American Diabetes Association: Fish Oils Do Not Reduce Cardiovascular Event Risk

The American College of Cardiology now recommends that individuals take “fish oil” supplements in pill form to prevent coronary artery and vascular disease. The scientist who discovered that fish oils may have beneficial effects has publically come out and let it be known that he feels differently on the subject. While he once advocated eating two fleshy cold water fish meals a week to gain some degree of protection, he has most recently reduced that requirement to two meals a month. He has additionally scolded the nutritional supplement community for the promotion of fish oils in pill form when it can be safely and effectively obtained by eating a few cans of tuna fish or salmon per month.

Recently, at the annual meeting of the American Diabetes Association, Jackie Bosch, MSc, from McMaster University and Hamilton Health Sciences in Hamilton, Ontario presented data that suggested that fish oils did not reduce cardiovascular deaths or events.  The data was abstracted from the ongoing ORIGIN (Outcome Reduction with Initial Glargine Intervention) study of 12,536 patients with type 2 diabetes, impaired fasting glucose levels or impaired glucose tolerance. These study participants were composed of 65% men with a mean study age of 64 years who were followed for over six years. The study group received one gram daily of n-3-fatty acids.

The data showed that fish oils did not make a difference in the number of fatal or non-fatal heart attacks, fatal and non-fatal strokes, hospitalizations for heart failure, revascularization procedure numbers, and loss of a limb or digit due to poor circulation for any cardiovascular cause. The study additionally showed that the use of a long-acting insulin Glargine had no detrimental or beneficial effects on cardiovascular disease.  The story was covered and summarized in the online periodical of the University of Pennsylvania Medical School, MedPage.  Interestingly, the placebo group received one gram per day of olive oil.

Clearly this is another indictment against taking pills instead of acquiring nutrients in a well prepared balanced diet that includes cold water fleshy fish weekly.  Upon reading the study, I wondered if the use of olive oil by the placebo group was cardio-protective and fish oils were just no more cardio-protective than olive oil?  Once again, further research is needed. While the research is ongoing, eating cold water fleshy fish once a week as part of a nutritionally sound, well prepared diet rather than taking fish oil pills seems to make sense.

FDA Approves New Prostate Cancer Blood Test

The PSA blood test which has been used to screen for prostate cancer has come under a barrage of criticism in recent weeks. The PSA level increases in many non-cancer conditions and this has led to many biopsies and procedures that created more harm, and cost, than good. For this reason, the prestigious Institute of Medicine (IOM) and the U.S. Preventive Task Force have indicated that men should not be routinely screened for prostate cancer with the PSA blood test.

A new test may be on the horizon.  Beckman Coulter said its application for the Prostate Health Index test has been approved by the FDA. The test measures a PSA precursor protein known as [-2] pro-PSA in men with elevated PSA’s between the level of 4 and 10. This, coupled with the PSA and free PSA, helps create the Prostate Health Index.  The company’s data showed that by using the Prostate Health Index there were 31% fewer negative biopsies of the prostate.   The test will be commercially available by the fall of 2012.

We will make this test available when the commercial labs inform us that they are ready to perform it. It remains to be seen whether the health insurance companies will pay for it immediately.  We will need to monitor whether the promise and initial data are accurate when the test is introduced into the general public. We will also need guidelines on how often to follow this index.

Statins May Reduce Your Energy Level

Beatrice A. Golomb, MD, PhD. of the University of California San Diego and colleagues discussed the results of their ongoing studies in the Archives of Internal Medicine online edition regarding cholesterol lowering drugs Simvastatin and Pravastatin and recipients’ perception of their energy level. Their research suggested that Simvastatin might leave its users, especially women, feeling tired and drained after exertion.  The scores hinted that almost 40% of women felt more tired and fatigued during physical activity on Simvastatin than without the lipid-lowering drug.

The trial included 1,016 men and women with low-density lipoprotein (LDL) cholesterol screened at 115- 19- mg/dL who were randomized to receive 20 mg Simvastatin, 40 mg Pravastatin, or placebo each day for 6 months. These patients did not have documented heart disease, cardiovascular disease or diabetes.

There was a worsening of perceived energy level and exertion related fatigue in 4 of 10 women on Simvastatin. The effect was much less, and not significant, with Pravastatin or placebo.   In a recent review of statins and adverse effects in the Cleveland Clinic Journal of Medicine, the authors pointed out that muscles performing work required  fats and lipids as a source of fuel and energy to work successfully. They hypothesized the possibility that the goals of cardiology to reduce lipid levels to prevent cardiovascular disease to extremely low levels may create an environment in working muscles where the lipid levels are too low to generate the fuel or energy needed to perform the exercise and work needed to be done.

Clearly, further research needs to be done.  We must remember all these participants DID NOT have vascular disease and this is a primary prevention study to prevent them from developing cardiovascular disease.  Might there be other methods to achieve this?  Is Simvastatin the only statin to cause this type of problem or will the other statins do the same?  Is this a problem of the particular generic brand of Simvastatin used or is it an across the board effect of Simvastatin?  All these questions require additional research to obtain the answers that we need.

United States Preventive Care Can Be Better, Center for Disease Control Says

Ralph Coates, PhD of the Center for Disease Control (CDC) described in the June 15, 2012 issue of Morbidity and Mortality Weekly Report that by looking back at a U.S. study done between 2007-2010 called “Use of Selected Clinical Preventive Services among Adults,” health providers need to do a more comprehensive job of offering preventive services.

According to the report, only 47% of patients with documented heart and vascular disease were given a recommendation to use aspirin for prevention. They additionally found that only 44% had their blood pressure under control. When looking at cholesterol and lipid control only 33% of the men and 26% of the women were tested with a blood lipid test in the last five years.  Of those patients who did measure their lipid levels, only 32% of the men and women surveyed had their lipids under control. Among diabetics, 13% had poor sugar control with a HgbA1C > 9 (goal is 6-8).

The data indicate that at 37% of the visits, patients weren’t asked about their smoking or tobacco status.  When patients were asked, and answered that they were smoking, only 21% were given smoking cessation counseling and only 7.6 % were prescribed medications or a way to stop smoking.

Screening for cancer needs improvement as well. Twenty percent of women between the ages of 50-74 had not had a mammogram in over two years.  In the same age group, a third of the patients were not current on screening for colon and rectal cancer.

The data was collected prior to the passage of the controversial Affordable Care Act. When the data was analyzed and divided according to socioeconomic status, education level, and health insurance status; it was clear that the poorest and least educated had the fewest screenings. It is hoped that with passage of the new health care law, and new insight by health insurers that it is cheaper to prevent a disease than treat it, these numbers will improve.

There are several other factors that need to be looked at as well. Data is now being collected from electronic medical health records.

I ask my patients about tobacco status on every patient visit.  When I note that the patient is smoking in their electronic health record, there are three or four ways to document counseling has been offered. Only one of them triggers the audit data for the government to review. Our software instructors were unaware of that when they taught us to use the system.  How much of this study is the result of data collection error is unknown.  “Health care providers” – not just physicians, are now delivering health care.

Access to physicians and a shortage of primary care physicians exacerbate the problem. It takes time to extract this information, record it, and counsel the patient. Because PCPs are underpaid, they will continue to see patients in high volumes to cover their expenses, causing the use of comprehensive preventative questioning to remain low.

Fish Oils Fail To Stave Off Mental Decline

Dietary supplementation with Omega-3 fatty acids did not prevent cognitive decline in older individuals according to a study which reviewed the subject in the online magazine MedPage, a publication of the University of Pennsylvania School of Medicine.  By the year 2040, more than 80 million people will be affected with dementia. There has been increasing interest in identifying dietary factors that could help diminish these numbers.

The study was performed by Emma Sydenham, MSc of the London School of Hygiene and Tropical Medicine in response to some previous observational studies that suggested that consuming high levels of polyunsaturated fatty acids may reduce the likelihood of cognitive decline with aging. Some evidence does exist that fatty acids play an important role in brain health through the maintenance of neuronal functioning while acting as mediators of inflammation and oxidative stress.

Sydenham and associates looked back at three major studies designed primarily to assess the efficacy of Omega-3 fatty acids in preventing cardiovascular disease.  Cognitive function was assessed by various methods in all three well-designed studies.  All three studies indicated that Omega-3 fatty acids played no role in preventing cognitive decline.

Sydenham’s team suggested that more research is needed in this area. I believe this study emphasizes the wisdom of eating a balanced diet prepared in a way to retain the nutrients – inclusive of several portions of cold water fleshy fish per week.

In general, if you provide your body with the nutrients it needs by consuming appropriately prepared healthy portions, your body will extract what it needs.

Exercise Induced Muscle Soreness May Not Benefit from Regular Use of NSAID’s

The June 11, 2012 issue of MedPage carries coverage of the meeting of the European League Against Rheumatism where work by Matthias Rother, MD, PhD suggested that taking Ketoprofen or even Celecoxib (Celebrex) for exercise induced muscle soreness may not be a great idea.

The study looked at 64 healthy volunteers who were asked to walk down stairs totaling 400 vertical meters – similar to walking all the way down from the top of a 100-story building.  Forty of the volunteers were randomized to take 200 mg of Celebrex or a placebo twice a day. Twenty-four of the participants were randomized to take Ketoprofen or a placebo.

The patients in the Ketoprofen reported no improvement in pain.  In fact, their pain lasted longer (122 hours) than the placebo groups pain (105 hours).  Patients taking the Celecoxib had a mild pain improvement – so mild that it was not felt to be statistically significant.  This led the researchers to conclude that NSAID’s did not provide significant pain relief to justify their use in post-exercise muscle soreness. They went on to say that muscle inflammation and soreness are part of the inflammatory reaction following exercise that is “essential for recovery.”

This was a small study and it is hard to conclude anything. I will still recommend RICE therapy (Rest, Ice, Compression, Elevation) immediately following post injury or exercise.  Celecoxib (Celebrex) did reduce pain by 12- 13%, so, possibly the dosage and frequency of administration of the NSAID needs to be looked at as well. If my patients do not have a medical reason to avoid NSAIDs, they will still be advised to try them for work and exercise related aches and pains.

The Heat Index

The heat index tells you how hot it feels outside in the shade. It is not the same as the outside ambient temperature. It combines the humidity with the temperature.  When you are standing in the open and full sunshine the heat index is even higher. A heat index of 90 or greater is considered dangerous.

Sunburn, Sunscreen and How to Avoid Damaging Ultraviolet (UV ) Light

Summer has arrived and individuals are outside trying to obtain the perfect tan.  Exposing yourself to the sun allows your skin to be exposed to ultraviolet light. We are most concerned about ultraviolet light in UV-A spectrum (320-400 nm) and the UV-B spectrum (290-320).  UV-A rays penetrate deeply and cause skin damage including photoaging of the skin, immunosuppression both locally on the skin and systemically and increased risk of cancer and infection. It is the UVB radiation that causes tanning.  The delayed tanning that occurs 3 days after exposure is due primarily to UV-B radiation and is due to a redistribution of melanocytes and new melanin synthesis and formation. This delayed tanning is at best mildly protective against sunburn SPF 2-3 but has no effect on protecting against cancer or photoaging.

Sunscreens can help reduce your risk of developing skin damage and cancer.  Sunscreens are either inorganic containing products that physically shield and block the effects of ultraviolet rays or organic compounds that physically absorb the ultraviolet rays. You should be looking for a sunscreen that is “broad spectrum” protecting against UV-A and UV-B rays.  You want a sunscreen that is substantive.  “Water resistant” products protect up to 40 minutes after water immersion.  “Very water resistant” products protect up to 80 minutes after water immersion.  Data and research shows that a broad spectrum sunscreen with SPF 17 or greater will provide protection against squamous cell carcinomas and photoaging but are less effective in preventing basal cell cancers and melanomas.

It is recommended that we use sunscreen daily on all sun exposed skin. The clouds only scatter UV-B Rays so on cloudy days you are being bombarded with UV-A rays despite it appearing to be overcast.  It will require about a shot glass worth of sunscreen to protect the most sun exposed areas (two tablespoons) which are the face, ears, hands, arms and lips. You should be using an SPF of at least 30 which should be applied 15-30 minutes BEFORE sun exposure.  It should be reapplied every two hours and after swimming or heavy perspiration.

  • Remember that the sun’s rays are strongest between 10 a.m. and 4:00 p.m.
  • Water, sand and, in the winter, even snow reflect UV radiation so be extra careful in those environments.
  • Wear protective clothing such as closely woven, natural fiber, long sleeve shirts and pants, sunglasses and wide brimmed hats.
  • Do not use tanning beds.
  • Do not expect sunscreens to allow you to spend more time in the sun. Long exposure to the sun’s damaging UV rays increases your risk of skin cancer and photoaging.

Summer means longer days and more time spent outside. Be prepared and protect your skin from damage and injury.

What is SPF “Sun Protection Factor” and What is the Daily UV Index?

SPF is a laboratory measure of the efficacy of sunscreen and is defined as the amount of ultraviolet radiation needed to produce sunburn on protected skin relative to unprotected skin. It is a measurement of redness or “erythema” and is mainly a measure of UV-B radiation exposure not UV-A (the more damaging type of radiation to deep skin structure) exposure.

The SPF of a product is not related to the duration of UV radiation exposure. The relationship between SPF and UV-B radiation protection is not 1:1 or linear meaning that an SPF 30 does not protect you for twice as long as an SPF 15.  For example, an SPF of 15 can filter 94% of the suns UV-B radiation while a SPF of 30 will filter 97%. UV radiation dosage depends on both how long you are out in the sun and how intense the UV radiation is.

The daily UV index is a measure of the level or intensity of UV radiation. It is presented on a scale of 1 (low) to 11+ (extremely high). The US National Weather Service and the US Environmental Protection Agency provide this data which is presented on most weather reports and published in newspapers and on line daily.