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Monthly Archives: May 2012

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A number of diseases respond favorably such as AMD and rheumatoid arthritis

Last week, I shared the depressing news that omega-3 fatty acids from fish and/or fish oil may not have any positive effects in some diseases, such as heart disease, cancer and multiple sclerosis — a surprise to the medical community. However, omega-3s from these sources may be beneficial in other diseases and disorders, including age-related macular degeneration, dry eye, Alzheimer’s, rheumatoid arthritis, diabetes, anxiety and, ironically, depression. So don’t avoid fish or fish oil yet. Talk to your doctor first. Let’s review some of the studies.

AMD effect

In the Women’s Health Study, there was a significant reduction in risk of developing AMD for those women who ate fish on a regular basis (Arch Ophthalmol. 2011;129(7):921-929). AMD is the leading cause of central vision loss or blindness in patients over 55. The great news is that you don’t have to eat a substantial amount of fish — just one serving per week results in a 42 percent reduction in risk. The fish that had most impact included salmon, mackerel, tuna, bluefish, swordfish and sardines.

I would recommend sardines and salmon, which are lower in mercury than the others and higher in omega-3s. In those who were taking fish oil supplements containing docosahexaenoic acid and eicosapentaenoic acid there were significant, though slightly less robust, reductions in the risk of AMD, 38 percent and 34 percent respectively.

This was a large observational study with 39,000 participants and a mean 10 year follow-up duration. The researchers believe that the mechanism of action may have to do with an anti-inflammatory process, since AMD has underlying inflammation.

AREDS 2 is an ongoing five-year randomized controlled trial, the gold standard of studies, that includes fish oil (clinicaltrials.gov). It will be interesting to see if it reinforces these results.

Alzheimer’s disease
Alzheimer’s disease is neurodegenerative disease. There are no medications yet to reverse or slow its progression, only to treat its symptoms. Thus, it is crucial to find lifestyle modifications that may prevent and treat its effects. In a recent study, consumption of omega-3s from fish showed a significant reduction in beta-amyloid protein, a nonspecific marker of Alzheimer’s disease, as measured in the blood (Neurology online May 2).

In another study, consumption of fish at least one time a week showed preservation of brain volume, tested using MRI scans, in the hippocampus and frontal lobe. These areas are responsible for memory and cognitive function.

Both studies are encouraging for Alzheimer’s disease prevention (RSNA Abstract SST11-04). In yet another study, fish oil seemed to reduce the progression of cognitive impairment in patients with very mild Alzheimer’s disease (Arch Neurol. 2006;63:1402-1408).

Rheumatoid arthritis

In the May 24 article, I wrote about a meta-analysis that showed reduction in joint pain and morning stiffness in those who consumed fish oil (Pain. 2007 May;129(1-2):210-23).
These are two of the most common complaints of patients with rheumatoid arthritis.

Diabetes

Omega-3 fatty acids seem to play a role in prevention of type 2 diabetes. In the Cardiovascular Disease Study, there was a 36 percent reduction in the risk of developing diabetes for those who consumed the most omega-3s (Am J Clin Nutr. 2011;94(2):527-33).
The study was unique in that it tested the levels of DHA and EPA in the blood, a quantitative approach, and determined that participants with the highest levels of these omega-3s were least likely to develop the disease.

This was an observational study with 3,000 participants over a 10-year period. These are encouraging results and may indicate another way to reduce diabetes risk.

Dry eye syndrome

The prevalence of dry eye syndrome increases with age and is a common problem, with a higher prevalence among women (Am J Ophthalmol. 2003;136(2):318-26). In the Women’s Health Study, omega-3 fatty acids reduced the risk of dry eye by 17 percent (Am J Clin Nutr. 2005; 82(4):887-93). The omega-3s may work by blocking pro-inflammatory factors in the eye. The best results were found with tuna: one serving per week reduced risk by 19 percent, while two servings reduced risk by a whopping 68 percent. Interestingly, a high omega-6 (pro-inflammatory) to omega-3 ratio increased the risk of dry eye 2.5 times. The typical American diet is low in omega-3s but very high in omega-6s. Included in this latter category are processed foods; meats — especially red meat; dairy such as cheese, whole milk and butter; and certain processed oils. These are foods that are high in fat, but not good fats.
Omega-3s play a potentially significant role in many diseases, but not in all. There is greater upside for omega-3 fatty acids than downside, except as it relates to prostate cancer risk. However, just as with other substances, it may be better to obtain omega-3s from fish than to rely on fish oil. One thing is sure: We get too many omega-6s and not enough omega-3s in our diet and thus may have a higher propensity toward inflammation, which promotes chronic diseases.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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Scientist studies wild ancestors of domestic fruit to increase productivity

Going into his tomato project, Zachary Lippman expected something different. After all, over thousands of years, breeders had been growing the juiciest tomatoes they could.

A team of scientists from 14 countries had already put together a genetic blueprint of the 35,000 genes spread across 12 chromosomes for the “Heinz” tomato.

Lippman, meanwhile, led a group of scientists at Cold Spring Harbor, including Richard McCombie and Doreen Ware, to put together a similar genetic blueprint for the naturally occurring wild type. The tomato Lippman studied, which is an edible South American currant tomato, was much more like the original fruit our agricultural ancestors stumbled upon thousands of years ago.

Even before he finished the two-year effort to create his own genetic blueprint, Lippman suspected there would be plenty of genetic differences. After all, corn and rice, among others, had changed a great deal since its domestication.

“The expectation was that we’d see a lot of changes in the DNA,” offered Lippman. “What we found was the opposite. We see a remarkable similarity between the wild and domesticated tomato.”

Indeed, that scientific finding — and the years of work preparing and comparing the genetic libraries of the different tomato types — was flavorful enough for the scientific journal Nature to include it in its most recent issue.

Calling the genetic sequence of the two tomato types a “major first step,” David Spector, Cold Spring Harbor’s research director, explained that this type of research could help identify critical genes that scientists could manipulate to help improve the tomato, in terms of number of flowers that might give more fruit, or its ability to withstand drought conditions or insect infestations.

Longer term, identifying specific genes that could improve the quality and durability of the tomato could have implications for the world’s food supply, suggested Spector.

“Any developments that can be made to help increase yield and resistance to various conditions such as drought or insects will have a huge impact worldwide. What he’s doing is going to have huge global significance. He’s starting with the basics of the sequence of the plant and is working his way up from there.”

Lippman plans to use the information from the genetic sequences of the two tomato types   in several ways.

Using classical and modern genetics and breeding technologies, he studies tomato mutants that affect how many flowers are produced by a tomato plant on a branching structure called “inflorescence.” These mutants can cause tomato plants to produce either fewer than normal or more than normal flowers, by changing how many branches are produced on the inflorescence.

He then identifies the genes that are “not working properly” in the mutants and studies how these are turned on and off during growth of the tomato plant. He specifically looks at how these genes change in their activity as the tomato plant transitions from making leaves to making flowers.

He is also crossing wild species that produce a lot of branches and flowers with those that producer fewer flowers. He then “genetically maps” the location of the responsible genes. He studies how these genes change during the reproductive transition and what DNA changes occurred to cause the evolution of the different species that produced different numbers of flowers.

Lippman lives in North Bellmore with his wife Shira, a dentist, and their four children, who range in age from three to nine years old.

Lippman isn’t just a leading expert in the field of tomatoes: he’s also a consummate consumer, carting containers of V8 juice back from trips to Costco.

“It’s not a joke,” he insists. When he’s not working on tomatoes, he likes to eat, or drink, them.
Indeed, his favorite way to eat tomatoes is in a cold tomato salad, with basil and fresh mozzarella, and a pinch of salt and pepper.

Lippman, who was raised in Milford, Conn., first became interested in plants and agriculture, particularly pumpkins and tomatoes, when he took a summer job at Robert Treat Farm, a family-owned farm within a mile of his house.

Lippman hopes large-scale farmers, farm stands and backyard gardeners from around the world will benefit from his research on the genetic sequences and the genes of wild and domesticated tomatoes.

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Effects are disease dependent: Studies show no benefits in MS and cardiovascular disease

Omega-3 fatty acids are found in many substances, such as fish, supplements and even an approved drug. Fish oil is one of the most frequently used supplements, and we eat fish in the hope that it will prevent chronic diseases. We believed that the effects of omega-3s are beneficial, since they have anti-inflammatory properties and reduce triglycerides (Brit J. Pharmcol. 2008:153:S200-215; Am J Clin Nutr. 2003:77;300-307). But does the research into clinical outcomes confirm this, or is it conjecture?

The answer is complicated, since the effects seem to be disease dependent. On the one hand, omega-3 FAs are beneficial for Alzheimer’s, age-related macular degeneration, dry-eye syndrome, depression, anxiety and rheumatoid arthritis. On the other, omega-3s have no effect in cardiovascular disease, multiple sclerosis or cancer prevention, and may even increase the risk of prostate cancer. Let’s look at the studies.

Cardiovascular disease

The prevailing thought has always been that omega-3s, especially from fish oil, reduce the risk of stroke and heart disease. Unfortunately, one recent study did not show a beneficial outcome for secondary (second event) prevention of cardiovascular disease with supplemental fish oil.

These results were surprising to many in the medical community and went counter to the treatment paradigm. In the Korean Meta-analysis Study Group (a group of 14 randomized clinical trials, the gold standard of studies), the results did not show a reduction in heart attacks, all-cause mortality, sudden cardiac death, transient ischemic attacks or strokes (Arch Intern Med. online April 9, 2012).

In a commentary by a respected researcher at Harvard Medical School, Dr. Frank Hu, these results should be taken in stride — trials for fish oils have shown mixed results in cardiovascular disease. There were also flaws in the Korean meta-analysis: Many of the studies may have been too small, too short in duration and the primary endpoints were not focused on cardiovascular disease.

It will be interesting to see the effects in the VITAL trial, an ongoing primary prevention trial in cardiovascular disease using fish oil plus vitamin D (Contemp Clin Trials. 2012;33(1):159-171).

Right now, the evidence is inconclusive to recommend fish oil for cardiovascular disease. However, fish has benefits that go beyond omega-3s. It is a good source of protein and of astaxanthin, a member of the carotenoid family of phytochemicals (Arch Intern Med. online April 9, 2012).

Effect on cancer

In the SU.FOL.OM3 study, patients who had cardiovascular disease were given fish oil and vitamin B (B6, folate and B12) to reduce the risk of cancer and cancer deaths. The results were disappointing. In fact, with women, the fish oil increased the risk of cancer, though the number of cases was extremely small. It did not matter whether the fish oil was given alone or in combination with B vitamins — the results fell short of expectations (Arch Intern Med. 2012 Apr 9;172(7):540-7).

In a shocker, the Prostate Cancer Prevention Trial, fish consumption actually increased the risk of aggressive prostate cancer by 2.5 times when high levels of DHA (docosahexaenoic acid), an omega-3 FA, were found in the blood. This trial was observational and involved 3,461 men (Am J Epidemiol. 2011 Jun 15;173(12):1429-39). Before jumping to conclusions, know that other studies have shown that omega-3s either had no effect or potentially beneficial effects with prostate cancer (Am J Clin Nutr 2010;92(5):1223-1233).

Regardless, I would not recommend omega-3s to reduce the risk of cancer risk — especially prostate cancer. Those with a family history of high-grade prostate cancer should consult their physician about the risk-benefit ratio of consuming omega-3s in the form of fish and fish oil. This does not have any impact on omega-3s from other sources, such as from nuts and seeds, since these are low in DHA.

Multiple sclerosis
Since omega-3s have supposed anti-inflammatory effects and autoimmune diseases are based on inflammation, it would make sense to assume that multiple sclerosis patients would benefit from fish oil. However, in an RCT, there were no differences in either objective or subjective measures including MRI findings, frequency of relapse, quality of life and fatigue between the groups that took fish oil and not (Arch Neurol. online April 16, 2012).
Researchers even added the standard-of-care medication, interferon beta-1a, to both groups after six months. The only effects seen were from the drug therapy. This was the first RCT in MS with fish oil supplementation, and the size of the trial was small with only 92 patients.
Fish oil supplementation must be undertaken with caution. Does this mean we should avoid fatty fish and fish oils? Not at all. Even in trials with negative results, there are others to counterbalance them.

Next week, I will write about the positive contributions of omega-3s to disease prevention and treatment.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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Working on three stopping points, scientist tries to anticipate terrorists’ next move

One day, Joseph Brady hopes he’s unemployed. He doesn’t hate his job, but he wishes it weren’t necessary. Brady teams up with law enforcement — the Suffolk County Police Department and the Federal Bureau of Investigation — to prevent those bent on blowing things up from succeeding.

Brady, who joined the Nonproliferation and National Security Department staff at Brookhaven National Laboratory last summer, is a chemist who specializes in explosives. He explained that there are three potential points when law enforcement can stop the “bad guys” (a term he uses to describe would-be bombers).

First, law enforcement can prevent them from making explosives. They can interfere with one of the key ingredients — even a household product — in making deadly weapons. He calls this process denaturing explosive precursors.

Brady has put additives in hydrogen peroxide — yes, the same liquid parents apply to skinned knees after their kids fall off a bicycle — that make it less reactive with other chemicals. Those additives don’t interfere with the disinfectant’s intended use.

The second stopping point is in detection. Once an explosive is made, law enforcement may be able to detect it at airports, bridges, tunnels and other areas he calls “choke points.” Brady mimics the way bad guys manufacture explosives and studies the results. He looks at the properties, searching for byproducts that might be indicative of illicit activities. He examines how current detection technologies respond to these materials.

The third stopping point is to figure out how to get rid of a device once it’s detected — without allowing it to explode. Scientists can accomplish this by stabilizing the materials in the device or by introducing some new element that could “chemically digest the explosives.”

Brady has worked with triacetone triperoxide, the common homemade explosive that was part of the shoe bomber’s device. Attempting to move TATP could result in an unintended detonation because it’s so unstable. As part of Brady’s dissertation, he showed that chemists can destroy TATP on the 100-gram scale without detonation by using combinations of commonly available chemicals.

Brady, whose research is funded in part by the Department of Homeland Security, explained that “Bad guys are always finding new materials to use against us. A lot of times, they find old materials that have no value to military or commerce.”

He pointed to nitrate esters as one explosive he expects to see “on the scene.” Brady is working on ways to detect the presence of these homemade explosives.

Brady feels he’s playing a type of cat and mouse game with would-be terrorists, trying to anticipate what they’ll do next. Fortunately, he said, he’s working with a team of skilled law enforcement officials who offer suggestions.

“It’s a feedback loop,” he explained. Law enforcement “comes with a question, he provides an answer, then they have a new question.”

While Brady plans to conduct lab experiments with chemicals that can create explosives, the amount of materials he uses is on the order of milligrams — the equivalent of a few grains of salt. He’s unlikely to see explosive reactions that could cause any of the destruction he’s trying to prevent.

Brady, who worked on chemotherapeutic agents in college at the University of Rhode Island, studied explosives when he realized he could play a role in protecting people.

“You see that the bad guys are trying to do something and you can do something about it,” he said. “They are always working hard, so you try to work harder.”

Brady earned his Ph.D. from the University of Rhode Island. He’s been writing for grants to build his lab. The proximity of BNL to New York City and Washington, D.C. makes it an ideal resource for national law enforcement, he said.

Brady was involved with the FBI and the Suffolk County Police Department in presenting a class for Transportation Security Administration screeners on explosiveness awareness. Because BNL is on a former Army installation, the Suffolk County police could use an old grenade range to show TSA officials how the homemade, commercial and military explosives work.

Brady, who is not married, said when he’s not working to build his lab, he enjoys visiting beaches on the North and the South Shore.

Brady said his father, John, a counselor for troubled children, and his mother, Judi, a psychologist, are supportive of his work.

“They are proud,” he offered. “They say, ‘Good for you. Go get ’em.’”

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In 125 years, Port Jefferson Fire Department has seen many changes to firefighting and the village

Volunteers from Hook & Ladder Company No. 1 of the Port Jefferson Fire Department assemble on East Main Street in 1892. Photo from the Port Jefferson Village Digital Archive

Fred Gumbus still remembers the time he burned off his eyebrows, decades ago in a brush fire.

“The wind changed” and the flames “came across a big field of grass,” Gumbus said. He goes by “Pop” at the Port Jefferson Fire Department, where he is an honorary chief and a member since 1948.

Port Jefferson firefighters work at the Sinclair bulk storage plant during a 1964 fire. The blaze kept igniting because the fuel lines had not been turned off. Photo from the Port Jefferson Village Digital Archive
Port Jefferson firefighters work at the Sinclair bulk storage plant during a 1964 fire. The blaze kept igniting because the fuel lines had not been turned off. Photo from the Port Jefferson Village Digital Archive

He and Hugh Campbell, a former chief who joined the same year, were running from the fire, but realized it was gaining on them and they couldn’t outrun it. “We have to go through,” Gumbus said, and they covered their noses and mouths with their hands.

Campbell said, “We were going to burn to death if we stayed there.”

They made it out, coughing and choking.

Gumbus said his buddy was laughing at him and when he asked what was so funny, Campbell told him he didn’t have any eyebrows. He responded that Campbell didn’t either, “and we busted out laughing.”

The pair, who were once in the first grade together in Stony Brook, were in their 20s then. Now they are in their late 80s, and still members of a department that has since seen great changes.

The Port Jefferson Fire Department marks its 125th anniversary this year, and equipment and techniques are drastically different from the days these men first joined.

Fred Gumbus, James Newcomb, Walter Baldelli and Hugh Campbell, at the Port Jefferson firehouse, talk about the toughest and most memorable calls they went on in their many years with the department. Photo by Elana Glowatz
Fred Gumbus, James Newcomb, Walter Baldelli and Hugh Campbell, at the Port Jefferson firehouse, talk about the toughest and most memorable calls they went on in their many years with the department. Photo by Elana Glowatz

James Newcomb, an honorary chief who joined almost 69 years ago, said firefighters once used something called an “Indian can,” which was a metal backpack that held five gallons of water and squirted with a hand pump. Firefighters also used to just wear a rubber coat.

Campbell said those coats would burn or melt. He also noted changes to the way firefighters work — “in the old days we had more surround and drown,” but now firefighters attack the flames, and put them out where they are. They no longer “stand outside and watch it burn.”

One fire Walter Baldelli remembers was at the O.B. Davis Furniture Store on East Main Street. Baldelli, a 93-year-old honorary chief and a member since 1948, said the department fought flames through the whole night at the old wood-floored building, and found the body of a night watchman the next day.

Campbell said he was on the stoop next door taking a break and saw the man’s toes sticking up in the bathroom of the scorched building. The watchman was flat on the floor and his body “was like it was boiled” because the water shooting in from the hoses turned to steam. The firefighters knew the man was in there somewhere because he had left his hat at the back door of the building.

Firefighters battle flames at the O.B. Davis Furniture Store on East Main Street in 1960. Photo from the Port Jefferson Village Digital Archive
Firefighters battle flames at the O.B. Davis Furniture Store on East Main Street in 1960. Photo from the Port Jefferson Village Digital Archive

Another large fire was at the post office when it was on Main Street. It was 1948, and Baldelli said hoses drafted water from the harbor to put out the flames. He could taste the saltwater in the air.

The fire had started in the cellar, Baldelli said, and when the blaze was put out and he went down there, the water came up high and it was warm. He added that an employee on the scene when the fire broke out saved all the first class mail.

At one brush fire, Newcomb was on Norwood Avenue and the fire was jumping through the treetops on both sides of him. Newcomb said it was his scariest fire and when the flames came over his head, he stuck his nose in the dirt and the explosion “sounded like a jet coming down.” He said he couldn’t breathe for about 30 seconds.

Newcomb will be the grand marshal of the department’s 125th anniversary parade, which is on June 9 at 5:30 pm. The fire department, which was established in 1887, is also holding a block party on Maple Place that evening, with a display of antique apparatus.

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Aspirin and Plavix together are cause for concern in stroke

Last week, I wrote about the positive effects of medications and the complexities that chronic diseases add to the risk profile of stroke. In this article I will focus on the confusion around aspirin’s use in combination with another antiplatelet drug and its ideal preventive dose. Then, I will suggest lifestyle modifications that can help lower stroke risk.

Medication combination: negative impact

There are two antiplatelet medications that are sometimes given together in the hopes of reducing stroke recurrence — aspirin and Plavix (clopidogrel). The assumption was that these medications together would work better than either alone. However, in a randomized controlled trial, the gold standard of studies, this combination not only didn’t demonstrate efficacy improvement, but significantly increased the risk of major bleed and death (ISC 2012; Abstract LB 9-4504; www.clinicaltrials.gov NCT00059306).

Major bleeding risk was 2.1 percent with the combination versus 1.1 percent with aspirin alone, an almost twofold increase. In addition, there was a 50 percent increased risk of all-cause death with the combination, compared to aspirin alone. Patients were given 325 mg of aspirin and either a placebo or 75 mg of Plavix. The study was halted due to these deleterious effects. The American Heart Association recommends monotherapy for the prevention of recurrent stroke. If you are on the combination of drugs, please consult your physician.

Aspirin: low dose vs. high dose

Greater hemorrhagic (bleed) risk is also a concern with daily aspirin regimens greater than 81 mg, which is the equivalent of a single baby aspirin.

Aspirin’s effects are cumulative; therefore, a lower dose is better over the long term. Even 100 mg taken every other day was shown to be effective in trials. There are about 50 million patients who take aspirin chronically in the United States. If these patients all took 325 mg of aspirin per day — an adult dose — it would result in 900,000 major bleeding events per year (JAMA 2007;297:2018-2024). The ideal dose of aspirin to prevent a recurrent stroke is 81 mg.

Lifestyle modifications

On Dec. 20, 2011, I wrote about stroke prevention. A study showed that white fleshy fruits — apples, pears, bananas, etc. — and vegetables — cauliflower, mushrooms, etc. — decreased the risk of ischemic stroke by 52 percent. Not to be left out, the Nurses’ Health study showed that foods with flavanones, found mainly in citrus fruits, decreased the risk of ischemic stroke by 19 percent (Stroke 2012;43:946-951).

The authors suggest that the reasons for the reduction may have to do with the ability of flavanones to reduce inflammation and/or improve blood vessel function. This study involved about 70,000 women with 14 years of follow-up. I mention both of these trials together because of the importance of fruits in prevention of ischemic (clot-based) stroke.

Alcohol’s effect

I am continuously asked about my stand on alcohol consumption. There are definite benefits to drinking alcohol in moderation, and stroke reduction appears to be one. Findings published in March from the Nurses’ Health Study showed a decreased risk of stroke by 17-21 percent in women who consumed between half a glass to one glass of alcohol per day, compared to those who did not (Stroke 2012; 43: 939-945). A serving size is 4 ounces of wine or a 12-ounce beer. This was a very large observational study involving 83,000 women over 26 years.

The authors hypothesize that the effect has to do with improving the lipid profile and/or preventing clot formation. Does this mean if you don’t drink you’re at a disadvantage? Not at all! There are plenty of other lifestyle modifications you can make to reduce your risk equally or more, including eating flavanone-full foods, such as citrus fruits, as well as white fleshy fruits. In addition, the Mediterranean and Dash diets reduce stroke risk. In one recent study, the Mediterranean diet was shown to reduce the risk of ischemic stroke by a resounding 63 percent (J. Nutr. 2011;141(8):1552-1558). Too much alcohol can increase your risk of atrial fibrillation, an arrhythmia that increases stroke risk.

Fiber’s important role

Fiber plays a key role in reducing the risk of a hemorrhagic stroke. In a study involving over 78,000 women, those who consumed the most fiber had a total stroke risk reduction of 34 percent and a 49 percent risk reduction in hemorrhagic stroke. The type of fiber used in this study was cereal fiber, or fiber from whole grains.

Refined grains, however, increased the risk of hemorrhagic stroke twofold (Am J Epidemiol. 2005 Jan 15;161(2):161-9). When eating grains, it is important to have whole grains. Read labels carefully, since some products that claim to have whole grains contain unbleached or bleached wheat flour which are refined.

Fortunately, there are many options to help reduce the risk or the recurrence of a stroke. Ideally, the best option would involve lifestyle modifications. Some patients may need to take statins, even with lifestyle modifications. However, statins’ side-effect profile is dose related. Therefore, if you need to take a statin, lifestyle changes may help lower your dose and avoid harsh side effects. Once you have had a stroke, it is likely that you will remain on at least one medication — low-dose aspirin — since the risk of a second stroke is high.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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Post-doctoral student Attreyee Ghosh and Professor William Holt study plate tectonics

They only travel about four inches per year. That makes a sloth, which can achieve a top speed of 6.5 feet per minute, seem like a furry blur by comparison. And yet, when they move, they can change the face of the planet.

The slow shifting of the enormous tectonic plates — like puzzle pieces pressing against and pulling away from each other over the surface of the planet — can not only cause devastation through earthquakes, but can also build mountains and form deep-water ocean trenches.

Ever since the 1960s, when scientists accepted the theory of continental drift, they have been trying to understand and predict where those plates move. There has been a rift in the scientific community itself over what forces (and where those forces are located) that determine plate movement.

“Some people have been saying the deep Earth is everything and is the most important role and force in making the plates move,” said Attreyee Ghosh, a post-doctoral student at Stony Brook University’s Geosciences Department. “Another group has been saying that the deep Earth doesn’t have to play that much of a role and they can explain [the movements] looking at the top 100 kilometers of the Earth.”

As it turns out, both groups are right, depending on where you are on the planet, Ghosh explained.

The viscosity (or thickness) of the middle layer in between the top Earth and the deeper parts of the planet determines which contribution can be more important in driving the movement of the plates.

“A higher viscosity increases the contribution from the deeper mantle,” Ghosh suggested. “When the viscosity is weaker, there is a decoupling from the deeper mantle, so the [deeper Earth] doesn’t play as dominant a role” as the lithosphere, or the upper layer.

Working with professor William Holt, Ghosh created a mathematical model to predict movements of the plates. The scientists input readings from “literally hundreds if not thousands” of other researchers using data points from seismic records and earthquakes as they built and tested their computer model, Holt recalled.

The results were so much more effective than most of the models that one of the most prestigious journals in the country, Science, published their findings earlier this year.
Despite its effectiveness, the model, which was created on a relatively simple computer, can do better, Holt said.

“We are not very far away from having models that can predict surface observations at a level of accuracy that approaches the uncertainty in the measurements themselves,” Holt suggested.

What that means is that the models may become as accurate as the data they receive.

So, what does this increased accuracy mean for anticipating earthquakes?

While the science of predicting earthquakes is still years away, this is an important step toward building a better foundation for long-term earthquake forecast models. Holt explained. “We’re getting more accurate forecasts for the probabilities of earthquakes in particular regions,” he explained. “That enables one to prepare through proper retrofitting of buildings and construction for long-term mitigation of potential hazards from earthquakes.”
Holt, who has been working in this field for 20 years, said scientists have boosted dramatically the amount of information they gather about the Earth.

When he started, “we didn’t have observations to understand how the interior of Tibet was moving or how the interior of Nevada was moving, so there was this big revolution through the 1990s, with the advent of space geodesy,” he said. “I can see incredible progress over the last 20 years.”

When he’s not collecting and interpreting data about the planet, Holt is a busy father of two primary school daughters and the husband of Troy Rasbury, a geochemist at Stony Brook.
Holt enjoys sea kayaking and, more recently, fly fishing, although he said most of the time, he “catches nothing.”

As for Ghosh, she is a resident of Manhattan and commutes to Long Island. She expects to finish her post-doctoral work at Stony Brook in the next few months.

Inspired by her progress thus far, Ghosh expects to continue to look deep into the Earth to understand the movement of some of its larger pieces.

“I’m intrigued by how much of our Earth we still don’t know,” she offered.

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Age-related macular degeneration, rheumatoid arthritis and some migraines increase risk

I have written on stroke several times, due to the constant flow of intriguing and valuable new studies. On the one hand, it is great to have refinement of treatment paradigms. On the other, unfortunately, stroke remains one of the top five causes of mortality and morbidity in the United States.

Recent studies have involved issues from identifying chronic diseases that increase stroke risk (AMD, RA and migraine) to examining the roles of medications and lifestyle in managing risk.

Impact of chronic diseases

There are several new studies that show chronic diseases — such as age-related macular degeneration, rheumatoid arthritis and migraine with aura — increase the risk for stroke. Therefore, patients with these diseases must be monitored.

AMD study

In the ARIC study, stroke risk was approximately 50 percent greater in patients who had AMD, compared to those who did not — 7.6 percent vs. 4.9 percent, respectively (Stroke online April 2012). This increase was seen in both types of stroke: ischemic (complete blockage of blood flow in the brain) and hemorrhagic (bleeding in the brain). The risk was greater for hemorrhagic stroke than for ischemic, 2.64 vs. 1.42 times increased risk. However, there was a smaller overall number of hemorrhagic strokes, which may skew the results.

This was a 13-year observational study involving 591 patients diagnosed with AMD, ages 45 to 64. Most patients had early AMD. If you have AMD, you should be followed closely by both an ophthalmologist and a primary care physician.

Rheumatoid arthritis

In a recent observational study, patients with RA had a 30 percent increased risk of stroke (BMJ 2012; Mar 8;344:e1257), and those under 50 years old with RA had a threefold elevated risk. This study involved 18,247 patients followed for a 13-year period.

There was also a 40 percent increased risk of atrial fibrillation, a type of arrhythmia or irregular heartbeat. Generally, AF causes increased stroke risk, however, the authors were not sure if AF contributed to the increased risk of stroke seen here. They suggested checking regularly for AF in RA patients, and they surmised that inflammation may be an underlying cause for the higher number of stroke events.

Migraine with aura

In the Women’s Health Study, an observational study, the risk of stroke increased by twofold in women who had migraine with aura (Neurology 2008 Aug 12; 71:505). Only about 20 percent of migraines include an aura, and the incidence of stroke in this population is still rather rare, so put this in context (Neurology. 2009;73(8):576).

As I mentioned in my previous article on migraine, there are studies, as well as anecdotal stories showing diet plays a significant role in preventing and decreasing the frequency of migraine.

Medications with beneficial effects

There are two medications recently that have shown positive impacts on reducing stroke risk: statins and valsartan. Statins are used to lower cholesterol and inflammation, and valsartan is used to treat high blood pressure.

Statins have received bad press recently due to their risks of side-effects, such as diabetes, cognitive impairment and myopathy (muscle pain). However, used in the right setting, statins are very effective. In one study, there was reduced mortality from stroke in patients who were on statins at the time of the event (AAN conference: April 2012). Patients who were on a statin to treat high cholesterol had an almost sixfold reduction in mortality compared to those with high cholesterol who were not on therapy.

There was also significant mortality reduction in those on a statin without high cholesterol, but with diabetes or heart disease. The reason for the latter result is not clear, so we should not jump to conclusions, especially since the study is only published in abstract form.

The authors surmise that this result might be from an anti-inflammatory effect of the statins. Of course, if you have side effects, you should contact your physician immediately.

Valsartan is an angiotensin II receptor blocker that works on the kidney to reduce blood pressure. However, in the post-hoc analysis (looking back at a completed trial) of the Kyoto Heart Study data, valsartan used as an add-on to other blood pressure medications showed a significant reduction, 41 percent, in the risk of stroke and other cardiovascular events for patients who have coronary artery disease (Am J Cardiol 2012; 109(9):1308-1314).

It is important to recognize that chronic disease increases stroke risk. High blood pressure and high cholesterol are two of the most significant risk factors. Fortunately, statins are an effective way to reduce cholesterol, and valsartan may be a valuable add-on to prevent stroke in those patients with coronary artery disease.

Next week, we will continue our discussion of medications, exploring a surprising finding with combination therapy and the effects of lifestyle modifications.

This is part one of a two-part series on strokes.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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From fine tuning the synchrotron to authenticating a Rembrandt

In the late 1980s, just a few years after Peter Siddons started working at Brookhaven National Laboratory, a company called BASF ran ads with the line, “We don’t make a lot of the products you buy, we make the products you buy better.”

That idea is similar to the work Siddons does on BNL’s synchrotron: He doesn’t perform research, but he makes the research of other scientists better.

By being what he describes as a “gearhead,” Siddons, a native of Yorkshire, England, makes best use of the optics and the X-ray beams from the National Synchrotron Light Source to give scientists a fast, clear picture of small molecules and particles inside a wide range of objects.

When polymers melt, they go through a process called reptation, where they form long, linear entangled molecules (they look like a collection of snakes mixing together).
Andrei Fluerasu, a BNL scientist who has studied polymers, has worked with Siddons since he arrived three years ago and has been impressed with his colleague’s ability to fine-tune the detecting device.

He is “building a device that works exactly how it should,” Fluerasu said. “We can go 100 times faster and can detect things which move 100 times faster.”

Siddons has worked with scientists from all over the world, including Australian geologist Chris Ryan. The tandem first started collaborating a decade ago.

“We went through many generations of designs,” Ryan wrote in an email to the Times Beacon Record. Ryan praised Siddons, suggesting he had a “vision of new generations of detector technologies.”

Ryan said the enhanced detecting abilities have had applications in everything ranging from optimizing the availability of iron in rice, barley and wheat, to the study of organisms used as models for neurodegenerative diseases, to art.

Indeed, Siddons made headlines recently when he became involved in a debate over the effort to authenticate a painting called “Old Man with a Beard” that some art historians believed Rembrandt had created.

When he received the painting, it “took a while to figure out how to hold it without damaging it,” Siddons laughed. Once he worked out the logistics, Siddons used X-ray fluorescence on it to look deep inside the layers of the painting.

Using a detector called Maia, Siddons imaged the painting in eight hours. Using other technology, that analysis would have taken 30 days, Siddons said.

The approach showed there was a 400-year old image beneath the painting, likely of a younger self-portrait of Rembrandt. But that wasn’t where the effort ended. There was a third image hidden beneath the painting, of a person wearing a turban with a feather. There were enough similarities between these images and others done by the master painter to confirm that the “Old Man with a Beard” was an authentic Rembrandt.

“It was great fun,” concluded Siddons, who said he spent several evenings putting the data together.

One of his colleagues, noticing the similarity between the subject of the painting and Siddons, photoshopped the BNL scientist into a copy of the painting.

“It’s pretty convincing,” admitted Siddons, “except for the spectacles.”

While Siddons can appreciate a Rembrandt — and his role in authenticating one — the “gearhead” spends much more of his time in another cultural area, playing Renaissance music in a lecture room at BNL with his musically-inclined colleagues once a week on the guitar, recorder or other instruments.

Siddons lives in Cutchogue with his wife Elizabeth, who works across the street from his lab at the Physical Review. While they carpool to work, they rarely have lunch because she reserves that time for bridge.

They have three children: Giles, a vegan chef in Boston; Rebecca, a teacher in Providence, R.I. and Louise, an art professor at Oklahoma State University. Louise was the one who brought her father into the Rembrandt debate.

Siddons has a need to understand the benefits and limitations of technology, even outside the high-tech synchrotron where he works.

“I can’t use any instrument I haven’t taken to pieces,” he confesses. “It’s pathological. I used to do my own car maintenance. When I turn something on, I want to know where the warts are and what can go wrong.”

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It is important to check MMA blood levels and supplement with B12 where needed

I am not a big believer in supplements, unless they are used to treat a proven deficiency. However, we may be deficient in vitamin B12 (cobalamin) without knowing it. Contradictory recommended levels of B12 across the world, the lack of sensitivity in B12 deficiency tests and confusing symptoms all add to the complexity of diagnosing and treating it.
B12 is an integral part of many of the body’s systems. For example, B12 plays a role in proper immune system functioning (www.medscape.com).

What are the symptoms of B12 deficiency?

Symptoms of B12 deficiency include fatigue, diarrhea or constipation, exercise-induced shortness of breath and neurological deficits, such as difficulty concentrating, memory problems and paresthesias (tingling and numbness in the appendages) (Geriatrics. 2003 Mar;58(3):30-4, 37-8). However, these symptoms can mimic many different diseases. Typically, physicians test for B12 and anemia levels when symptoms occur. However, approximately half of those with B12 deficiency are in the “normal” range (Am Fam Physician. 2003 Mar 1;67(5):979-986). To add to the complexity, early B12 deficiency may be asymptomatic.

Minimum blood levels of B12

Unfortunately, there is no worldwide consensus on minimum acceptable B12 levels. Other countries, such as Japan, have significantly higher recommended levels than the United States.

In Japan, minimum recommended blood levels of B12, 500 pg/ml (Jpn. J. Psychiatry Neurol. 1988 Mar:42(1):65–71), are more than twice the minimum acceptable levels in the U.S., 200 pg/ml (www. nlm.nih.gov). There are those who suggest U.S. B12 recommended levels are too low (J Am Geriatr Soc 1996 Oct;44(10):1274–5). If we were to follow Japanese guidelines, we would still be far below the upper limit of the U.S. recommended range.

Diagnostic tests to avoid deficiency

B12 blood levels may not be the most accurate test for determining deficiency (Proc Nutr Soc. 2008 Feb;67(1):75-81). There is a much more specific blood test: methylmalonic acid (MMA). If this level is high, then it is a reliable indicator that B12 levels are low (Subcell Biochem. 2012;56:301-22). Deficient levels of B12 lead to increased MMA levels, since MMA requires B12 to metabolize (Am Fam Physician. 2003 Mar 1;67(5):979-986). Both B12 and MMA levels should be checked.

Who needs to have their levels monitored?

The elderly should be tested regularly, but surprisingly people from young adulthood to middle age can also be affected. The Framingham Offspring Study found that more young adults may be affected than thought previously (Am J Clin Nutr. 2000;71:514-22). Interestingly, those in three different age groups ranging from 26 to 65 years old and older were impacted similarly (Am Fam Physician. 2003 Mar 1;67(5):979-986).

When I attended the Harvard-Brigham and Women’s CME program, we went over a B12 deficiency case in the aptly named “Can’t Miss Diagnoses” seminar. The case involved a 40-year-old woman with symptoms of tingling in her right foot. Her B12 levels were 250 pg/ml — the low end of normal. Three months later, she complained of being tired, having memory problems plus tingling in both feet. Her labs showed no anemia. Five months later, her MMA levels were checked; they were abnormally high. She was given B12 injections and her symptoms diminished.

What causes B12 deficiency?
Sixty to 70 percent of the time, B12 deficiency is caused by absorption issues (CMAJ. 2004;171(3):251–259). Affected populations include those taking medications, such as Glucophage (metformin) and proton pump inhibitors (PPIs); those who have autoimmune diseases, such as pernicious anemia or Crohn’s disease; alcoholism; and those who have had bariatric surgery (www.ncbi.nlm.nih.gov).

PPIs impact

The reason that proton pump inhibitors such as Protonix (pantoprazole), Nexium (esomeprazole) and Prevacid (lansoprazole) reduce B12 absorbed from diet is that acid in the stomach is required to free B12 from protein molecules in food. PPIs reduce this much-needed pepsin (acid). Therefore, those on PPIs should be monitored for B12 deficiency. It can take approximately three years of continuous use before someone becomes deficient (Aliment Pharmacol Ther. 2008 Jun 1;27(11):1110-21).

Treatments

The amount of B12 absorbed is limited. In a dose of 500 mcg of B12, only 10 mcg are actually absorbed (Blood 2008;112:2214-21). Unless patients have significant symptoms, it may be best to give oral B12 supplements to patients who have high MMA levels and/or low “normal” B12 levels.

One recommendation for B12 oral treatment is 1000 to 2000 mcg daily for one week and then 1000 mcg daily for maintenance (JAMA. 1991;265:94–5). For those with significant symptoms, B12 injections may be preferable.

Dietary sources

Foods with the most B12 are fish and seafood, as well as meat and dairy. This means that those who focus on a primarily vegetable-based diet require B12 supplementation.

Don’t wait until symptoms are severe. Have your B12 blood levels and MMA levels checked, regardless of your age. Symptoms, including peripheral neurologic symptoms, are potentially reversible if treated early.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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