Preventing Breast Cancer

Dr. Graham Colditz is a professor at Washington University Medical School where he is the chief of public health sciences and the lead investigator of a National Cancer Institute research center focused on cancer prevention. Dr. Colditz's research shows that breast cancer is a largely preventable disease controlled by lifestyle. By far the most important factor is diet. A whole food plant based (WFPB) diet which is mostly or entirely whole plant foods with little or no animal products or vegetable oils controls cancer development and growth rates even in women with the BRCA 1 and 2 gene mutations. He estimates that 68% of breast cancer will be prevented by starting this lifestyle in childhood and 50% by starting as an adult. He labels milk as an especially dangerous food, and advises an early start on good dietary habits for greater effect and also because peer pressure becomes more important than parental input after age 8 or 9. This is not the advice of one of the writers on diet; this is the advice of "an internationally recognized leader in cancer prevention." 

onlinelibrary.wiley.com/doi/10.3322/caac.21225/full 
(This website requires scrolling down to get to text. The top area is blank.)

Dietary fat and animal proteins control the development and growth of breast cancer in laboratory animals. Excess body weight and higher levels of serum estrogen are also potent breast cancer stimulators. A WFPB diet decreases all these critical factors.

Women with diagnosed breast cancer, even metastatic disease, also do much better on this diet. When cancer cells in a laboratory petri dish are exposed to serum of women with breast cancer who are eating a WFPB diet most are killed; this is not true for serum from those eating the standard high fat and animal protein western diet. Read the story of Ruth Heydrich, a long term survivor of metastatic breast cancer.

allfor-health.blogspot.com/2013/01/interview-with-dr-ruth-heydrich.html

Diet is as important in breast cancer prevention as smoking is in lung cancer. It is similarly critical in prostate and colorectal   cancers.

                   Interval Training

Several physiology labs study interval training, a form of exercise which varies intensity of an activity during a cardio workout. Any activity like running, swimming, cycling etc. can be used but exercise bikes are often the most practical for many people.
Regular cardio workouts increase cardiopulmonary reserve, help reach or maintain optimal weight, support good sleep and increase longevity. There is good evidence that high levels and more time spent provide better results but that even modest brisk walks several times a week are very helpful.
A Danish research lab documented excellent results from this regime:
   short warmup
   30 seconds of normal exertion
   20 seconds of greater exertion 
   10 seconds of maximal exertion
   short cooling off

  https://www.ncbi.nlm.nih.gov/pubmed/25439558

This is repeated up to a total of 10-15 times in sets of five separated by two minutes of very light activity. Three times a week is more effective than daily workouts just as is true for building strength through weight training. As with all workout programs numbers and intensity of the workout should be gradually increased until 10 to 15 reps can be done comfortably. 
Their comparison with other cardio training methods showed superior conditioning results with relatively little time invested.
I use this method and find it easy to follow- not too painful or or time consuming.
Mayo Clinic researchers tried different exercise regimes (vigorous weight training; light weight lifting plus moderate intensity exercise bike; interval training) on young and older subjects who allowed muscle biopsies to monitor results. All activities improved fitness and ability to regulate blood sugar. Cellular genetic mitochondrial changes reflecting cellular health and younger apparent age were much greater in those who did interval training. Remarkably, these effects were much more in older people. Interval training can now be called "a fountain of youth." 

http://newsnetwork.mayoclinic.org/discussion/mayo-clinic-discovers-high-intensity-aerobic-training-can-reverse-aging-processes-in-adults/

                       Modern Medical Care and Dietary Confusion

Medical schools and teaching hospitals control medical education. Curriculum content is determined by licensing requirements together with the preferences and knowledge of medical school deans and faculty. My working medical career was spent at several of these schools where I got to know many other faculty members. Most were intelligent, hard working and ambitious, but we were all specialists in a small corner of medicine with no or limited knowledge of other important aspects of medical science. Many faculty members are also constrained by the need to obtain funding for research projects that are the focus of their career and the determinant of salary, promotion and recognition. Increasingly, more research funding is coming from the drug and other medical industries. Professors have rarely been trained in diet and nutrition; they also have no time or motivation to learn this material. Even worse, there is often a conflict when diet information would devalue the benefits of medications- the bread and butter of medical research and medical schools. It’s no surprise that physicians and other medical workers have little or no training or interest in diet and nutrition.
This crisis in medical research and practice has been decried by some of the most respected leaders in medicine but medical institutions want money and medical businesses have the money.  Business effectively controls research, faculty priorities and medical education. Physicians come out of school and residency poorly trained except in writing prescriptions and performing complicated procedures. But health depends on lifestyle choices much more than it does on other factors. Reliance on medical professionals to give optimal guidance in health care has led to epidemics of preventable conditions: heart attacks, strokes, cancer, dementia, auto-immune diseases. The large majority of these are avoidable with proper lifestyle choices, particularly diet.
Another big problem is misinformation about best dietary choices. Everyone has dietary preferences based on family tradition and past eating habits. Human nature is to look for support for our preferences. For decades some physicians advocated cigarettes and smokers were delighted to hear that “Doctors prefer Camels,” even if they themselves smoked Luckies. The tobacco industry spent lavishly to support this misinformation just as agribusinesses, fast and processed food industries are doing now. Healthy foods are whole plant foods but billions of dollars in spending are dependent on people believing that other choices- animal products, processed and refined foods are as good or better options.
Modern medical centers are dependent on high volume to pay for expensive facilities and equipment. They often advertise these services and encourage medical providers and patients to use them. Dr. H. Gilbert Welch, a Dartmouth Medical School professor, and his colleagues have done extensive research documenting the harm from over-utilization of diagnostic and treatment options. Welch’s work has been the subject of several NY Times op-ed pieces and he has written many scientific articles published in top peer reviewed journals plus several excellent books on this topic. Medical care is big business and uses the techniques of other businesses to encourage over-utilization. The unfortunate result is often poor health for patients and huge amounts of wasted money.

                   Value of Screening Mammography

Several months ago I sent an email which described recent studies questioning the value of screening mammography. Replies from radiologists who do mammography expressed surprise, unhappiness and even convinced disagreement.

One of the problems with the evaluation of studies on mammography is that they are often done or sponsored by those with financial or professional advantage from the examination. The big pushers are usually radiologists who have devoted their careers to mammography. Evaluations of studies on drugs done or sponsored by drug companies have showed strong bias towards advocating their product.

JOURNAL WATCH has a review of a recent study from OBSTETRICS AND GYNECOLOGY, a major peer reviewed journal, which did a paired study of Sweden vs. Norway, Ireland vs. No. Ireland and The Netherlands vs. Belgium. In each of these pairs nationwide mammography was implemented by 1990 in one and substantially later in the other. All 6 countries showed a substantial decrease in breast cancer mortality between 1989 and 2006. For example -24% in Norway and -16% in Sweden but the decreases were no more in the fully screened countries (Sweden started full screening much earlier than Norway.) A similar study of cervical cancer screening in the Nordic counties showed that nationwide screening was highly correlated with decrease in mortality from cervical cancer. Countries which implemented earlier screening showed a much greater decrease in cervical cancer mortality. The reviewer concludes that a decrease in mortality from breast cancer due to mammography has not been shown, and that recent decreases in mortality from breast cancer in developed countries can be explained by changes in treatment, not by earlier diagnosis through mammography.

Mammography screening is very expensive nationally, leads to many unnecessary work ups with anxiety, biopsies and even surgery, radiation or chemotherapy for those who don't need it. Every radiologist, surgeon, clinician can cite examples of early diagnosis of breast cancer through mammography followed by appropriate therapy with long term survival, perhaps cure. The problem is that this does not show that this test is of any value. My suggestion to women is to get screening mammograms if they will be anxious or unhappy without them, but not to get them because they believe that mammography is definitely shown to improve their chance of not dying due to breast cancer. Mammography may be of value but the large number of studies done on the subject has not shown it convincingly. Those who get screening mammograms are guaranteed a much greater chance of unnecessary expensive and, perhaps dangerous, work ups with the associated anguish involved.

               

          Diet, Longevity and Quality of Life

Longevity is the gold standard for evaluating diet and other lifestyle choices since there are strong correlations between longevity, overall health and quality of day-to-day life. According to researchers at the New England Centenarian Study “The older you are, the healthier you’ve been. “ Studies of long-lived Adventists confirm this. Most who live into their late 80’s and beyond have compressed end of life morbidity (morbidity defined as significant sicknesses.) The argument “I don’t care how long I live; I just want to enjoy life” doesn’t work since enjoying life with decades of painful and expensive chronic illnesses is very difficult. Using longevity to compare different dietary choices is much simpler and more accurate than using other parameters like weight, blood sugar, or cholesterol. Normal blood sugar is no consolation to a diabetic who dies prematurely after several years of living paralyzed by a stroke or dialysis due to chronic kidney disease.

Many advocates of different diets and medications use weight, blood sugar or serum cholesterol results to support their choice. Using longevity is simpler and much more accurate. Longevity studies are unequivocal. The only diets associated with longevity are those consisting mainly or entirely of whole plant foods. Nutrition experts debate how much fish, lean white meats or non-fat dairy should be included but agree that an optimal diet is filled with whole grains and other unrefined starches, vegetables, legumes, fruits, seeds and nuts. The bulk of calories should come from unrefined starches, not fat and protein as it is in the typical American diet.

Several excellent studies confirmed the value of this type diet in China, Okinawa, and the Mediterranean area. Since many Adventists are vegetarian or vegan the diets of Adventists in southern California have been the subject of hundreds of scientific studies. These studies confirm that the fewer animal products in the diet, the longer you live and the healthier you are. It is not the climate or some other variable in the Mediterranean area, China or Okinawa, it’s the food!

The New England Centenarian Study has examined characteristics of long-lived people and concluded that most people can live into their late 80’s through a healthy life style that includes not smoking and a diet that is mainly whole plant foods. Genetics determines who will live past that age. Some reach very old age in spite of poor life style but these people are rare exceptions with unusual genetics. Even those with good genes usually need a healthy life style to reach 100 or more.

                                        More on Osteoporosis

In my first post about osteoporosis I discussed calcium and vitamin D, the commonly prescribed and sometimes necessary nutritional supplements for bone health. Since bone is a very active, complex organ system it requires many other nutrients.

Protein is essential to develop and maintain strong bones. Fortunately, protein deficiency is a rare problem which is only seen with severe malnutrition. Starvation, a diet composed entirely of junk food, and major intestinal disorders are the common situations where there can be protein deficiency. Totally plant-based diets have no problem with protein lack. Almost everybody can ignore this basic nutrient since virtually all diets have plenty.

Three vitamins essential for bone health are associated with dangers from supplementation. These are vitamin A, vitamin E, and folic acid. A diet which includes a variety of vegetables, nuts and seeds will have plenty of these three vitamins. Supplementation is dangerous.

People who eat mainly plants may be deficient in vitamin B12 or zinc. Vitamin B12 should be regularly supplemented by those with this diet. Zinc levels should be checked in the laboratory and supplements taken if necessary.

A wide range of other important bone nutrients are present in virtually any reasonable diet. These include potassium, magnesium, silica, phosphorus, manganese, copper, boron and vitamin C. Supplementation is not necessary for most people.

In recent years interesting research has been done on vitamin K2. Vitamin K, unlike most other vitamins, has no minimum daily requirement recommended by the USDA and it is found in many foods. Two forms of vitamin K have been identified: vitamin K1 which is present in many vegetables, particularly green vegetables; and vitamin K2, found in some legumes, meat and dairy. Biologic activity of vitamin K is typically assessed by its effect on blood clotting where both K1 and K2 have similar effects. But vitamin K is also important for bone health and vitamin K2 appears to be more important than K1 in this regard.

Studies have been done in Japan where people in a certain area frequently eat a fermented soybean called natto which has very high levels of vitamin K2. Those who eat this food have less than half as many fractures as those who do not. I asked a Japanese friend about natto and she made a face. Apparently, it is an acquired taste which if you haven't developed makes natto an unpleasant dietary option.

Fortunately, supplements of vitamin K2 derived from natto are available in a soft gel. This is called MK-7 vitamin K2. There is also a laboratory created form of K2 called MK-4. Both forms of vitamin K2 appear to help bone health and prevent fractures. The MK-7 lasts longer in the body and needs be taken only once a day. MK-4 is shorter acting and must be taken three times a day. Although some osteoporosis experts advocate taking both forms I have chosen to only use the MK-7. Standard dosage is a soft gel containing 90 µg a day. This is available from Jarrow Formulas via Amazon at modest cost.

In summary, I suggest a supplement of MK-7 for those with osteoporosis or osteopenia. Plant-based eaters should supplement vitamin B12 and perhaps zinc. Except in unusual circumstances other supplements are a waste of money and some of them are potentially harmful.

                                      Fractured Foot and Osteoporosis

 Several months ago I fractured two bones in my foot. Because of this I was evaluated and found to have mild osteoporosis. Since then I have been studying osteoporosis and would like to share what I have found.
 Bone is an active tissue which responds to nutrients, level of activity, hormones and drugs fairly quickly. Strong bone is essential to avoid fractures after mild or moderate trauma. Definitive diagnosis of osteoporosis is made with a DXA (formerly DEXA) scan. Bone density which is lower than normal but not osteoporotic is termed osteopenia.
 As with all body tissues, bone requires a wide spectrum of nutrients including many vitamins and minerals. Most of these nutrients are in generous supply from a diet which includes vegetables, fruits, legumes, seeds, nuts and whole grains. A few critical nutrients can be lacking even in an otherwise healthy diet. These include vitamin D, vitamin B12, vitamin K2, zinc and iodine.
 Calcium is the major mineral involved in bone formation and logically might be an important dietary deficiency in osteoporosis. This is not true for those who regularly eat a variety of green vegetables and/or dairy. Legumes, almonds, tofu and canned fish (Atlantic sardines best) with bones left in are also good calcium sources. Calcium supplementation has been widely studied and debated. For many years it was assumed that supplemental calcium would help people who had osteoporosis, but recent research has not confirmed this. In fact, in some studies calcium supplementation has been associated with higher rates of heart attacks and other vascular disease but not with lower rates of fracture. Current good practice is not to offer calcium supplementation, or, at most, to prescribe a small supplement such as 500 mg a day unless the patient will not eat calcium containing foods. One theory is that supplemental calcium supplies a sudden burst of calcium in the blood which increases clotting so much that blood vessels can be blocked causing a heart attack or stroke.
 Another major nutrient for bone formation is vitamin D. This vitamin is critical in all body tissues but has been particularly studied in bone health because it was long ago discovered to be the major cause of rickets, a deforming bone disease that was once common in children. An enormous amount of research on vitamin D has still not resolved many questions. Experts debate the range of adequate serum levels, whether supplementation is a good idea, and, if using supplementation, what is the optimal dose. Hundreds, perhaps thousands, of researchers around the world devote much of their time to study these questions.
 Current guidelines for serum vitamin D are a level between 20 and 80 ng/mL. It is generally accepted that below 20 or above 80 are potentially dangerous ranges. Studies of likelihood of dying indicate that people with a level of around 50 have the lowest chance of death. Most people who do not take supplements are healthy with levels between 20 and 80.
Vitamin D is created in the skin after exposure to sunlight and people with adequate sun exposure will not need supplementation. Darker skin pigmentation and increasing age both require more sun exposure or supplementation. Vitamin D is a fat soluble vitamin and therefore is well stored in the body: an excess can be saved for a rainy day. Unfortunately, high levels (when serum values are above 80) are also a problem so that vitamin D cannot be supplemented in very large quantities, but someone who is deficient can take large doses for a few weeks or months to replenish body stores. Tablets with up to 50,000 international units of vitamin D are commercially available. Some suggest 300 to 800 international units a day supplementation, but there is good evidence that doses up to 2000 international units a day are safe and more reliably raise serum levels to optimal. People with little sun exposure will need higher amounts of supplementation than those who are frequently in the sun. Some foods, particularly cows’ milk and soy milk, are fortified with vitamin D but the contribution of food to vitamin D levels is modest for most people. Most supplements are in the form of vitamin D3, which is what is usually recommended. The D2 form can also be used and is as effective for most people.
 My experience is that many physicians are confused and poorly informed about appropriate calcium and vitamin D supplementation. I recommend not to take calcium supplements unless your physician has determined that you have a specific reason why you need extra calcium or you are unable or unwilling to eat calcium containing foods. Someone who eats mainly junk food might need 500 mg. a day. The diagnosis of osteoporosis or osteopenia alone is not an indication for calcium supplementation. I would supplement with vitamin D3, the dose dependent on how much sun exposure you have. With little or modest exposure, I suggest 2000 units a day; with good exposure 1000 units a day. Vitamin D should be taken with meals since it is absorbed much better at that time. Even better is to have your vitamin D serum levels checked. If they are in the 40 to 80 range no supplementation is necessary.
 I will send future messages about other nutrients, exercise, and other issues relating to osteoporosis.

Nutrition Facts summary:

                                                  NutritionFacts 

Dr. Michael Greger has a website called NutritionFacts which I frequently reference when I send out information about diet and nutrition. Usually his excerpts are a few minutes long but today's was over an hour and was a summary of many things he's come across in the past year.

Gargling with tap water greatly reduces the incidence of colds and flus. (Antiseptic mouthwashes are not recommended since they kill important mouth bacteria which help digest important nutrients. Another corollary is that vigorous rinsing water in the mouth after eating is a very effective way of removing debris which leads to gum disease and caries.)

As simple an intervention as a glass of water before school improves student performance significantly. Presumably many children go to school dehydrated.

A few minutes of vigorous exercise have dramatic effects on the symptoms of ADHD and also cause a dramatic rise in measurable immune function.

Regular eating of nutritional yeast and/or mushrooms results in a more than 50% rise in antibody activity, a strong, accurate marker of immune function.

Greger reminds us that drugs for multiple sclerosis are very expensive, are largely ineffective, and have many serious complications. In contrast, treatment of early-stage multiple sclerosis with a low-fat vegan or near vegan diet allowed no progression of disease in 95% of thousands of patients over a 34-year follow-up. No drug results are remotely comparable but there's no money in recommending diet and the big drug companies make a fortune with MS drugs that have little or no value.

Essential tremor is a Parkinson's like disease which starts to affect many people in their 40s with 20% or more of all Americans past the age of 80 showing signs of this condition. While it is not a disease associated with premature death and severe disability like Parkinson's, essential tremor does lead to discomfort and mild to moderate disability. This condition has been shown due to a substance which is found almost exclusively in meat and fish. Correlation of this condition with heavy meat and/or fish eaters is stronger than the correlation found between cigarette smoking and lung cancer.

Greger quotes the head of Harvard Medical School epidemiology that a vegan diet is "extreme" but it is what science shows is the best for health.

The USDA was founded and is still run to support the American business of agriculture. Somehow, they have also gotten the role of telling the American public what correct diet is. A recent USDA letter to the egg industry board told them that they could no longer indicate that eggs were safe, healthy, or nutritious in their advertising since all of these have been scientifically proven to be incorrect. This from the department in charge of supporting US agriculture business!

Recent studies with fibromyalgia have shown by far the best results are from a whole food plant based diet.


HPV is the source of most cervical and many oral cancers. Vegetarians, and especially vegans, have much lower rates of significant HPV infection. Diet somehow overcomes the persistent organisms and helps them to be eradicated. Also vegan women have been shown to have much lower rates of all female cancers including breast and ovary.

29% of American women have bacterial vaginitis which is typically identified by doctors through the sniff test (a fishy odor from the vagina.) A vegan or near vegan diet eliminates this condition.

The United States is again number one in the world. This time it's in erectile dysfunction which has the same cause as coronary artery disease and now is generally recognized as an excellent marker for significant heart disease. 40% of American men over the age of 40 have erectile dysfunction. Again a diet of whole food vegetable products greatly reduces the incidence of this problem.

A study was done looking at weight loss in various diets. It turns out that all calories are not created equal. People who ate a vegan diet but consumed the same number of calories as those eating an omnivorous diet lost significantly more weight.

A high percentage of Americans are constipated. A recent study showed that prunes were a significantly better treatment for this than Metamucil. Needless to say vegans have virtually no constipation.

Cancer tumor growth requires the formation of new blood vessels which are supported by a hormone secreted by the cancers. Plants, vegetables and fruits, suppress the formation of this hormone.

Almost all cancers need methionine to grow. High methionine foods are chicken and fish. Moderate amounts are found in red meat and dairy. Methionine levels are low in fruits and vegetables.

Consumption of poultry and eggs is the worst for cancer development and progression. The so-called "healthy choice" is not so healthy!
Consumption of legumes were shown to be a strong predictor of longevity.

Consumption of one serving a day of cruciferous vegetables like broccoli, cauliflower, kale, collards, bok choy, arugula etc. leads to one half the chance of recurrence in breast and several other cancers.

A group of patients with estrogen negative breast cancer was evaluated. Estrogen negative breast cancer is in general worse because it does not respond to any sort of hormonal intervention. The group of these patients who had five helpings of fruits and veggies a day and a 30 minute or longer walk six days a week reduced their chance of death in the next five years from 16% to 4%. There is no anticancer intervention or drug that comes close to these results.

Berries have been shown to reverse the progression of precancerous changes in the mouth and the esophagus. In the esophagus 52% were totally cleared and 80% were significantly improved.

Dairy, eggs and meat are almost uniformly contaminated with bacteria, often pathogenic bacteria. A federal district court ruled that this was acceptable since virtually all meat and dairy products were contaminated and everybody was used to eating them.

Many bladder infections come from contaminants from animal products, the worst of which is chicken. It turns out you don't have to even eat the chicken, just bring it into the house and prepare it. So if you are eating food from a kitchen which uses chicken you have a significant chance of exposure to many of the organisms which cause bladder infections.

                 Drinking Diet Soda Linked to a Widening Waistline  

http://www.medscape.com/viewarticle/841717?nlid=78588_3041&src=wnl_edit_medp_diab&uac=155521DT&spon=22
 (Reuters Health) - People over age 65 who drink diet soda daily tend to expand their waistlines by much more than peers who prefer other beverages, possibly contributing to chronic illnesses that go along with excess belly fat, according to a new study.
Research in other age groups has directly associated drinking sodas that replace sugar with artificial sweeteners and increased risk of diabetes, metabolic syndrome and preterm birth, said lead author Dr. Sharon P.G. Fowler of the University of Texas Health Science Center at San Antonio.
The new study only observed people over time, and did not test whether drinking diet soda actually caused gains in abdominal fat, she cautioned. "We can't prove causality but there is quite a consistency in observational studies," Fowler told Reuters Health
For older people, who are already at increased risk for heart and metabolic diseases, increasing belly fat with age just adds to health risk, Fowler and her colleagues write.
To see what role diet soda might play, the study team followed people over age 65 for an average of nine years. The study started with physical examinations and questions about daily soda intake among 749 people who were over age 65 when first examined between 1992 and 1996. By 2003-2004, 375 participants were still living and had returned for three more examinations.
People who reported not drinking diet soda gained an average of 0.8 inches in waist circumference over the nine-year period compared to 1.83 inches for occasional diet soda drinkers and more than three inches for people who drank diet soda every day, according to the results online March 17 in the Journal of the American Geriatrics Society.
The authors had taken other factors like physical activity, diabetes and smoking into account.
"It cannot be explained by the calories," said Dr. Francisco Lopez-Jimenez of the Mayo Clinic in Rochester, Minnesota, who was not involved in the study.
People who drink diet soda may be more likely to overeat in other areas, he told Reuters Health.
"The main point is for those who drink a lot of soda, diet or not, there may be a relationship with obesity," Lopez-Jimenez said.
"I think it probably is true that for some people, if they are not being really hardcore about losing weight and getting a healthier lifestyle, if they switch over to diet soda that allows them to have an extra slice of pizza or a candy bar," which translates to actually consuming more calories than would have been in a can of regular soda, Fowler said.
But another possibility is that there is a real causal relationship at the molecular level, which she believes is the case.
Diet sodas are very acidic, more so even than acid rain, and the acidity or the artificial sweeteners may have a direct impact on things like gut microbes, which influence how we absorb nutrients, Fowler noted.
"Calorie free does not equal consequence free," she said.
Although it's still unclear if diet soda actually causes dangerous changes to health, Fowler hopes that frequent users will try to wean themselves onto other beverages, like fresh brewed coffee, tea or mineral water with natural juices added.
"It's possible to find things without sweeteners or dose the sweetener themselves," she said.
The study doesn't justify a recommendation to avoid soda, but it does very clearly show that drinking diet soda does not lead to weight loss, Lopez-Jimenez said.
SOURCE: http://bit.ly/18ZeLeD
J Am Geriatr Soc 2015.

Statins and Heart Disease - Do Women Differ From Men?

http://www.docsopinion.com/2013/06/24/heart-disease-and-statins-do-women-differ-from-men/

The link above is to a discussion of heart disease and cholesterol in women by a prominent cardiologist (a man, not Roberts) on his blog. Roberts’s books on the subject are the current bible for women.  Her conclusion is that your HDL levels are very important, statins don’t help and have bad side effects (including cataracts.)

               
                      Statins and Heart Disease – Do Women Differ From Men?

Recent studies have shown that the symptoms of heart disease may differ between men and women. For example, women are less likely than men to have chest pain while suffering an acute heart attack (acute myocardial infarction). This may delay diagnosis and may partly explain why women seem to fare worse than men under these circumstances. Furthermore, the role of risk factors for heart disease may be different between the two genders. It has also been suggested that treatment with cholesterol lowering drugs, so-called statins, may be less effective for women than men, in particular in primary prevention (individuals without known cardiovascular disease.)

These important issues were recently discussed in Reykjavik, Iceland, when visited by Barbara H. Roberts MD who is a prominent expert in this field. Dr. Roberts is director of the Women’s Cardiac Center at the Miriam Hospital in Providence, R.I. and associate clinical professor of medicine at the Alpert Medical School of Brown University. She has written two hugely interesting books,  How to Keep From Breaking Your Heart: What Every Woman Needs to Know About Cardiovascular Disease and The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs.

I ran across Dr. Roberts recent book on statins while visiting New York last December for a cardiovascular meeting. I became very fond of it because it is extremely well written and can easily be read both by laymen and professionals. Her discussion is objective, evidence based, and she does not jump to any conclusions. Although Dr. Roberts has a point to make, her writing is careful and unbiased. Of course, the book has a strong message which I know many of my cardiologist colleagues will not agree with.
The internet may affect our lives more than we sometimes realize. A few days after I finished reading Dr. Roberts book I mentioned it in one of my blog posts because I felt it had an important message to everyone interested in cardiovascular disease and modern-day health care. Statins are used by millions of people worldwide. Whether we like it or not, we have an obligation to look at both the positive and negative effects of this therapy.
By coincidence, Dr Roberts read my article and we became acquainted. Six months later she arrived in Reykjavik to give two talks, a public lecture on how women may reduce their risk of heart disease, and another lecture at aimed at professionals at our University Hospital on statin therapy.
Dr. Roberts gave her first talk on the evening June 18th 2013. It was attended by more than 300 people, mostly women.  I was really proud by the huge interest. Thank you, Icelandic women for showing so much interest in how to improve your health and reduce the risk of heart disease. Dr. Roberts gave a fascinating overview of cardiovascular disease, risk factors, lifestyle and prevention. It was a memorable evening.
She started by addressing the anatomy of the normal heart, the coronary vessels and the blood circulation.  She then discussed important symptoms and disease concepts such as angina pectoris, myocardial infarction or heart attack, congestive heart failure, and palpitations.  She touched on the underlying pathology of cardiovascular disease and introduced important disease mechanisms like atherosclerosis, plaque rupture and clot formation.
Dr. Roberts then went on to describe how the symptoms of an acute heart attack may differ between men and women. Men are more likely to experience chest pain than women. Women are more likely to have nausea, back, shoulder, abdominal or neck pain than men. Women are also more likely to have no chest pain, and just shortness of breath or sometimes fatigue.
Dr. Roberts went through most of the known modifiable risk factors for heart disease like smoking, high LDL cholesterol, low HDL cholesterol, high blood pressure, diabetes, obesity, sedentary lifestyle, the metabolic syndrome and inflammation.
Dr. Roberts dedicated a part of her talk to treatment with statin drugs. Statins are frequently used to lower cholesterol and to reduce the risk of heart disease. It is her opinion that the benefits of statins have been greatly exaggerated and that their dangers have been greatly downplayed. She mentioned the most common side effects of statin therapy like muscle pain, rhabdomyolysis, cognitive dysfunction, tendon and nerve damage, diabetes, liver and kidney damage, fatigue, cataracts and congenital defects in babies exposed before birth. She summarized the results from clinical trials addressing the effects of statins in women. She underlined that no study has ever shown that treating women who do not have established vascular disease or diabetes with a cholesterol lowering medicine lowers the risk of cardiac death or cardiac events.
Dr. Roberts concluded that high levels of LDL cholesterol appear less predictive of cardiovascular risk in women than in men. In women, HDL cholesterol appears more predictive of risk than any other lipid level. She emphasized that abnormal blood cholesterol is but one of many risk factors for cardiovascular disease and that it´s not all about the LDL-cholesterol. After covering the health risks of diabetes, inflammation, obesity and the metabolic syndrome Dr. Roberts went on to talk about the influence of diets. She mentioned a few dietary fictions like “Eating foods high in cholesterol raises your cholesterol” and “Low fat diets are good for your heart“. She also mentioned a few dietary facts like “Low fat diets lower HDL cholesterol so they are NOT heart healthy. You need to eat heart healthy fats” and “You can eat your way through any cholesterol lowering medicine“. Finally she underlined the strong scientific evidence indicating that a Mediterranean type diet reduces cardiovascular risk. Dr Roberts concluded her lecture with this message:
Prevention of Heart Disease Made Easy:
• If you smoke, STOP
• If your cholesterol is high, get it down
• If your blood pressure is high, get it down
• If your blood sugar is high, get it down
• If your weight is high, get it down
• Do moderate exercise 30 minutes/day
• Eat a heart healthy diet
• Pick your parents wisely

     The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs

Dr. Barbara Roberts gave her second lecture in Reykjavik on June 19th at Landspitali University Hospital. Again she did a wonderful job with a highly informative and provocative talk. Unfortunately, only about 40 people attended, among them only a handful of cardiologists. I know doctors are busy people, but I have to admit that I would have loved to see more colleagues. Statins are the most frequently prescribed drugs by cardiologists all over the world. Many of us believe they are our most important weapon when it comes to pharmacological treatment of cardiovascular disease. So, I can understand that it may be unpleasant to hear about their presumed bluntness.
Dr. Roberts started by going through many of the advantages and disadvantages of statin therapy. She quoted Doctor Rita Redberg: “There are millions of women on a drug with no known benefit and risks that are detrimental to their lifestyle — and no one is talking about it”. She also quoted Dr. Sidney Blumenthal: “The totality of the available biologic, observational and clinical-trial evidence strongly supports the selective use of statin therapy in adults demonstrated to be at high risk for heart disease”. So, “are statins angels or devils” she asked?
Next Dr. Roberts took us through the history of the lipid hypothesis, from the work of the German pathologist, Rudolph Virchow on atherosclerosis in 1856, to the modern day clinical trials. She underscored the difference between absolute and relative risk reduction. She summarized data from clinical trials on the use of statins in secondary prevention. The result was that statins significantly reduce the number of cardiac events among individuals with cardiovascular disease, although the effect appears less pronounced among women than men. Again, she underscored the fact that clinical trials have not shown that treating women who do not have established vascular disease or diabetes with a cholesterol lowering medicine lowers the risk of cardiac death or cardiac events.
Dr. Roberts then went through all the most common side effects of statin therapy. Unfortunately this list appears to be growing, not unsurprisingly though, considering the huge number of people taking these drugs. Recently the increased risk of diabetes and cognitive dysfunction associated with statin therapy has been highlighted. Finally, she talked about possible alternatives to statin therapy. Again she underscored the positive effects of the Mediterranean diet.

Dr. Roberts final conclusions were:
                                                The Bottom Line
We, cardiologists tend to focus on the positive effects of statins. This is completely reasonable because clinical trials have shown that these drugs are very effective under certain conditions, and they improve the prognosis of patients with cardiovascular disease. Statins may also be effective among individuals at high risk for developing cardiovascular disease, such as those with diabetes. Nobody doubts the important role of statins in patients with familial hypercholesterolemia (FH).
Sometimes it is much easier for doctors to prescribe a drug than not to do it. Furthermore, the positive effects of statins are highly emphasized by the medical community, and these drugs are generally considered well tolerated. I am much more likely to be criticized by my colleagues if I don´t put a patient on statin therapy who might benefit, than if I put someone on such therapy who will probably not benefit from it. Sometimes we forget the words of our ancestors: Primum non nocere; first do no harm.
Sooner or later we will have to face the fact that many people have side effects from statin therapy. Often, these effects are not obvious. As doctors, we have to be alert and monitor patients for such side effects.
It has been pointed out by some of my colleagues that highlighting the negative effects of statins may encourage some patients to stop taking their drugs. Obviously, if these are individuals who are benefitting from their therapy, this may cause harm. On the other hand, providing truthful unbiased information to our patients can never be ethically wrong. Indeed, such information is necessary for shared decision making. Otherwise, our patients will not be able to make a truly informed decision on whether they want a certain treatment or not.
Finally, I would like to sincerely thank Dr. Barbara Roberts for visiting Iceland and sharing her knowledge and experience. Again, I recommend everyone interested in cardiovascular disease and modern-day health care to read her book on statin drugs. It is a strong reminder of our limited knowledge of the long-term effects of drugs that are being prescribed to millions of people worldwide.

                                     Should We All Go Gluten-Free?

http://www.medscape.com/viewarticle/857971_4

Differentiating between celiac disease, NCGS, and other wheat-related disorders can be challenging, but it is important for appropriate management. As stated in a recent editorial, it is counterproductive to debate whether NCGS is "real"; the patients are real and are seeking care.
The current clinical approach involves ruling out celiac disease and wheat allergy, testing for additional food intolerances or gastrointestinal conditions, and providing the latest data on the benefit/unintended consequences of gluten avoidance and these evolving entities. It is also important to inform patients and their families about what is not known. It may also be effective to individualize the recommended dietary strategy by eliminating certain components of the FODMAP class, wheat products, and/or gluten sequentially.
Because there is no specific biomarker for NCGS, the diagnosis is "confirmed" by dietary elimination, followed by double-blind, placebo-controlled gluten-based re-challenges. This is a cumbersome, time-consuming, and difficult-to-access clinical approach. Even with this information at hand, the diagnosis of NCGS may remain unclear, raising the question of whether the salutary effects of gluten withdrawal are specifically attributed to the gluten-protein per se or to nongluten components such as fermentable carbohydrates and amylase-trypsin inhibitors.
Khabbani and colleagues reviewed records from 238 patients who presented for the evaluation of symptoms responsive to gluten restriction without prior exclusion of celiac disease. Of these study subjects, 42% had celiac disease and 52% had NCGS; the remainder had an indeterminate diagnosis. The majority (67%) of subjects with celiac disease presented with symptoms of malabsorption, compared with 25% of the NCGS subjects. In addition, those with celiac disease were significantly more likely to have a family history of celiac disease, personal history of autoimmune diseases, or nutrient deficiencies.
On the basis of these findings, the authors proposed a diagnostic algorithm to differentiate celiac disease from NCGS. They state that subjects with negative celiac serologies (IgA tTG or IgA/IgG DGP) ingesting a gluten-containing diet are unlikely to have celiac disease. Those with negative serology who also lack clinical evidence of malabsorption and risk factors for celiac disease are highly likely to have NCGS and may not require further testing. Those with equivocal serology should undergo HLA typing to determine the need for biopsy.
Guandalini and colleagues proposed assessment of the levels of gamma delta T-cell receptors in intraepithelial lymphocytes (which are specific for celiac disease) or detection of IgA anti-tissue transglutaminase antibody deposits in intestinal mucosa in order to more clearly exclude celiac disease in problematic cases.

Remaining Questions:
As stated by Fasano and colleagues, a better understanding of the clinical presentation of NCGS is needed, as well as its pathogenesis, epidemiology, management, and role in conditions such as IBS, chronic fatigue, and autoimmunity. There also must be agreement on the nomenclature and definition of gluten/wheat-related disorders based on proper peer-reviewed scientific information.
It is hoped that in the future, the terms NCGS, NCWS, and wheat intolerance syndrome will be replaced by well-defined nosology, that the phenotypes and mechanisms of syndromes responsive to gluten withdrawal will be better defined, and that there will be biomarkers and definitive therapy for distinct entities.

Low Carbohydrate Diets and Low Fat Diets

Recently I have been re-studying low carbohydrate diets spurred on by an extensive email dialogue with Dr. Richard Feinman, Prof. of Cell Biology at Downstate Medical School in Brooklyn (my alma mater), and by multiple inquiries about the Paleo diet from friends and acquaintances. Dr. Feinman is a highly-regarded scientist who has done research on metabolism in low carb diets and I have learned a lot from him. He studies and advocates a VLCKD (very low carb diet-20% of total calories from carbs with no fat restriction.) This is the diet that most lab research has been done on. It produces ketosis and ketone bodies supply much of nutritional needs of the cells rather than glucose. Dietary ketosis, as opposed to diabetic ketosis, is not harmful to the body. The source of the limited amount of carbs is optional but most advocates including Dr. Feinman eat leafy green and other non-starchy vegetables for their nutrient value and fiber.

Most low-fat and other low-carb diets recommend consumption of non-starchy vegetables and most fruits while avoiding sugars, refined grains and limiting salt. Some low carb programs suggest avoiding saturated fat as much as possible.

Vegetables and fruits can rarely supply enough calories for long-term existence in humans. Remaining calories have to come from either starches or animal products or refined vegetable oils.

Low-carb advocates suggest meat (some including Paleo want this to be low fat), fish, vegetable oils, and dairy products (Paleo excludes dairy and others say low fat dairy.)

Most low-fat advocates suggest starches.

Inside each camp there is variation with some low-carb people favoring organ meats and full fat dairy while others suggest no dairy at all. Many in the low-fat group aim at total fat consumption of 10% of calories and total protein consumption about the same. This is not the "low" fat diet of the AHA, ADA, Framingham Study, or Nurses Health Initiative Study which suggest 30% of calories from fat. But again there is variation, particularly in regard to the amount of seeds and nuts consumed. This group also advocates little or no vegetable oils except as found naturally in whole foods.

Books and articles on the subject have mainly been quite well written and sometimes very thoroughly researched. Low-carb supporters emphasize the need for insulin control as a basis for good health while low-fat advocates want to avoid almost all dietary fat especially saturated fat and cholesterol. There is excellent laboratory and clinical support for both these positions. Each of the writers from both groups tend to ignore the strong positions of the others while showing the rationale and clinical evidence for their position. I've not found a book or article which looks at it well from both sides. Some have termed this the war of the diets and I don't think that term is far off based on the approaches many scientists and authors have staked.

Another group of diets looks more towards portion control while supporting high vegetable and fruit intake with avoidance of sugar, refined grains and saturated fat. Variations on this theme were the most popular with professional nutritionists as seen in the 2013 "US News and World Report" evaluation of 29 diet programs by a panel of 21 nutrition experts selected by the magazine. In this survey, most of the low-fat diet programs were in the middle of the ratings and most of the low carbohydrate programs were at the bottom with the Paleo diet tied for last. Objections to both the low-fat and low-carb diets often centered around palatability and ease of adherence to the diet with the low-carb diets also criticized as not having long-term performance experience and a danger for development of vascular disease. My observation on these rating criteria is that many, if not most, people have a serious problem with portion control and keeping track of what quantity of food is eaten while they can more readily adapt to relatively unlimited quantities of certain foods while avoiding other foods entirely. Both the low-fat and low-carb diets typically offer this approach which many people I have talked to find easier. Also, results of these moderation diets are poor in the treatment of chronic disease. They may help somewhat in prevention but effects are small compared to a true plant based whole food diet.
Two popular versions of a lower fat, higher nutrient diets do not stress portion control. The Mediterranean Diet advocates lots of fruits, vegetables and fish plus oils with less meat, dairy, refined carbs. Compared to the standard American diet (SAD) people who eat this way live longer and have better health but do not have nearly the longevity or lack of chronic disease which those who eat a whole food plant based diet enjoy. This diet is not very effective in the treatment of chronic disease. Another version of a low-fat diet is flexitarian, in which the low-fat plant based whole food diet is modified to include small amounts of fish, low fat dairy and/or meat. Several knowledgeable physicians I've met follow this diet as preventative but say they would eliminate all animal products for themselves or patients to treat many chronic diseases. The issue for advocates of the low-fat diet is what qualifies as a "small" amount and how reliable patients will be if allowed this flexibility. Esselstyn says that he knows he can successfully treat all his patients with coronary disease so why take a chance on a modification.

Low-carb programs have convincingly shown excellent control of weight and metabolic syndrome (MetS) including diabetes and high blood pressure. Low-fat programs have had similar results with a comparison study between the two-favoring low-carb. However, in this study in the low-fat group 24% of calories came from fat which does not come close to the guidelines suggested by the low-fat diet promoters. Low-carb diets may also induce good serum lipid profiles which suggests to some researchers that atherosclerosis would be well treated and controlled by this diet. This diet also generates low blood insulin levels together with a ketotic state both favoring less cancer development and growth. Another hormone, IGF-1, a strong promotor of cancer growth, is increased with animal, not vegetable, protein consumption. I don't know how these changes balance out for tumor growth. I have not seen a study which treats patients with advanced coronary artery disease with a low-carb diet nor am I aware of any long-term studies in groups of patients following this program except those of contemporary indigenous groups in whom heart attacks are rare until western food choices are introduced. The few autopsy studies pre-western food in these people usually show atherosclerosis but they often die young for other reasons so that clinically relevant vascular disease and cancer rates are uncertain.

Low-fat diet programs are well documented to prevent and reverse advanced coronary artery disease and population studies of large groups following this diet show low rates of cancer and other chronic diseases especially vascular disease. This diet typically is associated with longevity and low end-of-life morbidity where there is not famine or infectious disease.
Many people have asked me about body building and diet. Most body builders and professional athletes eat large amounts of animal protein and many take protein supplements, usually but not always from animal products. I am convinced that any protein supplement, animal or vegetable is a bad idea. Isolated protein concentrates promote cancer growth according to many studies. Some world class athletes eat plant based diets and feel they perform better because of it (Venus and Serena Williams, Martina Navratilova, Arian Foster, Tony Gonzalez among others) and a few champion body builders also eat a plant based diet. However, I'm sure it is easier to build muscle bulk with animal products. A plant based diet may be as good or better for performance.
It is certain that you are very unlikely to have good health with lots of processed food, sugars, salt, and refined carbs in your diet and that if you combine a high carb with a high fat diet that you will have a poor diet likely to lead to chronic diseases. The question is; are some people better off with low carb and others with low fat. Certainly, some people strongly prefer one over the other. Is this genetic or due to degree of fat addiction or due to an individual's body doing better on one of them? Is it cultural? Does it matter which you choose? I am confident that you will thrive on a plant based whole food diet which avoids processed oils. A few people have reported doing poorly on this diet, then feeling better switching to a low carb diet or some modification of a fully plant based diet. When physicians have evaluated the few, who don't thrive typically they find a deficiency in vitamin B-12, an essential fatty acid, or a mineral (often zinc or iodine.) These deficiencies are easily treated. Constipation and headaches are usually a problem with low-carb diets but this is not the case with low fat (8-12%) diets. Incidence of vascular disease and cancer are certainly much lower on a low-fat diet. I don't know what they would be on a long term low carb diet.

Green Smoothies

Dr. Michael Greger, editor of NutritionFacts website, recently made an extensive video about green smoothies. He emphasized their health value, simplicity and tastiness.

The basic recipe includes leafy greens, berries, and flaxseeds or flax meal. All three of these foods are super-nutritious and they complement each other to provide most important vitamins, minerals, anti-oxidants, healthy protein and fat. The greens and berries can be fresh or frozen but frozen is quicker and less work. Frozen berries will be less expensive than fresh, but the opposite may be true for greens. Another advantage of frozen is that the smoothie produced is immediately cold if that is your preference. If a high-speed blender is not used, flax meal is a better choice than the seeds since the blender may not break down flaxseeds enough to release their nutrients.

Optional ingredients include banana, pineapple, soy or nut milk, turmeric, and coconut water. Sweeteners, even juices, should be avoided. Since the fine pulverization of ingredients allows much better absorption in the G.I. tract you will be getting most of the nutrients. Fiber is not degraded sufficiently to lose its healthy potency.

Nutritionists have long known that soups are very healthy in many ways. Nutrients from ingredients are easily absorbed and satiety is high. Soup before a meal or as the main course leads to fewer calories eaten over the rest of the day. This effect was not seen with smoothies until researchers looked at different delivery methods. Warming a smoothie seems to have no effect, but drinking the smoothie slowly, at the pace you would normally eat soup with a spoon, does indeed lead to greater satiety and less calories ingested over the rest of the day. The best way to drink your smoothie is to sip it as you might hot coffee or tea. Blood sugar rate of rise and peak, insulin secretion and other measures of good metabolism are enhanced by doing this. The French have much fewer overweight people and much of the reason may be pace of eating, but as more fast food is consumed in France this advantage will be lost.

The downside of smoothies is that concentrated fruits and vegetables are tough on tooth enamel. This problem can be overcome by drinking your smoothie with a narrow, flexible straw so that contact with teeth is minimized. In addition, rinsing your mouth out with water after the smoothie (or eating fruit) saves enamel. Put off brushing your teeth for up to an hour after eating fruits or drinking a smoothie since the enamel will be softer and damaged by the toothbrush in the hour after the smoothie.