High cholesterol affects a great deal of Americans – millions upon millions (a modified homage to the late, great scientist Carl Sagan), and cuts across many demographics, affecting young and old and those in between.  When we think of hyperlipidemia (high cholesterol), what do you think is the mainstay of medical treatment?  If you said, “statins,” you would be correct. 

Do statins deserve this central role in treatment?  They have been convincingly shown in studies to significantly lower cholesterol, and they play an important role for those who have cardiovascular disease.  However, should we be using statins as liberally as we have?  Well, the new guidelines for the treatment of high cholesterol, which came out in Nov. 2013, suggest that we should.  In fact, these guidelines would most likely increase the use of this medication, especially in those over the age of 60.  Some in the medical community have even joked that statins might as well be put in the drinking water.  To read more about the guidelines, please see my November 20, 2013 article, entitled “New cholesterol guidelines released,” online at northshoreoflongisland.com.

This is a medication that patients may be on for life.  I don’t know about you, but that thought sends chills down my spine.  We know all medications have pros and cons.  Statins are no exception; they have been mired in controversy.

For one thing, they have side effects.  These include possibly increasing the risk of diabetes, myalgias (muscle pain), hepatic (liver) toxicity, kidney disorders and negatively affecting memory.

They also may reduce the benefits of exercise, and they may not be as effective in women as they are in men.

Because statins are such effective cholesterol-lowering medications, does this mean that patients on these drugs may become complacent with their diets?   A new study indicates that this is exactly what might be happening.

Let’s look at the evidence.

Diet complacency

The “S” in statins does not stand for “super immune to eating anything.”  In a newly published study in JAMA Internal Medicine, results show that those who are taking statins tend to eat more calories and fats and, ultimately, increase their (body mass index) by gaining weight, compared to those who were not taking statins. (1)  In fact, in this study that used 11 years of NHANES data, results showed that there were a 14 percent increase in fat intake and an almost 10 percen increase in overall calorie intake among statin users.  This resulted in a BMI that rose by 1.3 percent in those on statins, while in non-users over the same period, BMI only rose by 0.4 percent.

In other words, if you took an average male who was 5 feet 9 inches and weighed 200 lbs., the difference between statin users and non-users would be the difference between obesity and being just below obesity.  Those on statins were consuming about 200 extra calories a day.  This increase in calorie consumption occurred after they were placed on statins.   Their weight also increased by 6.6 to 11 lbs.  This is especially concerning to the researchers, since the guidelines for statin use call for a prudent diet to help reduce fat and calorie intake with the ultimate goal of reducing weight. 

However, the opposite was found to have happened – consuming more calories and gaining more weight. This is an observational study with over 27,000 participants, therefore no firm conclusions can be made.  However, statins are not a license to gorge at the all-you-can-eat buffet line.  We already know that statins may increase the risk of diabetes.  Why worsen this risk with dietary indiscretions that are harmful to your BMI?  As an aside, the authors note that this increased calorie and fat consumption may be a contributing reason for the increased risk of diabetes with statins, but it’s too early to tell.

Impact on women

We tend to clump data together from trials that focus predominantly on one demographic, in this case men, and apply the results broadly to both men and women.  However, in a May 5 article in the New York Times, some in the medical community, including the editor of JAMA, note that this may be a mistake. (2)  According to the dissenters, the thought process is that women have been underrepresented in statin trials, and cholesterol may not play the same role in women as it does in men.  Yet almost half of the patients treated with statins are women.  These physicians referring to the use of statins in primary prevention, or in those who have high cholesterol, but who do not have documented heart disease.

Lest you think their views are based solely on opinion or anecdotal data from clinical experience, this data on women was from the JUPITER trial, which looked at almost 7,000 initially healthy female participants. (3)  Statins did benefit women by reducing the occurrence of chest pain and reducing the number of stent placements and bypass surgeries, but they did not reach the primary endpoints of showing statistical significance in reducing the occurrence of a first heart attack, stroke or death.

The caveat is that there were not a large number of cardiovascular events – heart attacks, strokes or death – that occurred in either the treatment group or the control group. These results were in women over the age of 60.  This may give slight pause when giving statins.  By no means do I think these physicians are advocating to not give women statins, just that we may want to weigh the benefits and risks on a case-by-case basis.

Tamping down exercise benefits

Since exercise is beneficial for lowering cardiovascular disease risk and statins are as well, the logical presumption might be that the two together might create a synergistic effect that is greater than the two alone – or at least an added benefit from combining the two.  Unfortunately, what seems straightforward is not always the case.  In a small, yet randomized controlled trial, participants who were put on statins and monitored for cardiopulmonary exercise saw a blunted aerobic effect compared to the control group, which exercised without the medication. (4) In the treatment group, there was a marginal 1.5 percent improvement with aerobic exercise, while the control group experienced a much more robust 10 percent gain. The reason for this disappointing discrepancy is that statins seem to interrupt the enzymes that are responsible for making the mitochondria (the powerhouse or energy source for the cell) more efficient.  The most troubling aspect of this trial is that the participants chosen were out of shape, overweight individuals in need of aerobic exercise.

Whether or not a patient, male or female, is placed on cholesterol-lowering medication, one thing is clear: there is a strong need to make sure that lifestyle modifications are always emphasized to help reduce the risk of cardiovascular disease to its lowest levels.  But the quandary becomes what to do with statins and exercise.  And statins, as powerful and effective as they may be, still do have side effects, may reduce exercise benefits, and may not have the same effects for women.  Thus, they may not be appropriate for everyone.  A healthy diet and exercise, however, are appropriate for all.

References:

1 JAMA Intern Med. online April 24, 2014.  2 nytimes.com.   3 N Engl J Med. 2008 Nov 20;359(21):2195-207.  4 J Am Coll Cardiol. 2013;62(8):709-14.

* If you would like to see a specific topic covered in Medical Compass, please email [email protected].

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 medicalcompassmd.com and/or consult your personal physician.

Cancer, a word that for decades was whispered as taboo, has become front and center in the medical community. Cancer is the No. 1 killer of Americans, at least those less than 85 years old, even ahead of cardiovascular disease (1). We have thought that diet may be an important component in preventing cancer. Is diet a plausible approach?

A recent article published in The New York Times on April 21, titled “An Apple a Day, and Other Myths,” questions the validity of diet in the prevention of cancer. This article covers cancer in general, which is a huge and daunting topic. The article’s author references a comment by Dr. Walter Willett, a professor and chair of the Harvard School of Public Health’s nutrition department, as indicating that the research is inconsistent when it comes to fruits and vegetables. The article goes on to state that even fiber and fats may not play significant roles in cancer.

I don’t necessarily disagree with their assessment. However, I would like to emphasize that Willett also commented that there are no large, well-controlled diet studies. This leaves the door open for the possibility that diet does have an impact on cancer prevention. I would like to respond.

As Willett hinted, the problem with answering this question may lie with the studies themselves. The problem with diet studies in cancer, in particular, are that they rely mainly on either retrospective (backward-looking) or prospective (forward-looking) observational studies.

Observational studies have many weaknesses. Among them is recall bias, or the ability of subjects to remember what they did. Durability is also a problem; the studies are not long enough, especially with cancer, which may take decades to develop. Confounding factors and patient adherence are other challenges, as are the designs and endpoints of the studies (2). Plus, randomized controlled trials are very difficult and expensive to do since it’s difficult and much less effective to reduce the thousands of compounds in food into a focus on one nutrient.

Let’s look at the evidence.

The EPIC trial

Considered the largest of the nutrition studies is the European Prospective Investigation into Cancer and Nutrition. It is part of what the author is using to demonstrate his point that fruits and vegetables may not be effective, at least in breast cancer. This portion of the study involved almost 300,000 women from eight different European nations (3). Results showed that there was no significant difference in breast cancer occurrence between the highest quintile of fruit and vegetable consumption group compared to the lowest. The median duration was 5.4 years.

Does this study place doubt in the diet approach to cancer? Possibly, but read on. The most significant strength was its size. However, there were also many weaknesses. The researchers were trying to minimize confounding factors, but there were eight countries involved, with many different cultures, making it almost impossible to control. It is not clear if participants were asked what they were eating more often than at the study’s start. Risk stratification was also not clear; which women, for example, might have had a family history of the disease.

Beneficial studies with fruits and vegetables

Also using the same EPIC study, results showed that fruit may have a statistically significant impact on lung cancer (4). Results showed that there was a 40 percent decrease in the risk of developing lung cancer in those that were in the highest quintile of fruit consumption, compared to those in the lowest quintile. However, vegetables did not have an impact. The results were most pronounced in the Northern European region. I did say the answer was complex.

Ironically, it seems that some other studies, mostly smaller studies, show potentially beneficial effects from fruits and vegetables. This may be because it is very difficult to run an intensive, well-controlled, large study.

Prostate cancer

Dr. Dean Ornish, a professor of medicine at University of California, San Francisco Medical School, has done several well-designed pilot studies with prostate cancer. His research has a focus on how lifestyle affects genes. In one of the studies, results of lifestyle modifications showed a significant increase in telomere length over a five-year period (5). Telomeres are found on the end of our chromosomes; they help prevent the cell from aging, becoming unstable and dying. Shorter telomeres may have an association with diseases, such as cancer, aging and morbidity (sickness). Interestingly, the better patients adhered to the lifestyle modifications, the more telomere growth they experienced. However, in the control group, telomeres decreased in size over time. There were 10 patients in the lifestyle (treatment) group and 25 patients in the control group — those who followed an active surveillance-only approach.

In an earlier study with 30 patients, there were over 500 changes in gene expression in the treatment group. Of these, 453 genes were downregulated, or turned off, and 48 genes were upregulated, or turned on (6). The most interesting part is that these changes in gene transcription occurred over just a three-month period with lifestyle modifications.

In both studies, the patients had prostate cancer that was deemed at low risk of progressing into advanced or malignant prostate cancer. These patients had refused immediate conventional therapy including hormones, radiation and surgery. In both studies, the results were determined by prostate biopsy. These studies involved intensive lifestyle modifications that included a low-fat, plant-based, vegetable-rich diet. But as the researchers pointed out, there is a need for larger randomized controlled trials to confirm these results.

Cruciferous vegetables

A meta-analysis involving a group of 24 case-control studies and 11 observational studies, both types of observational trials, showed a significant reduction in colorectal cancer (7). This meta-analysis looked at the effects of cruciferous vegetables, also sometimes referred to as dark green, leafy vegetables.

In another study that involved a case-control observational design, cruciferous vegetables were shown to significantly decrease the risk of developing multiple cancers, including esophageal, oral cavity/pharynx, breast, kidney and colorectal cancers (8). There was also a trend that did not reach statistical significance for preventing endometrial, prostate, liver, ovarian and pancreatic cancers. The most interesting part is that the comparison was modest, contrasting consumption of at least one cruciferous vegetable a week with none or less than one a month. However, we need large, randomized trials using cruciferous vegetables to confirm these results.

In conclusion, it would appear that the data are mixed in terms of the effectiveness of fruit and vegetables in preventing cancer or its progression. The large studies have flaws, and pilot studies require larger studies to validate them. However, imperfect as they are, there are results that indicate that diet modification may be effective in preventing cancer. I don’t think we should throw out the baby with the bath water.

There is no reason not to consume significant amounts of fruits and vegetables in the hopes that it will have positive effects on preventing cancer and its progression. There is no downside, especially if the small studies are correct.

References:

(1) CA Cancer J Clin. 2011;61:212-236. (2) Nat Rev Cancer. 2008;8:694-703. (3) JAMA. 2005;293:183-193. (4) Int J Cancer. 2004 Jan. 10;108:269-276. (5) Lancet Oncol. 2013 Oct.;14:1112-1120. (6) Proc Natl Acad Sci USA. 2008 June 17;105:8369-8374. (7) Ann Oncol. 2013 April;24:1079-1087. (8) Ann Oncol. 2012 Aug.;23:2198-2203.

• If you would like to see a specific topic covered in Medical Compass, please email [email protected].

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 medicalcompassmd.com and/or consult your personal physician.

Not surprisingly, osteoarthritis is widespread. The more common joints affected are the knees, hips and hands. There are three types of treatment for this disease: surgery, involving joint replacements of the hips or knees; medications; and nonpharmacologic approaches. The most commonly used first-line medications are acetaminophen and nonsteroidal anti-inflammatory drugs, such as ibuprofen. Unfortunately, medications mostly treat the symptoms of pain and inflammation.

However, the primary objectives in treating osteoarthritis should also include improving quality of life, slowing progression of the disease process and reducing its disabling effects (1).

What are the most productive approaches to treatment? This is good time to test your knowledge. This will hopefully get you thinking and make you an active participant for the evidence to follow. There are three responses to choose from: True (T), False (F) and Unclear (U) — a new twist, because I want to keep you on your toes.

1) Dairy is effective in the treatment of osteoarthritis.

2) Low-fat and nonfat milk have potentially disease-modifying effects.

3) Vitamin D is a necessary supplement in this disease.

4) Glucosamine is an effective treatment.

5) Weight loss may provide symptom relief and disease-modifying effects.

6) Diet and exercise are more important than either alone.

So how do you think you did? The answers are as follows: 1) F, 2) U, 3) F, 4) U, 5) T and 6) T.

Let’s look at the evidence.

Dairy and milk

When we think of dairy, specifically milk, there are two distinct camps: one believes in the benefits, and the other thinks it may contribute to disease. In this case they both may be at least partly correct. In the Osteoarthritis Initiative study, an observational study of over 2,100 patients, results showed that low-fat (1 percent) and nonfat milk may slow the progression of osteoarthritis (2). The researchers looked specifically at joint space narrowing that occurs in those with affected knee joints. Radiographic imaging changes were used at baseline and then to follow the patients for up to 12 to 48 months for changes. Compared to those who did not drink milk, patients who did saw significantly less narrowing of knee joint space.

Was it a dose-dependent response? Not necessarily. Specifically, those who drank less than three glasses/week and those who drank four to six glasses/week both saw slower progression of joint space narrowing of 0.09 mm. Seven to 10 glasses/week resulted in a 0.12 mm preservation. However, those who drank more than 10 glasses/week saw less beneficial effect, 0.06 mm preservation compared to those who did not drink milk. Interestingly, there was no benefit seen in men or with the consumption of cheese or yogurt.

However, there are significant flaws with this study. First, the patients were only asked about their dietary intake of milk at baseline, therefore their consumption could have changed during the study. Second, there was a recall bias; patients were asked to recall their weekly milk consumption for the previous 12 months before the study began. I don’t know about you, but I can’t recall my intake of specific foods for the last week, let alone for the past year. Third, there could have been confounding factors, such as orange consumption.

Oddly, this was not a dose-response curve, since the most milk consumption had less beneficial effect than lower amounts. Also, why were these effects only seen in women? Finally, researchers could not explain why low-fat or nonfat milk had this potential benefit, but cheese was detrimental and yogurt did not show benefit. We are left with more questions than answers.

Would I recommend consuming low-fat or nonfat milk? Not necessarily, but I may not dissuade osteoarthritis patients from drinking it. There are very few approaches that slow the progression of joint space narrowing.

Vitamin D

Over the last five years or so, the medical community has gone from believing that vitamin D was potentially the solution to many diseases to wondering whether, in some cases, low levels were indicative of disease, but repletion was not a change-maker. Well, in a recent randomized controlled trial, the gold standard of studies, vitamin D had no beneficial symptom relief, nor any disease-modifying effects (3). This two-year study of almost 150 men and women raised blood levels of vitamin D on average to 36 ng/ml, which is considered respectable. Researchers used MRI and X-rays to track their results.

Glucosamine

There is raging debate about whether glucosamine is an effective treatment for osteoarthritis. In the latest installment, there was a RCT, the results of which showed that glucosamine hydrochloride was not effective in treating osteoarthritis (4). In the trial, 201 patients with either mild or moderate knee pain drank diet lemonade with or without 1500 mg of glucosamine hydrochloride.

There was no difference in cartilage changes in the knee nor in pain relief in those in the placebo or treatment groups over a six-month duration. Bone marrow lesions also did not improve with the glucosamine group. The researchers used 3T MRI scans (an advanced radiologic imaging technique) to follow the patients’ disease progression. This does not mean that glucosamine does not work for some patients. Different formulations, such as glucosamine sulfate, were not used in this study.

Weight

This could not be an article on osteoarthritis if I did not talk about weight. Do you remember analogies from the SATs? Well here is one for you: Weight loss, weight loss, weight loss is to osteoarthritis as location, location, location is to real estate. In a recent study involving 112 obese patients, there was not only a reduction of knee symptoms in those who lost weight, but there was also disease modification, with reduction in the loss of cartilage volume around the medial tibia (5). On the other hand, those who gained weight saw the inverse effect. A reduction of tibial cartilage is potentially associated with the need for knee replacement. The relationship was almost one-to-one; for every 1 percent of weight lost, there was a 1.2 mm3 preservation of medial tibial cartilage volume, while the exact opposite was true with weight gain.

Exercise and diet

In a recent study, diet and exercise trumped the effects of diet or exercise alone (6). Patients with osteoarthritis of the knee who lost at least 10 percent of their body weight experienced significant improvements in function and a 50 percent reduction in pain, as well as reduction in inflammation, compared to those who lost 5 to 10 percent and those who lost less than 5 percent. This study was a well-designed, randomized controlled single-blinded study with a duration of 18 months.

Researchers used a biomarker — IL6 — to measure inflammation. The diet and exercise group and the diet-only group lost significantly more weight than the exercise-only group, 23.3 pounds and 19.6 pounds versus 4 pounds. The diet portion consisted of a meal replacement shake for breakfast and lunch and then a vegetable-rich, low-fat dinner. Low-calorie meals replaced the shakes after six months. The exercise regimen included one hour of a combination of weight training and walking with alacrity three times per week.

Therefore, concentrate on lifestyle modifications if you want to see potentially disease-modifying effects. These include both exercise and diet. In terms of low-fat or nonfat milk, while the study had numerous flaws, if you drink milk, you might continue for the sake of osteoarthritis, but stay on the low end of consumption. And remember, the best potential effects shown are with weight loss and with a vegetable-rich diet.

References:

(1) uptodate.com. (2) Arthritis Care Res online. 2014 April 6. (3) JAMA. 2013;309:155-162. (4) Arthritis Rheum online. 2014 March 10. (5) Ann Rheum Dis online. 2014 Feb. 11. (6) JAMA. 2013;310:1263-1273.

•If you would like to see a specific topic covered in Medical Compass, please email [email protected].

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 medicalcompassmd.com and/or consult your personal physician.

Longer days are here again, and you can feel the jubilance of people coming out of hibernation after a long, hard winter. Summer weather will be here before you know it, and millions will be heading to the beaches. What could possibly be wrong with this picture? With all of these benefits, you need to be cognizant of cutaneous (skin) melanoma. It is small in frequency, compared to basal cell and squamous cell carcinomas, responsible for only about 5 percent of skin cancers; however, it is much more deadly.

Statistics

Unfortunately, melanoma is on the rise. Over the last 40 years from 1970 to 2009, its incidence has increased by 800 percent in young women and by 400 percent in young men (1). These were patients diagnosed for the first time between 18 and 39 years old. Overall, the risk is greater in men, with 1 in 37 afflicted by this disease in their lifetimes. The rate among women is 1 in 56. It is predicted that in 2014, there will be over 76,000 cases, with over 12 percent of these resulting in death (2).

Melanoma risk involves genetic  and environmental factors. These include sun exposure that is intense, but intermittent; tanning beds; UVA radiation used for the treatment of psoriasis; the number of nevi (moles); Parkinson’s disease; prostate cancer; family history; and personal history. Many of these risk factors are modifiable (3).

Presentation

Fortunately, melanoma is mostly preventable. What should you look for to detect melanoma at its earliest stages? In medicine, we use the mnemonic “ABCDE” to recall key factors to look for when examining moles. This stands for asymmetric borders (change in shape); border irregularities; color change; diameter increase (size change); and evolution or enlargement of diameter, color or symptoms, such as inflammation, bleeding and crustiness (4). Asymmetry, color and diameter are most important, according to guidelines developed in England (5).

It is important to look over your skin completely, not just partially, and have a dermatologist screen for potential melanoma. Screening skin for melanomas has shown a six-times greater chance of detecting them. Skin areas exposed to the sun have the highest probability of developing the disease. Men are more likely to have melanoma tumors on the back, while women are more likely to have melanoma on the lower legs, but they can develop anywhere (6).

In addition, most important to the physician, especially the dermatologist, is the thickness of melanoma. This may determine its probability to metastasize. In a recent retrospective (backward-looking) study, the results suggest that melanoma of >0.75 mm needs to not only be excised, or removed, but also have the sentinel lymph node (the closest node) biopsied to determine risk of metastases (7). A positive sentinel node biopsy occurred in 6.23 percent of those with thickness >0.75 mm, which was significantly greater than in those with thinner melanomas. When the sentinel node biopsy is positive, there is a greater than twofold increase in the risk of metastases. On the plus side, having a negative sentinel node helps relieve the stress and anxiety that the melanoma tumor has spread.

Prevention

The two most valuable types of prevention are clothing and sunscreen. Let’s look at these in more detail.

Clothing can play a key role in reducing melanoma risk. The rating system for clothing protection is ultraviolet protection factor. The Skin Cancer Foundation provides a list of which laundry additives, clothing and cosmetics protect against the sun (8). Clothing that has a UPF rating between 15 and 24 is considered good, 25 to 39 is very good and 40 to 50 is excellent. The ratings assess tightness of weave, color (the darker the better), type of yarn, finishing, response to moisture, stretch and condition. The most important of these is the weave tightness (9).

Interestingly, The New York Times wrote about how major companies are producing sun-protective clothing lines that are fashionable and lighter in weight. The article is entitled “Fashionable options reshape sun-protective clothing” (10).

We have always known that sunscreen is valuable. But just how effective is it? In an Australian prospective (forward-looking) study, those who were instructed to use sun protective factor 16 sunscreen lotion on a daily basis had significantly fewer incidences of melanoma compared to the control group members, who used their own sunscreen and were allowed to apply it at their discretion (11). The number of melanomas in the treatment group was half that of the control group’s over a 10-year period. But even more significant was a 73 percent reduction in the risk of advanced-stage melanoma in the treatment group. Daily application of sunscreen was critical.

The recommendations after this study, and others like it, is that an SPF of 15 should be used daily by those who are consistently exposed to the sun and/or are at high risk for melanoma according to the American Academy of Dermatology (12). The amount used per application should be about one ounce. However, since people don’t use as much sunscreen as they should, the academy recommends an SPF of 30 or higher. Note that SPF 30 is not double the protection of SPF 15. The UVB protection of SPFs 15, 30 and 50 are 93 percent, 97 percent and 98 percent, respectively.

The problem is that SPF is a number that registers mostly the blocking of UVB, but not so much the blocking of UVA1 or UVA2 rays. However, 95 percent the sun’s rays that reach sea level are UVA. So what to do?

Sunscreens come in a variety of UV filters that are either organic filters (chemical sunscreens) or inorganic filters (physical sunscreens). The FDA now requires broad spectrum sunscreens pass a test showing they block both UVB and UVA radiation. Broad spectrum sunscreens must be least SPF 15 to decrease the risk of skin cancer and prevent premature skin aging caused by the sun. Anything over the level of SPF 50 should be referred to as 50+ (3).

The FDA also has done away with the term “waterproof.” Instead, sunscreens can be either water-resistant or very water-resistant if they provide 40 and 80 minutes of protection, respectively. This means you should reapply sunscreen if you are out in the sun for more than 80 minutes, even with the most protective sunscreen (3). Look for sunscreens that have zinc oxide, avobenzone or titanium oxide; these are the only ones that provide UVA1 protection in addition to UVA2 and UVB protection.

In conclusion, to reduce the risk of melanoma, proper clothing with tight weaving and/or sunscreen should be used. The best sunscreens are broad spectrum, as defined by the FDA, and should contain zinc oxide, avobenzone or titanium oxide to make sure the formulation not only blocks UVA2 but also UVA1 rays. It is best to reapply sunscreen every 40 to 80 minutes, depending on its rating. We can reduce the risk of melanoma occurrence significantly with these very simple steps.

References:

(1) Mayo Clin Proc. 2012; 87:328–334. (2) CA Cancer J Clin. 2014;64:9-29. (3) uptodate.com. (4) JAMA. 2004;292:2771-2776. (5) Br J Dermatol. 1994;130:48-50. (6) Langley R. G. et al. Clinical characteristics. In: Cutaneous Melanoma, Third Edition. St. Louis, Mo., Quality Medical Publishing Inc. 1998. p. 81. (7) J Clin Oncol. 2013;31:4385-4386. (8) skincancer.org. (9) Photodermatol Photoimmunol Photomed. 2007;23:264-274. (10) nytimes.com. 2013 July 17. (11) J Clin Oncol. 2011;29:257-263. 12 aad.org.

*If you would like to see a specific topic covered in Medical Compass, please email  [email protected].

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 medicalcompassmd.com and/or consult your personal physician.

Cardiovascular disease is anything but boring; what we know about it is constantly evolving.  New information comes along all the time, which on the whole is a good thing.  Even though this disease has been on the decline, it is still the number one killer of Americans, responsible for about one million deaths per year.1  However, not all studies nor all analyses on the topic are created equal.  Therefore, I thought it apropos to present a quiz on cardiovascular disease myths and truths.

Without further ado, here is a challenge to your cardiovascular disease IQ.  The questions below are true or false.  The answers and evidence are provided after.

1) Saturated fat is good for us, but processed foods and trans-fats are unhealthy.

2) Fish oil supplements will help reduce the risk of cardiovascular disease and mortality.

3) Fiber has significantly beneficial effects on heart disease prevention.

4) Unlike sugary sodas and drinks, diet soda is most likely not a contributor to this disease.

5) Vitamin D deficiency may contribute to cardiovascular disease.

Now that was not so difficult. Or was it?  The answers are as follows: 1-F, 2-F, 3-T, 4-F, 5-T.  So how did you do? Regardless of whether you know the answers, the reasons are even more important to know.  Let’s look at the evidence. 

Saturated Fat

Most of the medical community has been under the impression that saturated fat is not good for us.  We need to limit the amount to no more than 10% of our diet.  But is this true?  The results of a newly published meta-analysis (a group of 72 randomized clinical trials and observational studies) would upend this paradigm.2   While saturated fat did not decrease the risk of cardiovascular disease, it did not significantly increase the risk either.   Also, the results showed that trans-fats increase the risk of this disease. Of course trans-fats are a processed fat, so this is something that most of us would agree upon.  And in the clinical trials portion of the meta-analysis, omega-3 and omega-6 polyunsaturated fats did not significantly reduce the risk of cardiovascular disease. 

Does this mean that we can go back to eating saturated fats with impunity?  Well, there were weaknesses and flaws with this study.  The authors only looked at the one dimension of fat.  Their comparison was based on the upper-third of intake of one type of fat versus the lower-third of intake of the same type of fat (whether it was saturated fat or a type of unsaturated fat).  It did not consider whether saturated fat was substituted with refined grains or unsaturated fatty acids.  Also, what was the source of saturated fats, animal or plant, and did these sources also contain unsaturated fats as well, like olive oil or nuts which contain good fats?  Therefore, there are many unanswered questions and potentially several significant flaws with this study.

While I respect the New York Times, I was a bit surprised to see Mark Bittman’s March 25, 2014 column, “Butter is Back,” referencing the new meta-analysis above. Many of his articles in the past have contributed to the health and wellness of his readers. However, he misses the boat by promoting butter and other sources of saturated animal fat, such as cheese, pork and the skin from chicken. I think he does a disservice to his readers, making statements that are downright dangerous and hopefully will not result in more cardiovascular disease.

The meta-analysis above, which Bittman uses to buoy his arguments, does not differentiate among plant or animal saturated fat sources.  But in one that does, the researchers found saturated fats from animal sources increased cholesterol and the risk of cardiovascular disease.3  Also in another study, specifically using unsaturated fats in place of saturated fat reduced the risk of this disease.4, 5

Fish oil

There is whole industry built around fish oil and reducing the risk of cardiovascular disease.  Yet the data don’t seem to confirm this theory.  In the latest study, the age-related eye disease study 2 (AREDS2), unfortunately, 1 g of fish oil (long chain omega-3 fatty acids) daily did not demonstrate any benefit in the prevention of cardiovascular disease nor its resultant mortality.6  This study was done over a five-year period in the elderly with macular degeneration.  The cardiovascular primary endpoint was a tangential portion of the ophthalmic AREDS2.  This does not mean that fish, itself, falls into that same category, but for now there does not seem to be a need to take fish oil supplements for heart disease, except potentially for those with very high triglycerides.  Fish oil, at best, is controversial ; at worst, it has no benefit with cardiovascular disease.

Fiber

We know that fiber tends to be important for a number of diseases, and cardiovascular disease does not appear to be an exception.  In a meta-analysis, involving 22 observational studies, the results showed a linear relationship between fiber intake and decreased in risk for developing cardiovascular disease.7  In other words, for every 7 grams of fiber consumed, there was 9% reduced risk in developing the disease.  It did not matter the source of the fiber from plant foods; vegetables, grains and fruit all decreased the risk of cardiovascular disease.  This did not involve supplemental fiber, like that found in Fiber One or Metamucil.  To give you an idea about how easy it is to get a significant amount of fiber, one cup of lentils has 15.6 grams of fiber, one cup of raspberries or green peas has almost 9 grams, and one medium-size apple has 4.4 grams.  Americans are sorely deficient in fiber. 8

Diet Soda

An upcoming presentation at the American College of Cardiology examines the Women’s Health Initiative: the study suggests that diet soda may increase the risk of heart disease.9  In those drinking two or more cans per day, defined as 12 ounces per can, there was a 30% increased risk of a cardiovascular event, such as an a stroke or heart attack, but an even greater risk of cardiovascular mortality, 50%, over 10 years.  These results took into account confounding factors like smoking, diabetes, high blood pressure, and obesity.  This study involved over 56,000 postmenopausal women for almost a nine-year duration.

Vitamin D

The results of a recent observational study in the elderly suggest that vitamin D deficiency may be associated with cardiovascular disease risk.  The study showed that those whose vitamin D levels were low had increased inflammation, demonstrated by elevated biomarkers including C-reactive protein (CRP).10  This biomarker is related to inflammation of the heart, though is not as specific as one would hope.

Beware in regards to saturated fat.  If a study looks like an outlier or too good to be true, then probably it is.  I would not run out and get a cheeseburger just yet. However, study after study has shown benefit with fiber.  So if you want to reduce the risk of cardiovascular disease, consume as much whole food fiber as possible.  Also, since we live in the northeast, consider taking at least 1000 IUs of vitamin D daily.  This is a simple way to help thwart the risk of the number one killer.

References:

1 uptodate.com.  2 Ann Intern Med. 2014;160(6):398-406. 3 JAMA 1986;256(20):2623. 4 Am J Clin Nutr. 2009;99(5):1425-32. 5 Cochrane Database Syst Rev. 2012:5;CD002137. 6 JAMA Intern Med. Online March 17, 2014.  7 BMJ 2013; 347:f6879.  8 Am J Med. 2013 Dec;126(12):1059-67.e1-4. 9 ACC Scientific Sessions 2014; Abstract 917-05.  10 J Clin Endocrinol Metab online February 24, 2014. 

With spring officially here and — believe or not — beach weather around the corner, millions of American will expose their toes. Some will be more self-conscious about it than others, because of a disease called onychomycosis, better known as nail fungus.

Nail fungus usually affects toenails, but can also affect fingernails. It turns the nails yellow, makes them potentially brittle, creates growth underneath the nail (thickening of the nails) and may cause pain.

Many patients are bothered by this disorder. Most patients consider getting treatment for cosmetic reasons, but there are also medical reasons to treat, including the chronic or acute pain caused by nail cutting or pressure from bedsheets and footwear. There is an increased potential risk for infections, such as cellulitis, in those with compromised immune systems (1). Onychomycosis is not easy to treat and can be quite uncomfortable.

Onychomycosis affects approximately 8 percent of the population (2). The risk factors are unclear, but may be relate to family history, tinea pedis (athlete’s foot), older age, swimming, diabetes, psoriasis, suppression of the immune system and/or living with someone affected by it (3).

There are a number of organisms that can affect the nail. The most common class is dermatophytes, but others are yeast (Candida) and nondermatophytes. A test commonly used to differentiate the organisms is a KOH (potassium hydroxide) preparation, which is a simple microscopic exam of skin and nail shavings. This is important since some medications work better on one type than another. Also, yellow nails alone may not be caused by onychomycosis; they can be a sign of the autoimmune disease psoriasis.

There are a plethora of therapies available for treatment. These range from over-the-counter alternative therapies to prescription topical medications to systemic, or oral, prescription therapies to laser therapies and, finally, surgery. I am regularly asked which treatment works best.

With all of these options, how is one to choose? Well, there are several important criteria, including effectiveness, length of treatment and potential adverse effects. The bad news is that none of the treatments are foolproof, and the highest “cure” rate is around two-thirds. Oral medications tend to be the most efficacious, but they also have the most side effects. The treatments can take from around three months to one year. So there is no overnight success. Unfortunately, the recurrence rate of fungal infection is thought to be approximately 20 to 50 percent with patients who have experienced “cure” (4).

Fortunately, most cases of nail fungus are benign, with only a fraction leading to infections. Infection is most common in those with diabetic neuropathy, where the patient loses feeling in their feet.

Let’s look at the evidence.

Oral antifungals

There are several options for oral antifungals, including terbinafine (Lamisil), fluconazole (Diflucan) and itraconazole. These medications tend to have the greatest success rate, but the disadvantages are their side effects.

In a small but randomized controlled trial, terbinafine was shown to work better in a head-to-head trial than fluconazole (5). Of those treated, 67 percent of patients experienced a clearing of the fungus in their toenails with terbinafine, whereas 21 percent and 32 percent experienced these benefits with fluconazole, depending on the duration. The patients in the terbinafine group were treated with 250 mg of drug for 12 weeks. Those in the fluconazole group were treated with 150 mg of drug for either 12 weeks or 24 weeks, with those in the 24-week group experiencing the better results. Thus, this would imply that terbinafine is the more effective drug. This is a small trial, but the results are intriguing. The disadvantage of terbinafine is the risk of potential hepatic (liver) damage and failure, though it’s an uncommon occurrence. Liver enzymes need to be checked while using terbinafine. Its advantages are the efficacy and the duration.

Another approach to reduce side effects is to give oral antifungals in a pulsed fashion. In a RCT, fluconazole 150 mg or 300 mg was shown to have significant benefit compared to the control arm when given on a weekly basis (6). However, the efficacy was not as great as with terbinafine or itraconazole (7).

Topical medication

A commonly used topical medication is ciclopirox (Penlac). The advantage of this lacquer is that there are minor potential side effects. However, the disadvantages are that it takes approximately a year of daily use, and its efficacy is not as great as the oral antifungals. In two randomized controlled trials, the use of ciclopirox showed a 7 percent “cure” rate in patients, compared to 0.4 percent in the placebo groups (8). There is also a significant rate of fungus recurrence. In this trial, ciclopirox had to be applied daily for 48 weeks. These results were in patients with mild to moderate levels of fungus in the surface area of the infected nails.

Laser therapy

Of the treatments, laser therapy would seem to be the least innocuous. However, there are very few trials showing significant benefit with this approach. A study with one type of laser treatment (Nd:YAG 1064-nm laser) did not show a significant difference after five sessions (9). This was only one type of laser treatment, but it does not bode well. To make matters worse, many of the laser treatments are not covered by insurance, and they can be expensive. Another research paper that reviewed the current literature concluded that laser therapies are lacking in randomized clinical trials (10).

The advantage of laser treatment is the mild side effects. The disadvantages are the questionable efficacy and the cost. We need more research to determine if it is effective.

Alternative therapy

Vicks VapoRub may have a place in the treatment of onychomycosis. In a very small pilot trial with 18 patients, 27.8 percent or 5 of the patients experienced complete “cure” of their nail fungus (11). Additionally, partial improvement occurred in the toenails of 10 patients. But what is more interesting is that all 18 patients rated the results as either “satisfying” or “very satisfying.” The gel was applied daily for 48 weeks. The advantage is low risk of side effects and low cost. The disadvantages are a lack of larger studies for efficacy, the duration of use and the lower efficacy compared to oral antifungals.

So when it comes to onychomycosis, what should one do? None of the treatments are perfect. Oral medications tend to be the most efficacious, but also have the most side effects. If treatment is for medical reasons, then oral may be the way to go. If you have diabetes, then treatment may be of the utmost importance. If you decide on this approach, discuss it with your doctor; there are appropriate precautionary tests, such as liver enzyme monitoring with terbinafine (Lamisil), that need to be done on a regular basis. However, if treatment is for cosmetic reasons, then topical medications or alternative approaches may be the better initial choice. No matter what you and your physician agree upon as the appropriate treatment, have patience. The process may take a while; nails, especially in toes, grow very slowly.

References:

(1) J Am Acad Dermatol. 1999 Aug.;41:189–196;Dermatology. 2004;209:301–307. (2) J Am Acad Dermatol. 2000;43:244–248. (3) J Eur Acad Dermatol Venereol. 2004;18:48–51. (4) Dermatology. 1998;197:162–166; uptodate.com. (5) Pharmacoeconomics. 2002;20:319–324. (6) J Am Acad Dermatol. 1998;38:S77. (7) Br J Dermatol. 2000;142:97–102; Pharmacoeconomics. 1998;13:243–256. (8) J Am Acad Dermatol. 2000;43(4 Suppl.):S70-S80. (9) J Am Acad Dermatol. 2013 Oct.;69:578–582. (10) Dermatol Online J. 2013 Sep. 14;19:19611. (11) J Am Board Fam Med. 2011;24:69–74.

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 medicalcompassmd.com or consult your personal physician.

Most of us know that type 2 diabetes is an epidemic in America and continues to grow. Type 2 diabetes was thought to be an adult-onset disease, but more and more children and adolescents are affected as well. The most recent statistics show that 50% of teens with diabetes between the ages of 15 and 19 have type 2 (1). Thus, this disease is pervasive throughout the population.

Let’s test our diabetes IQ. See if you can determine if the following are true or false. Don’t worry, you won’t be judged or graded for wrong answers; this is meant to encourage you to learn more.

1) Whole fruit should be limited or avoided.

2) Soy has detrimental effects with diabetes.

3) Plant fiber provides too many carbohydrates.

4) Coffee consumption contributes to diabetes.

5) Bariatric surgery is an alternative to lifestyle changes.

My goal is to help debunk type 2 diabetes myths. All of these statements are false.

Let’s look at the evidence.

Fruit

Fruit, whether whole fruit or fruit juice, has always been thought of as taboo for those with diabetes. This is only partially true. Yes, fruit juice should be avoided because it does raise or spike glucose (sugar) levels. The same does not hold true for whole fruit. Recent studies have demonstrated that patients with diabetes don’t experience a spike in sugar levels whether they limit the number of fruits consumed or have an abundance of fruit (2).  In another study, whole fruit actually was shown to reduce the risk of type 2 diabetes (3).

In yet another study, researchers looked at different whole fruits to determine their impacts on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (4). That’s right, bananas and grapes, two fruits people associate with spiking sugar levels and increasing carbohydrate load. The only fruit that seemed to have a mildly negative impact on sugars was cantaloupe. To read more detail about some of these studies, please see my article, “Sugar, Sugar.” Fruit is not synonymous with sugar. One of the reasons for the beneficial effect is the flavonoids, or plant micronutrients, but another is the fiber.

Fiber

We know fiber is important in a host of diseases, and it is not any different in diabetes. In the Nurses’ Health Study and NHS II, two very large prospective (forward-looking) observational studies, plant fiber was shown to help reduce the risk of type 2 diabetes (5). Researchers looked at lignans, a type of plant fiber, specifically examining metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine, compared to the control group without diabetes. There was a linear, or direct, relationship between the amount of metabolites and the reduction in risk for diabetes. The authors therefore encourage patients to eat more of a plant-based diet to get this benefit.

Foods with lignans include: flaxseed; sesame seeds; cruciferous vegetables, such as broccoli and cauliflower; and an assortment of fruits and grains (6). The researchers could not determine which plants contributed the most benefit. They believe the effect is from antioxidant activity.

Soy and kidney function

Soy sometimes has a negative association. However, in diabetes patients with nephropathy (kidney damage or disease), soy consumption showed improvements in kidney function (7). There were significant reductions in urinary creatinine levels and reductions of proteinuria (protein in the urine), both signs that the kidneys are beginning to function better. This was a small but randomized controlled trial, considered the gold standard of studies, over a four-year period with 41 participants. The control group’s diet consisted of 70% animal protein and 30% vegetable protein, while the treatment group’s consisted of 35% animal protein, 35% textured soy protein and 30% vegetable protein. This is very important since diabetes patient are 20-to-40 times more likely to develop nephropathy than those without diabetes (8). It appears that soy protein puts substantially less stress on the kidneys than animal protein, which creates nitrogenous waste products. However, those who have hypothyroidism should avoid soy.

Coffee

Coffee is a staple in America and in my household. It is one thing my wife would never let me consider taking away. Well she and the rest of the coffee-drinking portion of the country can breathe a big sigh of relief when it comes to diabetes. There is a new meta-analysis (involving 28 prospective studies) that shows coffee decreases the risk of developing diabetes (9). It was a dose-dependent effect; two cups decreased the risk more than one cup. Interestingly, it did not matter whether it contained caffeine or was decaffeinated. This suggests that caffeine is not necessarily the driving force behind the effect of coffee on diabetes. The authors surmise that other compounds, including lignans, which have antioxidant effects, may play an important role. The duration of the studies ranged from 10 months to 20 years, and the database was searched from 1966 to 2013, with over one million participants.

Bariatric Surgery

In the last few years, bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m2) and obese (BMI >30 kg/m2) diabetes patients. In a meta-analysis of bariatric surgery (involving 16 RCTs and observational studies), the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (10). During this time period, 72% of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss. However, after 10 years without proper management involving lifestyle changes, only 36% remained in remission with diabetes, and a significant number regained weight. Thus, whether one chooses bariatric surgery or not, altering diet and exercise are critical to maintain long-term benefits.

There is still a lot to be learned with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. The take-home messages are: don’t avoid whole fruit; soy is potentially valuable; fiber from plants may play a very powerful role in preventing and treating diabetes; and coffee may help prevent diabetes. Thus, the overarching theme is that you can’t necessarily go wrong with a plant-based diet focused on fruits, vegetables, beans and legumes. And if you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to increase the likely durability over 10 or more years.

References:

(1) JAMA. 2007;297:2716-2724. (2) Nutr J. 2013 Mar. 5;12:29. (3) Am J Clin Nutr. 2012 Apr.;95:925-933. (4) BMJ online 2013 Aug. 29. (5) Diabetes Care. online 2014 Feb. 18. (6) Br J Nutr. 2005;93:393–402. (7) Diabetes Care. 2008;31:648-654. (8) N Engl J Med. 1993;328:1676–1685. (9) Diabetes Care. 2014;37:569-586. (10) Obes Surg. 2014;24:437-455.

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 medicalcompassmd.com or consult your personal physician.

We should all reduce the amount of added sugar we consume, because of its negative effects on our health. It is recommended that we get no more than 5 to 15 percent of our diet from added sugars and solid fats, combined. (1) However, approximately 13 percent of our diet is from added sugars alone. (2)

Is all sugar bad for us? The answer is not straightforward. It really depends on the source, and when I mention source, my meaning may surprise you.

We know that white, processed sugar is bad. But, I am constantly asked which sugar source is better: honey, agave, raw sugar, brown sugar or maple syrup? None are really good for us; they all raise the level of glucose (a type of sugar) in our blood. Two-thirds of our sugar intake comes from processed food, while one-third comes from sweetened beverages, according to the most recent report from the CDC. (2) Sweetened beverages are defined as sodas, sports drinks, energy drinks and fruit juices. That’s right: even 100 percent fruit juice can raise our glucose levels. Don’t be deceived because it says it’s natural and doesn’t include “added” sugar.

These sugars increase the risk of, and may exacerbate, chronic diseases, such as diabetes, heart disease, high blood pressure, cancer and obesity. This is such a significant problem that California’s legislature is considering adding warning labels to sweetened drinks. (3) The label would indicate that added sugars can increase the risk of diabetes and obesity, as well as tooth decay.

However, I did say that sugar’s source impacts its effect. Most fruits have beneficial effects in preventing disease, including diabetes, and do not raise sugar levels, even in patients with diabetes. It is a myth that whole fruit raises your sugar levels. However, dried fruits, fruit juice, and fruit concentrate do raise your sugar levels. Note that sugar extracted from fruit has an effect similar to that of sugar added to foods and sweetened beverages. Let’s look at the evidence.

Heart disease

When we think of sugar’s effects, heart disease is not usually the first disease that comes to mind.

However, results from a 20-year study of 31,000 U.S. adults showed that, when comparing those who consumed the least amount of added sugar (less than 10% of calories daily), with those who consumed 10-25% and those who consumed more than 25% of daily calories from sugar, there were significant increases in risk of death from heart disease, 30% and a 275%, respectively (4). The added sugar was from foods and sweetened beverages, not from fruit and fruit juices.

This was not just an increased risk of heart disease, but an increased risk of cardiovascular death. This is a wake-up call to rein in our sugar consumption.

Obesity and weight gain

Does soda increase obesity risk? A recent assessment published in PLoS One, a highly respected, peer-reviewed journal, showed that it depends whether studies were funded by the beverage industry or had no ties to any lobbying groups.(5) Study results were mirror images of each other: studies not affiliated with the industry show that soda may increase obesity risk, while studies funded by the beverage industry show there may not be any association.

In studies without beverage industry funding, greater than 80 percent (10 of 12) showed associations between sugary drinks and increased weight or obesity, whereas with the beverage industry-funded studies, greater than 80 percent of them did not show this result (5 of 6). The moral of the story is that patients must be diligent in understanding studies’ funding, and if the results sound odd, they probably are. If this is the case, make sure to ask your doctor about the studies’ findings. Not all studies are equally well-designed.

Diabetes and the benefits of fruit

Diabetes requires the patient to limit or avoid fruit altogether, correct? This may not be true. Several recent studies may help change the long-standing, commonly held paradigm that fruit should be restricted in patients with diabetes and to prevent development of diabetes.

One study found that whole fruit may reduce the risk of diabetes by reducing inflammation and reducing insulin resistance. (6) Specifically, results demonstrated a reduction in the inflammatory biomarker hsCRP. Ultimately, this may result in better glucose control. A potential reason for these impressive results may be the high levels of flavonoids, specifically anthocyanins and flavones. Flavonoids, as a class, are phytochemicals (plant nutrients) that provide pigment to fruits and vegetables and may have substantial antioxidant activities. Substances that are high in these two flavonoids include red grapes, berries, tea and wine.

Another study, a meta-analysis that looked at three large studies, including the Nurses’ Health Study, NHS II, and the Health Professionals Follow-up Study, showed that those who consumed the highest amount of anthocyanins were likely to experience a 15 percent reduction in the development of type 2 diabetes. (7) Researchers compared those in the highest quintile of anthocyanin consumption with those in the lowest quintile.

Specifically, at least two servings of blueberries per week were shown to reduce the risk of diabetes by 23 percent, and at least five servings of apples and pears per week were also shown to reduce the risk by 23 percent. These were compared to those who consumed less than one serving per month. This is a small amount of fruit for a significant reduction.

From the same three studies, it was also shown that grapes, bananas and grapefruit reduce the risk of diabetes, while fruit juice and cantaloupe may increase risk. (8)

In still another diabetes study, involving those who were newly diagnosed with type 2 diabetes, the risk of increasing glucose levels was no greater in those who consumed more than two servings of fruit per day compared to those who consumed fewer than two servings per day. (9) For more details on this study, please review my March 14, 2013, article, “Diabetes: looking beyond obesity to other factors.”

The properties of flavonoids, for example found in whole fruit, may also result in anticancer and anticardiovascular disease properties, the opposite of added sugars. (10)

Chronic disease incidence and complications from these diseases have skyrocketed in the last several decades. Therefore, any modifiable risk factor should be utilized to decrease our risk. By keeping added sugar to a minimum in our diets, we could make great strides in the fight to maintain our quality of life as we age.

We don’t have to avoid sugar completely; we still can satiate a sweet tooth by eating ripe fruits. Our access to fruit, even off-season, has expanded considerably. The most amazing thing is that fruit may actually reduce the risk of diabetes, something for years we thought might exacerbate it.

References: (1) 2010 Dietary Guidelines for Americans. (2) cdc.gov. (3) reuters.com. (4) JAMA Intern Med. online February 03, 2014. (5) PLoS Med. 2013 Dec;10(12):e1001578. (6) J Nutr. 2014 Feb;144(2):202-8. (7) Am J Clin Nutr. 2012 Apr;95(4):925-33. (8) BMJ. online August 29, 2013. (9) Nutr J. published online March 5, 2013. (10) Plant Foods Hum Nutr. 2004 Summer;59(3):113-22.

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 medicalcompassmd.com or consult your personal physician.

Testosterone is a hot topic in the news lately. Men are going through andropause or have unusually low testosterone (hypogonadism), or as it is most recently referred by the pharmaceutical industry: “Low T.” We are bombarded continually with ads suggesting that men should talk to their doctors about Low T. The formal name for treatment is androgen replacement therapy.

Is this all hype, or is this a serious malady that needs medical attention? The short answer is it depends on the candidate. The best candidates have deficient testosterone levels and are symptomatic.

The greatest risk factor for lower testosterone is age. As men age, the level of testosterone decreases. Respectively, 20, 30 and 50 percent of those who are in their 60s, 70s and 80s have total testosterone levels of less than 320 ng/dL. 1 However, some of the pharmaceutical ads would have you think that most men over 40 should seek treatment. Treatments include gels, transdermal patches and injections.

While real estate is all about “location, location, location,” with testosterone “caution, caution, caution” should be used.

Who are the most appropriate candidates for therapy? Those who have symptoms including lack of sexual desire, fatigue and lack of energy. However, what is scary is that around 25 percent of patients are getting scripts for testosterone without first testing their blood levels to determine if they have a deficiency.2 A simple blood test can measure total testosterone, as well as free and weakly bound levels at mainstream labs.

The number of testosterone scripts has increased threefold from 2001-11 for men more than 40 years old.3 Either we have discovered vast numbers of men with low levels or, more likely, marketing has caused the number of scripts to outstrip the need.

What are the risks and benefits of treating testosterone levels?

Is testosterone treatment really the fountain of youth?

There are benefits reported for those who actually have significantly deficient levels. Benefits may include improvements in muscle mass, strength, mood and sexual desire.4

However, several studies have recently suggested that testosterone therapy may increase the risk of cardiovascular disease, including stroke, heart disease and even death. These are obviously serious side effects. It also may cause acquired hypogonadism by shrinking the testes, resulting in a dependency on exogenous, or outside, testosterone therapy.

When testosterone is given, it may be important to also test PSA levels.5 If they increase by more than 1.4 ng/ml over a three-month period, then it may be wise to have a discussion with your physician about considering discontinuing the medication. You should not stop the medication without first talking to your doctor, and then a consult with an urologist may be appropriate. If the PSA is greater than 4.0 ng/ml initially, treatment should probably not be started without a urology consult.

How can you raise testosterone levels and improve symptoms without hormone therapy? Lifestyle changes, including losing weight, exercising and altering dietary habits, have shown promising results.

Let’s look at the evidence:

Cardiovascular risk

In the newest study, results showed that men were at significantly increased risk of experiencing a heart attack within the first three months of testosterone use.6 There was an overall 36 percent increased risk. When stratified by age, this was especially true of men who were 65 and older. This population had a greater than twofold risk of having a heart attack. The risk may have to do with an increased number of red blood cells with testosterone therapy. Those who were younger showed a trend toward increased risk, but did not meet statistical significance.

However, if the patient was younger than 65 and had heart disease, there was a significant twofold greater risk, but those without did not show risk. This does not mean there is no risk for those who are “healthy” and younger, it just means the study did not show it. This observational study compared over 50,000 men who received new testosterone scripts with over 150,000 men who received scripts for erectile dysfunction drugs: phosphodiesterase type 5 (PDE5) inhibitors, including tadalafil (Cialis) and sildenafil (Viagra). PDE5 inhibitors have not demonstrated this cardiovascular risk.

Unfortunately, this is not the only study that showed potential cardiovascular risks. Another recent study reinforces these results. In 2013, results showed that there was an increased risk of stroke, heart attack and death after three years of testosterone use.7 Ultimately, it found a 30 percent greater chance of cardiovascular events.

What is worse is that risk was significant in both those with a history of heart disease and those without. This was a retrospective study involving 1,200 men with a mean age of 60.

We need randomized controlled trials to make a more definitive association. Still, these are two large studies that suggest increased risk.

If you already have heart disease, be especially careful when considering testosterone therapy.

FDA response

As of Jan. 31, the FDA, which approved testosterone therapy originally, will now investigate the possible cardiovascular risk profile based on the above two studies.8 The FDA doesn’t suggest stopping medication if you are taking it presently, but it should be monitored closely. The agency, in the meantime, has issued an alert to doctors about the potential dangerous side effects of androgen replacement therapy. The FDA says that the use of testosterone therapy is for those with low levels and other medical issues, such as hypogonadism from either primary or secondary causes.

Obesity and weight loss

Not surprisingly, obesity is an important factor in testosterone levels. In a study that involved 900 men with metabolic syndrome — borderline or increased cholesterol levels, sugar levels and a waist circumference greater than 40 inches — those who lost weight were 50 percent less likely to develop testosterone deficiencies. Those who participated in lifestyle modification had a highly statistically significant 15 percent increase in testosterone.9 Also, when men increased their physical activity and made dietary changes, there was an almost 50 percent risk reduction one year out, compared to their baseline at the start of the trial.

Interestingly, metformin had no effect in preventing lower testosterone levels in patients with abnormal sugar levels, but lifestyle modifications did. These patients were relatively similar to the average American biometrics with prediabetes: HbA1c of 6 percent and glucose of 108 mg/dL; a mean of 42-inch waists; and a BMI that was obese at 32 kg/m2. The mean age was between 53 and 54.

If there is one thing that you get from this article, I hope it’s that testosterone is not something to be taken lightly. You can improve testosterone levels if you’re overweight by losing fat pounds. If you think you have symptoms and you might need testosterone, talk to your doctor about getting a blood test before you do anything. It may be preferable to try alternate medications that improve erections such as sildenafil and tadalafil.

References:

1 J Clin Endocrinol Metab. 2001 Feb;86(2):724. 2 J Clin Endocrinol Metab. Online 2014; Jan 1. 3 JAMA Intern Med. 2013 Aug 12;173(15):1465-6. 4 J Clin Endocrinol Metab. 2000 Aug;85(8):2839. 5 UpToDate.com. 6 PLoS One. 2014 Jan 29; 9(1):e85805. 7 JAMA. 2013;310:1829-1836. 8 FDA.gov. 9 ENDO 2012; Abstract OR28-3.

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.

The brain has to be the most important and complex organ, yet what we know about the brain is inverse to its prominence. In other words, our knowledge only scratches the surface. While other organs can be transplanted readily, it is the one organ that can’t, at least not yet.

The brain also has something called the blood-brain barrier. This is an added layer of small, densely packed cells, or capillaries, that filter what substances from the blood they allow to pass through from the rest of the body (1). This is good, since it protects the brain from foreign substances; however, on the downside, it also makes it harder to treat, because many drugs and procedures have difficulty penetrating the blood-brain barrier.

Unfortunately, there are many things that negatively impact the brain, including certain drugs, head injuries and lifestyle choices. There are also numerous disorders and diseases that affect the brain, including neurological (dementia, Parkinson’s, stroke); infection (meningitis); rheumatologic (lupus and rheumatoid arthritis); cancer (primary and secondary tumors); psychiatric mood disorders (depression, anxiety, schizophrenia); diabetes; and heart disease.

These varied diseases tend to have three signs and symptoms in common: they either cause an alteration in mental status; cognitive decline, weakness or change in mood; or a combination of these.

Probably our greatest fear regarding the brain is cognitive decline. We have to ask ourselves if we are predestined to this decline, either because of the aging process alone or because of a family history, or if there is a third option, a way to alter this course. Dementia, whether mild or full-blown Alzheimer’s, is cruel; it robs us of functioning. We should be concerned about Alzheimer’s because 5.2 million Americans have the disease, and it is on the rise, especially since the population is aging (2).

Fortunately, there are several studies that show we may be able to choose the third option and prevent cognitive decline by altering modifiable risk factors. They involve rather simple lifestyle changes: sleep and exercise and possibly omega-3s. Let’s look at the evidence.

The impact of clutter

The lack of control over our mental capabilities as we age is what frightens us the most since we see friends, colleagues and relatives negatively affected by it. Those who are in their 20s seem to be much sharper and quicker. But are they really?

In a recent study, German researchers found that educated older people tend to have a larger mental database of words and phrases to pull from since they have been around longer and have more experience (3).  When this is factored into the equation, the difference in terms of age-related cognitive decline becomes negligible.

This study involved data mining and creating simulations. It showed that mental slowing may be at least partially related to the amount of clutter or data that we accumulate over the years. The more you know, the harder it becomes to come up with a simple answer to something.

We may need a reboot just like a computer. This may be possible through sleep and exercise and omega-3s.

Sleep

I have heard people argue that sleep gets in the way of life. Why should we have to dedicate 33% of our lives to sleep? There are several good reasons. One involves clearing the mind, and other involves improving our economic outlook.

For the former, a recent study shows that sleep may help the brain remove waste, such as those all-too-dangerous beta-amyloid plaques (4). When we have excessive plaque buildup in brain, it may be a sign of Alzheimer’s. This study was done in mice. When mice were sleeping, the interstitial space (the space between brain gyri, or structures) would increase by as much as 60 percent.

This allowed the lymphatic system, with its cerebrospinal fluid, to clear out plaques, toxins and other waste that had developed during waking hours. With the enlargement of the interstitial space during sleep, waste removal was quicker and more thorough because cerebrospinal fluid could reach much further into the spaces. When the mice were anesthetized, a similar effect was seen as with sleeping. Interestingly, the follow-up study may be done in collaboration with Helene Benveniste, M.D., an anesthesiologist at Stony Brook University Hospital.

In the second study, done in Australia, results showed that sleep deprivation may have been responsible for an almost 1 percent decline in gross domestic product for the country (5). The reason is obvious: people are not as productive at work when they don’t get enough sleep. Their attitude tends to be more irritable, and concentration may be affected. We may be able to turn on and off sleepiness on an acute, or short-term, basis, depending on the environment, but it’s not as if we can do this continually.

According to the Centers for Disease Control, 4 percent of Americans have fallen asleep in the past month behind the wheel of a car (6). I hope this hammers home the importance of sleep.

Exercise

How can I exercise, when I can’t even get enough sleep? Well there is a study that just may inspire you to exercise.

In the study, which involved rats, those that were not allowed to exercise were found to have rewired neurons in the area of their medulla, the part of the brain involved in breathing and other involuntary activities. There was more sympathetic (excitatory) stimulus that could lead to increased risk of heart disease (7). In those rats that were allowed to exercise regularly, there was no unusual wiring, and sympathetic stimuli remained constant. This may imply that being sedentary has negative effects on both the brain and the heart.

This is intriguing, since we used to think that our brain’s plasticity, or ability to grow and connect neurons, was finite and stopped after adolescence. This study’s implication is that a lack of exercise causes unwanted new connections. Of course, these results were done in rats and need to be studied in humans before we can make any definitive suggestions.

Omega-3 fatty acids

In the Women’s Health Initiative Memory Study Magnetic Resonance Imaging Study, results showed that those postmenopausal women who were in the highest quartile of omega-3 fatty acids had significantly greater brain volume and hippocampal volume than those in the lowest quartile (8). The hippocampus is involved in memory and cognitive function.

Specifically, the researchers looked at the level of omega-3 fatty acids, called eicosapentaenoic acid and docosahexaenoic acid, in red blood cell membranes. The source of the omega-3 fatty acids could either have been from fish or supplementation. This was not delineated. The researchers suggest eating fish high in these substances, such as salmon and sardines, since it may not even be the omega-3s that are playing a role, but some other substances in the fish.

It’s never too late to improve brain function. You can still be sharp at a ripe old age. Although we have a lot to learn about the functioning of the brain, we know that there are relatively simple ways we can positively influence it.

References: (1) medicinenet.com. (2) alz.org. (3) Top Cogn Sci. 2014 Jan.;6:5-42. (4) Science. 2013 Oct. 18;342:373-377. (5) Sleep. 2006 Mar.;29:299-305. (6) cdc.gov. (7)J Comp Neurol. 2014 Feb. 15;522:499-513. (8) Neurology. 2014;82:435-442.

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 medicalcompassmd.com and/or consult your personal physician.