International Panel Questions the Wisdom of Strict Sodium Guidelines

A technical paper published in the online version of the European Heart Journal suggested that individuals should strive to keep their sodium intake to less than 5 grams per day. This is in marked contrast to the recommendations of the American Heart Association of 1.5 grams per day and American College of Cardiology recommendations of 2.3 grams per day. The authors of the papers included some of the world’s experts on the topic of hypertension including Giuseppe Mancia, MD, Suzanne Oparil, MD and Paul Whelton, MD.  They agreed that consuming more than five grams per day was associated with an increased cardiovascular risk. They believe there is no firm evidence that lowering the sodium intake to below 2.3 or 1.5 grams per day reduces cardiovascular disease without putting you at risk of developing other health issues from having too little sodium.

The report triggered a firestorm of controversy in the hypertension and cardiovascular field with proponents on each side of the issue. Both sides agreed that we need more meticulous research to determine the best lower end of daily sodium intake because current information makes recommending one level or another a guess at best with little data to back you up. That leaves clinicians and patients scrambling for clarity and the media reporting this paper in a manner threatening to further erode the public’s confidence in the scientific method and physicians in general.

As a practicing physician I will continue to recommend a common sense approach to salt intake. Those patients who have a history of congestive heart failure or hypertension which is volume related will still be encouraged to read the sodium content of the foods they are purchasing and try to avoid cooking with or adding sodium chloride to their food at the table. This will be especially important for patients with cardiomyopathies and kidney disease who are following their daily weights closely. For the rest of my patient population I will ask them to use salt judiciously and in moderation only. I will suggest not adding salt at the table and if they do to please add it in moderation. I will allow more salt intake in those patients who work outside all day and are exposed to our high temperatures and humidity.

Like everyone else, I will wait for the meticulous research studies to be performed over time to determine how low and high our sodium chloride consumption should be without hurting ourselves.

Red Meat May Not Increase The Risk For Vascular Disease But Is It Healthy?

A study published in the online version of Consultant 360 magazine looked at the relationship between eating red meat and cardiovascular risk factors. The study was performed at the Department of Nutrition Science at Purdue University. Researchers reviewed 24 studies on the topic listed on PubMed, Cocrane Library and Scopus databases. These studies examined individuals 19 years old or older who consumed at least 35 grams of red meat per day and whom listed at least 1 cardiovascular risk factor. They then examined the study participants blood total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides plus systolic and diastolic blood pressures.

They found that red meat at these quantities did not increase lipids, lipoproteins or blood pressure. This led them to conclude that the risk for cardiovascular disease did not increase in individuals consuming more than the recommended daily amount of red meat.

While this study gives hope to meat lovers, cardiovascular disease is not the only cause of illness or death. High consumption of red meat has been implicated in a greater risk of developing colon cancer, breast cancer, diabetes and an overall increased risk of death from all other causes. Some individuals seem to believe that you can counteract this negative effect of red meat by eating large quantities of fresh fruits and vegetables. Unfortunately a Swedish study published this year in the American Journal of Clinical Nutrition disproved this theory. For men, the more red meat they ate the more likely they were to develop diabetes. For both women and men, those who ate the most red meat had a 21% greater risk of all – cause mortality than those who ate the least. This higher risk did not change when the authors took into account fruit and vegetable intake. Interestingly it was processed meat that caused the rise in health risk with unprocessed meats only being associated with a slightly increased death risk even at high consumption levels.

I believe the take home advice is that consumption of unprocessed red meat in moderation with plenty of fresh fruits and vegetables doesn’t impair your risk of dying. Processed meats are to be avoided if you wish to avoid multiple illnesses and disease. Give up the bologna and salami and other processed meat products except on limited occasions.

Need To Expand the Recommendations for Screening for Lung Cancer in Former Smokers

In 1976 when I began my internship in internal medicine almost all cigarette smokers 35 years of age or older received an annual chest x ray to screen for lung cancer. In the 1990’s as managed care and insurers’ stopped paying for these screenings, we were told by the experts that the cost of saving one life by looking at every smoker was not cost effective. Insurance companies stopped paying for these films at the same time that medical advisory boards insisted on clinicians sending their chest x-rays out to be read by radiologists, adding extra costs to each film.

The practice of routine screening virtually disappeared. With it came a large increase in the number of smoking related deaths from lung cancer. It took the “experts” almost two decades to realize the errors of their decision.

In 2014 the US Preventive Services Task Force endorsed performing low dose computed tomography (CT Scans) in patients who were a high risk for lung cancer. This group was defined as individuals aged 55 to 80 years who had smoked at least 30 pack years (computed as number of packages of cigarettes smoked per day times the years the individual smoked) in individuals who continued to smoke or had quit within the last 15 years. The data to back up this recommendation came from Ping Yang, MD, PhD and colleagues at the Mayo Clinic. Their research and the new recommendations have helped reduce lung cancer deaths by 20%.

Since these recommendations were instituted, Dr. Yang and colleagues have continued to evaluate the guidelines. They found that individuals who quit smoking 15 -30 years ago are being diagnosed with lung cancer at a rate of 12-17 % of the newly diagnosed cases. They consequently are now recommending that we screen all adults 55- 80 with a 30 pack year history even if they quit more than 15 years ago.

The US Preventive Services Task Force which produces the recommendations that insurers consider has not yet endorsed this suggestion. In our practice we will be recommending low dose CT lung scanning annually on all our smokers who meet the Mayo Clinic criteria. If you, as my patient, fall into that group and have not been getting annual low dose CT Scanning of the lung for lung cancer detection please let us know so that we may set up a surveillance program. We understand the increased cost and ionizing radiation exposure that CT Scans involve but Dr Wang’s research suggests that the benefits outweigh the costs and risks.

Aspirin Use for Targeted Breast Cancer

The indication to take aspirin to prevent various diseases has certainly been confusing over the last few years. A Veterans Administration (VA) study in the 1950’s noted that men over 45 years of age who took an aspirin per day had fewer heart attacks and strokes. The exact dosage of aspirin to take to prevent heart attacks and strokes has been the subject of many studies and much disagreement. In more recent times researchers have questioned whether aspirin should only be taken by those individuals who already have survived a heart attack or stroke for secondary prevention.

Taking aspirin is not risk free with users having a higher risk of gastrointestinal bleeding and cerebral hemorrhage especially if head trauma was involved. Recent studies have made it even more confusing with some experts not wanting patients to take aspirin for primary prevention of a first heart attack or stroke unless their 10 year risk of an event was 6% or greater. Others thought 6% was too high a figure and suggested 3%. The guidelines and suggestions for aspirin use to prevent cardiovascular disease have certainly become more confusing and have made the decision to use it far more complicated.

As a result of the use of aspirin in prevention of vascular and heart disease, researchers noted that people who took aspirin had fewer pre-cancerous adenomatous colon polyps and less skin cancer. In a 2010 study in the Journal of Clinical Oncology, Drs. Michelle Holmes and Wendy Chen of the Harvard Medical School noticed that women with breast cancer who took one aspirin per week had a 50% lower chance of dying from breast cancer. This observational study required a more detailed sophisticated double blind study to prove the point but the authors did not receive the necessary funding to begin the research study. This left the relationship between aspirin use and breast cancer development very unclear.

In the December 22, 2015 edition of the Mayo Clinic Proceedings, Bardia A, Keenan TE, and Ebbert JO and associates published data hinting that aspirin use was associated with a lower incidence of breast cancer for women with a history of breast cancer and those with a personal history of benign breast disease. This study of 26,580 postmenopausal women followed the study participants for three years. In the online journal Internal Medicine News, Neil Skolnik, MD talked about the exciting possibility of decreasing breast cancer in this specific group of women by 30 – 40% by taking a daily aspirin.

There is no question that aspirin therapy increases the risk of bleeding especially in the GI tract and the brain. Trauma and cuts will lead to increased bleeding and blood loss. Individuals will need to discuss with their physician the pros and cons of preventive aspirin therapy for heart disease prevention, skin cancer prevention, colon cancer prevention and now breast cancer prevention based on their personal and family medical history and balance it with the risk of bleeding.

Does Not Testing the PSA Lead to More Advanced Prostate Cancer?

Mortality from prostate cancer has diminished by almost 40% since the introduction of the PSA test in the late 1980’s. Much of this is due to the use of the PSA blood test for screening purposes. In 2011 The US Preventive Screening Task Force strongly condemned the use of PSA screening. They felt that we were finding too many inconsequential early malignancies that would not lead to death and were being over treated. In their eyes, prostate cancer treatment with surgery and or radiation carried a high price tag with multiple long term complications and the benefit of screening was not worth the risk. Prior to the USPSTF”s 2011 recommendation against screening for prostate cancer with a PSA there were 9000 – 12,000 new cases of prostate cancer diagnosed per month. In the month following the USPSTF recommendation not to screen with PSA the number of new cases dropped by almost 1400 a month or over 12%. Over the next year the decline in prostate cancer diagnosis was 37.9 % for low-risk prostate cancer, 28.1% for intermediate risk, 23.1 5 for high risk and 1.1% for non-localized cancer. Clearly if you do not look for a disease you will not find it.

In the December issue of the Journal of Urology, Daniel Barocas, MD, of Vanderbilt University and colleagues discussed the PSA testing controversy. They too noted that the consequences of not screening for intermediate and high risk prostate cancer by performing the PSA test may lead to individuals presenting with far more advanced disease that is more difficult to treat, has more complications and ultimately leads to disease related deaths. His position was debated by two major urologists in the editorial section of the journal with no firm conclusion being reached.

In an unrelated article, the Center for Medicare Services or CMS announced that it is considering penalizing physicians who test the PSA for screening in Medicare patients beginning in 2018 as part of their paying for value and quality. They said that physicians need to present their patients with an ABN (advanced beneficiary notice) stating that Medicare will not pay for this test, before the blood is drawn or face fines and penalties.

Men in their forties and older have been put in an uncomfortable and inappropriate position by health policy leaders. The truth is we are currently unsure how and when to test for prostate cancer in men with a normal digital rectal exam (DRE). The consequences of not paying for screening will not be known or understood for easily ten to fifteen years. It is clear that early stage disease has the option to be observed for progression with minimal consequences in the short term. Not enough time has elapsed for anyone to know the long term effects of this policy change. Unfortunately, men in this age group are all guinea pigs in the public health policy laboratory while the data to reach a firm scientific conclusion is assembled. The predominant policy today is spending less and doing less. With this in mind, it is best for men to see their doctor, have an annual digital rectal exam, discuss their family history of prostate disease and reach an individual decision on PSA screening appropriate for their unique situation rather than one based on large population policy.

Fish Oils in Osteoarthritis – Low Dose vs. High Dose

Using the common sense approach that if a little bit is good then more is better in the treatment of “rheumatism” Catherine Hill, M.D., of the University of Adelaide in Australia and colleagues looked at the effect of taking low dose fish oil supplements versus high dose fish oil supplements. When one looks at the adult population of Australia, one third of them take fish oil supplements and had within a month of this study. The typical dose is one ml of fish oil per day. Experts say the dose for anti-inflammatory effect for arthritis is considerably higher at 2.7 gram or 10 ml per day. Dr Hill’s theory was that high dose fish oil for symptomatic and structural outcomes in people with knee osteoarthritis was better.

She enrolled 202 symptomatic patients in a double blind study. High dose group patients received 4.5 g EPA/HPA per day. The low dose group were given a blended of fish oil containing 0.45 g EPA /DHA per day in combination with Sunola oil. Both supplements were flavored with citrus oil.

All patients received a baseline MRI of the knee at inception of the study and at two years. The patients mean age was 61 years and body mass index was 29kg/meter squared. Both groups showed x-ray evidence of arthritis in the knee at inception and both groups were allowed to take non-steroidal anti-inflammatory medications and acetaminophen for arthritic pain during the course of the study.

At two years there was no difference in the MRI findings or cartilage volume loss between the high dose and low dose groups. Each group took similar amounts of NSAIDs and acetaminophen for pain on a regular basis. The high dose had no benefit over the low dose.

The researchers concluded that there was no benefit in their study to high dose versus low dose fish oil supplementation for arthritis. They reasoned that since patients in the study were permitted to take additional fish oils on their own during the study this may have altered the findings. The researchers additionally had little control over how much fish the participants ate.

In reviewing the data it seems to indicate that fish oil played a minor role in slowing down arthritis in the knee joint. Low dosage had as good of an effect as high dosage but the studies lack of a true control group who did not take fish oil at all made the conclusions hard to accept.

I will suggest to my patients that they continue to eat two fleshy fish meals per week to get their fish oils for arthritis and cardiovascular protection, rather than purchasing and taking low dose or high dose fish oil supplements.

Brown Fat Injections Reverse Weight Gain in Obese Mice

There is hope for those of us battling weight gain and obesity. An article appeared this week in the journal Endocrinology discussing the research of Wanzhu Jin, PhD, of the Chinese Academy of Sciences involving weight loss and reversal of Type I diabetes. Researchers are well aware of the different types of lipid or fat in all mammals. Brown fat or brown adipose tissue has been felt to have protective effects against weight gain, lipid abnormalities and glucose metabolism problems.

Dr Jin, used mice that were genetically engineered to be overweight or fat. He injected them with a quantity of Brown Adipose Tissue (BAT) and these mice lost weight and improved their glucose metabolism into the non-diabetic range. The success in weight loss and sugar control was felt to be due to the BAT increasing the energy expenditure of the genetically altered mice. The sugar control occurred through similar mechanisms and was unrelated to the production of insulin or insulin metabolism. Dr Jin’s team of researchers felt that the transplanted brown adipose tissue activated and enhanced the BAT already present in these obese mice allowing it to produce the weight loss and improvement in glucose and lipid metabolism. Their research seemed to hint that brown adipose tissue actually acted as an endocrine gland like the pancreas or adrenal gland or thyroid gland, secreting substances that improved metabolism of obese mice.

Dr Jin’s work will provide an incentive for human researchers to look at brown adipose tissue and its modulation and enhancement as a way to control human obesity and diabetic epidemic in the future.