Fish Consumption and Reduction of Risk of Developing Breast Cancer

Fish v2MedPage, the online medical journal of the University of Pennsylvania School Of Medicine reviewed an article published in the British Medical Journal concerning a relationship between consumption of marine fish oil from fish and a reduction in the risk of developing breast cancer. The study was published by Duo Li, MD, a professor of nutrition at Zhejiang University in Hangzhou, China. They reviewed data from 21 “prospective cohort studies involving nearly 900,000 people”. According to their data, eating just one or two portions a week of salmon, sardines, mackerel or other fish rich in marine n-3 polyunsaturated fatty acids is associated with a 1 % reduced risk of breast cancer in later life. Their data came from questionnaires that asked about patients’ intake of fatty acids and from blood levels measured in several studies. When they looked at similar fatty acids which come from plants not fish, such as alpha linoleic acid, they could not see a similar protective effect.

The study was critiqued by Alice H Lichtenstein, DSc, director for the cardiovascular nutrition lab at Tufts University. She had numerous questions and concerns about the methodology and conclusions but did support the need for future prospective studies to examine this question. While I have neither the credentials nor experience of Dr. Lichtenstein in evaluating this type of data I believe strongly in the KISS (keep it simple stupid) principle. Fleshy fish provides fish oils which are felt to be beneficial to our health. The same cannot be said for fish oils which you receive in pills and preparations.

My advice is to eat fish two or three times per week. Prepare it simply in a Mediterranean diet style and obtain the benefits that research seems to consistently show for this eating pattern.

Exercise May Protect Against Memory Loss of Aging

Senior Citizens, exercise v2Dorothy Edwards, PhD of the University of Wisconsin in Madison and colleagues presented a study at the Alzheimer’s Association International Conference this week that implies that physical exercise and activity slows down or prevents age related memory loss in patients considered high risk for developing Alzheimer’s disease or Minimal Cognitive Impairment. The data was presented in the University of Pennsylvania’s School of Medicine on line journal MedPage.

The study showed that the brain hippocampus was more resistant to the memory loss effects of aging in a population that had first degree relatives with dementia and who exercised aggressively. Past research has shown that physical exercise stimulates “neurogenesis “in the hippocampus.

Maria Carrillo, PhD, vice president of medical and scientific relations at the Alzheimer’s Association said, “We already know that exercise is important in terms of all sorts of health measures. Now it appears that over time, it also had benefits in preserving memory and other aspects of cognition, even in high risk people.”

The study of 317 patients is one more supporting piece of evidence that should be encouraging us all to get out and walk, cycle, swim, run and participate in whatever physical activities we find enjoyable to do. The health benefits are too important to ignore.

Women and Cardiovascular Disease – There is A Difference Between Men and Women

Front view of woman holding seedlingThe American Society of Preventive Cardiology presented an educational seminar recently in Boca Raton, Florida to educate physicians, nurses and health care providers that cardiovascular disease in women can be very different than in men.  Failure to recognize these differences has resulted in women being under diagnosed, under treated and suffering worse outcomes.

The difference is first noticeable in pregnancy when the development of elevated blood pressure, super elevation of lipids and the development of gestational diabetes predispose young mothers to earlier, more serious, cardiovascular risk later in life. The faculty noted that women of child bearing age tend to use their obstetrician as their primary care doctor.  They suggested that women with pregnancy related diabetes, hypertension and lipid abnormalities should be referred to a medical doctor knowledgeable in preventive cardiology, post-delivery, for ongoing care.

For reasons that are unclear, women are less likely to be treated to recommended guidelines for lipids, diabetes and hypertension.  Diabetic women have a far worse prognosis with regard to cardiovascular disease as compared to men. They are less likely to be treated with aspirin, which while not as effective in preventing MI in women, is apparently protective against stroke.

Women about to have a heart attack have different symptoms the weeks, to months, before the event. They are more likely to have sleep disturbances, unexplained fatigue, weakness and shortness of breath than the standard exertional angina seen in men.   When they do have a heart attack they are as likely to have shortness of breath and upper abdominal fullness and heartburn as they are to have chest pain. They are more likely to have neck and back pain with nausea than men are.  

Since women have different symptoms than men they are more likely to be sent home from the emergency room without treatment.  They are less likely to have bypass surgery than men, less likely to be treated with the anticoagulants and antiplatelet medications that men are treated with and, they are less likely to be taken to the catheterization lab for diagnosis and intervention as compared to men.

The faculty was comprised of world-class researchers, clinicians and educators who happened to be outstanding speakers as well, bringing a vital message to our community.  They pointed out the different questions and diagnostic tests we should be considering in evaluating a woman as opposed to a man.

This was my first educational seminar through the American College of Preventive Cardiology and I thank them for the message they delivered to the medical and nursing community at probably one of the finest seminars I have had the privilege to attend.

Flu Shots Are Coming

ShotWe recently ordered our influenza prevention vaccine. The official public health kickoff to the influenza 2013 prevention campaign is September 1, but in order to have an adequate supply you have to order it long in advance. Once again the price per dose has increased. Once again we will be competing with Walgreens, and CVS and every country club association for the right to immunize you against a potential lethal but preventable disease. I would prefer that all my adult patients receive the flu shot and I do not care where you get it. Yes I would like to administer enough vaccine to cover my costs but the most important aspect of the flu shot campaign is to vaccinate as many people and protect as many patients as you can.

What’s different about the flu shot campaign this year? Jennie McCarthy, the beautiful and outspoken ex–Playboy playmate and well known almost evangelical opponent of vaccination programs, has now been given a pulpit on the television show “The View.” Her anti-vaccine opinion will certainly be heard loud and clear as the local public health departments get out the word to get your shot. There is a new egg free vaccine for adults 18- 49 years old with a history of severe allergy to eggs. Flublok or RIV3 is not grown in eggs but is made through recombinant DNA technology especially for individuals with egg allergy. I have no information on pricing or availability of the RIV3 vaccine yet but it will be administered to individuals with documented severe egg allergies not just anyone. At the current time any patients in the practice who require RIV3 or Flublok will be referred to a center that stocks it.

The other piece of new but positive news is that a study by Roger Baxter, MD of the Kaiser Permanente Vaccine Study Center in Oakland, California and published in the online version of the Journal of Clinical infectious Disease showed that there is no relationship between the administration of inactivated influenza vaccine and the development of Guillan-Barrre’ Syndrome ( GBS). The study originated after the 1976 vaccination against the Swine Flu virus was found to increase the risk of GBS. Since then in a review of 32.7 million person-years of follow-up there were 415 cases of GBS. Of those 415 incidents ONLY 25 were associated with vaccination in the previous weeks.

We urge our adult patients especially those with chronic health conditions to get flu shot this season. While you are making your plans for a flu shot make sure you are current on tetanus vaccine, shingles vaccine and pneumovax. Keep in mind our peak local flu season occurs in January and February with most adults requiring two weeks after the vaccine is administered to develop complete immunity.



Should You Reduce Your Salt Intake?

SaltThere has been a resurgence of the controversy over the effect of sodium chloride or salt on blood pressure and disease. The theory is that by reducing salt intake you reduce blood pressure and ultimately reduce cardiovascular risk. That theory was questioned recently by a researcher who suggested that salt reduction had adverse effects on human hormones and lipids which offset the benefit of the blood pressure drop.

The Cochrane Library compiles and analyzes scientific and medical research and reports on what the data really shows. They reviewed 34 studies of salt reduction and its effect on blood pressure which included 3230 participants. They found that a modest reduction in salt intake for four or more weeks resulted in a significant drop in both systolic and diastolic blood pressure in both hypertensive and normotensive patients regardless of their sex or ethnicity. They examined the effects of the salt reduction on hormones and found that there was an increase in plasma rennin activity plus aldosterone and noradrenaline. There was no change in lipid levels. They felt that the drop in blood pressure associated with decreasing your salt intake was not offset by the change in any of these hormone levels.

The authors of the Cochrane Library study concluded that we need to decrease our salt intake. This will likely lower our BP and reduce our risk of heart attack and stroke.  Current recommendations call for us to reduce our salt intake to the 5-6 grams per day level. They suggest cutting it to 3 grams per day.  I will remove the salt shaker from my table and make sure that I advise my patients to do the same.

Senior Citizens Can Walk Off Meal Related Spikes in Their Blood Sugar

Elderly Couple Walking on Beach v1 - Steve Reznick, M.D.As a physician, it is extremely difficult to motivate older adults to exercise – especially those that do not like to sweat.  At the same time we are always trying to find ways to treat or prevent illness without adding additional pills, medicines or chemicals to a person’s life.  To address these concerns, Loretta DiPetro, PhD of the George Washington University School of Public Health and Health Services in Washington, D.C. presented data in the online journal of Diabetes Care presented from her studies on the effects of post dinner walking on blood sugar.

She followed 10 healthy but obese adult onset diabetics who were sedentary and disliked exercise.  None of the study participants were taking diabetic blood sugar altering medications. The mean age was 69 years old and all were considered Class I obese.  She asked them to take a 15 minute walk after dinner at 3 mph on a treadmill. She compared the glucose response at this speed to a 45 minute walk after breakfast or a 45 minute walk after lunch.  She followed their fasting blood sugars and post dinner glucose levels.  Her results showed that the 15 minute post dinner meal walk was the only exercise period to significantly lower the blood sugar three hours after a meal. The 15 minute walk helped improve 24 hour overall blood sugar control as well.  All the walks helped lower blood sugar but only the 15 minute post dinner walk lowered the sugar at a statistically significant level.

It is well known that exercise of the large muscle groups helps improve glucose metabolism and the body’s sensitivity and response to insulin.  We usually lower the prescribed insulin dosage of actively competing athletes before they compete because their usual dose lowers blood sugar much lower when combined with exercise. This study used that knowledge to assist older, sedentary individuals to improve their glucose control. 

 The message is simple – take a 15 minute walk after dinner. Your life depends on it.


Mediterranean Diet Improves Cognition

Grilled Fish Entree in BarcelonaDiets come and go as do recommendations for healthy living and eating. Once again the traditional Mediterranean Diet was found to be a superior way of living to a traditional low fat diet in individuals who were high risk for the development of cardiovascular disease. The study published in the May edition of the journal Neurology, Neurosurgery & Psychiatry 2013, May 13 is known as PREDIMED (Prevention with Diet Mediterranean) looked at 552 participants in a high risk population. These were men ( ages 55-80) and women ( ages 60-80) free of cardiovascular disease at study entry but high risk due to the presence of either type 2 diabetes or at least 3 of the following major risk factors: current smoking, high blood pressure, elevated lipids, obesity or strong family history of premature cardiovascular disease. The study was performed in Spain and used the Mini-Mental State Examination (MMSE) and Clock Drawing Test (CDT) to assess cognitive function after 6.5 years of nutritional intervention. The participants were randomly divided with the researchers blinded to which group they were in. One group practiced a Mediterranean Diet with Extra Virgin Oil and mixed nuts. The other group was placed on a low fat diet generally recommended for individuals with cardiovascular disease.

At 6.5 years the practitioners of the Mediterranean diet scored significantly higher on the cognition studies. The authors concluded that an intervention with a Mediterranean dietary pattern enhanced cognition compared with a low fat diet. The authors believe that even at an advanced age and with major risk factors for cardiovascular disease, a simple lifestyle modification improved brain health.

We have seen results of studies that show that a Mediterranean style diet improves your chances of avoiding heart attacks and strokes. Now we have a study which suggests that if you follow a Mediterranean type diet you will reduce your risks of developing dementia. Isn’t it time that we start educating our citizens and patients about the benefits of such a program and how to shop, prepare and live with this type of lifestyle?

Hope for HIV Prevention and Treatment

HIV is a disease that has evolved during our lifetime. As a clinician, during my years of training I saw men and women present to the Jackson Memorial Hospital emergency room with a strange overwhelming lung infection and a shutdown of the body’s immune response to infection. Even with aggressive treatment they failed and succumbed to the disease quickly. We had no idea what the process was back in the early 1970’s and were privileged to be around to see pioneers like Margaret Fischl, MD at the University of Miami Miller School of Medicine, begin to take on this dreaded disease in a population no one else would care for.

Hard work and millions of dollars in expense for research coupled with courageous patients has led to announcements like the one released by Michael Martin , MD of the Center for Disease Control that a drug called tenofovir, administered to high risk intravenous narcotic users, significantly reduced the risk of catching the disease. One pill a day In the 2400 volunteers, from 17 drug treatment centers in Thailand, taking one dose of tenofovir per day reduced the risk by almost half. The results were so striking amongst IV drug users that the author recommended beginning a once a day tenofovir program as a pre-exposure prophylaxis in all the high risk groups. He defined the high risk groups as men who have sex with men, heterosexual individuals and heterosexual couples where one person is HIV positive and the other HIV negative.  The drug was surprisingly well tolerated with only 8% of the patients experiencing episodes of nausea.

The purpose of discussing this article is to fan the hope among all individuals, providers and citizens, who have seen the ravages of this disease and did not believe a treatment, prevention or cure would occur in our lifetime. The presence of newer medications for prevention should not allow any of us to let our guard down and eliminate using the tried and true methods that prevent transmission of the disease.  Practicing safe sex by using condoms, avoiding sharing needles when injecting medication and being aware that when you are sexually active you are exposing yourself to your partner’s entire sexual past history will still need to be the cornerstone of prevention.


Electrical Stimulation May Improve Sleep Apnea

Sleep Apnea v2Patrick Strollo Jr., MD of the University of Pittsburgh Medical Center presented preliminary data on the use of a surgically implanted neurostimulator to improve sleep apnea symptoms. The device was implanted to stimulate the hypoglossal nerve. The participants in the study were 124 patients who could not tolerate the CPAP mask treatment or who were never before treated. After implantation they were treated and followed for one year. The participants were mostly men (83%) in their mid-fifties (mean age 54.5 years old), Caucasian and overweight (mean BMI 28.4 kg/m2). Thirty eight percent of the participants had hypertension, 9% were diabetic, and 5% had COPD. Interestingly, 18% had undergone previous surgery on the uvula called uvulopalatopharyngoplasty which was felt to be an effective alternative to wearing a CPAP mask for sleep.

At 12 months all the parameters to assess the effects of sleep apnea had improved dramatically. Interestingly enough, some of the study participants were allowed to continue treatment while others were randomized to stop the neurostimulation. Those who stopped the treatment were followed and their scores regressed.

Like all treatments there were some adverse effects such as tongue pain and mild to moderate infection in 1%.

This is very preliminary data. The study must be presented to a peer review journal, evaluated and published before this treatment becomes acceptable. We recognize sleep apnea as a dangerous disease that leads to pulmonary hypertension and right heart failure if not treated. CPAP masks work well but are cumbersome, awkward and difficult to travel with. The epidemic of sleep apnea is being fueled by a worldwide epidemic of obesity. The current preliminary work at the University of Pittsburgh holds out hope for a future solution that may be easier to live with.

Sunscreen Works!

Sunscreen - FDA v2For decades, dermatologists and health care professionals have been urging patients to use sunscreen to protect against sun damage and skin cancer. What has been lacking is excellent research to prove the point.

The June 4th edition of the Annals of Internal Medicine Volume 158 #11 contains the results of just such a study. The study originated in Australia in a collaborative study of the University of Queensland and the Manchester Academic Health Sciences Centre in the United Kingdom under the authorship of Maria Hughes, Gail Williams, Peter Baker and Dele Green – all PhD’s. Nine hundred and three adults, younger than 55 years old, were randomized into one of four groups. One group used a broad spectrum sunscreen daily and 30 mg of Beta Carotene. The second group used sunscreen and a placebo, the third group had a choice of using sunscreen and beta carotene when they felt they needed to and; the fourth group had a choice of using sunscreen and a placebo.  All four groups were then followed between 1992 and 1997 for changes in their skin.

The findings:

·         ~ At 4 ½ years, the daily sunscreen group showed no detectable increase in skin aging.

·         ~ Skin aging was 24% less in the daily sunscreen group compared to the discretionary sunscreen group.

·         ~ Beta Carotene had absolutely no effect on retarding skin aging.

Despite some questions about the methodology, the study clearly showed that, in middle aged men and women, daily use of sun screen prevented skin aging.

As we head into summer it’s important to take this research to heart and use sunscreen of SPF applied to sun exposed areas before you go out.  Depending on how long you are exposed to the sun, you will need to reapply the sunscreen to continue receiving the protection you require.