Center and Balance in Da Vinci's Vitruvian Man

Leonardo Da Vinci's Vitruvian Man has amazed me for at least the past 15 years.  Here is a little video I made to explain some of my reasons and perceptions, particularly from a functional anatomy point of view.

 

 

 

I am not the only individual to believe that there may be physical exercises within Da Vinci's drawings.  Michael Gelb has written several books, and this link has some of the exercises he has developed from the drawing.  http://www.signlanguageofthesoul.com/leonardo.html. 

 

My view is more static.  I simply ask the individual to stand in the "box" position for several minutes or lie down on the floor or the bed in the circular position for several minutes and to truly feel one's center of balance in the body.  Regardless of whether you engage in these exercises, Mr. Gelb's exercises, or simply a thought exercise, I hope the genius of Da Vinci shines through this little video.

Marlboro, Portion Distortion and Marketing Magic

Marlboro.

 

Whether you smoke or not, what do you think of when you hear that word? Cowboys and the American West, right? I grew up in 1970s suburbia and have been on a horse once in my life. I have more to with the American West than Marlboro!

Where does Marlboro come from? Marlboro is owned by a British corporation, Philip Morris. The name comes from a street in London called Great Marlborough on which its factory was first situated.  It originally started as a cigarette for women in the 1920s, and was known with the tagline, Mild as May, because their first “smokeperson” was not the Marlboro Man, but rather the famous movie star Mae West.

As can be seen in the ad, smoking was considered a feminine activity and not considered “manly.” In the 1950s, Philip Morris wanted to change their marketing to men and worked with Leo Burnett of New York  to create the Marlboro Man to market to men. The cowboy was chosen and the rest is history. Instead of thinking of a street in London, England, we associate Marlboro with the American cowboys. That is the power of advertising and brand identification.

Marketing does not take place on a billboard, on a television station, or in a magazine. It takes place in one’s individual consciousness. It creates a mental image that the viewer identifies with or wants to identify with.

As Al Reis and Jack Trout state in Marketing_Warfare (p . 44) “Marketing battles are fought in a mean and ugly place. A place that’s dark and damp with much unexplored territory and deep pitfalls to trap the unwary. The mind is the battleground. A terrain that is tricky and difficult to understand. The entire battlefield is just 6 inches wide. This is where the marketing war takes place. You try to outmaneuver and outfight your competitors on a mental mountain about the size of a cantaloupe. A marketing war is a totally intellectual war with a battleground that no one has ever seen. It can only be imagined in the mind, which makes marketing warfare one of the most difficult disciplines to learn.”

It is the power of advertising to effect behavioral change in an individual and a society that most interests me. Personally, I believe advertising has led to some remarkable changes in American life in terms of one’s health. From my perspective we can see this in how it has changed our social norms.

For instance, I believe the greatest cause of increase in our calories as a country is related to increase in portion sizes. Supersized meals and supersized sodas now look normal. A “typical” (based on RDA values) individual serving size now appears small. This is not because the serving size has changed, but because how we perceive them has changed. A great deal of this was accomplished through very successful marketing by different organizations.  For instance, as detailed in Greg Crister's Fatland. David Wallerstein, who was a director at McDonald's corporation, was first to suggest to the founder, Ray Kroc, to introduce supersized fries.  He argued that it was a values proposition.  People felt (and bought) that they were getting an increased value for the extra money they spent on the larger fries.  The consumer thus doesn't feel they are suffering from gluttony but rather they convince themselves they are being "frugal" shoppers by paying a little more for a much larger portion.  Meanwhile the franchisee is able to spend just a few extra pennies to create the supersized meal, with the extra charge being  primarily pure profit.

This has had a caloric effect on the individual consumer.  From Fatland, p. 28: "By the end of the century, supersizing --the ultimate expression of the value meal revolution -- reigned.  As of 1996, some 25 percent of the $97 billion spent on fast food came from items promoted on the basis of either larger size or extra portions.  A serving of McDonald's French fries had ballooned from 200 calories (1960) to 320 calories (late 1970s) to 450 calories (mid 1990s) to 540 calories (late 1990s) to the present 610 calories (2003).  In fact, everything on the menu had exploded in size.  What was once a 590-calorie McDonald's meal was now...1550 calories.  By 1999 heavy users -- people who eat fast food more than twenty times a month -- accounted for $66  billion of the $110 billion spent on fast food...Kids had come to see bigger everything -- bigger sodas, bigger snacks, bigger candy, and even bigger doughnuts -- as the norm; there was no such thing as a fixed immutable size for anything, because anything could be a made a lot bigger for just a tad more."

We can see this change from  the National Institute of Health Portion Distortion website, regarding how portion sizes have changed over 20 years from 1984 to 2004

Just look at the first picture of the coffee.  I believe it is almost impossible to view the coffee on the left as "small."  However, if we went back 20 years, we may have looked at the coffee on the right as "huge."  The latter view is probably a more correct one from a caloric perspective.  Here are some more examples of portion distortion

 

 

 

 

 

 

 

But how do we go back?  Our appetite in a variety of ways has fundamentally changed, and we've entered a "new normal."  This blog is not a criticism of brand marketing. Rather it is to help us become aware of its impact. We often state how hard it is to effect behavioral change, yet many companies are quite effective at creating it and we may have something to learn from them.

Perhaps we can use similar marketing techniques to create a healthier society, but the question is, how?  This post may lead to more questions in this regard than answers; however, I think it may be beneficial to study how marketers can move products and in so doing effect behavioral change.  It often requires an understanding not of rational concerns, but emotional ones.  We must be able to connect with the individual -- understand and appreciate his/her anxieties, fears and desires.  Perhaps, if we are honest with ourselves, we can learn a great deal from this marketing warfare to truly effect a healthier society.

Is It Cholesterol or Is It Oxygen?

I am virtually a vegetarian. (I eat pizza, which has milk, and had a meatball in New York last summer). However, my cholesterol is high, and I take cholesterol-lowering medication. Cholesterol comes from the animal family, and I eat virtually no animal products, so why would my cholesterol be high?

Approximately 75% of our cholesterol comes from what our liver produces, NOT from what we eat.   An enzyme called the HMG-CoA reductase is used by the liver to create cholesterol.  Medications called statins, which act on this enzyme, can lower one's cholesterol by up to 60%.   By contrast, medications that block cholesterol absorption from our diet will only lower cholesterol approximately 10%.

What exactly is cholesterol, and why, for many of us, does the liver produce so much of it?

To understand cholesterol, we must go back to basic biology and discuss prokaryotes and eukaryotes. Prokaryotes are cellular organisms whose cells do not have a nucleus, and eukaryotes are cellular organisms whose cells have a nucleus and other membrane-bound organelles. Prokaryotes do not have cholesterol, while eukaryotes use cholesterol to form the nucleus and other membrane-bound organelles. The cholesterol allows a stiffness and organization to the cellular membranes. The cholesterol also acts as a means of intracellular transport within the membrane itself. We humans, as well as all mammalians, are eukaryotes. 

Konrad Emil Bloch received the Nobel Prize for Medicine for his work on the biological synthesis of cholesterol in 1964. He noted that the creation of cholesterol required a great deal of energy and oxygen. The creation of cholesterol requires approximately 27 separate processes. He hypothesized that the utilization of oxygen to create cell walls and cholesterol walls was a complex organism's response to an oxygen-rich environment.  From this theory, we understand that cholesterol formation is an ingenious process of using the oxygen for the organism's benefit.

As we age, this cholesterol production can contribute to atherosclerosis through the process of developing an atheroma, or an intracellular lipid accumulation. Here is a nice picture of it from Wikipedia.

Cholesterol is insoluble in water and requires lipoproteins to transport it. Low Density Lipoproteins (LDL) deposit the cholesterol in plaques inside the arterial walls, while High Density Lipoproteins (HDL) act like scavengers and can help remove some of the plaques. The amount of LDL in the human organism is strongly related to cardiovascular risk.

However, it was discovered that it was not just LDL, but the degree of oxidized LDL that correlated with endovascular injury.  Oxidized LDL can damage the endothelial cells and allow cholesterol to build deposits in the subendothelial area (the space right below the endothelium lining the artery). This injury to the endothelial lining allows more cholesterol deposits to be created in the subendothelial area, creating more inflammation. White blood cells known as macrophages, which fight inflammation, try to repair the injury caused by oxidized LDL and consume them, causing “foamy macrophages.” This process is a very aggressive, angry, inflammatory process. If any of the area ruptures, then a blood clot can be formed, as stated in the prior post on coronary artery disease.

This process is known as “oxidative stress.” It is like rust on the bottom of an old car. Oxygen can be a very hungry molecule and has the ability to rip electrons off other nearby molecules. The molecules with the missing electrons are known as free radicals, and they can rip electrons off other nearby molecules, causing a free radical chain reaction.  As ferric oxide eats away at a car, so can this oxidative injury damage the endothelial lining of our cell walls.

As scientists understand more about this inflammatory, aggressive process, more unique treatments are being discovered. For instance, although powerful antioxidants such as Vitamin E and Vitamin C were not necessarily found to be beneficial for decreasing heart disease, other types called polyphenol antioxidants may be quite effective. In fact, in a study in the Journal of Clinical Nutrition, the use of pomegranate juice (a polyphenolic antioxidant) actually reduced atherosclerotic plaque in individuals with carotid artery stenosis. In a study in the journal Atherosclerosis, the addition of pomegranate extract to statins actually reduced macrophage foam cell formation and was felt to potentially decrease atherogenesis.

In short, cholesterol itself is amazing. It plays an essential role in the membranes of animal cell walls. It also is critical in the formation of molecules such as Vitamin D, steroid hormones and bile acids. But it appears intimately associated with oxygen.  Cholesterol may be created as a response to an oxygen-rich environment, and oxidative stress can impact the LDL receptors that carry it and contribute to the creation of atherosclerotic disease.  Perhaps in the future, we may become wiser about various lifestyles that may optimize the benefit of both oxygen and cholesterol without creating a disease process from them.

The Heart of the Matter

"And all of a sudden he just dropped dead. He ran and everything."

My friend told me as we drank in the bar, acknowledging with sorrow and fear the death of a male coworker. It was an acceptance of the toll of heart disease in our country, particularly among two 45-year-old men. According to the Centers for Disease Control, heart disease is responsible for approximately 1 out of 4 (600,000) of all American deaths and 1 out of 3 if you include stroke.  It is the leading cause of death for both men and women. Of these deaths the majority are from coronary artery disease (385,000). There are approximately 715,000 heart attacks a year, of which approximately 190,000 occur in individuals who have had one previously.

Although death from heart disease is a great burden on our population, it has decreased dramatically over the years.

Ford and Capewell, J Am Coll Cardiol. 2007; 50 (22):2128-2132

According to a 2011 article by Ford and Capewell in the Annual Review of Public Health, approximately 44%-76% of this decline appears to be because of prevention (such as smoking cessation) and the remaining from treatment such as coronary care units and rapid cardiac catherization during an acute heart attack.

Heart disease is a particularly sobering situation for men, as it affects us more than women. What man reading this post is as fit as Neil Reid was? He played college basketball for Indiana University in 1999. He died of a heart attack at age 36. Dana Carvey, the famous Saturday Night Live alum, had coronary artery bypass surgery at age 42. James Fixx, marathon runner, died of a heart attack at age 52. Former president Bill Clinton had coronary artery bypass surgery at age 57 and then had cardiac stents placed 6 years later. Personally, I think I will suffer a heart attack some time in my own life. Hopefully, it will just be later rather than sooner (at least from my perspective).

For me, the question is not why do we have so many heart attacks, but rather why don’t they occur even more frequently? There are only three main arteries around the heart (coronary arteries), and each is about the size of a piece of spaghetti. Considering how small these precious arteries are, it’s amazing they function as well as they do. The main arteries are the left anterior descending, the left circumflex and the right coronary artery. Smaller arteries arise from these larger arteries and provide blood flow to the whole heart.



From Wiki


Many people do not understand how most heart attacks occur. Many think that cholesterol clogs up a coronary artery by causing a cholesterol plaque (similar to a clogged pipe drain), leading to a heart attack. Actually, these plaques can often be very small and not cause much occlusion of the coronary artery. A heart attack usually occurs because a plaque int he coronary artery ruptures. The body then tries to repair this rupture. Just like when you cut yourself and your body forms a scab, the body tries to repair the damage caused by the rupture of the plaque by forming a blood clot inside the blood vessel. This blood clot prevents blood from flowing in the blood vessel, and therefore a heart attack occurs immediately.

This is the reason that the first medication given to heart attack victims in the emergency room is blood thinners to help increase blood flow (usually it begins with 4 baby aspirin which the patient chews) followed by a catherization to open up the blood clot, often with a stent, followed by more blood thinners such as Plavix.

Knowing one’s risk factors can help decrease the probability of heart disease. One of the largest public health undertakings to study heart disease began in Framingham, Massachusetts in 1948. The original study involved 5209 men and women and in 1971 it enrolled another 5,124 men and women to study the risk factors for heart disease. This large epidemiological study created the Framingham Risk Score, which allows an individual or a provider to calculate a 10-year risk score for an individual. You can find such a calculator here. The main risk factors are high blood pressure, high blood cholesterol, smoking, obesity, diabetes, and physical inactivity.

One critical element is that these risk factors are additive. Such that if a person smokes, has diabetes and has hypertension, they are at a much greater risk of future heart disease than if that person only had one risk factor.

Whatever one can do to limit the totality of risk factors, the more likely there is to be a favorable benefit.

Lastly, I want to emphasize again that, if at all possible, it is better to prevent heart disease than treat it, particularly in regards to coronary artery disease. If one is having a heart attack and has a stent put in (a wire mesh device that opens the artery), it can, and often is, life-saving and can prolong one’s life. Further, if one is having “unstable angina,” or pain from coronary artery disease that is changing in duration or severity, a stent can also be live-saving.

However, many cardiac stents are not placed for acute heart attacks or unstable angina, but rather for chest pain from stable angina. That is, the pain occurs at specified time and duration, (such as walking up the fourth flight of stairs). The primary purpose of such stents is to decrease pain, NOT to prolong life or prevent another heart attack. It is critically important to understand this, because too many people feel their artery is clogged and, like a plumber, the cardiologist has put in a stent which will open the coronary artery and prevent a future heart attack and prolong life.

There was a large study called the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial in 2007 that enrolled 2,287 individuals, half of which received stents and half of which received medication for chronic stable angina. The follow-up was 4½ years. There was no statistical difference between death, nonfatal heart attack, or stroke (20% in the angioplasty group, versus 19.5% in the medical group). This is what Steve Nissen, a past president of the American College of Cardiology said about placing stents in individuals with chronic stable angina on the PBS Newshour “We know that stents do, in fact, help to relieve chest pain, but they really do not prolong life or reduce the risk of a heart attack in patients that are otherwise stable.”

This all points to the idea that coronary artery disease, like nearly all disease, is a process, not a static event. It is not treated by one pill, or one stent or one "magic bullet." Rather, try to curb the entire process by taking appropriate medications, lowering blood pressure, keeping one’s blood sugar down, and not smoking. And if you have chest pain that you think is coming from the heart, chew several baby aspirin (4 are usually given in the ER) and GET TO THE ER!