Your cholesterol

Who needs drugs?

M ost men with heart disease should be on cholesterol lowering ‘statin’ drugs like Lipitor.  The science is less clear for women, who are usually put on a drug anyway. Carotid artery disease, peripheral vascular disease and diabetes count as heart disease.

LDL below 100
Keep LDL below 100. Your doctor may  decide to push it below 70. If you can’t tolerate a statin, you may get another class of drug. Although other drugs may lower your cholesterol, not  all of them have been shown to prevent heart attacks or death.

Lifestyle change essential
A Mediterranean diet is over twice as effective as drugs, with fewer side effects. It’s a mistake to indulge in  bad food  because you’re on a drug.

Statin drugs do more than lower cholesterol.  They reduce inflammation, retard clot formation, and prevent acute rupture of existing artery blocking plaques. These  other effects may be what really protects your heart.

Statin drug side effects
Muscle aches and pains — 1 in 20. Severe muscle damage, ‘rhabdomyolysis’, is extremely rare. Your doctor will also check for liver damage, also rare. Statins can cause brain fog. This improves off the drug. Statins lower production of coenzyme Q10, a factor in your body’s energy  system. Consider supplementing 50-100 mg a day.

Are you a special case?
Healthy but with a family history of early heart disease? (Father heart attack 55 or younger or mother 65 or younger ).  You can find out if you have atherosclerotic lesions in your coronary arteries. Coronary calcium screening is a relatively cheap CAT scan of the heart. The amount of calcium corresponds to the degree of heart disease, if any. It can then be used as a basis for further evaluation, therapy and risk modification. Some insurance plans cover this potentially useful test.

Take-Home Message
If you have heart disease and are taking a drug, don’t forget diet and exercise. Their benefits far outstrip any medication effect. Include at least one gram a day of fish oil for protection against sudden death.

SB PG 1
C – Reactive protein

C-reactive protein is a sensitive blood test that measures inflammation and heart disease risk independent of cholesterol. Under 2.0 is desirable. High levels can result from poor teeth and H.pylori, a stomach bacteria associated with ulcers.  The best way to lower it?  If necessary, fix teeth or treat H.pylori. Diet, exercise and weight loss are most effective. Statins, aspirin, fish oil, tumeric, plant sterols, and soy can also help.

COMPLEMENTARY ALTERNATIVE

Mind/body medicine part 2
Spirituality and good health — the power of belief

Many folks call on their beliefs in times of illness and need. This supplies comfort and can have a positive impact on health.
Research supports the healthy role of spiritual and religious commitment.  I see many patients who benefit from active spiritual practice and involvement in a worship group.

Here are some compelling findings with broad relevance:

Improve immune functioning
Weekly churchgoers were half as likely to have elevated levels of IL-6, an immune protein elevated in a variety of age-related diseases.

Lower risk of early death
Weekly churchgoers were 25% less likely to die than infrequent attenders. Once frequent attenders began to attend church, they were more likely to quit smoking, exercise, expand their social network and stay married.

Recovery from depression
In medically ill hospital patients, strong religious faith went with quicker recovery from depression.

Longer life span
Attending church more than once a week was associated with up to seven years increased life span. Religious attendance was a strong predictor for living longer, even when other important clinical and social factors were taken into account. 21,000 adults from across the nation were tracked.

Surviving heart surgery
Elderly patients in the hospital were 14 times less likely to die following surgery if they remained socially involved and found comfort in their religious faith. 232 patients were studied at Dartmouth Medical School.

Preventing high blood pressure
Risk of high blood pressure was 40% less among people who attended weekly religious services and who prayed daily.

We know that smoking cessation, exercise, social support, prayer and meditation and supportive, loving partners all have positive health benefits. Active spirituality, faith and membership in a supportive worship community encourage these healthy practices.
Perhaps we don’t need scientific studies to tell us these things. But if science convinces even a few of us to explore our inner needs and improve well being, I say that’s just fine!

Take-Home Message
Active spirituality, faith and membership in a worship community along with appropriate medical care are a powerful combination for support of good health and longevity.

READ this book
Timeless Healing:
The Power and Biology of Belief
By Herbert Benson, M. D.
A fascinating study of the integration of body, mind and soul. By an eminent cardiologist and professor at Harvard Medical School.

10 Facts you should know about Carbs
Your Essential Life Fuel

Low carb, no carb, good carbs, bad carbs, fructose, sucrose, glycemic index, glycemic load . . . no wonder everbody’s so confused!
Carbohydrates are the body’s primary fuel. Most of our cells ultimately burn sugar (glucose, to be exact) for energy, whether it’s broken down from protein, fat or carbohydrates. The energy in carbohydrates comes from the sun via plants. We’ll focus mainly on grains, both whole (good) and processed (bad).

#1  Less processing is better
Processing strips vital nutrients and fiber from grains. This increases the glycemic index. Stick with whole grains and whole grain breads.

#2  Protect against diabetes
Whole grains keep your blood sugar on track.Cola drinks, white rice and bread, and french fries increase diabetes risk.

#3  Reduce heart disease risk
2H average daily servings of  whole grains reduce cardiac risk in women by 30%, compared to one serving a week.

#4  Promote gastrointestinal health
Fiber from whole grains helps prevent constipation and diverticulosis, tiny irritating pouches in the colon. These can become painfully inflamed, called diverticulitis.

#5  Lower risk of cancer
Whole grains lower risk of mouth, stomach, colon, gallbladder and ovarian cancer. We can’t say which part of the grain is responsible. It’s probably the fiber plus all the nutrients working together!

#6  Avoid high fructose corn syrup
Cheap, excessively sweet and lethal.  In soft drinks plus many processed baked, canned and frozen food products. Avoid entirely.

#7  Artificial sweeteners — who needs them?
More worthless man-made chemicals. Small amounts of sugar for sweetening are OK for most.

#8  Bran and wheat germ are incomplete foods
Wheat bran lacks the vitamins of the oil-rich germ. Wheat germ lacks the fiber-rich bran. Stick with the whole grain.

#9  Butter your bread
Or dip it in olive oil. The fats slow carbohydrate absorption creating an effectively lower glycemic index. Fat soluble vitamins like vitamins A and D complement nutrients in whole grains.

#10  Processed grains and trans-fats
Unhealthy trans fats (hydrogenated and partially hydrogenated oils) hide out in most packaged baked goods, especially crackers. Check labels. Avoid entirely.

Take-Home Message
Stick with whole grains and whole grain breads. Have some fat with your carbs — butter, oil, nuts, seeds. Add extra carbs if you exercise. Most folks will get between 40-60% of calories from carbs (4 calories per gram).

LOW CARB DIETS

Whole grains are OK in moderation Focus on fruits and vegetables. Get adequate protein and fat. Exercise daily. Include strength training. Lose 1-2 pounds a week, no more.     This is a reasonable way to   lose weight and achieve good health. Diets are a bad idea, unless supervised by a healthcare professional.

Glycemic index — not the whole story

Glycemic index: a measure of how quickly specific foods spike blood sugar and insulin. Insulin, made by your pancreas, stores excess carbs as fat. Chronically high levels promote disease. High glycemic index  foods trigger higher insulin levels. But glycemic index isn’t the whole story . . .

Glycemic load the ultimate effect on blood sugar and insulin levels. The result of the glycemic index(speed of absorption) plus total amount of carbs in a food. Carrots  have a high glycemic index of 131, but not much carbohydrate. Half a cup of raw carrots has a glycemic load of 5. An English muffin has a glycemic index of 86 but a glycemic load of 23 — 5 times more!

IMPORTANT: Context is important.  The net glycemic load is based on all the foods you consume at a time. Potatoes or bread with high glycemic indexes have lower effective indexes when served with fats. A small piece of cake at the end of a meal has a lower effective glycemic index and load than cake  eaten at 4 o’clock on an empty stomach. So when you snack, include protein and fat.

WHATS NEW
MEDICINE CHEST
Generic Synthroid

A recently approved generic version of levothyroxine (the scientific name for Synthroid) is significantly more potent than Synthroid itself, up to 15% stronger.

Because levothyroxine has a narrow correct dose range, a slightly higher potency can cause problems. These include anxiety, rapid heart rate, cold intolerance and poor sleep.

What to do? Know what you’re getting. Some pharmacies may switch products. Stick with the same preparation, if possible. If changed, make sure you get a thyroid stimulating hormone test within 4 – 6 weeks.

SUPPLEMENTS
Valerian for sleep

Do you suffer from insomnia? The herb valerian has a long history of use for sleep. It’s safe, non-toxic and non-habit-forming. Take it every night for at least 2 weeks.  A single dose usually doesn’t work. Don’t quit suddenly. Taper over 1 to 2 weeks. This prevents withdrawal symptoms (confusion, rapid heart beat).

I recommend Nature’s Way Standardized Valerian Extract, 1 – 3 capsules taken 30 minutes before bedtime. Again, give it at least 2 weeks to work.

IMPORTANT: Chronic sleep problems involving frequent awakening can be caused by sleep apnea (airway blockage during sleep where you stop breathing) or depression. Please discuss any sleep problem with your doctor.

YOUR BRAIN
Folate and depression

This important B vitamin helps the brain use its mood regulating substances, serotonin and dopamine. Folate is low in 35% of people with depression. In fact, depression is the most common symptom found in folate deficiency.

800 mcg daily is safe and can have other benefits — prevention of neural tube defects in the developing fetus and lowering of elevated homocysteine, a likely risk factor for heart disease, dementia and osteoporosis. Make sure you also take B12 (at least 100 mcg) and B6 (50 to 100 mg).

Folate can improve response to antidepressant medications. Leafy green vegetables, citrus fruits, beef liver, peas and dried beans and fortified cereals are good sources.

PAIN UPDATE
Acupuncture for headache and knee arthritis

A large study from Germany showed acupuncture can cut migraine and tension type headache frequency in half. It can also reduce need for pain medications by about 30%. Therapy was 15 treatments over 3 months. Effects lasted for 3 months.

An American study showed  relief from knee arthritis pain. The effect was modest but clear. Most subjects were on arthritis medications,too, so the positive effect was significant. Therapy was 25 treatments over 6 months.

The good news? Acupuncture is safe without side effects. The bad news? You usually have to pay for it yourself, which is interesting as arthritis drugs (NSAID’s) kill over 15,000 people a year, mostly from stomach and intestinal bleeds.

FOR WOMEN ONLY
How good are mammograms?
Why you need a good breast exam

If you’re a woman over 40, you probably  get an annual mammogram. In spite of years of research, experts disagree over their true value.

The benefit is small
The benefit is small. But when applied to large numbers of women, it doesn’t appear small.

If you start with 1000 60-year-old women, nine will die of breast cancer by age 70. With annual mammograms, only six will die. To save those three lives, 10,000 mammograms need to be read over 10 years!

Make sense? That’s a lot of mammograms. Now take a million 60-year-old women — 3,000 lives saved. Ten million women — 30,000 lives saved.

The problems
Mammograms have many problems. In studies where different radiologists read the same mammograms, some of known cancers, results vary widely: missed cancers, healthy people diagnosed with cancer.

Still another problem: mammograms are more likely to miss fast growing tumors. In one  study, the first  set of mammograms missed 30% of cancers. These were picked up as a lump on manual exams before the second mammogram a year later. Cancers found on the second mammogram weren’t there at the time of the first.

A thorough breast exam
There is no perfect answer. Many experts, however, recommend annual mammograms plus a thorough breast exam. “Thorough” means careful palpation from the collarbone to the bottom of the rib cage, one fingertip area at a time, at three pressures — just below skin, mid-breast, and against the chest wall.  Five minutes each breast. Trained nurses usually perform breast exams as well as physicians, if not better

The role of ultrasound
Ultrasound may be especially helpful if you have dense breast tissue or are high risk with a family history — sister or mother with breast cancer.

Prevention — the big three
Good diet, adequate exercise and not smoking all show clear benefit in reducing breast cancer risk. Fat cells make hormones that cause cancer cell growth, although there’s no clear link between breast cancer and dietary fat.
The future

Genetic testing may help predict which tumors are most likely to grow and spread. Thus women with less harmful tumors will avoid over treatment, a big problem nowadays.

Take-Home Message
Make sure you get a thorough breast exam in addition to your regular mammogram.
Diet and exercise are the foundation of good prevention. What else? No smoking!

READ this book
Dr. Susan Love’s Breast Book
By Susan Love M.D.
The definitive resource for all women. By a courageous leading expert in the field.

Your Questions Answered

PSA testing

QI have heard the PSA test (prostate specific antigen) is of limited usefulness. I am 53 and my doctor is recommending I get one. I have no family history of prostate cancer.. Is this a good idea?

A Many people want to believe that medical science is an exact, black-and-white process that delivers clear, unambiguous answers. The opposite is often the case. PSA testing is a good example of this problem.

PSA is produced by the normal prostate. Probability of cancer increases as PSA increases. A PSA under 4 is usually considered normal. Over 10 is high. Between 4 and 10 a troubling gray area, usually resulting in biopsy.

One problem: You can have a normal PSA and still have cancer. Another problem: Your PSA can be elevated with no cancer. Still another problem: You can have cancer and it can be slow growing. That is, it will never cause a problem. There will be no symptoms.   There will some other eventual cause of death.

PSA testing in this country started in 1990. Since then newly diagnosed prostate cancers have more than doubled, from 100 per 100,000 men to nearly 250. Yet deaths from prostate cancer have decreased only slightly.

As a result, many (up to 50%) receive unnecessary treatment: painful biopsies, powerful drugs,  and prostate removal surgeries that result in loss of bladder control, inability to achieve erection and emotional distress.

The answer? A PSA test can be useful. But it should be regarded as one of several risk factors, including age, ethnicity, results of a rectal exam and family history.

Another test may help. A high percentage of Free PSA, suggests your PSA level may result from simple non-cancer enlargement, a very common problem. “Free” refers to the PSA not protein-bound. 20% or higher suggests lower cancer risk.

Another important concept is  PSA velocity.  A rapid increase over a few months may signal a cancer.

A PSA above 4 usually results in a biopsy. Prostate cancers are diagnosed with biopsies. Anywhere from 6 to 12 or more tissue samples are taken. Even with 12 or more samples, cancer can be missed. Biopsies cover a very small part of the  prostate.

What’s the best approach for you? Understand the ins and outs of PSA testing. Discuss them with your doctor. PSA testing should be an individual decision.

I usually recommend ordering a PSA and sometimes will subsequently order a Free PSA, especially if there is a family history before age 70.

Doctors have been successfully sued for not ordering PSA tests in patients who developed prostate cancer, although it is not clear that  PSA testing is an effective screening test. This is an unfortunate reality of practicing medicine in this country, although such lawsuits are actually quite rare.