Monday, February 25, 2013

How Much Exercise Does One Need?

Everyone agrees that physical activity is a key part of a healthy lifestyle. Yet, there is no absolute consensus as to what is the best form of such activity and how much activity provides the most benefit. For example, does one need to set aside specific time for exercise each day or does a physically active lifestyle such as gardening or playing golf suffice? Before, I share a new study that may shed some light on this question, let's just review some basic information.

There are four types of exercise: endurance, strength, balance and flexibility. By endurance, we mean what is commonly referred to as cardio or aerobic. By strength, we often refer to anaerobic or weight bearing. All four forms of exercise confer specific benefits for healthy living. But how much do we really need and what are the benefits?  Is 60 minutes better than 30 minutes and 90 minutes better than 60? Is it better to do more intensive exercise for a shorter period of time or less intensive for a longer duration? Is endurance better or more important than strength? The answers depend on what your goal is. If your goal is longevity than the answer may be different than if your goal is to have more pronounced muscles.

For many years, doctors have been more comfortable prescribing medication than an exercise routine. That may be about to change. A new study from the Harvard School of Public Health now offers doctors specific exercise prescriptions. In the study led by I Min Lee, a professor of medicine at Harvard Medical School, researchers analyzed data of more than 650,000 people older than 40 who were followed for an average of ten years.

Here's what they found:
1. Subjects that completed the equivalent of 75 minutes of brisk walking each week--roughly 11 minutes per day--lived 1.8 years longer than those who did not exercise at all.
2. Subjects that completed the equivalent of 150 minutes (as federally recommended) of brisk walking each    week--roughly 22 minutes every day or 30 minutes five days a week day--lived 3-4 years longer.
3. The benefits plateaued at about 43 minutes of brisk walking a day.

The noted gains applied to people at all weight levels, including the obese. This means that even if weight was not lost, the benefits of exercise were still realized.

The researchers focused on brisk walking because it is the most commonly reported exercise, but any moderate intensity exercise, from riding a bike, doing gardening and yard work, running around with the kids, would be just as good. The only requirement is that you get your heart rate beating to a level where speaking is still comfortable, but singing becomes difficult (that means hard for you to sing, not for people to hear you sing.)

The researchers also concluded that those who engage in more vigorous exercise, say running or playing basketball, enjoyed the same gains but in half the time. In other words, the benefits of vigorous exercise plateaued at 21.5 minutes per day for the more intense exercisers. In fact, a previous study showed that women who exercise 60 consecutive minutes a day actually burned fewer calories over the entirety of the day than those who only exercise for 30 minutes. Combining the two studies, we can extrapolate that too much exercise may be counterproductive. That said, moving around all day, as opposed to sitting for large parts of it, is known to confer many benefits.  From my perspective, I advise patients in general to do five minutes of moderate activity for about eight or nine hours during the day. I believe, although it has not yet been proven scientifically, that this will confer the most benefit.  As always, follow the advice of your physician who knows your personal medical history and limitations.

This new study is not the final say on exercise as it only addressed longevity, but it offers an excellent guideline for improving your longevity. As other recent studies have shown, exercise may also help prevent dementia and even cancer. So if you have been sitting reading this blog, may I suggest you now get up and get moving. It will probably extend your life.

Friday, February 22, 2013

Dr. Oz and Asprin: Is He Being Irresponsible?

Do not, and I repeat do not, stop taking aspirin prescribed by your physician (Dr. Oz on TV is not your physician) based on what you read here today. Today's blog highlights why it is a huge mistake to take medical advice from any doctor, including Dr. Oz, who does not personally know your medical history.

On a recent episode of The Dr. Oz Show, Dr. Oz spoke about aspirin -which he calls the Miracle Over The Counter Drug. As he has done multiple times before, Oz recommended that everyone take two baby aspirins every day. He prefaced his recommendation based on a video stream of medical conditions that he claims benefit from aspirin therapy. Heart attacks, strokes, arthritis, etc. were on the list. He highlighted aspirin's anti-inflammatory benefits and the role it may play in cancer prevention (a topic obviously dear to my heart). He did not, however, cite any of the side effects of aspirin therapy. He did not mention the risk for bleeds, easy bruising, ulcers, asthma, macular degeneration, etc. Aspirin can wreak havoc if used inappropriately and he gave no hint of such dangers. In my opinion, this is irresponsible and unprofessional behavior, worthy of revocation of his medical license.

Why am I so strident in my feelings?  Personal experience. First, I use to take aspirin and developed an ulcer from it. It took months of suffering, an eventual endoscopic procedure to make the diagnosis, and months of drug treatment to cure it. Anytime I take a baby aspirin, my nose begins to bleed the next day. Obviously, aspirin and I do not agree. But I am not alone. Aspirin and other anti-platelet drugs are known to cause bleeding and be corrosive to the esophagus and stomach linings. In fact, aspirin, a member of the non-steroidal anti-inflammatory (NSAIDS) class of drugs, has been cited as one of the top four categories of drugs responsible for emergency room visits and hospitalizations. (By the way, on a subsequent episode Oz cited the potential harms caused by NSAIDS, but did not make a single reference to aspirin.)  Many patients who take aspirin note the easy skin bruising that develops.

Another one of my family members has a condition where aspirin therapy triggers an asthmatic attack.  This well known syndrome is a triad that includes aspirin, asthma, and a nasal polyp.

A number of recent studies have shown a correlation between aspirin therapy and the development of age-related macular degeneration, an eye condition with very poor treatment options.

The bottom line is that a daily aspirin has both associated benefits and risks and no one should initiate therapy with out first consulting a physician who can help you calculate your risks and benefits.

But what gets me really upset about Oz's pronouncements is that he not only fails to identify potential risks to an unwary audience, but he goes so far as to recommend two baby aspirins instead of one despite the paucity of evidence to support his stand. Don't take my word for it. Quoted below is information from the United States Preventive Services Task Force, which gives aspirin therapy prescribed by a physician its highest recommendation. But here's what it writes about the dose:

"The optimum dose of aspirin for preventing cardiovascular disease events is not known. Primary prevention trials have demonstrated benefits with various regimens, including dosages of 75 and 100 mg/d and 100 and 325 mg every other day. A dosage of approximately 75 mg/d seems as effective as higher dosages. The risk for gastrointestinal bleeding may increase with dose."

Two baby aspirins represent 162 mg.

Not good enough for you? Here's the Mayo Clinic's weigh in on the topic quoted directly from their website:

"Should you take a daily aspirin?

You shouldn't start daily aspirin therapy on your own in an effort to prevent a heart attack. Your doctor may suggest daily aspirin therapy if:
  • You've already had a heart attack or stroke
  • You haven't had a heart attack, but you have had a stent placed in a coronary artery, have had coronary bypass surgery, or you have chest pain due to coronary artery disease (angina)
  • You've never had a heart attack, but you're at high risk of having one
  • You're a man with diabetes older than 50, or a woman with diabetes older than 60
Although aspirin has been recommended in the past for certain groups of people without a history of heart attack, there's some disagreement among doctors about this approach. Guidelines are changing and have varied between organizations. The bottom line is that before taking a daily aspirin you should have a discussion with your doctor."

Still want another opinion? Here's an excerpt from a gastroenterologist writing in The New York Times:

A Hidden Danger of ‘an Aspirin a Day’

Dr. Neena S. Abraham, a gastroenterologist at the Michael E. DeBakey V.A. Medical Center and associate professor of medicine at the Baylor College of Medicine in Houston, recently took readers’ questions about ulcers, a potentially life-threatening condition increasingly tied to Nsaid pain relievers. Here, Dr. Abraham discusses the potential dangers of taking a daily baby aspirin, which doctors often recommend for those at high risk of heart disease.
An Underappreciated Risk of an Aspirin a Day
By Neena Abraham, M.D.
If your physician has suggested you take aspirin to reduce your risk of heart disease, it is important to remember that even small doses of daily aspirin — including “baby aspirin,” at a dose of 81 milligrams daily — can increase your risk of ulcers and bleeding. It is important to remember that all Nsaids, including over the counter aspirin, have the potential to damage the tissue of the gastrointestinal tract. Damage can occur anywhere, from mouth to anus.
Over-the-counter doses of aspirin, or buffered or enteric coated aspirin preparations, do not eliminate the risk of developing an Nsaid-related ulcer. Your risk for bleeding is still two- to four-fold greater than if you were not taking the aspirin product at all.
This risk increases in magnitude as the dose of the aspirin increases. Some studies have suggested that one-third of aspirin-induced ulcers are related to over-the-counter aspirin use. The excess ulcer bleeding risk associated with aspirin use is estimated at 5 extra cases per 1,000 patients per year.
However, it is important to remember that your risk of aspirin-induced ulcer will further increase if you have high-risk features such as:
  • being older than 60,
  • having a history of gastric or duodenal ulcer,
  • having active Helicobacter pylori infection (the bacterium linked to ulcers),
  • taking aspirin at the same time as you take full strength Nsaids (such as ibuprofen, Motrin and naproxen), anticoagulants (such as warfarin) or antiplatelet agents (such as clopidogrel or ticlopidine); or taking aspirin if you are a chronic steroid user.
Aspirin is not a nutritional supplement — it is a medication with real risks and side-effects, so it should not be taken without explicit cardiovascular risk assessment by your physician.
If you and your doctor determine that the benefit of taking aspirin to prevent heart disease exceeds the risk of gastrointestinal bleeding, ensure you are only taking the minimum dose of aspirin required for cardiovascular risk reduction (in the United States, that is a dose of 81 milligrams a day).
If you have high-risk features for aspirin and Nsaid-induced ulcers, as discussed above, discuss with your physician the appropriateness of taking a stomach protecting medication, such as a proton-pump inhibitor. It may also be important to be tested and treated for H. pylori infection to minimize your risk of ulcer formation."

The bottom line is that aspirin therapy may be indicated for certain, if not many patients, under the right set of circumstances. But is it for everyone? Absolutely not. Do you need two baby aspirins? No good evidence to support that position. Should Dr. Oz be telling a national television audience to start aspirin therapy without consulting a physician, and to take two, not one baby aspirins when they do? You be the judge.

I say shame on you, Dr. Oz.

Thursday, February 21, 2013

Which Routine Medical Tests and Treatments Should You Avoid?

Often when you go to a doctor with a problem, you expect tests and a prescription. Such actions are not always the best course of action and can sometimes be counterproductive. Unnecessary tests can lead to more expensive, time-consuming, stressful, and sometimes painful tests with side effects that could have been avoided. Medications have side effects and if you don't need a drug, you shouldn't take it.  But how do you know which tests to avoid?

Choosing Wisely® is an initiative of the American Board of Internal Medicine Foundation to help physicians and patients engage in conversations to reduce overuse of tests and procedures, and support physician efforts to help patients make smart and effective care choices.

A new list of tests and treatments to avoid was released last week. The entire list is listed below with links to the sites.

I find the lists to be very thoughtful and well developed. That doesn't mean that they are gospel or infallible. Physicians must continue to use their clinical judgment to make the right decisions for their patients. I hope the information provided makes you a smarter patient, one capable of asking the right questions from your doctor to get the best care for you or a loved one. Avoiding unnecessary tests and treatments is as important as receiving the right ones. It is worthwhile to familiarize yourself with all the tests so if you ever find yourself in a situation where such a test is being recommended for you or a family member, you are more knowledgeable and better prepared to decide.

Patient-Friendly Resources from Specialty Societies and Consumer Reports:
Download PDF It’s worth getting a bone-density test if you’re older or have other risk factors for weak bones, because without it the first sign of osteoporosis is usually a broken bone. But if you’re not at higher risk, you should think twice about the test. Here’s why:
The test usually isn’t necessary in younger people without risk factors for weak bones.
Many women and some men are routinely screened for weak bones with an imaging test called a dual-energy X-ray absorptiometry (DEXA) scan. If it shows that you have outright osteoporosis, the results can help you and your doctor decide how to treat the problem, usually with drugs. But many people learn they have only mild bone loss, a condition known as osteopenia, and for them the risk of fracture is often quite low.
It can pose risks.
A DEXA scan isn’t likely to harm you directly. But a diagnosis of osteopenia can lead to treatment with such drugs as alendronate (Fosamax and generic), ibandronate (Boniva and generic), and risendronate (Actonel, Atelvia, and generic), which pose numerous risks. Those include thigh fractures; throat or chest pain; difficulty swallowing; heartburn; and more rarely, bone, eye, joint, and muscle pain; bone loss in the jaw; and possibly abnormal heart rhythm. In addition, there is little evidence that people with osteopenia get much benefit from the drugs. Other types of osteoporosis drugs are linked to risks such as blood clots, heart attacks, strokes, and serious infections.
It can be a waste of money.
A DEXA scan costs about $132, according to Though that isn’t as expensive as some tests, any money spent on unnecessary tests is money wasted. In addition, a month’s supply of generic alendronate costs $38 to $70. Fosamax, the brand-name version, costs $125 to $148. People often take the drugs for years and sometimes indefinitely.
So when is the test warranted?
Women should have their bone density measured at age 65. Men 70 and older might also want to talk with their doctor about the test. Women younger than 65 and men 50 to 69 should consider it if they have risk factors such as a fracture from minor trauma, rheumatoid arthritis, a parent who had a hip fracture, or a history of smoking, heavy drinking, or long-term use of corticosteroid drugs. Whether you need a follow-up bone-density test depends on the results of the initial scan.

Treating heartburn and GERD

Use Nexium, Prilosec, and related drugs carefully
Download PDF If you have heartburn, or a feeling of burning pain in your upper abdomen or lower chest, you might be tempted to try a powerful drug such as Nexium, Prevacid, or Prilosec. Those drugs, called proton pump inhibitors (PPIs), can be good choices for severe or frequent heartburn. But in most cases PPIs aren’t necessary. And when they are, consider using the lowest dose necessary for as short a time as possible. Here’s why:
You might not need a PPI.
A PPI can help if you have heartburn more than twice a week for several weeks, or a condition called gastroesophageal reflux disease (GERD). But studies suggest that up to 70 percent of people taking a PPI were never diagnosed with GERD. Instead, they might have less serious heartburn, which can often be eased with dietary and other lifestyle changes and, if necessary, antacids like Rolaids and Tums or another class of medication, known as H2 blockers, such as Pepcid AC and Zantac.
The drugs can pose risks.
High doses of PPIs, and taking them for a year or longer, has been linked to an increased risk of bone fractures. Long-term use might also deplete magnesium blood levels, which, in turn, can trigger muscle spasms, irregular heartbeats, and convulsions. Another complication of long-term use is an intestinal infection called Clostridium difficile that can lead to severe diarrhea, fever and, in rare cases, death. PPIs can also interact with other medications. For example, omeprazole (Prilosec) can reduce the blood-thinning effect of the drug clopidogrel (Plavix), which can increase the risk of heart attack and even death. Esomeprazole (Nexium), and the H2 blocker, cimetidine (Tagamet), might also interact with Plavix in that same way.
PPIs cost more.
A month’s supply of a prescription strength PPI could cost you about $100 to $300 more than you would pay for antacids or an H2 blocker. A low-dose, over-the-counter PPI such as Prilosec OTC or store-brand or generic version, costs less than the prescription options, but still runs about $10 more a month than the other heartburn drugs.
When should you consider a PPI?
Talk with a doctor if you have heartburn at least twice a week for several weeks, if you often regurgitate food into your throat, or if your heartburn is not relieved by lifestyle changes and antacids or H2 blockers. When a PPI is necessary, start with a low dose of omeprazole or Prilosec OTC (15 mg) or Prevacid 24HR (15 mg). If symptoms improve, consider taking a break after a few weeks. To reduce the risk of rebound heartburn, gradually lower your dose, try taking it every other day, or take an antacid.

One final thought. The next time you think that all doctors want is to make more money, think of the many doctors involved in forming these lists for the sole purpose of sparing patients from the costs and hardships of wasteful testing and treatments. The medical profession is not perfect and it has its problem practitioners, but concerted efforts like these give me hope for a better tomorrow.

Wednesday, February 20, 2013

Alcohol and Cancer

My last blog titled "Can Breast Cancer Be Prevented?" offered few clues if prevention is even possible. The reason for the lack of insight was because there are a very limited number of even close to conclusive studies available.  Therefore, imagine my delight, when yesterday a new study comes along that may shed light on a well known dietary factor that may lead to breast and other forms of cancer such as mouth, throat, esophagus, liver, colon, and rectum. That factor is alcohol.

If you are among those who think that drinking alcohol, even in moderation, poses no risks, a new report finds that alcohol is to blame for one in every 30 cancer deaths each year in the United States.
According to the study's researchers, the effects of alcohol consumption are even more pronounced with breast cancer, with 15 percent of those deaths directly related. Even worse, drinking in moderation doesn't help because 30 percent of all alcohol-related cancer deaths are linked to drinking 1.5 drinks or less a day. Quoting one of the researchers, "Alcohol is a cancer-causing agent that's in "plain sight," but people just don't see it." Study author Dr. David Nelson, director of the Cancer Prevention Fellowship Program at the U.S. National Cancer Institute added, "As expected, people who are higher alcohol users were at higher risk, but there was really no safe level of alcohol use."

Published online Feb. 14 in the American Journal of Public Health, the study sought to determine the risks related to drinking and cancer.  The study involved the compilation of data from various sources, including the 2009 Alcohol Epidemiologic Data System, the 2009 Behavioral Risk Factor Surveillance System and the 2009-2010 National Alcohol Survey. Both women and men were affected by alcohol with alcohol-related cancer deaths in men, accounting for about 6,000 deaths each year. The researchers estimated that each alcohol-related cancer death accounted for an average of 18 years of potential life lost.

According to the report, previous studies have shown drinking is a risk factor for cancers of the mouth, throat, esophagus, liver, colon, rectum and, in women, breast cancer, and one expert was noted on Medline to weigh in, stating that the findings in this study are consistent with what has been shown before.
So does this mean you shouldn't drink alcohol, even in moderation? Before I answer, let me tell you my bias. I don't like alcohol and I never did. I've never had more than two drinks in my life at one time and I can say with pride that I've never been inebriated (maybe a little tipsy). Nevertheless, I'm not completely buying this study. Here's why. There is no doubt that alcohol is a toxin, poorly tolerated by several organs such as the brain, liver, etc.  It does not, however, rise to the level of causing cancer like cigarettes that are said to kill over 100,00 each year.

The reasons that alcohol may lead to cancer deaths are not well understood even by researchers.  Some studies claim that alcohol may actually be good for the heart in moderation. No one, including me advocates that one should start drinking if they aren't already in order to prevent heart disease. No one, including me can say with certainty that alcohol isn't causing cancer. I have a problem with studies that don't show cause and effect. It's not that I don't quote them often because they sometimes are the best we have and that's the problem.

My real problem is these one off studies based on compilation of data. Like I wrote in my last blog, we need to shift our research focus to figuring out more definitively what works and what doesn't work when it comes to our health and not rely on retroactive gathering of statistics. For the moment, it's the best we have so it's probably wise not to ignore it; but, I look forward to the day when we know for sure.

In the interim, if you are one of those people who are cancer-phobic, and I wish more were, my recommendation is to really limit your alcohol consumption to special occasions and to limit your consumption to one glass of alcohol (three ounces or less) when such occasions arise. My apologies to those who consume one glass or more regularly with dinner--the numbers are simply not in your corner. In fact, the researchers say their findings suggest there's no safe amount of alcohol when it comes to certain types of cancer.

Update 5.13.13.  A new meta-analysis study, a study that looks at multiple other studies to reach a conclusion, shows again that even moderate alcohol consumption ups the risk for developing breast cancer. 

Saturday, February 16, 2013

Can Breast Cancer Be Prevented?

Breast cancer sucks! It afflicts our mothers, grandmothers, sisters, wives, daughters, aunts, girlfriends, and even men. Pink ribbons everywhere speak to its far-reaching effects. We walk for breast cancer, make donations, and highlight it every chance we get. Everyone knows someone who has been diagnosed with it. Breast cancer devastates lives and families. For survivors, it hangs over their heads like a 'Sword of Damocles,' ever fearful of a relapse.

So what are we doing about it? The National Institutes of Health spent almost $2.4 billion on breast cancer research in fiscal years 2008 to 2010. The question is do we have the right strategy to stop its growth? Are we making the right research moves? The answer is unfortunately mostly no.  Maybe now, that will finally change.

On October 8, 2008, Congress passed the Breast Cancer and Environmental Research Act. The Act required the Secretary of Health and Human Services (HHS) to "establish an Interagency Breast Cancer and Environmental Research Coordinating Committee (IBCERCC) of federal and nonfederal members to examine the current state of breast cancer and the environment, research and make recommendations for eliminating any knowledge gaps in this area."

A new report just published after nearly four and a half years of meetings and information gathering, highlights the committee's conclusions that breast cancer research needs to focus more aggressively and coherently on environmental factors that may contribute to its development. Chemicals, radiation, drugs and consumer products are foremost among the environmental factors addressed in the report, but so are less obvious factors related to lifestyle and socioeconomic concerns.

But the most important recommendation of the committee is evident in the title of its report, "Prioritizing Prevention." Why? Because according to the report, "despite decades of productive breast cancer research, the number of women diagnosed with breast cancer continues to rise.  In 2012, 227,00 women and 2,200 men will be diagnosed with breast cancer and 40,000 women will die from it."

While untold money has been spent on early detection of breast cancer and on research for treatments, scientists and doctors have barely dented the epidemic of cases.  Along comes a federal commissioned group tasked with stepping back and figuring out where we should spend our resources and what does it decide? Spend the most money on prevention, it urges.

The facts are clear. Most women who get breast cancer have no family history. The interaction of genetic and environmental factors are known to play a role because as the report states, "breast cancer rates can vary with changing environmental circumstances." Like most cancer and disease prevention efforts, the committee recognized that efforts to prevent cancer have lacked sufficient resources and that moving forward, our limited resources should be mostly reapplied towards prevention versus detection and/or treatment/cure.

The report's first recommendation states that not enough has been done "to identify and mitigate the environmental causes of the disease." It asks that we prioritize prevention. It states that we should modify "social and lifestyle factors implicated in breast cancer." Early this past week, I wrote a blog before this report came out asking "Isn't It Time We Got Serious About Prevention?"  I don't know how many more federal dollars will be spent trying to figure out where we should spend our valued research dollars, but one thing should be certain-avoiding cancer should be our number one priority.

In addition to protecting its citizens from known environmental carcinogens found in foods, household chemicals, and pollutants, the government needs to pay doctors to take the lead in helping patients modify lifestyle factors, such as obesity, to prevent cancer. Even among cancer survivors, recurrence rates are much higher among obese women. A recent study showed that breast cancer survivors who lose weight reduce the rate of the return of the disease.

It is sometimes lonely for me to keep crying out about the importance of choosing the right foods and staying physically active, managing stress effectively, socializing, finding meaning and purpose, and getting adequate sleep, but it's reassuring that others are now reaching the same conclusions about the importance of lifestyle factors. A recent study showed that flaxseed, for example, may prevent breast cancer. Did anyone even hear about the study? (Here's the study: Consumption of flaxseed, a rich source of lignans, is associated with reduced breast cancer risk. based on this one study, should women run out and consume lots of flaxseed? I don't know the answer. In general flaxseed is a healthy foodstuff, but does it really prevent breast cancer? We need more studies to know for sure and so the question is why aren't there more studies looking at the role of diet in breast cancer prevention?

A review of the last two hundred plus studies published about breast cancer prevention revealed that only a handful of studies focused on actual prevention. (By the way, one interesting study showed a correlation between sun exposure and reduced rates of several cancers. The more sun, the less cancer. The researchers felt more was involved than the fact that it's known that the more sun you get, the more Vitamin D you produce.  I have always been a fan of daily sun exposure and encourage my patients to get at least a half hour of sun exposure everyday without fail. I do caution them, however,  to cover their faces with wide brim hats.  Here's the study:
Is prevention of cancer by sun exposure more than just the effect of vitamin D? A systematic review of epidemiological studies.

A recent study looked at the role different fats play in breast cancer development and showed that only the Omega-3 fats seem to be protective. (Here's the study: Dietary intake of specific fatty acids and breast cancer risk among postmenopausal women in the VITAL cohort.  Another study focused on the role that the combination of polyphenols (found in berries, etc.) and alcohol play in breast cancer development. (Here's the study: Dual association between polyphenol intake and breast cancer risk according to alcohol consumption level: a prospective cohort study. As the federal committee just concluded, we need a lot more of these types of studies focused on prevention and environmental factors such as diet.

You get the drift. There are scattered studies that fail to nail down any real conclusions, which leaves everyone to their own devices to figure it out or do nothing. If you are one of the people trying to figure it out, here's what I can tell you at this point. Prevention efforts seem to pay off and lifestyle intervention is the key. "Prevention is the key to reducing the emotional, physical, and financial burden of breast cancer," wrote the committee. "By urgently pursuing research, research translation, and communication on the role of the environment in breast cancer, we have the potential to prevent a substantial number of new cases of this disease in the 21st century."

My preventive medicine practice can show you how today; I want to help you, but you need to want to be helped. Make the right choices now and enjoy the fruits (no pun intended) of wise decision-making. With one out of three women developing some form of cancer and one out of two men doing the same, again I ask, isn't it time you got serious about preventing cancer? Stop waiting for the terrible news and take charge of your health today. There's no better time!

Remember, prevention is preferable to cure.

Friday, February 15, 2013

Calcium and Heart Disease: What's The Story?

I don't know many doctors who would tell you that taking calcium supplement pills may be a bad thing.  Alas, I was one of them, but I think that's about to change big-time.

As far back as I can remember, women were told to take calcium supplements to prevent osteoporosis. It was practically a staple of childhood that we all needed to drink milk with calcium to develop strong bones. Apparently as we grow older this need increases, and ignoring the debate if dairy is even healthy, most doctors must believe that dairy is no longer a sufficient source of calcium because they recommend that women take 1,000 to 1,200 mg of extra calcium daily as supplements to keep their bones strong.

If you had asked me two years ago, I would have raised no objections to such advice.  Then a funny thing happened. (Not the "ha, ha" kind of funny, but the "that's odd" type.) I started noticing over the past couple of years a few studies that suggested that calcium supplements may actually do more harm than good. A study in New Zealand showed that even 500 mg a day of calcium increased the risk of heart attack by 30%.

Looking around, I kept expecting to hear something from other parts of the medical community warning about calcium and chastening doctors to weigh the risks and benefits before making further recommendations. But there was nothing. Nevertheless, I began to speak about it in my lectures sharing my new knowledge about the potential role of calcium supplements in the calcification of arteries and heart disease.  My audiences were stunned; I would literally hear gasps. How could a doctor be openly challenging the long held assumption that all post-menopausal women should take calcium supplements to prevent osteoporosis and not hear a peep of concern from their own doctors.  Obviously, I must be wrong.

The truth be told, sometimes I wonder if I misread or misunderstand the information I come across. For example, when the Institute of Medicine lowered the threshold for a Vitamin D deficiency from 30 ng/ml to 20 ng/ml, again I waited for the reactions from the medical community.  Again, zip.  So confused by the lack of reaction, I went back and reread it. There it was again clear as day. The threshold had definitively been lowered and like the line from poem, "not a creature was stirring, not even a mouse." There was nothing but dead silence.

Well I hope that's about to change. During the past week or so a flurry of studies has emerged which has put the issue on the national radar. The first study cautioned men about the role of calcium supplements in forming kidney stones and the second study warned about its role in heart disease. This week a new study about women came out that should have everyone talking.

Checking if calcium supplements raise the risk of dying from heart disease, Dr. Karl Michaelsson, a clinical professor in the department of orthopedic surgical sciences at Uppsala University in Sweden, analyzed data collected on more than 61,000 women enrolled in a study on mammograms. The study, published in the British Medical Journal, showed that over 19 years of follow-up, nearly 12,000 women died with the highest rates of death identified among women whose calcium intake was higher than 1,400 milligrams a day. Women who took less than 600 milligrams of calcium a day also were noted to have an increased risk of death.  (That makes sense since calcium is an essential mineral, which means you can't live without it.)

The Swedish study showed that death was ONLY increased among women whose calcium came partly or wholly from calcium supplements.  (Of course, a supplement industry representative weighed in immediately that the study was flawed because it was not specifically meant to address calcium supplements and heart disease. Who cares? Even though it was not a cause and effect study, didn't look at Vitamin D, and its initial research purpose was not to evaluate what calcium does to the heart, the study offers a pretty compelling argument that calcium supplements may be very dangerous.)

But don't take my word for it. Quoting from Medline, "Many older adults increase dietary intake of calcium or take calcium supplements to prevent bone loss and there had been speculation that increased calcium intake with or without vitamin D could improve cardiovascular health," said Dr. Gregg Fonarow, an American Heart Association spokesman who wasn't involved in the study.

However, a number of recent studies have suggested that higher dietary intake or calcium supplementation may not only not improve cardiovascular health -- they may be associated with increased risk for cardiovascular events and mortality, said Fonarow, a professor of cardiology at University of California, Los Angeles."

For over a year, I have been asking my audiences if their doctors adjust their calcium recommendation based on how much calcium they get from their diet. The answer has always been no. The key finding in the new study was that if women exceeded 1,400 mg of calcium a day based on a combination of food and supplements or supplements alone, the death risk doubled. No such risk was seen with food alone.

So the bottom line is everyone needs calcium and it is best and safest to get it from foods like broccoli, almonds, tofu, sardines, kale and other leafy vegetables, and almond milk. As I am not a fan of dairy, I don't recommend dairy products but Greek yogurt, etc. are also good sources of calcium. Avoid antacids with calcium, they are just as bad as calcium supplements.

It will be curious to see if doctors now change their calcium recommendations and actually take the time to adjust for diet. I give patients handouts with the concentration of calcium in healthy foods so they can make their own adjustments. As I like to say, to paraphrase Sy Syms the retailer, "an educated patient is my favorite type."

By the way, if you are interested in strong bones and a healthy body, there is no substitute for weight-bearing exercises.

Wednesday, February 13, 2013

Isn't It Time We Got Serious About Prevention?

The United States Preventive Services Task Force (USPSTF) recently posted a draft research plan for public comment under the banner: behavioral counseling to promote a healthy diet and physical activity for cardiovascular disease (CVD) prevention in persons with known risk factors for CVD The USPSTF describes itself as “an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists).”

The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screenings, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements."

Having previously founded, built, and sold HealthDrive, the largest medical and dental practice in the U.S. providing care to elderly residents of nursing homes and assisted living facilities, I witnessed during my tenure what happens to older Americans who succumb to chronic diseases and require constant nursing care. Spurred on by the introduction of Medicare’s Annual Wellness Visit, I came out of a short retirement almost three years ago to answer the same basic question, does counseling work to prevent disease, now also posed by the USPSTF. The Annual Wellness Visit, now only covered by Medicare, is a service in which a physician is paid to identify health risk factors as opposed to performing a routine exam or treating an existing condition.  It is an opportunity to try to prevent disease as opposed to treat it.

As a doctor who practices primary prevention on a daily basis, having last year counseled hundreds of patients to eat better and get more physical activity, I can share that success is a function of spending considerable time with patients to help them identify their motivations to live a longer and healthier life. I have found this process to be different for each patient and very time-consuming, often extending beyond an hour and sometimes more than two hours; my longest session took over four hours. Helping patients identify and articulate their motivations takes time and effort because motivation is often not the simple “I want to live.”  
True motivations range from wanting to meet their great grandchildren to seeing what gets invented next (mine).  Often they are uniquely personal.  Case in point was a patient who after considerable discussion ultimately shared that his prime motivation to live healthier was to outlive his wife so he could spend more time with the other woman he also loved.

Once I identify a patient's prime motivation, it is then critical to choose the right intervention(s).  For example, a patient who has lived a sedentary life for many years will often find it difficult to suddenly initiate physical activity on his or her own.  Extensive muscle atrophy from lack of use may require the services of a physical therapist or personal trainer (which few can afford) to start moving again. Eating healthy takes work as well. For both those who knowingly eat unhealthily or are simply confused what comprises healthy food choices because of widespread food marketing and misinformation, it is helpful for them to sit with a registered dietitian to learn how to develop healthy meal plans. 

This can sometimes be a complicated undertaking because of underlying medical conditions. For example, a patient taking Coumadin, a blood anticoagulant, cannot simply add more green vegetables to the diet as such vegetables can reverse the effect of the drug.  A plan is needed to reintroduce green vegetables while adjusting drug dosages.  A patient with fecal incontinence, a condition where bowel movements are not well controlled, must be very careful with how much fiber is added to the diet, as one of my patients recently learned as he barely made it to the toilet in time.  It requires much reassurance to overcome the fears of patients with diverticulosis, an abnormality of the colon that results in growth of out-pockets of tissue that can become clogged,  that they can in fact consume nuts and seeds after years of being told otherwise. But with patience and perseverance, I have seen the amazing happen.

One of the largest draws to my practice is our obesity counseling program.  As part of the Affordable Care Act’s new preventive measures, in 2012, The Centers for Medicare and Medicaid Services (CMS) introduced a new service called Intensive Behavioral Therapy for Obesity (IBTO). This service was introduced in accordance with the USPSTF’s conclusion that there was value in offering such a service for treating the growing obesity epidemic now estimated to affect thirty-six percent of the population, with seniors no exception.  Each obesity counseling session may last up to fifteen minutes. This limited time allotted for by Medicare has proven to be insufficient to fully address all weekly concerns as patients try to adapt new foods into their diets and change their overall lifestyle.  The hastened time often adds to patient frustration, particularly for those who need much hand holding.

But losing weight often involves more than food.

For most patents there are psychosocial reasons why they eat too much or fail to engage in significant physical activity. On the food side, there are sugar addictions or what many call “a sweet tooth,” poorly managed stress leading to inadequate sleep which stimulates increased appetite and food consumption, eating to punish one's self or gaining weight as a buffer from a difficult world, etc. Many seniors for example, suffer from depression, and food offers comfort. Excess food leads to added weight, which leads to pain which leads to decreased physical activity, which leads to little to no sun exposure, which in totality exacerbates their depression.  To change the way people with relevant psychosocial issues eat and live, a psychologist is often needed.  (Psychiatrists are often too quick to prescribe medications that don’t address lifestyle issues.) At a time when an increasing number of Americans, particularly seniors, are  suffering from emotional and mental health issues, not only are psychologists not getting their due, in 2013, Medicare further decreased their reimbursement.

The costs of entitlement programs such as Medicare and Medicaid clearly consume a large portion of our tax dollars but that is no excuse for being penny wise and dollar foolish.  For example, according to CMS provided data, in 2012, the first year of availability of IBTO services, there were only a total fifty thousand total sessions (patients are entitled to 16-22 sessions per year) provided in the entire United States.  It’s not surprising. IBTO has not been well received by the medical community because it is impractical and not cost-effective for most busy medical practices to expend their resources to schedule patients for sessions of not more than fifteen minutes to receive reimbursement which is one-third of similar reimbursement for a fifteen minute Evaluation & Management code (E&M).  For less than thirty dollars a session (national average according to CMS: twenty five dollars), a primary care medical practice must verify eligibility, schedule a patient, remind them of the appointment, greet them and process their arrival, gather biometric data such as height, weight, blood pressure, temperature, calculate body mass index, discuss progress and counsel the patient, and bill for the service.   

The realities of running a medical practice today with associated overhead costs and regulatory demands, makes it impractical for most primary care medical practices (only primary care practices can offer the service per CMS guidelines) to provide a behavioral counseling related service for which it will probably lose money.

The Centers for Disease Control has weighed in that the evidence for the power of prevention is now indisputable.  Accordingly, behavioral counseling can and will have a meaningful impact on patient's lives, as I have demonstrated with my patients. However, other doctors will not embrace preventing chronic diseases such as CVD until adequate reimbursement is available. For doctors to invest in the knowledge needed to be effective counselors for their patients will take time and for them, time is money.  Today, few physicians have meaningful knowledge of the nutritional sciences. Many physicians still graduate medical school without a single course dedicated to nutrition.  Most states don’t even mandate it in the curriculum. Therefore it is probably fair to say that if we want physicians to be motivated to educate themselves regarding their patients’ nutritional needs, we will have to incentivize them.

The bottom line is that behavioral counseling can be highly effective in altering the trajectory of patients’ chronic disease development and advancement when a practice either has the resources to address the myriad factors that affect behavior or can make appropriate referrals for critical assistance. 

Having previously built a national health care practice which I sold to a private equity firm, I find myself in the unique position of being able to experiment with my own money to prove my points.  Unfortunately, to date, even though my medical practice is the largest provider of IBTO in Florida, such services have been provided at a financial loss because of inadequate reimbursement.  This is obviously not a perpetually sustainable model for us or for anyone else for that matter. While it is not within the scope of the USPSTF's mandate to set reimbursement rates, I urge it to consider the importance of not only identifying the value of the behavioral counseling service it now is attempting to determine, but also to make clear to its constituencies that allocating enough time and resources for medical practices to fully embrace such services that can decrease the burdens of chronic disease, both for individuals and society, is of utmost importance.

About twenty-five hundred years ago, Hippocrates, the widely acclaimed father of medicine, was noted to have said that “prevention is preferable to cure.”  I know that message has never fully resonated with our sick-care oriented system, but I hope most people would agree that the time has come to shift resources from not only  treating diseases but to also preventing them. The USPSTF has wisely reached the same conclusion in the past and I trust it will do so again. I hope in this time of much needed fiscal constraint, CMS will recognize as Ben Franklin once said that “an ounce of prevention is worth a pound of cure” and fund prevention efforts accordingly by setting reimbursement rates at levels likely to encourage more doctors to act.

Sunday, February 10, 2013

If You Jump Up and Down After Reading Today's Blog, You May Actually Remember It When You Get Older!

It won't come as news to anyone that exercise helps you stay fit and being fit is good for your health. It also probably won't come as a surprise that being fit is good for your mood. But what about memory? Will exercise preserve memory? Does being fit earlier in life affect what happens many years later? Will being fit prevent Alzheimer's and other forms of dementia?

Until now, scientists have had strong suspicions that lifestyle plays a meaningful role in preserving healthy brain function, but they didn't know for sure. A new study just came along that moves the needle along in validating the key role that exercise plays in prevention.

Published in the February 5, 2013 issue of the Annals of Internal Medicine, the study titled "The Association Between Midlife Cardiorespiratory Fitness Levels and Later Life Dementia" was a cohort study that does not prove cause and effect but deserves close attention. The study performed at The Cooper Institute in Dallas Texas involved 19, 458 middle aged people who had a treadmill exercise test as part of health care preventive visit. Based on the amount of time that a person was able to run on the treadmill, researchers grouped them into two categories of most fit and least fit. They then followed these people for many years, beyond the time they reached 65 years, to see who developed dementia.

What did they find? You guessed it. The people in the most fit group were far less likely to develop dementia. Although the study did not look at diet, which is obviously an important contributing factor to health, and was limited to mostly healthy white people, it does offer possible evidence of an association between fitness and memory preservation.  Again, the study did not prove cause and effect but it does provide yet another reason to stay fit by being physically active.

While only 1 out of 8 Americans develop dementia by the age of 65, that number rises to 3 out of 7 by age 85. Although that represents less than half of those over the age of 85, no one, but the most cynical, would disagree that it would be better to avoid dementia than experience it.  It's no fun to lose your memory. Just ask anyone who suffers from a form of dementia or watched a loved one die from it. The good news is that science suggests that if you get to age 90 without developing dementia, the probability of development appears to decrease due to possible suppression of the gene responsible for it.

So if you are sitting down when you read this, it may be a good idea to get off your seat and jump up and down.  If you keep doing that long enough and as often as possible, you may remember this blog for many years to come. That would be nice, right?

Nu? So what are you waiting for? Get up and get moving! Now, before you forget how important it is to your future memory...

Tuesday, February 5, 2013

Beware of Doctors Bearing (Medifast) Meals!

When MDPrevent first opened in Delray Beach, Florida, I visited with many of the physicians whose practices surround us. One of those physicians was a cardiologist who expressed concerns about his expectation that we would emphasize supplements as his view of the world was that a preventive medical practice would push supplements. Of course given my disdain for such products, he had nothing to fear. Nevertheless, I was impressed at the time that he was concerned about his patients being subjected to a doctor trying to push unnecessary products on them.

So imagine my surprise when after having never heard from him again, I suddenly received a call two weeks ago.  He had heard about MDPrevent's success with running an intensive lifestyle intervention program for weight management and wanted to discuss a new undertaking in which he was getting involved.

He proceeded to explain how he had heard about the weight loss program created by Medifast and how he had found a way to not only help his patients lose weight, but also make more money for himself.  Over the course of two phone discussions, he explained how Medifast would sell his patients a '5 and 1 meal plan' that involved the patient buying five small daily meals from Medifast and preparing one on their own. Medifast would charge the patient $2 for each meal and  $10 in total for the five meals, which would be consumed every two to three hours. (Really, $2 a meal? What kind of quality food can you buy for $2??? None that I have ever seen.)

In return for peddling the product, the doctor would receive a fee of anywhere from 2 to 20% of the sales money that Medifast received from the doctor's efforts.  The doctor's efforts involved not only initiating the sale of Medifast's products, but also serving as a health coach to the patient and answering any questions about weight loss that may arise. The higher percentages would be paid for enlisting more doctors to sell products to their patients as well.

In this multi-level marketing like scheme, the more doctors a doctor signed to sell products to patients, the more money the doctor on top made, with each doctor in the pyramid at a lower level earning slightly less. If you are the only doctor selling, you only get 2%. He said that this plan had resulted in some doctors earning as much as an additional $80,000 a month in income.  I guess he thought it was impressive to throw out the potential of earning roughly an extra million dollars a year, which I suspect very few doctors if even more than one have ever achieved.

Nevertheless, I asked him a few basic questions.

My first question was is the food healthy?

His response was that studies showed that it helped people lose weight.  He couldn't answer the question if the food was fundamentally healthy or is the same processed food used by many similar programs. (Wondering myself, I launched an investigation into the ingredients used in their products.  I wish I could tell you that I was pleasantly surprised, but it would not be true. Their products were similar to many other commercially produced products that include artificial flavors, sugar, dyes, and other chemicals. I could never in good conscience recommend such products to my patients as a daily meal replacement plan. Shame on any doctor who would.)

The doctor also forwarded Medifast's propaganda package that included several studies.  Suffice it to say that in fact, many of the studies provided to support the effectiveness of the program were unpublished studies, studies published in unimpressive journals, or studies that proved little.)

My second question was how could he afford to be an unlimited health coach to a patient for $73 a year?  (I calculated that if the patient buys the $10 food for an entire year, that would generate $3650 in revenue for Medifast. The doctor's cut at 2% would be $73.)

His response was that he would hand off the coaching responsibilities to his nurses or assistants. He didn't have a good answer as to what qualified them to be health coaches under any circumstances, let alone for weight loss purposes.  Coaching is generally a skill that must be developed and it would be potentially harmful to give unlearned counsel to a patient expecting professional advice.

Finally, I asked since Medicare now pays 100% for Intensive Behavioral Therapy for Obesity, how can he charge his Medicare patients privately for weight loss coaching?

His answer was that there was no conflict as the programs could work together. Since I know he has never referred a patient to MDPrevent's program, the only known integrated primary care practice offering Intensive Behavioral Therapy for Obesity services here in South Florida and the provider of one-third of all such services in Florida in 2012, I believe he has no intention of doing so.

It is a very sad commentary that a doctor who initially impressed with his apparent ethical standards has decided to sell out to a scheme to embellish his income.  Between the doctor who recently tried to convince me of the merits of selling NuSkin's dietary supplement products to this one doing the same with Medifast's program, I can only fear for the future of the medical profession.  Doctor's are getting desperate to maintain their incomes and that forebodes poorly for patients' best interests. There is a rising tide of these get rich quick schemes that are detracting our doctors (I say "our" because I am also a health care consumer) from the basics of good patient care.

So if a doctor comes bearing processed food meals, I suggest you run as far away as possible. Actually, running may be the best part of the deal.

Sunday, February 3, 2013

Think Like A Doctor, Act Like A Patient

An Op-ED article appeared in today's NY Times, The Boy With a Thorn in His Joints, about a mother that found relief for her child's malady by incorporating alternative therapy.

In response, I posted the following comments.

As a physician that practices integrative healthcare, but defines integrative differently, I combine the services of a MD, registered dietitian, health psychologist and physical therapist into one practice that addresses the four main constituents of healthy living.

1. Identify and address any underlying medical condition(s).
2. Optimize nutritional status.
3. Identify and develop a strategy to tackle encumbering emotional and psychological issues.
4. Ensure that a person can engage in low to moderate intensive physical activity as part of daily living.

Everything we do is based on the scientific method of trial and error. If it works great; if not, next. Each patient is treated as an individual. No one size fits all.

First, let's look at some numbers to start. The reported statistic for Celiac disease is that it affects about 1% of the population, with 4 out of 5 cases going undetected. A gGT test is very good at making the diagnosis. Somewhere between another 1 to 10% or so may suffer from gluten insensitivity. A food allergy test can help diagnose that as well.

Second, I often tell my patients to "think like a doctor and act like a patient." Thinking like a doctor means considering all possible diagnoses and all possible treatments, using those considered most effective for the diagnosis most likely. If that doesn't work, you must consider alternatives.

Acting like a patient means following the therapy prescribed by a doctor you trust. Acting independently unnecessarily raises risks and creates confusion as to what did and did not work.

If traditional medicine fails, it is more than prudent to consider alternatives. But don't be fooled into thinking that alternatives that have medicinal properties don't carry the same risks as do all medicines. Don't use an alternative until you have researched its viability and discussed it with your physician. You also need to confirm that you are taking the right dose, understand the side effects and contraindications, are aware of the effects on other medications, and have a product that is properly manufactured and labeled. Otherwise, you may end up doing more harm than good.

There's a reason why botanicals and other non-regulated supplements are called "complementary and alternative" therapies because they are usually not the best first-line treatment. It pays to keep that in mind when you are looking for a solution to a new health problem. As for eating properly, which mostly includes whole foods, that always make sense regardless of your health state.