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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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By Matthew Kearns, DVM

In our previous article we discussed predisposing factors to obesity such as breed, spay/neuter status, age and underlying disease. This article will focus on a brief overview of tackling the obesity problem. The short answer here is there is no magic bullet for weight loss, but rather the same answer there is for humans: diet and exercise. With that said let’s take a closer look at that and give some more specific recommendations.
Diet:    In a veterinary article I recently read, management of obesity in dogs and cats is as easy as following the three A’s: awareness, accurate accounting and assessment.

Awareness refers not only to coming to terms with obesity in your pet but also certain risks as well (breed, spay/neuter status, etc.). How does one identify obesity in a pet? Usually it’s a vet (the bad guy) that hints at the fact that Spike has gotten a little husky or Fifi a little fluffy. However, you can actually assess your own pet at home. Just go online and look up “Body Conditioning Score,” or “BCS” for short. If, after reviewing information online you are still unsure, I would recommend scheduling an appointment to consult with your veterinarian.

Accurate accounting may be the hardest thing (for us as pet owners) to face.  Food can be an act of bonding not only with other people but also with our pets.  We had one pet owner at our clinic with an obese dog she swore was only getting its food and no extra snacks or table food. After a bit of investigation I found out that the owner loved to cook and the dog was the “official taster” for every meal.  No table food meant no food directly from the table. This was a smart woman, but she felt that the dog would no longer love her if she took this bonding moment away. Unfortunately, this also meant the dog would soon have to be rolled into the clinic and not walk in under its own power.

To make life a little easier, there is a way to actually calculate calorie requirements by using a calculation called the Resting Energy Requirements, or RER for short. The RER is a starting point, and then in conjunction with your veterinarian or a veterinary nutritionist you can calculate how much food to give at each meal. After accurately calculating how much food your dog needs for the whole day, you can break that up into as many meals as you’d like. It has been found that it is more effective to feed at least two and up to four smaller meals a day to lose weight than to free feed (fill up the bowl).

Treats also have calories and should not exceed 10 percent of the diet. There are now low-calorie treats available both commercially and as prescription low-calorie treats through your veterinarian.

Lastly, in terms of assessment, it is important to either weigh your pet at home or bring your pet to your veterinarian’s office for a weight (this helps with consistency especially for larger pets). We encourage pet owners with obese pets trying to lose weight to bring their pets in (at no charge) to be weighed.

Exercise: Exercise is key to good health for many reasons: It helps to maintain and strengthen muscle, it promotes cardiovascular health, it provides mental stimulation, and it increases energy expenditure and fat oxidation.

Obese dogs should be given low-impact cardiovascular exercise (a longer walk or swimming rather than chasing a ball) to avoid heat stroke or injury.

Obese indoor-only cats should have their play geared toward outdoor hunting and playing behaviors (climbing, balancing, scratching). Toys work well for some cats, while others prefer cat trees or play stations.  Interactive toys with the owner are best (especially for single-cat households) to lose weight, as well as promote bonding with the owner.

I hope that this series of articles will help to make our pets the healthiest and happiest pets ever this summer.

Dr. Kearns has been in practice for 16 years.

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