, but with disease-free longevity is just an extension of Herbert Spencer concept he proposed in 1852 after reading Charles Darwin's On the Origin of Species – in his Principles of Biology published in 1864. Evolutionary biology, an area of study coincidentally I happened to be familiar with at Cambridge. 

I think the best analogy to explain this is like a lamp with very little fuel. The lamp will adjust itself conservatively by demanding very little fuel. It will then burn with a very low flame, a slow dim glow for a very long time till the fuel runs out naturally.  But if we start to pour a lot of oil over the lamp, it will suddenly burst into a big fire that will not last very long as the fuel burns itself out fiercely.  In fact, the big fire will destroy the entire lamp and burn it down instead. Likewise, with caloric (energy) restriction, the metabolic rate slows down with less metabolic wastes generated, the body becomes physically less active, and its lifespan is prolonged. 

Vegans and Life Expectancy:

Similarly, I believe if vegans too restrict their plant-based consumption with lower caloric content they too would have longer spans together with the protective effects of antioxidants and thousands of phytochemicals in them. Although the studies on the longevity of vegans are mixed and limited, we cannot refute the belief they would live a longer disease-free life if they do not compensate for their low-caloric diet with greater amount of food intake. But I think vegans do overeat in their belief that: 

"If a little does me good, a lot will do me even better"?

 I am not sure. Perhaps vegans can tell me better! 

  

The lengthy and laborious job of conducting an assessment of nutritional status is summarized in this link below.

https://scientificlogic.blogspot.com/2023/05/the-assessment-of-nutritional-status-in.html

We can see in the study above, how elaborate it is, as it involves so many medical and scientific experts with their expertise working together, not just the doctor or the nutritionist alone.  It is not just the case of just taking medical history, doing some clinical examination, conducting some blood, urine, serological tests, microbiological assays, radiological examination, HPE (biopsies) only, and just prescribing some medicine. It is far, far more and complicated than that.   

 

I hope I have answered your questions and have explained. Nutritionists too are very highly paid. I personally know many of them work as Senior Consultants and in managerial positions in drug, health companies, clinical or analytical laboratories with over RM 18,000 per month salary, or in private practice or teaching in universities as professors or as Dean of a medical faculty like my course mate, the late Professor ST Teoh or Professor Sim my former course mate one year ahead of me in London, who then became a professor at the University of Singapore.

 I myself was offered a WHO job in cancer research at Lyon, France which I declined, and was offered to work at the Massachusetts Institute of Technology (MIT) as a medical and food toxicologist, and later was offered a permanent senior position with the Ministry of Health at the Institute for Medical Research in Kuala Lumpur as a Senior Medical Research Officer and Deputy Head of Rural Health and Community Medicine. Of course, I am now happily retired.

 

So, Mrs Shanzey, the scope in all fields of medicine and health care is very wide, all with good income. Ask your doctor daughter to make her own choice, except in emergency and forensic medicine if she intends private practice later. Emergency medicine, pathology and forensic medicine are only for those who were offered permanent and pensionable jobs with the government. They are a failure and wash out if in private practice.

Regards

Lim ju boo.   

 

 

Which Field of Medicine is Most Difficult and Challenging,

 

 I received a question from the mother of a doctor in Singapore. She posted her question under this article:

“The Management of Chronic Diseases via Different Therapeutic Modalities with Peptic Ulcer Disease as an Example”

https://scientificlogic.blogspot.com/search?q=the+management+of+peptic+ulcers

Greetings Dr. Lim,

My name is Shanzey, a Malaysian working in Singapore. My daughter and myself have been reading all your articles with great interest especially on health and medicine. My daughter is a doctor here in Singapore who intends to specialize but she is unsure which area would be easiest, and which would be hardest, and which area in medicine can earn her better money. The area should not take too long to study, but more importantly not too tough especially with diagnosis. We solicit your expert advice and thank you in anticipation.

 

My question is:

Which field of medicine is most challenging, time consuming but with better income?

--------------------------------------------

 

Thank you for your question, Shanzey.

You have asked me a very tough question. If your daughter cannot decide, how am I to know? I can’t decide for her. The study or the practice of medicine, like everything else in life, is very personal. All depends on individual taste.

Some like to study a certain field to be an expert on it in their working life, others not.  It all depends on individual taste, interest and aims in life.  affordability, economic and social circumstances and other environmental and influencing issues, outcome and dynamics. There is no one sure answer that suit all.

If your daughter is thinking about earning capacity, I think an area such as cardiac and liver surgery can be very specialized and technically very challenging, besides good income as there are not many doctors around who are good in this area. She may not need any other specialist doctors to help out, except in surgery with teamwork effort from supporting staff such as the anesthesiologist, perfusionist, hematologist, immunologists and theatre nurses.

But this does not mean other areas in medicine or surgery are less important, less difficult, less in demand with less earning outcome. I should say, all health-care professions are equally important, and all are in demand.

However, if your daughter intends to go into private practice, there are only two areas I strongly would not advise her, or any doctor for that matter.  Never go for emergency medicine and forensic medicine. The reason is obvious. If you are in private practice, who would send an emergency case, say a serious trauma case in the streets or in a shopping mall, or someone who is already dead as in forensic medicine to your private clinic?

A Good Samaritan, say who saw a street accident, or someone with a heart attack in the office, or anywhere, even at home, would straight away call an ambulance to dispatch a casualty to the emergency department of a government or public hospital.

He is not going to send him or her to your private clinic or to a private hospital and pay for it. Neither would any sensible person send a person who is already dead to your private practice. He will send him straight away to a mortuary and call the police. He or she will never send a dead person to your private clinic or to a private hospital and pay the private doctor to “treat” a dead person. He will of course straight away send the body to a government hospital and ask them to deal with it. It is a police case. So don’t touch these two extreme areas in medicine unless your daughter intends to stay in government service where she will be paid whether the patient is dead or alive.  

Emergency medicine, which I am more familiar with, is very dramatic and lifesaving, but in terms of income and earning capacity it is almost zero. A doctor specializing in this area in private practice can wait for all eternity, and not get even one patient sent to him or her. It is the same with forensic medicine. It is a dead medicine. Both are at the extreme ends, one highly dramatic sent to the triage red zone in a public or government hospital, the other on the extreme end, into the black or white zone (mortuary). Never, never go into these two extreme areas of specialization if your daughter is thinking of going into specialized private practice later.

I should say, choose something in between where there is a demand such as general medicine meant for all, or O & G for female doctors, pediatrics for families with young children. General medicine probably is the best because all patients generally go to an ordinary GP or a physician first because patients normally would not know what ailments are troubling them, except some symptoms they suffer. So, they will see their doctor or a GP first as front-line healthcare professionals to have it sorted out. I should say, most cases are medical in nature rather than surgical. Once a general doctor or a GP sort this out, he or she will refer the case to an appropriate specialist who may be anyone from a cardiologist, oncologist, rheumatologist, hematologist, psychiatrist, ENT, cardiac, neuro, orthopedic, eye surgeon all the way down from A to Z in specialty. All are relevant with good income in private practice.

As far as length of study and technical difficulty to your question is concerned, I think all are lengthy and challenging to study and to specialize. It takes at least another 4 years from a basic MBBS or an ordinary MD degree to get a master’s degree in a field of specialization. A general medical doctor will have to study all the basic medical sciences such as anatomy, physiology, biochemistry, pharmacology, bacteriology or microbiology, histology, pathology, cellular biology, genetics and basic molecular biology all over again especially if it was for the UK MRCP or MRCS Part 1 before going into the area of specialization where they need to pass the examinations on these subjects before going to Part II examination of the Royal College of Physicians or Surgeons or in other disciplines. It is a long ladder to climb.

Furthermore, in order for a doctor to specialize he or she has to be in permanent post for at least 3 years in a specialized department of a government hospital (not private hospital which is not recognized) for teaching and training purposes, experience and exposure in that area the doctor is interested in. He or she will have to work under the supervision of a specialist or a consultant. So that is another ladder to climb.

 The doctor cannot afford to be a contract doctor with no permanent position and is posted here and there especially to a small hospital or in a rural area where he or she is a stand-alone doctor where every little complication needs to be referred or sent by ambulance elsewhere. He or she can never specialize in any field of medicine or surgery. He / she has to be in a big, tertiary or in a teaching hospital for teaching, experience and exposure purposes first.  

As far as your question on technicality and difficulty on diagnosis is concerned, straight away I should emphasize the diagnosis of malnutrition and nutritional disorders. This is the most difficult and most technically challenging branch of medicine for any doctor or even for an expert nutritionist.

First of all, the word “malnutrition” actually means “bad nutrition” to mean “mal” “bad,” “wrongful,” “ill,” from French word “malapert” such as we say “malpractice, malodorous, malformation, malformed, maladjustment, and so on.

Malnutrition does NOT mean only undernutrition as most people, including even specialist physicians think. It technically includes those who are also over-nourished with excessive nutrition from overeating. Overnutrition too is bad or malnutrition. Does that surprise you? I am more than sure you do, including all medical doctors who thinks that malnutrition means only those suffering from nutritional deficiency diseases such as marasmus, kwashiorkor, beriberi, pellagra, rickets and hypocalcaemia, osteomalacia, vitamin K deficiency, xerophthalmia, anaemia and iron deficiency...all the way down to over 350 different types of nutrition deficiency diseases.

 Unfortunately, most doctors are not familiar with them. They tend to misdiagnose them as something else and prescribe them chemical drugs instead.

For instance, a person who is underweight and always feels tired and lethargic should be a suspect of caloric undernutrition. This is because of the body’s innate response to converse energy rather than to lose body mass. So, he or she feels tired and lethargic most of the time to need rest. This has nothing to do with an under thyroid function and needs to do a thyroid function test with all those T3 T4 and all those unnecessary stuffs.

 On the extreme end, over nutrition is the root cause of most of the chronic and degenerative diseases such as cardiovascular, diabetes, endocrine and metabolic syndromes, gout, arthritis, renal, liver, cancers and neoplastic diseases. All these are mainly caused by malnutrition, either under or over nutrition afflicting mankind today due to affluence and overeating and lifestyles. None of these can be “cured” by any chemical drugs that only mask them into other emerging linked diseases. The only way is dietary and lifestyle modifications which is best treated by a dietician. As clinicians and nutritionists, we are very clear on this.

One of the most difficult challenges in diagnosing malnutrition for a doctor or for a nutritionist whether under or over nutrition is, that their presentations (clinical signs and symptoms and even blood tests) do not show up. Most of them are subclinical without signs and symptoms which would be riskier unlike a heart attack, a fever, pain, nausea, vomiting where tell-tales signs are very clear which we can differential diagnose by asking questions, looking for signs and symptoms, taking medical history, clinical examination, blood tests, radiology and imaging and so on. These are not the slightest problems to do or observe. But not with malnutrition which is a disease that can be fatal leading chronic and degeneration of all body systems if not corrected with dietary and lifestyle modification. None of these nutritional diseases, whether under or over nutritional, can be “cured” by prescribing all sorts of drugs, or rather chemicals. That is more than sure. That makes diagnosis, management and compliance extremely difficult for both the doctor and the patient.  

For instance, if you were to ask me if you are malnourished, meaning either undernourished or over nourished, I would not know. You may appear well-fed and healthy physically in appearance and none of any blood tests would show anything. They would all appear as negative with no abnormality shown unless I perform what we call a saturation  test (British) or loading test (American) on you to look at your water-soluble vitamin such as thiamine, riboflavin or ascorbic acid or Vitamin B₆, (nicotinamide) status where we dose you a certain amount of the water soluble vitamins and see how much is been retained by the body, and how much excreted into the urine.

A person may look perfectly well and healthy but in truth his / her health is below optimal, and optimal health depends so much on optimal nutrition. But what then is optimal health and optimal nutrition? The answer is, we do not know as it varies from individual to individual depending on his / her daily nutritional needs which again depends on gender, age, physical activities, physiological requirements, perhaps race, environmental temperatures, body weights among other internal and external influences such as lifestyles. These problems are very complicated to sort out, and we can only take an average from large population studies of apparently healthy people. That is the reason why every country has their recommended daily allowance for various nutrients according to age, sex, pregnant and nursing mothers, heights, weights, physical activities among other factors to be considered. There is no standard dose for any nutrients so unlike drugs which are standardized. This is the reason why the practice of nutrition is so much more complicated than the practice of medicine where the dose is almost fixed and easy to titrate.

In nutrition variations in physiological and biochemical needs are so wide that no one can give a definitive answer. That is why if you were to ask me if you are eating the optimal requirements for your needs, or for the prevention of any disease I would not be able to tell you with certainty even though I am a nutritionist and clinician. You may only look every fit, healthy and well-fed, but within you, lies latent dietary and lifestyle diseases like metabolic syndrome like diabetes, cardiovascular, stroke and even cancers awaiting you in the years ahead. On the other end of malnutrition (undernutrition) you may suffer subclinical kwashiorkor (protein malnutrition), marasmus (caloric deficiency), beriberi (thiamine deficiency), scurvy (vitamin C / ascorbic deficiency), signs such as sore throat, lesions of the lips and mucosa of the mouth, glossitis, conjunctivitis, seborrheic dermatitis, and normochromic-normocytic anaemia (riboflavin or B2 deficiency), iron deficiency  anaemia, together with vitamin B12 deficiency resulting in Addisonian and pernicious anaemias.

Other nutritional deficiency diseases to name a few are, pellagra (niacin or vitamin B3 deficiency causing delusions or mental confusion, diarrhoea, photo-sensitive dermatitis, angular stomatitis, cheilosis, lacrimation, photophobia, Casal collar…etc, etc without you realizing them.

Most of them may be sub-clinical and do not show up. You may feel well, fit and healthy, but in fact you are not. That makes diagnosis exceedingly difficult. They don't even show up on any blood and biochemical examination unless very serve where certain metabolites appear in the blood due to incomplete metabolisms where these vitamins are needed. One example is erythrocyte transketolase activity coefficient (ETKAC) assay for thiamine (vitamin B1) status.  

Else the assessment of nutritional status is exceedingly difficult even for large populations, let alone for individuals based only on clinical examination alone or some blood tests.

 Please see link below how the assessment of nutrition status is done by the coordinated efforts from a team of nutritional, medical and other health professionals.

In fact, the diagnosis of malnutrition is more difficult even for an expert well-qualified nutritionist let alone for a doctor who knows very little on nutrition unless the clinician specialises in nutrition at post graduate level with a master’s degree in this area.

When I was doing my postgraduate in nutrition at Queen Elizabeth College, University of London we were all retrained by the University on the procedures in assessing nutritional status and how to diagnose clinically cases of acute or sub nutritional diseases. There were a number of us in our postgraduate course. They came from various countries. We were all there at London as students, all medical doctors, plus one biochemist from the University of Manchester and a Master degree holder in pharmacology from St Andrews University, one doctor from the University of Singapore, and one Dr Jason ST Teoh from the Faculty of Medicine, University of Malaya, who later began the Head of the Department of Social and Preventive Medicine, and later became a  Professor and Dean of the  Faculty of Medicine at the  University of Malaya. Unfortunately, Professor ST Teoh has since passed away.

One was a gynaecologist from Oslo, Norway, one doctor from Canada, another from Nigeria, one from Hong Kong, the rest of the doctors from the UK itself.  We were very, very well trained, over and over again by London University on how to recognize, diagnose and also how to assess the nutritional status of a community using all means available to us, not just clinically, using blood or urine tests.

Just to give readers  a glimpse how this is done, we need teamwork effort from other experts and specialists such as physicians, nutritionists, anthropologists, sociologists, behavioural scientists, statisticians, medical lab technologists, nurses, and general workers to work together, and not just the doctor or the nutritionist alone.

A nutritionist is a very well-qualified professional who underwent a 4-year degree broad-based training course in a good university. A medical course is just one year extra at 5 years. A student in nutrition too has to study all the basic medical sciences such as anatomy, biochemistry, physiology, pathology, microbiology, etc, plus basic medicine just like any medical student. He carries these subjects in great technical details in the first 2 years before studying applied nutrition and their practices 

Nutritionists like dieticians are licensed professionals with protected titles by law in this Malaysia as in most countries. Not everyone in recent years  can call themselves a nutritionist or a dietician. Both are protected professions and they must be qualified and licesnsed for practice. A nutritionist can diagnose malnutrition whether under or over or assess nutritional status far more qualified and much more expertly than a medical doctor or a clinician or a physician who has to deal also with other diseases. Normally a medical doctor will refer cases of nutritional deficiency diseases or nutritional-related disorders to a nutritionist for assesment and diagnosis. 

A dietician prescribes the proper diet for a patient especially for all those with dietary and lifestyle diseases, but a doctor prescribe drugs instead that unfortunately do not cure any nutritional or lifestyle disease. That’s the difference between these two healthcare professionals. But drugs too are very lifesaving in a medical emergency, not to say they are not good.

In most cases especially for modern lifestyle and dietary diseases a very difficult change for proper nutrition is the only medicine, but are we willing and compliant 

"Let Food be thy Medicine" (Hippocrates), and NOT let medicine be thy food as pharmacutical companies would promote. 

However, drugs too are useful, especially fast-acting ones in a medical emergency.

See my explanation on fast-acting emergency drugs that can be life-saving here: 

 

https://scientificlogic.blogspot.com/search?q=emergency+drugs

 

Having briefly explained all that, should you insist in asking me again since both, sub-nutrition and overnutrition are mal or bad nutrition, and you insist of which between the devil and the deep blue sea would be the worse, I would say overeating and over nutrition is the greater devil since as far back as in1935 Clive McCay at Cornell University has clearly shown that food restriction especially caloric restriction prolongs life span. Subsequently, over 100 studies done on literally all animals showed the same, not just longevity, but disease-free longevity. I think there is a lot of gospel truth in all these findings since McCay’s time since overeating and over nourishment generates a lot of harmful metabolites, especially damaging free radicals the body, especially the liver and kidneys have to deal with, besides not giving a chance for any bowel and body system rest. It is like churching our food waste and garbage 24 hours a day for clearance with excessive food being thrown out into the streets as garbage.

This is just one of the reasons. But I think if we look at this from the evolutionary perspective it just the way Nature wants any living animal, us included, to adapt to drastic changes in food supply and in harsh environments so that we can become hardier and able to survive with minimum nutritional needs. In a nutshell, the body conserves energy without sacrificing its body mass loss due to caloric restriction to thrive better and longer disease-free. It just merely obeys the biological laws of “survival of the fittest” by being more adaptable to changes in nutritional needs with lesser calories available by being less physically active in order not to loss body mass (body weight) so that it can survive longer

This theory of mine why we may live not just longer, but with disease-free longevity is just an extension of  Herbert Spencer  concept he proposed in 1852 after reading Charles Darwin's On the Origin of Species – in his Principles of Biology published in 1864. Evolutionary biology, an area of study coincidentally I  happened to be familiar with at Cambridge. 

I think the best analogy to explain this is like a lamp with very little fuel. The lamp will adjust itself conservatively by demanding very little fuel. It will then burn with a very low flame, a slow dim glow for a very long time till the fuel runs out naturally.  But if we start to pour a lot of oil over the lamp, it will suddenly burst into a big fire that will not last very long as the fuel burns itself out fiercely.  In fact, the big fire will destroy the entire lamp and burn it down instead. Likewise, with caloric (energy) restriction, the metabolic rate slows down with less metabolic wastes generated, the body becomes physically less active, and its lifespan is prolonged. 

Vegans and Life Expectancy:

Similarly, I believe if vegans too restrict their plant-based consumption with lower caloric content they too would have longer spans together with the protective effects of antioxidants and thousands of phytochemicals in them. Although the studies on the longevity of vegans are mixed and limited, we cannot refute the belief  they would live a longer disease-free life if they do not compensate for their low-caloric diet with greater amount of food intake. But I think vegans do overeat in their belief that: 

"if a little does me good, a lot will do me even better"?

 I am not sure? Perhaps vegans can tell me better! 

  

The lengthy and laborious job of conducting an assessment of nutritional status is summarized in this link below.

 

https://scientificlogic.blogspot.com/2023/05/the-assessment-of-nutritional-status-in.html

We can see in the study above, how elaborate it is, as it involves so many medical and scientific experts with their expertise working together, not just the doctor or the nutritionist alone.  It is not just the case of just taking medical history, do some clinical examination, conduct some blood, urine, serological tests, microbiological assays, radiological examination, HPE (biopsies) only, and just prescribing some medicine. It is far, far more and complicated than that.   

I have also written a very short summary here:

 

https://scientificlogic.blogspot.com/search?q=assessment+of+nutritional+status

 

I hope I have answered your questions and have explained. Nutritionists too are very highly paid. I personally know many of them work as Senior Consultants and in managerial positions in drug, health companies, clinical or analytical laboratories with over RM 18,000 per month salary, or in private practice or teaching in universities as professors or as Dean of a medical faculty like my course mate, the late Professor ST Teoh or Professor Sim my former course mate one year ahead of me in London, who then became a professor at the University of Singapore.

 I myself was offered a WHO job in cancer research at Lyon, France which I declined, and was offered to work at the Massachusetts Institute of Technology (MIT) as a medical and food toxicologist, and later was offered a permanent senior position with the Ministry of Health at the Institute for Medical Research in Kuala Lumpur as a Senior Medical Research Officer and Deputy Head of Rural Health and Community Medicine. Of course, I am now happily retired.

 

So, Mrs Shanzey, the scope in all fields of medicine and health care is very wide, all with good income. Ask your doctor daughter to make her own choice, except in emergency and forensic medicine if she intends private practice later. Emergency medicine, pathology and forensic medicine are only for those who were offered permanent and pensionable jobs with the government. They are a failure and wash out if in private practice.

Regards

Lim ju boo.