After reading in the New York Times Week in Review that the annual physical exam may have outlived its usefulness, I pondered whether this is actually true. Is it a reflex, or does it have an important role? The answer, I think, depends on how you perceive and utilize this yearly ritual.

If annual medical exams mean lots of expensive diagnostic tests and invasive procedures, it may be time to put it to pasture. However, if it fosters a physician-patient relationship and allows for a partnership in prevention and treatment of diseases, then this alone may be a good reason to keep it. Doctors and patients alike complain there is not enough time spent getting to know or understand each other’s approaches. Eliminating the annual physical would only worsen the situation.

So what are the pros and cons of this time-tested ritual?

Downsides

One of the downsides may be that the yearly ritual does not save lives. According to a Cochrane meta-analysis (a group of 16 studies), an annual physical exam had no benefit of on mortality risk and morbidity (disease) risk (Cochrane Database Syst Rev. 2012 Oct. 17). The report went on to say that it did not have an effect on overall mortality, nor on cancer survival and/or cardiovascular mortality. Nine trials were utilized for mortality data. The study weakness could be that the trials included were old and may not be applicable to more modern approaches. The authors also suggested that primary care physicians may already be treating patients at high risk for diseases.

PSAs

Another potential negative to annual exams is that certain diagnostics, such as prostate-specific antigen screenings to test for prostate cancer, could be harmful. In a recently presented abstract (European Cancer Conference 2013; Abstract 1481), the results of a meta-analysis show that routine screening for prostate cancer in the general, symptom-free male population may have more detrimental effects than benefits — a high PSA may lead to unnecessary invasive procedures, such as biopsies and prostatectomies (removal of the prostate). Side effects could be impotence and infection, and could result in hospitalization. The author acknowledged that there have been two large studies on PSAs, one touting the benefits and the other showing increased harm. This latest assessment may be the tiebreaker. Some urologists may disagree with these newest findings.

Upsides

What are the upsides of an annual medical checkup? Not all diseases show symptoms, especially in the earlier stages. Examples include hypertension (high blood pressure) and chronic kidney disease. This is also an opportunity to discuss mental health — stress levels, depression and anxiety. And, of course, there is the importance of lifestyle discussions, including weight, exercise and diet.

Chronic kidney disease

Though chronic kidney disease does not have an awareness month, it is no less significant than breast cancer or prostate cancer, causing upwards of 90,000 deaths per year. According to the Centers for Disease Control and Prevention, one in five patients with high blood pressure has chronic kidney disease (CDC.gov). Early to moderate stages of the disease may go undetected, since the only way to detect it when it has no symptoms is through blood tests and urinalysis.

If there is protein in the urine and/or reduction in the estimated glomerular filtration rate and creatinine in the blood, this may be a sign of CKD. To learn more about the treatment and prevention of CKD, I encourage you to read my Aug. 13 article. Detecting CKD early may be the key to halting its progress and preventing end-stage kidney disease resulting in dialysis. Without the annual medical exam, we may miss the opportunity to detect this disease in its early stages.

High blood pressure

High blood pressure is known as the “silent killer,” because there are frequently no symptoms until it is too late. According to a study, high blood pressure may be responsible for almost half of all heart attacks and a quarter of premature deaths in the U.S. (BMJ. 2001;322:977-980).

To reduce the risk of this “silent killer,” lifestyle modifications are in order. In a meta-analysis, involving 54 small, randomized controlled trials, aerobic exercise had significant benefits in reducing blood pressure. This was true of patients with elevated and with normal blood pressure, as well as those who were obese and those of normal weight (Ann Intern Med. 2002;136:493-503). Very few lifestyle changes alter blood pressure in “healthy” patients, but ones that do may reduce risk of ever developing the disease. In this trial, the systolic blood pressure (top number) was significantly reduced by a mean of 3.4 mmHg.

Body mass index

The first step toward obesity prevention and treatment is an awareness of the problem. According to a new report by the Institute of Medicine, physicians should regularly monitor patients’ body mass index (Evaluating Obesity Prevention Efforts, National Academies Press, online Aug. 2). This may give patients a sense urgency to lose weight. In my practice, I also assess body composition, which includes fat percent and fat mass. Though someone may not be obese, their fat mass may be higher than normal.

Depression

One of the most effective ways to get to know a patient and recommend effective prevention and treatment is with a thorough discussion of history. This is the art of medicine, and it involves the intangibles that may not show up in numbers, including mental health issues.

A recent abstract showed it is not what patients say, but how they say it that may be most important. Short essays were used to help determine whether patients were sad or actually mildly depressed (26th European College of Neuropsychopharmacology Congress; Abstract P.2.b.060). Those who were mildly depressed used significantly more verbs in the past tense than the present (100% versus 2.6%) and used less complex sentences, compared to the healthy control patients.

Ultimately, I think the success of an annual medical checkup has to do with the approach. If there is a strong focus on a thorough history, rather than a predominance of diagnostic testing leading to invasive procedures, there is very little downside. The yearly medical exam is an opportunity to discuss preventive measures, including lifestyle changes, whether the patients are healthy or have disorders that may be prevented from worsening.

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.

What I am about to say may be hard to comprehend, especially for those who have germophobic tendencies, which would be most of us, but we harbor microorganisms, or microbes (small organisms), in our body that outnumber our cells by a 10-to-1 ratio, even in healthy individuals. There are over one trillion microorganisms in the body.

These organisms make up what is called the microbiome. It includes bacteria, viruses and single-cell eukaryotes. Our relationship to these organisms is complex, spanning from parasitic (detrimental) to commensalistic (one benefits and the other is not affected) to mutualistic (both benefit). The microbiome is found throughout the body, including the skin, the eyes and the gut. Our focus is going to be on the gut, since that is where the majority of the microbiome resides.

What is the importance of the gut microbiome? The short answer is it may have a role in diseases — preventing and promoting them. These diseases include obesity, diabetes, irritable bowel syndrome, autoimmune diseases, such as rheumatoid arthritis and Crohn’s, and infectious diseases, such as colitis.

Like the Human Genome Project, which mapped our genes, there is a Human Microbiome Project, launched by the National Institutes of Health in 2007, to map out the composition and diversity of these gut organisms. We are still in the early stages of understanding this vast universe of microbes, yet there are some recent preliminary studies.

What affects the microbiome? It is affected by drugs, such as antibiotics that can wipe out the diversity in the microbes, at least in the short term, and by lifestyle modifications, such as diet. Microbiome diversity may be significantly different in distinct geographic locations throughout the world. Also, the birth process — vaginal compared to Cesarean section — may have a significant influence on an organisms’ composition. Let’s look at the evidence.

C-sections and
reduced breast-feeding

The mode of delivery may be important. While C-sections have become more common, they may have a negative impact on the development of gut microbes. In a recent study, infants who were delivered by C-section had a significant reduction in Escherichia-Shigella and a lack of Bacteroides in their guts, compared to those delivered by vaginal birth (CMAJ. 2013;185:373-374). This effect was seen mostly in elective C-sections, since emergency C-sections may have some vaginal influence. Elective C-sections may reduce exposure to maternal microbes.

Breast-feeding may be beneficial to the gut flora. Those infants who were breastfed had a significantly lower concentration of the bacterium Clostridium difficile, which causes colitis (infection of the colon) and diarrhea. The nonbreastfed infants had higher levels of Peptostreptococcaceae, part of the family of Clostridium bacteria, which as mentioned, relates to colitis. This was a very small study involving 24 healthy infants divided equally between male and female. Of course, consult your OB/GYN before making a decision on the birth process, especially if there are extenuating circumstances that prohibit vaginal birth. Fortunately, breast-feeding is already being encouraged.

Obesity: From mice
and men

Obesity can be one of the most frustrating disorders; most obese patients continually struggle to lose weight. Obese and overweight patients now outnumber malnourished individuals worldwide (“The Evolution of Obesity”; Johns Hopkins University Press; 2009).

I know this will come as a surprise, but we are a nation with a weight problem; about 70% of Americans are overweight or obese. For the longest time, the paradigm for weight loss had been that if you ate fewer calories, you would lose weight. However, extreme low-caloric diets did not seem to have a long-term impact. It turns out that our guts, dominated by bacteria, may play important roles in obesity and weight loss, determining whether we gain or lose weight. Let’s look at the data on obesity.

The results from a study involving human twins and mice are fascinating (Science. 2013;341:1241214). In each pair of human twins, one was obese and the other was lean. Gut bacteria from obese twins was transplanted into thin mice. The result: the thin mice became obese. However, when the lean human twins’ gut bacteria were transplanted to thin mice, the mice remained thin.

By pairing sets of human twins, one obese and one thin in each set, with mice that were identical to each other and raised in a sterile setting, researchers limited the confounding effects of environment and genetics on weight.

The most intriguing part of the study compared the effects of diet and gut bacteria. When the mice who had received gut transplants from obese twins were provided gut bacteria from thin twins and given fruit- and vegetable-rich, low-fat diet tablets, they lost significant weight. But they only lost weight when on a good diet; there was no impact if the diet was not low in fat. The authors believe this suggests that an effective diet may alter the microbiome of obese patients, helping them lose weight. These are exciting, but preliminary, results. It is not clear yet which bacteria may be contributing these effects.

This definitely suggests that the diversity of gut bacteria may be a crucial piece of the weight-loss puzzle.

Rheumatoid arthritis

Rheumatoid arthritis is an autoimmune disease that can be disabling, with patients typically suffering from significant morning stiffness and joint soreness. What if gut bacteria influenced RA risk? In a recent study, the gut bacteria in mice that were made susceptible to RA by deletion of certain genes (HLA-DR genes) were compared to those who were more resistant to developing RA (PLoS One. 2012;7:e36095). Researchers found that the RA-susceptible mice had a predominance of Clostridium bacterium and that those resistant to RA were dominated by bacteria such as bifidobacteria and Porphyromonadaceae species. The significance is that the RA-resistant mice bacteria are known for their anti-inflammatory effects.

Although nobody can say what the ideal gut bacterium should consist of, and the research is still evolving when it comes to the microbiome, there are potential ways of influencing this milieu, especially in our gut. While C-sections definitely have their place, vaginal deliveries may be more beneficial to the infants’ gut bacterium than elective C-sections.

Diet composition seems to be important to the composition and diversity of gut bacteria, impacting the development or prevention of diseases, such as obesity and rheumatoid arthritis.

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.

I recently wrote that mild cognitive impairment is one of the most feared disorders, especially as we age. One of the reasons for this is the fear of progressing to Alzheimer’s disease. The fear of developing Alzheimer’s with MCI is grounded in reality.

A recent study of patients with MCI and a protein biomarker called amyloid in the brain showed that the probability of developing Alzheimer’s disease was 50% after three years (ADI Conference 2012; Abstracts OC037 and OC035). However, those who had MCI without the amyloid proteins had a reduced one in ten chance of developing Alzheimer’s. Amyloid-beta plaques tend to accumulate in the brain and may be an early sign of Alzheimer’s. Researchers used a positron emissions tomography scan to make these assessments.

Modifiable risk factors for Alzheimer’s disease include chronic diseases, such as diabetes, high cholesterol and high blood pressure.

Where are we with medical therapies, and what can we do to possibly modify our risk for Alzheimer’s? Drug therapies in the research pipeline have had mixed results. However, one drug already on the market may be beneficial for those with diabetes: metformin.

What about diet? The answer depends on the type of diet. The standard American diet, with its high saturated fat and increased sugars, may increase the risk of Alzheimer’s, while a low-fat, nutrient-dense diet may reduce the risk of Alzheimer’s disease. Let’s review the evidence.

Future potential drug therapies

There is good news and bad news for potential Alzheimer’s drugs in development. Recently, the FDA stopped a drug trial because Phase III (the final stage) of development did not show better results than placebo in patients with Alzheimer’s (N Engl J Med. 2013;369:341-350). The drug that failed, semagacestat, was tested at two different doses and compared to a placebo. Its focus, like many Alzheimer’s drugs in development, was on reducing amyloid-beta plaques.

This was a well-designed, randomized controlled trial involving over 1,500 patients with a duration of about a year and a half. The patients on the drug actually did worse in terms of cognitive abilities and had more side effects than those on the placebo. This is disheartening.

However, don’t lose hope. There is another drug in the early stages of development, a microglial modulator. Microglia is to the brain as HDL or “good cholesterol” is to the cholesterol profile. They remove the “garbage.” Amyloid plaques interfere with microglia and ultimately cause inflammation. Microglial modulators are able to resist this process in mice, potentially reducing amyloid plaque deposits in the brain and improving memory. In a recent preliminary trial in humans, it showed promise for preventing patients with MCI from progressing to Alzheimer’s disease (AAI Conference 2013; oral presentation: O3-06-5). These were early results, and a much larger Phase III study is needed before conclusions can be drawn. But this is a potentially exciting new approach.

Dietary impact

Even mildly elevated blood glucose (sugar) levels may be a contributor to Alzheimer’s disease. In a recent study, even slightly elevated sugar levels led to increased risk (N Engl J Med. 2013;369:540-548). When a blood glucose level of 115 mg/dL, a prediabetes level, was compared to 100 mg/dL, risk increased by 18%. The risk of developing Alzheimer’s was even greater in those who were diabetic with higher sugars. Those with a blood glucose of 190 mg/dL, compared to those with a blood sugar of 160 mg/dL, had 40% greater risk for developing Alzheimer’s. This study followed over 2,000 patients for approximately seven years.

The scary aspect is that a slight rise in sugars from normal can lead to a significant rise in Alzheimer’s risk. The authors concluded that those who had slight glucose elevations should make lifestyle changes, including diet and exercise.

Metformin

It is thought that diabetes may increase the risk of Alzheimer’s by at least twofold. In a recent observational trial, involving over 14,000 patients with a follow-up of five years, they found that metformin may reduce the risk of Alzheimer’s dementia substantially (AAIC 2013. Oral Presentation: O1-05-05). There was an approximate 20% reduced Alzheimer’s risk with metformin. Other medications, when compared to metformin, increased the risk of Alzheimer’s. For example, insulin increased risk 23%. However, this was not a randomized controlled trial. So, I might lean toward using metformin in diabetes patients, but not draw dramatic conclusions about other diabetic medications.

Integrative conference

In July, I attended an integrative conference, the International Conference on Nutrition and the Brain, hosted by Physicians Committee for Responsible Medicine in Washington, D.C. Presented evidence suggested that diet has an impact on Alzheimer’s disease (medscape.com). A diet high in saturated fat may negatively affect cognition and increase the risk of Alzheimer’s. On the other hand, a high-nutrient, plant-based diet may have the opposite effect. The suggested diet consists of low saturated fat, a focus on fruits, vegetables, beans and legumes, and a small handful of nuts and seeds daily. They also stressed the importance of cardiovascular exercise, such as a walking with alacrity for 30 minutes, four times a week. You should also avoid aluminum from sources like cookware and antacids.

High saturated fat and high sugar effect

Interestingly there is a RCT that shows a high-saturated fat and high-sugar diet may increase the load of amyloid-beta protein plaques by preventing their clearance from the brain, whereas the diet with lower saturated fat and sugar had beneficial results (JAMA Neurol. 2013;70(8):972-980). According to the authors, diet may modify the risk profile for this disease, depending on the diet’s composition. Though the trial was small and short in duration, four weeks, it was still impressive.

I mentioned the word “fear” in the introduction several times. Hopefully, this article turned that fear into confidence that you can reduce the risk of developing Alzheimer’s disease. Decreasing saturated fat and sugar intake may be the first steps to reaching this goal. Whether metformin is needed by those with high blood sugar levels or not, lifestyle modifications, including a high-nutrient, plant-based diet, seems to have promise.

We hope for the best with drug therapies in the pipeline, though most have disappointed or are only in early stages of development, so it is even more imperative to utilize what may be our most powerful weapon, lifestyle changes.

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.

Mild cognitive impairment is one of the more common disorders that occur as we age. But age is not the only determinant. There are a number of modifiable risk factors. MCI is feared, not only for its own challenges, but also because it may lead to dementia, with Alzheimer’s disease and vascular dementia being the more common forms. Prevalence of MCI may be as high as 1 in 5 in those over the age of 70 (Ann Intern Med. 2008;148:427-434). It is thought that those with MCI may have a 10% chance of developing Alzheimer’s disease (uptodate.com).

Since there are very few medications presently that help prevent cognitive decline, the most compelling questions are: what increases risk and what can we do to minimize the risk of developing cognitive impairment? These are the important questions.

Many chronic diseases and disorders contribute to MCI risk. These include diabetes, heart disease, Parkinson’s disease and strokes. If we can control these maladies, we may reduce the risk of cognitive decline. This involves making lifestyle modifications such as exercise and diet. We know that we can’t stop aging, but we can age gracefully.

Heart disease

Although we have made great strides, heart disease continues to be prevalent in America. In a recent observational study, results demonstrate that those suffering from years of heart disease are at a substantial risk of developing MCI (JAMA Neurol. 2013;70:374-382). The study involved 1,450 participants who were between the ages of 70 and 89 and were not afflicted by cognitive decline at the beginning of the study. Patients with a history of cardiac disease had an almost two times greater risk of developing nonamnestic MCI, compared to those individuals without cardiac disease. Women with cardiac disease were affected even more, with a three times increased risk of cognitive impairment.

Nonamnestic MCI affects executive functioning – decision-making abilities, spatial relations, problem-solving capabilities, judgments and language. It is a more subtle form of impairment that may be more frustrating because of its subtlety. It may lead to vascular dementia and may be a result of clots. This gives us yet another reason to treat and prevent cardiac disease.

Stroke

Not surprisingly, stroke may have a role in cognitive impairment. Stroke is also referred to as a type of vascular brain injury. But what is surprising is that in a recent study, the results show that the location of the stroke was more relevant than the frequency or the multitude of strokes (JAMA Neurol. 2013;70:488-495). If strokes occurred in the cortical and subcortical grey matter regions of the brain, executive functioning and memory were affected, respectively. Thus, the location of strokes may be a better predictor of subsequent cognitive decline than the number of strokes. Clinically silent strokes that were found incidentally by MRI scans had no direct effect on cognition, according to the authors.

Exercise

Exercise may play a significant role in potentially preventing cognitive decline and possibly even improving MCI in patients who have the disorder. Interestingly, different types of exercise have different effects on the brain. Aerobic exercise may stimulate one type of neuronal development, while resistance training or weight lifting another.

In an animal study involving rats, researchers compared aerobic exercise to weight lifting (J Alzheimers Dis. 2012;32:329-339). Weightlifting was simulated by attaching weights to the tail of rats while they climbed ladders. Both groups showed improvements in memory tests, however, there was interesting divergence. With aerobic exercise, the level of the protein BDNF (brain-derived neurotrophic factor) increased significantly. This is important since BDNF is involved in neurons and the connections among them, called synapses, related mostly to the hippocampus, or memory center. The rats that “lifted weights” had an increase in another protein, IGF (insulin growth factor), that promotes the development of neurons in a different area of the brain. The authors stressed the most important thing is to exercise, regardless of the type.

In a recent study that complements the previous study, women were found to have improved spatial memory when they exercised – either aerobic or weight lifting (J Aging Res. 2013;2013:861893). Interestingly, verbal memory was improved more by aerobic exercise than by weight lifting. Spatial memory is the ability to recall where items were arranged, and verbal memory is the ability to recall words. The authors suggest that aerobic exercise and weight lifting affect different parts of the brain, which corroborates the animal study findings above.

This was a randomized controlled trial that was six months in duration and involved women, ages 70 to 80, who had MCI at the trial’s start. There were three groups in the study: aerobic, weight lifting and stretching and toning. Those who did stretches or toning alone experienced deterioration in memory skills over the same period.

Here is the catch with exercise: we know exercise is valuable in preventing disorders like cardiovascular disease and cognitive decline, but are Americans doing enough? A recent CDC report says the majority of the adult population is woefully deficient: only about 1 in 5 Americans exercise regularly doing both weights and aerobic exercise (Morb Mortal Wkly Rep. 2013;62:326-330).

Diet

Several studies show that the Mediterranean diet helps prevent MCI and possibly prevents conversion from MCI to Alzheimer’s (Neurology 2013;80:1684-1692; Arch Neurol. 2009 Feb.;66:216-225). In addition, a recent study showed that high levels of carbohydrates and sugars, when compared to lower levels, increased the risk of cognitive decline by more than three times (J Alzheimers Dis. 2012;32:329-339). The authors surmise that carbohydrates have a negative impact on insulin and glucose utilization in the brain.

Cognitive decline is a disorder that should be taken very seriously, and everything that can be done to prevent it should be utilized. Though the number of Americans exercising regularly is woefully deficient, the silver lining is that there is substantial room for improvement. Exercise has potentially positive effects on neuron growth and development. We need more campaigns like the NFL’s Play 60, which entices children to be active at least 60 minutes every day, but we need to also target adults of all ages. Let’s not squander the opportunity to reduce the risk of MCI, a potentially life-altering disorder.

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.