Scientific Reports, Media Reports and Ambiguity

Last week I read an article in a peer reviewed journal citing the benefits of a few eggs per week as part of a low carbohydrate dietary intervention for Type II Diabetes.  The information was so meaningful about a controversial food source of protein that I decided to write about it in my blog and pass it along to my patients.  Three days later the American Heart Association and American College of Cardiology discussed the increased risk of cardiovascular events and mortality in individuals consuming three or more eggs regularly. They talked about the detrimental cholesterol being concentrated in the yolk making egg white omelets look healthier than traditional omelets.

In the early 1970’s a VA study was published showing that veterans over 45 years of age who took an aspirin a day had fewer heart attacks and strokes and survived them better than those who don’t.  Fast forward almost 50 years and we have different recommendations for people who have never had an MI or CVA or evidence of cardiovascular disease compared to secondary prevention in individuals who have known coronary artery disease, cerebrovascular disease or diabetes. Throw in the controversial discussions of aspirin preventing colorectal adenomas from developing, aspirin preventing certain types of skin cancers and today’s report that suggests it may prevent liver cancer. Now three studies suggest that in older individuals (70 or greater) the risk of bleeding negates the benefits of cardio and cerebrovascular protection and aspirin may not actually prevent heart attacks and strokes in that age group.

We then turn to statins and prevention of heart attacks and numerous articles about not prescribing them to older Americans.  I saw articles on this topic covered by CNN, the Wall Street Journal, ARP Journal, AAA magazine and in several newsletters published by major national medical centers.  In each piece they caution you to talk to your doctor before stopping that medicine.

I am that seventy year old patient they all talk about.  I have never smoked. I exercise modestly on a regular basis, getting my 10,000 or more steps five or more days a week.  I battle to keep my weight down and find it difficult to give up sweets and bread when so many other of life’s pleasures are no longer available due to age and health related suggestions.

There are clearly no studies that look at patients who took a statin for 15 years and aspirins for over 20 years, stopped them and then were followed for the remainder of their lives.   How will they fare compared to patients who never took them?

I have this discussion every day with my patient’s pointing out the current guidelines and trying to individualize the suggestions to their unique lifestyle and issues. On a personal level, I still have no idea what the correct thing is to do even after discussing it with my doctors.  How can I expect my patients to feel any differently?

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Eggs and Diabetes – New Information

Diabetes has been known as a risk factor for cardiovascular diseases for years. Egg consumption was discouraged by experts.   Our perception of eggs as they relate to diabetes and heart disease may have to be reconsidered based on a study published in the American Journal of Clinical Nutrition in May 2015

The Kuopio Ischemic Heart Disease Risk Factor Study enrolled 2,332 men, aged 42 -60 years old, and followed them for more than nineteen years.  Four hundred thirty-two participants developed Type 2 Diabetes.  Men who ate the most eggs demonstrated a 38% lower risk of developing Type 2 Diabetes in this study.  Higher egg intake was associated with lower levels of fasting plasma glucose and serum C – reactive protein.

The researchers published a follow up paper in the Journal of Molecular Nutrition and Food Research this year and came up with similar results stating that “moderate egg consumption of eggs can be part of a healthy dietary pattern for preventive action against Type 2 Diabetes Mellitus.” Their definition of moderate was an average of one egg or less per day.

This is preliminary data involving eggs will be discussed and battled over for years to come. What is important is that once again a modest intake of a protein in moderation is probably not deleterious as previously thought.

When dealing with diabetes, lifestyle issues such as weight control, smoking status, alcohol intake, regular exercise and simple carbohydrate intake are far more important issues to address than egg consumption in moderation.  This topic was reviewed in the latest online publication of Medscape Medical News. 

A Large Review Proves Statins Are Safe

StatinsThe online version of Circulation: Cardiovascular Quality and Outcome published a review of the safety of statin drugs. The study looked at 135 randomized research trials including 246,955 participants. Medications examined included atorvastatin (Lipitor), fluvastatin (Lescol), simvastatin (Zocor), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and trials of pitavastatin.

They found there were no differences in the rates of discontinuation of the statins because of adverse events compared with discontinuation of placebo. The same applied to elevation of the muscle enzyme creatine kinase, muscle aches or myalgias and/or the development of cancer. As the doses of these medicines increased they found the participants reported more adverse effects.

Christie Ballantyne, MD of the Baylor College of Medicine reviewed the study for MedPage, the online journal of the University Of Pennsylvania School Of Medicine, and felt the study certainly confirmed the tolerability of the statins as a class of drugs to lower cholesterol and reduce cardiovascular events. He reaffirmed the very small increased risk of statin use and developing Type II Diabetes and the need to monitor liver function blood tests while taking the drugs. He concluded these risks were well worth taking in view of the benefits to your health statins provided.

Additional Study Discusses Relationship Between ACTOS and Bladder Cancer

Laurent Azoulay, PhD, of McGill University in Montreal presented data linking ACTOS with the development of bladder cancer.  His research specifically implicated ACTOS rather than implicating the class of drugs ACTOS belongs to. His group specifically did not see this effect when looking at Avandia (rosiglitazone).  Avandia has been removed from the US market because of its cardiac toxic effects.

Azoulay and associates looked at 115,727 patients given prescriptions for these antidiabetic medicines in the United Kingdom primary care data base between 1988 and 2009.  The mean age of participants was 64 years old and they were followed for over 4 years.  Patients who had been given a prescription for the thiazolidinediones tended to be more obese, smoked and have worse control of their diabetes.  These are all risk factors for the development of bladder cancer.

ACTOS has been removed from the market in some European countries. The FDA did not restrict it in a recent review.

With the new data it will become necessary to suggest alternatives to ACTOS to my diabetic patients until the matter is completely clarified.

Statin Use and Diabetes in Older Women

Older women who take statins may be at an increased risk of developing Type 2 Diabetes Mellitus (adult onset). In a study published in the Archives of Internal Medicine, Dr Ma, of the University of Massachusetts School of Medicine, looked at the 154,000 women in the Women’s Health Initiative who did not have Diabetes when the study began in 1993.  Seven percent (7%) of them were on statins at the time through follow-up, 12 years later.  At that point, 10,242 cases of new cases of diabetes were reported. They theorize that this computes to an almost 50% increase in becoming a Diabetic if you are on a statin as compared to women who are not. Surprisingly, this occurred far more frequently in thin women taking a statin than in heavy or obese women.

The salient points taken out of this research are that women on statins need their liver enzymes monitored frequently they need their blood sugars monitored as well. The overriding message is that as physicians and patients we need to make a monumental effort to control elevated lipids by diet , exercise and weight loss without statins if humanly possible.

This also raises the question of whether we should be measuring HDL and LDL subtypes an Lpa levels on all patients before instituting statin therapy?  While this raises doubt about a popular class of drugs that are a crucial part of the prevention of cardiovascular disease, it does not yet make it clear what the clinical implications are for postmenopausal women on statins.

I will reevaluate all my female patients on statins as I see them for follow-up visits.