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Residents participate in a CDC survey to accumulate data on health and diets of Americans. Photo by Alex Petroski

By Alex Petroski

Suffolk County residents will play an important role in improving the health of their fellow Americans in 2017. The Centers for Disease Control and Prevention selected Suffolk as one of 15 counties nationwide to participate in its annual National Health and Nutrition Examination Survey, a data collection study that is used to draw conclusions about the health and diets of people in the United States.

The CDC is the nation’s health protection agency, conducting research in the hopes of preventing the spread of diseases and tracking their prevalence. The NHANES is a 55-year-old program that tracks health and diet trends in the U.S. by selecting counties based on demographics with the goal of accumulating a set of data representative of the entire population of the country.

Three CDC trailers will spend about six weeks parked in Stony Brook’s Research and Development Park to study Suffolk County residents. Photo from CDC

This is the second time Suffolk was observed as part of the survey since the turn of the century, according to study manager Jacque DeMatteis. The CDC arrived April 29 at Stony Brook University’s Research and Development Park in three mobile trailers outfitted with dozens of pieces of medical equipment, researchers and physicians to begin assessments on the approximately 600 Suffolk residents selected.

“It’s important because right now we’ve got all of these miracles happening with cancer research and things like that, without information that people help us to provide — a lot of it comes from here — [researchers] don’t have anything to draw on,” DeMatteis said of the purpose of the yearly survey during a tour of the CDC mobile facility May 19.

Charles Rothwell, director of the National Center for Health Statistics, reiterated the importance of accumulating the data in a statement.

“The survey is a unique resource for health information, and without it we would lack important knowledge about major health conditions,” he said. “The comprehensive data collected by NHANES has a far-reaching and significant impact on everything from the quality of the air we breathe, to the vaccinations you get from your doctor, to the emergence of low-fat and ‘light’ foods on the shelves of your grocery store.”

A young participant in the study is measured. Photo from CDC

The process for selecting participants within a county begins with about 1,500 addresses, and interviewers scour the area in the hopes of securing about 600 willing participants who also provide a representative sample of age ranges, genders, races and ethnicities and degrees of health. The selected participants who are willing to be examined then visit the mobile facility to be subjected to a variety of tests of blood pressure, diet, dental/oral health, vision and hearing, bone density, liver function and much more using high-tech scans not often available through traditional physicians.

DeMatteis made the case for selected participants making the trip to be studied despite some minor possible inconveniences.

“For the people who participate, they get their results back,” she said. “If anything abnormal comes up they’re contacted immediately. Our national health officer will contact them and we’ve had a couple of situations where it was kind of life-threatening situations and they were totally unaware of it.”

Participating adults also receive $125, reimbursement for travel expenses and the opportunity to receive credit for five hours of community service. Newborns and up are required for data collection, though specific scans and tests are not done uniformly across age groups.

“A lot of people do it for the exams, and in the past even more people had no means to get access to health care, so they came here because they’re going to get a whole lot of data about their health that they otherwise can’t afford to get,” DeMatteis said.

No medical procedures are offered at the site, though on occasion physicians are forced to recommend immediate treatment if anything concerning appears as a result of a test. Patients are also allowed to pick and choose which tests they’d like to participate in of the ones they qualify for. The CDC urges anyone selected to participate in the survey.

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Chris Zenyuh.
Chris Zenyuh.

I have had the privilege of teaching high school science (biology, chemistry and physics) for the last thirty years. For the last ten years, I’ve had the additional privilege and responsibility of developing and teaching an elective we simply call “Food Science.” It’s not your usual health class dietary guidelines, nor does it rehash the familiar mantras of counting calories and exercising to balance intake. Instead, we study the cultural, historical, scientific, political and economic contexts of our food system and how that system impacts our environments, both external and internal. This in turn enables students to make much more informed decisions about what they want to put in their bodies.

When it comes to sugars, confusion is the name of the game. There are dozens of ingredients that mark the presence of sugars in our food: maltodextrin, dextrose, invert sugar, cane sugar, high fructose corn syrup and starch, to name a few. Regardless of what the food industry calls them, your body sees basically three end products of their digestion: glucose, fructose and galactose. Which ones you eat, and how much, will dictate both their value and their danger to you.

You may have heard of three additional sugars — lactose, sucrose and maltose. Lactose is a combination of one glucose and one galactose. Also known as “milk sugar,” lactose is the nemesis of lactose-intolerant individuals who lack sufficient quantities of the enzyme that can digest it. Instead, bacteria that reside in their intestines get to process it, making painful amounts of gas as a by-product. Galactose can be converted to glucose in your body, but most individuals do not consume enough dairy to make this a source of concern.

Maltose is another type of sugar. It is a pairing of two glucose units and is the namesake for maltodextrin, etc. Consuming foods with maltose adds glucose to your diet — worth keeping track of as part of your total glucose consumption.

However, the most likely source of sugars in your diet is either sucrose or high fructose corn syrup. Sucrose, known also as table sugar, can be derived from sugar cane (cane sugar) or sugar beets (sugar.) Like lactose and maltose, sucrose is a paired structure, made of one glucose subunit and one fructose subunit. That is what your body absorbs regardless of the source (even organic.)

Sparing you the science behind its production, high fructose corn syrup is approximately half glucose, and half fructose too. Regardless of the marketing efforts by the Sugar Association and the Corn Refiners Association to make you believe one is better for you than the other, they end up, metabolically, in a virtual tie. Debating which to consume is a distraction from the consequences of consuming too much of either, or both.

Stock photo.

The consumption of sugar (the term is legally owned by the Sugar Association as the sole name for sucrose) used to be limited by the relative expense and difficulty in obtaining it from its tropical source. Now the record levels of corn production in America have made it relatively cheap to produce and distribute sugar’s nearly identical-tasting competitor, high fructose corn syrup. You can find it in soda for sure, but also in pickles, peanut butter, ketchup and pretty much anywhere sugar might be used for additional appeal to consumers.

This has paved the way for the combined consumption of these sweeteners to reach more than 150 pounds per year per person in America. This far surpasses the 60 pounds per year considered by some experts to be the maximum amount that can be metabolized without ill consequences including diabetes, cardiovascular disease, fatty liver, cataracts, personality and cognitive dysfunction, some cancers and (by the way) obesity.

Tying glucose and fructose consumption to the metabolic consequences noted above requires further discussion. And now, you are properly prepared for those lessons. As we say in Food Science class, “Chow!”

Chris Zenyuh is a science teacher  at Harborfields High School and has been teaching for 30 years.

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Here we are, in a new year, and I am going to start off with a cautionary tale. I was just about to take a shower when I felt a small bump on my left thigh. I thought that was strange since I hadn’t before felt anything there but it was just beyond my view as I fingered the spot and craned my neck to try and see. Then, to my amazement, the bump came off in my hand, revealing itself to be a tick. Ugh!

The legs were moving so it was clearly alive and rather large, so I guessed it was a dog tick. With wonderful coincidence, I happened to have an appointment with the dermatologist that afternoon, so I put the tick into a little plastic baggie and brought him this present. Although I half expected him to just throw it away, he in fact filled out the paperwork and sent it to a lab.

Now I am sharing this with you because I suspect that, like me, you thought tick season had ended with the start of winter. I even stopped putting Frontline on my golden retriever, figuring any ticks would have gone into hibernation or been killed off by the colder weather. But I should have realized that the calendar and the weather aren’t always in sync. We have been enjoying fairly mild temperatures for this time of year and, as it turned out, so have the ticks.

Now I don’t know if the tick fancied me rather than my dog, or if he just found me as I was walking across the lawn or brushing against a bush while putting out the garbage. However it happened, I was, so to speak, stuck with him until that lucky moment when my fingers brushed against his body. Anyway, I got a call from the doctor four days later with the surprising news that despite its large size, the critter was an engorged deer tick.

Not good. We all know that deer ticks can carry Lyme disease and transmit it to humans when they suck up to you. We have had several deer sightings in the neighborhood, especially around a wooded piece of property nearby. To me they are beautiful, graceful animals, and I watch them with admiration as they run. But I certainly don’t appreciate the bugs they can bring and leave behind as a souvenir of their visits.

The doctor asked me if I preferred waiting for the blood test, six weeks away, to determine if in fact I had been infected or if I wanted to go on the antibiotic regime immediately. I chose the latter and began taking 100 mg of doxycycline, with lots of water but no food as seriously instructed, every 12 hours. But the story doesn’t end there.

After only two pills, I developed a headache that just wouldn’t quit. This is apparently a not uncommon side effect with this medicine. So I was then transferred to 500 mg of amoxicillin three times a day for at least 20 days and advised also to take a daily probiotic, though not within two to three hours of each other, and to eat lots of yogurt. As we know, that only partially works to offset the distress to the gastrointestinal tract that accompanies regular doses of antibiotics. Plus I have broken out in splotches of itchy rashes, another unhappy side effect.

Bottom line: A tick bite can be a nasty thing, bringing along all sorts of minor and even major miseries. So from my experience, I hope you will check your skin regularly, even hard to see places, and not assume that a tick is just another summer pest.

Oh, by the way, Happy New Year!

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Do you ever feel lonely? I’m not referring to an occasional time period when you might acutely feel alone. After awhile that loneliness passes as you get busy with making dinner or driving out purposefully to go food shopping. I’m talking about deep-seated, unremitting loneliness, where a person doesn’t leave his or her house most of the time and doesn’t think to call a friend. Perhaps the person is quite elderly and has outlived friends. Or perhaps that person struggles with depression and keeps to himself or herself, exacerbating the loneliness.

From what I have read lately, loneliness is not a good thing for one’s health. Indeed one of the recommendations for longevity is an active social circle. Whatever the age, loners in our society come to be suspect. People need to socialize and interact, or so the thinking goes.

There are statistics that correlate good health with a satisfying social life, particularly as we age. For some, this is easy. If a person is naturally outgoing, the fact that the world is filled with other people presents its own solution. One can get a part-time job, even if retired, and that usually brings along its own social structure, plus a few extra bucks. Sometimes part-time work isn’t so easy to find, but there are always groups that are grateful for a volunteer: hospitals, schools, churches, even businesses. We are forever running a classified ad asking for volunteers who might find it interesting and fun to work at a hometown newspaper, and we are seldom without someone, usually someone wonderful.

Because we live on an island that has many colleges and universities, there are always academic opportunities to avail oneself of, like the Osher Lifelong Learning Institute — formerly known as the Round Table — at Stony Brook University. There are a great variety of courses, including subjects one might have always wondered about but have been too busy to pursue.

Another source of learning and information is the neighborhood library, many of which offer courses, from understanding opera to understanding computers, at a nominal fee. By enrolling in some interest group or subject, one is likely to meet others with the same interests and perhaps strike up a friendship. At the very least, one can become a little smarter or at least a bit more knowledgeable.

That’s just a few social possibilities. But they require active seeking, and not everyone is blithely outgoing and comfortable in new situations. So what then?

My husband was shy pretty much all his life, but he discovered a way for the world to reach out to him. When he wasn’t working, he loved to take pictures. Behind the camera, he could be bold and interact with anyone who might be doing something that interested him. We ran many of his photographs in the newspaper, and readers appreciated the sense of place that the pictures conveyed and also contacted him with comments.

Eventually he was even invited by an art gallery to put up an exhibit of some of his favorite photos. I don’t have to tell you how he loved that and appreciated the feedback from the viewers. Now granted, not everyone has a wife with a newspaper, but it is my experience that most hometown newspapers will eagerly accept photos if they are reasonably good — and free.

Again, though, that sort of hobby takes a certain amount of initiative. Fortunately we live at a time when the need to reach out to those who may be struggling with loneliness has eventuated in a number of help groups, especially in Britain. There are centers in the U.K. manned by people, sometimes volunteers, who are there to lend a kind ear to those who call in to chat. The volunteers provide a valuable service in what has come to be seen as a public health issue. Sometimes these are trained and paid workers. Even fire brigades have been trained to recognize signs of isolation during their fire inspections. We should be sensitive to this most human need and do no less here.

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Prevention and treatment improve outcome

By David Dunaief, M.D.

Cataracts are incredibly common; about 50 percent of Americans will have a cataract or have had cataract surgery by age 80 (1). Cataracts, the nuclear type, reduce visual acuity in an insidious process. Cataract surgery can resolve this, reducing the risk of falls and hip fracture. At the same time, it can reduce pressure in the eye.

Interestingly, research suggests that a diet rich in carotenoids may prevent the occurrence of cataracts. However, statins may have the reverse effect by increasing risk.

Let’s look at the evidence.

Cataract surgery and hip fracture

In one study, elderly cataract patients who underwent surgery were significantly less likely to experience a hip fracture during a year of follow-up than those who did not have surgery (2). This was a retrospective (backward-looking) observational study, and its size was considerable, with over one million patients ages 65 and older. The results showed a 16 percent reduction in the risk of hip fractures overall. Those who were older, between ages 80 and 84, had the most to gain, with a 28 percent reduction in hip fracture risk.

The increased fall risk and subsequent hip fracture risk among those with cataracts result from decreases in visual acuity and depth perception and a reduction in visual field that accompany cataracts (3). Hip fractures have a tremendous impact on the ability of elderly patients to remain independent. Many of these patients do not regain their prior mobility. Thus, avoiding hip fractures is the best strategy.

Cataract surgery and intraocular pressure

Yet another benefit of cataract surgery is the potential reduction in intraocular pressure (IOP). Why is intraocular pressure (pressure within the eye) important? High IOP has been associated with an increased risk of glaucoma.

A comparative case series (looking at those with and without cataract surgery) utilizing data from the Ocular Hypertension Treatment Study showed that those cataract patients with ocular hypertension (higher than normal pressure in the eye) who underwent cataract surgery saw an immediate reduction in IOP (4). This effect lasted at least three years. The removal of the cataract lowered the IOP by 16.5 percent from 23.9 mm Hg to 19.8 mm Hg. This is close to the low end of glaucoma treatments’ pressure reduction goals, which are 20 to 40 percent. Therefore, cataract surgery may be synergistic with traditional glaucoma treatment.

Cataract surgery and macular degeneration risk

There has been conflicting information in recent years about whether cataract surgery increases the risk of age-related macular degeneration (AMD) progression. A 2009 study suggested that, rather than increasing AMD risk, cataract surgery may uncover underlying AMD pathology that is hidden because the cataract obfuscates the view of the retina (back of the eye) (5). The study’s strengths were the use color retinal photographs and fluorescein angiography (dye in blood vessels of eye), both very thorough approaches.

Cataract prevention with dietary carotenoids

Diet may play a significant role in prevention of cataracts. In the Women’s Health Initiative Observational Study, carotenoids, specifically lutein and zeaxanthin, seem to decrease cataract risk by 23 percent in women with high blood levels of carotenoids, compared to those with low blood levels (6). In fact, those in the highest quintile (the top 20 percent) had an even more dramatic 32 percent risk reduction when compared to those in the bottom quintile (the lowest 20 percent).

As the authors commented, it may not have been just lutein and zeaxanthin. There are more than 600 carotenoids, but these were the ones measured in the study. Some of the foods that are high in carotenoids include carrots, spinach, kale, apricots and mango, according to the USDA. Interestingly, half a cup of one of the first three on a daily basis will far exceed the recommended daily allowance. Thus, it takes a modest consistency in dietary carotenoids to see a reduction in risk.

Vitamin C effect

The impact of vitamin C on cataract risk may depend on the duration of daily consumption. In other words, 10 years seems to be the critical duration needed to see an effect. According to one study, those participants who took 500 mg of vitamin C supplements for 10 or more years saw a 77 percent reduction in risk (7). However, only very few women achieved this goal in the study, demonstrating how difficult it is to maintain supplementation for a 10-year period.

Those who took vitamin C for fewer than 10 years saw no effect in prevention of cataracts. In the well-designed Age-Related Eye Disease Study, a randomized controlled trial, the gold standard of studies, those who received 500 mg of vitamin C supplements along with other supplements did not show any cataract risk reduction, compared to those who did not receive these supplements (1). There were 4,629 patients involved in the cataract study with a duration of 6.3 years of daily supplement consumption. Therefore, I would not rush to take vitamin C as a cataract preventative.

Statin use

Statins have both positive and negative effects, and the effect on the eyes according to one sizable study is negative. In the Waterloo Eye Study with over 6,000 participants, those patients taking statins were at a 57 percent increased risk of cataracts (8). Diabetes patients saw an increased risk of cataracts as well. And in diabetes patients, statins seem to increase the rate at which cataracts occurred.

The authors surmise that this is because higher levels of cholesterol may be needed for the development of epithelial (outer layer) cells and transparency of the lens. This process may be blocked with the use of statins. Before considering discontinuing statins, it is important to weigh the risks with the benefits.

Thus, if you have diminished vision, it may be due to cataracts. It is important to consult an ophthalmologist for diagnosis and, perhaps, cataract surgery, which can reduce your risks of falls, hip fractures and intraocular pressure. For those who do not have cataracts, a diet rich in carotenoids may significantly reduce their risk of occurrence.

References:

(1) nei.nih.gov. (2) JAMA. 2012;308:493-501. (3) J Am Geriatr Soc. 2009 Oct;57(10):1825-1832. (4) Ophthalmology. 2012;119:1826-1831. (5) Arch Ophthalmol. 2009;127:1412-1419. (6) Arch Ophthalmol. 2008;126(3):354-364. (7) Am J Clin Nutr. 1997 Oct;66(4):911-916. (8) Optom Vis Sci 2012;89:1165-1171.

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, visit www.medicalcompassmd.com or consult your personal physician.

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Stock photo

Nineteen more mosquitoes and two birds have tested positive for West Nile virus in various neighborhoods across Suffolk County, Health Commissioner Dr. James L. Tomarken announced on Monday.

The mosquito samples, collected from Aug. 17 to 19, hailed from: Lindenhurst, West Babylon, Northport, Huntington Station, South Huntington, Greenlawn, Commack, Nesconset, Smithtown, Saltaire on Fire Island, Port Jefferson, Farmingville, Holtsville, Yaphand, Southold and East Hampton. Two blue jays collected on Aug. 14 from Stony Brook and a blue jay collected on Aug. 24 and Aug. 25 from Smithtown, also tested positive for the virus.

“The confirmation of West Nile virus in mosquito samples or birds indicates the presence of West Nile virus in the area,” Tomarken said. “While there is no cause for alarm, we urge residents to cooperate with us in our efforts to reduce the exposure to the virus, which can be debilitating to humans.”

To date, this year Suffolk’s total West Nile count comes to 99 mosquitoes and seven birds. No humans or horses have tested positive for the virus in Suffolk this year.

First detected in birds and mosquito samples in Suffolk in 1999, and again each year thereafter, the virus is transmitted to humans by the bite of an infected mosquito.

While Dr. Tomarken said there’s no cause for alarm, the county is urging residents to reduce exposure to the virus, which “can be debilitating to humans.”

“The breed of mosquito known as culex pipiens/restuans lay their eggs in fresh water-filled containers, so dumping rainwater that collects in containers around your house is important,” he said.

Residents should try to eliminate stagnant water where mosquitoes breed, in order to reduce the mosquito population around homes. That includes: disposing of tin cans, plastic containers, ceramic pots or similar water-holding containers; removing discarded tires; cleaning clogged gutters; turning over plastic wading pools and wheelbarrows when they’re not being used; changing the water in bird baths; and draining water from pool covers

Most people infected with West Nile will experience mild or no symptoms, but some can develop severe symptoms, including high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, vision loss, numbness and paralysis. The symptoms may last several weeks and neurological effects may be permanent. Individuals, especially those 50 years of age or older or those with compromised immune systems, who are most at risk, are urged to take precautions to avoid being bitten by mosquitoes.

Residents are advised to avoid mosquito bites by: minimizing outdoor activities between dusk and dawn; wearing shoes and socks, long pants and long-sleeved shirts when outdoors for long periods of time or when mosquitoes are more active; using mosquito repellent when outdoors, following label directions carefully; and making sure all windows and doors have screens and that all screens are in good condition.

To report dead birds, call the West Nile virus hot line in Suffolk County at 631-787-2200 from 9 a.m. to 4 p.m., Monday through Friday. Residents are encouraged to take a photograph of any bird in question.

To report mosquito problems or stagnant pools of water, call the Department of Public Works’ Vector Control Division at 631-852-4270.

For medical questions related to West Nile virus, call 631-854-0333.

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Eugene the hedgehog is enjoying a new diet to help him lose weight. Photo by Rachel Siford

By Rachel Siford

Even hedgehogs need to watch their calories.

Nesconset native Brianna Stiklickas went from being an extreme soccer player with recruitment offers from 40 different colleges to starting her own business to benefit her beloved exotic pet. The 22-year-old college sophomore and The Stony Brook School graduate recently celebrated a successful Kickstarter campaign in which she raised more than $12,000 to boost her new business, Meet Eugene, named after her hedgehog.

A severe leg injury forced her to the sidelines, but it was a blessing in disguise as Stiklickas found a new passion: to save Eugene from what his veterinarian diagnosed as severe obesity in the 3-year-old African pygmy hedgehog.

“Once I stopped being so heavy-duty with the sports, I really started to get into my academics,” Stiklickas said. “That’s when I first came up with the idea of Meet Eugene, an exotic pet food company.”

Her breeder originally said to feed Eugene high-quality cat food, as most hedgehog owners do, but through a lot of research, Stiklickas said she realized that it causes issues like obesity — one of the top health problems in hedgehogs. Hedgehogs typically live about four to six years, but if fed properly and taken care of, can live to up to nine. And with hopes of pushing that number, Stiklickas started an Instagram account called Meet Eugene months before she even decided to start her own company. All of a sudden, she found herself with 700 followers and counting; thus the name of her company was born. Today she has more than 1,200 followers.

She formulated HealthHog, a grain-free hedgehog food fortified with vitamins and minerals to support the hedgehog’s digestive and immune system, rather than a cat or dog’s.

“Just because something is a premium price, doesn’t mean it is a premium product,” Stiklickas said. “And I found that out the hard way.”

Stiklickas went to Babson College, one of the top schools in the country for entrepreneurship, where she learned to develop her company in class with the help of her professors and classmates.

Brianna Stiklickas and her pet, Eugene, spend quality time together. Photo by Rachel Siford
Brianna Stiklickas and her pet, Eugene, spend quality time together. Photo by Rachel Siford

“Throughout college, I worked five jobs, was on two sports teams, was a full-time student and was starting a business, so being able to use my company in class really benefitted me,” Stiklickas said.

She researched hedgehogs for two years with veterinarians, then moved on to market research when she sent out surveys to hedgehog communities online and to breeders. Stiklickas started looking on the market for hedgehog foods, and the few she found had ingredients that were not healthy, like blood meal, which is indigestible by most animals.

She made Eugene’s food from scratch and saw what he did well on, then worked with a food scientist to see if she could get it ready to manufacture. Since she put her hedgehog on this new diet, he started shedding the weight.

Stiklickas recently achieved her goal of $12,000 from her Kickstarter campaign, so she can manufacture and sell HealthHog, which she hopes to have ready in about four months.

“I want a food that’s actually made for them and not just made for profit,” Stiklickas said. “I realized how much of an issue it really was across the nation.”

With help from her classes as well as two start-up incubators, WIN Lab and Babson Summer Venture Program, she developed three parts to her company.

First, she has “For the Pet,” which includes the HealthHog food, accessories, cages and toys she is developing currently. Then, she has “For the Owner,” which will be a lifestyle brand for owners. And lastly, she has the “Education” section, which includes Meet and Greets, educational programing, and 4 children’s books she also wrote while at Babson.

She said she plans to host educational programs at libraries and schools to teach children and their parents how exotic animals, like hedgehogs, sugar gliders, chinchillas and prairie dogs, are as pets.

“A huge part of my company is not just trying to improve the lives of these animals, but is also trying to educate people so they know how to treat the animals,” Stiklickas said.

Stiklickas reminisced back to when she was little and used to make up companies. At first, she said, she wanted to do marketing, then finance. She later realized that entrepreneurship combined all the things she loved to do.

Working for five different startups throughout college also encouraged her that she had what it took.

“As much as I thought about starting my own company, I never thought I’d do it,” Stiklickas said.

Stiklickas’ dream, she said, is to do this full time and open the next exotic pet brand, but unfortunately she might have to take a job eventually because of college loans.

“Entrepreneurship is a lifestyle; it definitely takes a special type of person to work everyday on a company that may or may not be successful,” Stiklickas said.

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Suffolk officials discuss environmental issues facing Long Island after thousands of dead fish washed ashore in Riverhead. Photo by Alex Petroski

The estimated nearly 100,000 dead bunker fish that have washed ashore in Riverhead may seem astounding, but it wasn’t all that surprising to the panel of experts brought before the Suffolk County Health Committee on Thursday.

In late May, the thousands of dead bunker fish, formally known as Atlantic menhaden fish, began appearing in the Peconic Estuary, an area situated between the North and South Forks of Long Island. According to a June 2 press release from the Peconic Estuary Program, the bunker fish died as a result of low dissolved oxygen in the water. This shortage of oxygen is called hypoxia.

Walter Dawydiak, director of the county’s environmental quality division, who serves on the panel, which was organized by the health committee chairman, Legislator William “Doc” Spencer (D-Centerport), testified that the number of dead fish was at or approaching 100,000.

“This one is bigger and worse than any,” Dawydiak said.

According to the PEP, which is part of the National Estuary Program and seeks to conserve the estuary, bunker are filter-feeding fish and an important food source for many predatory fish, including striped bass and blue fish.

Alison Branco, the program’s director, said the fish are likely being chased into shallow waters by predators, but are dying because of low dissolved oxygen levels in the waters. In addition, an algae bloom is contributing to the low levels and is fueled by excess nitrogen loading. Much of that nitrogen comes from septic systems, sewage treatment plants and fertilizer use.

“We’ve reach a point where this kind of hypoxia was run of the mill. We expect it every summer,” Branco, who also served as a panelist, said following the hearing.

While magnitude of the fish kill was astounding, the experts said they weren’t so surprised that it happened.

“I definitely thought it could happen at any time,” Christopher Gobler, a biologist at Stony Brook University, said in a one-on-one interview after the panel hearing. “There’s been an oxygen problem there all along.”

Gobler called it largest fish kill he’d seen in 20 years.

According to panel members, the worst of the fish kill occurred between May 27 and May 30.

Branco did suggest that this shocking environmental event could be turned into a positive if the right measures are taken sooner rather than later.

“It’s always shocking to see a fish kill,” she said. “As much as we don’t want to have things like that happen I think the silver lining is that it did capture the public’s attention.”

Prevention of a fish kill this large is possible, according to Branco. While preventing the harmful algal blooms is not possible, reducing the frequency and severity can be done if the amount of nitrogen in the coastal water supply is controlled.

Adrienne Esposito, executive director of Citizens Campaign for the Environment, an environmental policy advocacy group, agreed that curtailing the amount of nitrogen in the water is the easiest and most impactful way for prevention of a fish kill of this magnitude.

“The journey of a thousand miles starts with the first step,” Esposito said in response to a question about the daunting task of fixing the Island’s sewage treatment techniques and facilities on a limited budget.

Esposito described the roughly $5 million from New York State, which was allotted to Suffolk County to deal with cleaning the coastal water supply, as seed money. Esposito and Branco both said they believe the commitment of time and money required to solve the nitrogen problem in the water supply will be vast.

“We can do this,” she said. “We have to do it. We have no choice.”

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It is very interesting that the amount of coverage by the lay press concerning thyroid nodules does not reflect the number of people who actually have them. In other words, more than 50 percent of people have thyroid nodules detectable by high resolution ultrasound (1); however, when I searched the New York Times website, the last time it wrote about them was in 2010.

Regardless, you can understand how coverage should be more in the forefront. Fortunately, most nodules are benign. A small percent, 4 to 6.5 percent, are malignant, and the number varies depending on the study (2). Thyroid nodules are being diagnosed more often incidentally on radiologic exams, such as CT scans of the chest, MRI scans, PET scans and ultrasounds of the carotid arteries in the neck (3).

There is a conundrum of what to do with a thyroid nodule, especially when it is found incidentally. It depends on the size. If it is over one centimeter, usually it is biopsied by fine needle aspiration (FNA) (4). This is the cutoff point for asymptomatic nodules found with a radiologic exam. Most are asymptomatic. However, if there are symptoms, these might include difficulty swallowing, difficulty breathing, hoarseness, pain in the lower portion of the neck and a goiter (5).

FNA biopsy is becoming more common. In a recent study evaluating several databases, there was a greater than 100 percent increase in thyroid FNAs performed over a five-year period from 2006 to 2011 (6). This resulted in a 31 percent increase in thyroidectomies, surgeries to remove the thyroid partially or completely.

However, the number of thyroid cancers diagnosed with the surgery did not rise in this same period. To make matters even more confusing, from 2001 to 2013, the number of thyroid cancers increased by 200 percent.

The study authors call for a need for more detailed guidelines, which are lacking for thyroid nodules.

Though the number of cancers diagnosed has increased, the mortality rate has remained relatively stable over several decades at about 1,500 patients per year (7). Thyroid nodules in this study were least likely to be cancerous when the initial diagnosis was by incidental radiologic exam.

DIFFERENTIATING WHEN FINE NEEDLE ASPIRATION RESULTS ARE INDETERMINATE
As much as 25 percent of FNA biopsies are indeterminate. We are going to look at two modalities to differentiate between benign and malignant thyroid nodules when FNA results are equivocal: a PET scan and a molecular genetics test. A meta-analysis (a group of six studies) of PET scan results showed that it was least effective in resolving an unclear FNA biopsy. The PET scan was able to rule out patients who did not have malignancies significantly but did not do a good job of identifying those who did have cancer (8).

On the other hand, a recent molecular-based test was able to potentially determine whether an indeterminate thyroid nodule by FNA was malignant or benign (9). This test was a combination of microRNA gene expression classifier with the genetic mutation panel. I know the test combination sounds confusing, but the important takeaway is that it was more effective than previous molecular tests in clarifying whether a patient had a benign or cancerous nodule.

Unlike in the PET scan study above, the researchers were able to not only rule out the majority of malignancies but also to rule them in. It was not perfect, but the percent of negative predictive value (ruled out) was 94 percent, and the positive predictive value (ruled in) was 74 percent. The combination test improved the predictive results of previous molecular tests by 65 to 69 percent. This is important to help decide whether or not the patient needs surgery to remove at least part of the thyroid. The trial used hospital-based patients, but follow-up studies need to include community-based practices.

IS A NEGATIVE FINE NEEDLE ASPIRATION DEFINITIVE?
We know that FNA is the gold standard for determining whether patients have malignant or benign thyroid nodules. However, a negative result on FNA is not always definitive for a benign thyroid nodule. When this occurs, it is referred to as a false negative result. In a recent retrospective (looking back at events) study, from the Longitudinal Health Insurance Database in Taiwan, 62 percent of thyroid nodules that were cancerous were diagnosed with one biopsy and 82 percent were found within the year after that biopsy (10). However, about 17 percent of patients needed more than two FNA biopsies, and 19 percent were diagnosed after one year with cancerous thyroid nodules.

THE POTENTIAL SIGNIFICANCE OF CALCIFICATION ON ULTRASOUND
Microcalcifications in the nodule can be detected on ultrasound. The significance of this may be that patients with microcalcifications are more likely to have malignant thyroid nodules than those without them, according to a small prospective study involving 170 patients (11). This does not mean necessarily that a patient has malignancy with calcifications, but there is a higher risk. The results demonstrated that more than half of the malignant thyroid nodules, 61 percent, had microcalcifications.

THE GOOD NEWS
As I mentioned above, most thyroid nodules are benign. The results of a recent study go even further, showing that most asymptomatic benign nodules do not progress in size significantly after five years (12).

This was a prospective (forward-looking) study involving 992 patients with between one and four benign thyroid nodules diagnosed cytologically (by looking at the cells) or by ultrasound. The factors that did contribute to growth of about 11 percent of the nodules were age (<45 years old had more growth than >60 years old), multiple nodules, greater nodule volume at baseline and being male.

The authors’ suggestion is that the current paradigm might be altered and that after the follow-up scan, the next ultrasound scan might be five years later instead of three years. However, they did discover thyroid cancer in 0.3 percent after five years.

In considering risk factors, it’s important to note that those who had a normal thyroid stimulating hormone (TSH) were less likely to have a malignant thyroid nodule than those who had a high TSH, implying hypothyroidism. There was an almost 30 percent prevalence of cancer in the nodule if the TSH was greater than >5.5 mU/L (13).

The bottom line is that there is an urgent need for new guidelines regarding thyroid nodules. Fortunately, most nodules are benign and asymptomatic, but the number of cancerous nodules found is growing. We are getting better at diagnosing nodules. Why the death rate remains the same year over year for decades may have to do with the slow rate at which most thyroid cancers progress, especially two of the most common forms, follicular and papillary.

REFERENCES:
(1) AACE 2013 Abstract 1048. (2) Thyroid. 2005;15(7):708. (3) uptodate.com. (4) AACE 2013 Abstract 1048. (5) thyroid.org. (6) AAES 2013 Annual Meeting. Abstract 36. (7) AACE 2013 Abstract 1048. (8) Cancer. 2011;117(20):4582-4594. (9) J Clin Endocrinol Metab. Online May 12, 2015. (10) PLoS One. 2015;10(5):e0127354. (11) Head Neck. 2008 Sep;30(9):1206-1210. (12) JAMA. 2015;313(9):926-935. (13) J Clin Endocrinol Metab. 2006;91(11):4295.

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

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Triglycerides is a term that most of us recognize. This substance is part of the lipid (cholesterol) profile. However, this may be the extent of our understanding. Compared to the other substances, HDL (“good” cholesterol) and LDL (“bad” cholesterol), triglycerides are not covered much in the lay press and medical research tends to be less robust than for the other components. If I were to use a baseball analogy, triglycerides are the Mets, who get far less attention than their crosstown rivals, the Yankees.

But are triglycerides any less important? It is unclear whether a high triglyceride level is a biomarker for cardiovascular disease – heart disease and stroke – or an independent risk in its own right (1) (2). This debate has been going on for over 30 years. However, this does not mean it is any less important.

What are triglycerides? The most rudimentary explanation is that they are a kind of fat in the blood. Alcohol, sugars and excess calorie consumption may be converted into triglycerides.

Risk factors for high triglycerides include obesity, smoking, a high carbohydrate diet, uncontrolled diabetes, hypothyroidism (underactive thyroid), cirrhosis (liver disease), excessive alcohol consumption and some medications (3).

What levels are normal and what are considered elevated? According to the American Heart Association, optimal levels are <100 mg/dL; however, less than 150 mg/dL is considered within normal range. Borderline triglycerides are 150-199 mg/dL, high levels are 200-499 mg/dL and very high are >500 mg/dL (3).

While medicines that focus on triglycerides, fibrates and niacin, have the ability to lower them significantly, it is questionable whether this reduction results in clinical benefits, like reducing the risk of cardiovascular events. The ACCORD Study, a randomized controlled trial, questioned the effectiveness of medication; when these therapies were added to statins in type 2 diabetes patients, they did not further reduce the risk of cardiovascular disease and events (4). Instead, it seems that lifestyle modifications may be the best way to control triglyceride levels.

Let’s look at the evidence.

EXERCISE – TIMING AND INTENSITY
If you need a reason to exercise, here is really good one. I frequently see questions pertaining to optimal exercise timing and intensity. Most of the answers are vague, and the research is not specific. However, hold on to your hats, because a recent study may give the timing and intensity answer, at least in terms of triglycerides.

Study results showed that walking a modest distance with alacrity and light weight training approximately an hour after eating (postprandial) reduced triglyceride levels by 72 percent (5). However, if patients did the same workout prior to eating, then postprandial triglycerides were reduced by 25 percent. This is still good, but not as impressive. Participants walked a modest distance of just over one mile (2 kilometers). This was a small pilot study of 10 young healthy adults for a very short duration. The results are intriguing nonetheless, since there are few data that give specifics on optimal amount and timing of exercise.

EXERCISE TRUMPS CALORIE RESTRICTION
There is good news for those who want to lower their triglycerides: calorie restriction may not the best answer. In other words, you don’t have to torture yourself by cutting calories down to some ridiculously low level to get an effect. We probably should be looking at exercise and carbohydrate intake instead.

In a well-controlled trial, results showed that those who walked and maintained 60 percent of their maximum heart rate, which is a modest level, showed an almost one-third reduction in triglycerides compared to the control group (maintain caloric intake and no exercise expenditure) (6). Those who restricted their calorie intake saw no difference compared to the control. This was a small study of 11 young adult women.Thus, calorie restriction was trumped by exercise as a way to potentially reduce triglyceride levels.

CARBOHYDRATE REDUCTION, NOT CALORIE RESTRICTION
In addition, when calorie restriction was compared to carbohydrate reduction, results showed that carbohydrate reduction was more effective at lowering triglycerides (7). In this small but well-designed study, patients with nonalcoholic fatty liver disease were randomized to either a lower calorie (1200-1500 kcal/day) or lower carbohydrate (20 g/day) diet. Both groups significantly reduced triglycerides, but the lower carbohydrate group reduced triglycerides by 55 percent versus 28 percent for the lower calorie group. The reason for this difference may have to do with oxidation in the liver and the body as a whole. Both groups lost similar amounts of weight, so weight could not be considered a confounding or complicating factor. However, the weakness of this study was its duration of only two weeks.

FASTING VERSUS NONFASTING BLOOD TESTS
The paradigm has been that, when cholesterol levels are drawn, fasting levels provide a more accurate reading. Except this may not be true.

In a new analysis, fasting may not be necessary when it comes to cholesterol levels. NHANES III data suggests that nonfasting and fasting levels yield similar results related to all-cause mortality and cardiovascular mortality risk. The LDL levels were similarly predictive regardless of whether a patient had fasted or not. The researchers used 4,299 pairs of fasting and nonfasting cholesterol levels. The duration of follow-up was strong, with a mean of 14 years (8).

Why is this relevant? Triglycerides are an intricate part of a cholesterol profile. With regards to stroke risk assessment, nonfasting triglycerides possibly may be more valuable than fasting. In a study involving 13,596 participants, results showed that, as nonfasting triglycerides rose, the risk of stroke also rose significantly (9).

Compared to those who had levels below 89 mg/dL (the control), those with 89-176 mg/dL had a 1.3-fold increased risk of cardiovascular events, whereas those within the range of 177-265 mg/dL had a twofold increase, and women in the highest group (>443 mg/dL) had an almost fourfold increase. The results were similar for men, but not quite as robust at the higher end with a threefold increase.

The benefit of nonfasting is that it is more realistic and, according to the authors, also involves remnants of VLDL and chylomicrons, other components of the cholesterol profile that interact with triglycerides and may affect the inner part (endothelium) of the arteries.

What have we learned? Triglycerides need to be discussed, just as we review HDL and LDL levels regularly. Elevated triglycerides may result in heart disease or stroke. The higher the levels, the more likely there will be increased risk of mortality – both all-cause and cardiovascular. Therefore, we ideally should reduce levels to less than 100 mg/dL.

Lifestyle modifications using carbohydrate restriction and modest levels of exercise after a meal may be the way to go to the best results, though the studies are small and need more research. Nonfasting levels may be as important as fasting levels when it comes to triglycerides and the cholesterol profile as a whole; they potentially give a more realistic view of cardiovascular risk, since we don’t live in a vacuum and fast all day.

REFERENCES:
(1) Circulation. 2011;123:2292-2333. (2) N Engl J Med. 1980;302:1383–1389. (3) nlm.nih.gov. (4) N Engl J Med. 2010;362:1563-1574. (5) Med Sci Sports Exerc. 2013;45(2):245-252. (6) Med Sci Sports Exerc. 2013;45(3):455-461. (7) Am J Clin Nutr. 2011;93(5):1048-1052. (8) Circulation Online. 2014 July 11. (9) JAMA 2008;300:2142-2152.

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

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