Mammography and Breast Cancer

If you have been reading my thoughts for some time, you know that I am not a big advocate of mammograms. I really wish they would do the job they are supposed to do, but they just don’t. Another study appeared recently, documenting the unpleasant consequences of well-intentioned mammographic screening. It is not the first study highlighting a dilemma that would be much more comfortable to deny. Years ago two large studies, including nearly one half million women, found that mammograms often found breast cancers that spontaneously disappeared, and that breast self exam did not reduce deaths from breast cancer. Much of the medical community and society at large have tried, pretty successfully, to ignore those powerful findings. The principle author (H. Gilbert Welch) is someone I respect highly, partly because he thinks so clearly and critically about the application of research in clinical practice. Like me, he is trained in Family Medicine in addition to his research bona fides, so he always considers the “bottom line” outcomes. In the past I have recommend one or another of his books because they contain such clear discussions of the vitally important but infinitely confusing matter of using research to make health care decisions. The concepts he explains so well confused just about every medical student, resident and practicing physician I have worked with through my career. It is no surprise then, that his review of mammography data created a white-hot firestorm of controversy. You can read a simple discussion of the study and its implications in an editorial he wrote- http://www.nytimes.com/2012/11/22/opinion/cancer-survivor-or-victim-of-overdiagnosis.html The essential findings of the study, reviewing the impact of three decades of mammographic screening in America, were: Mammograms did not lower the rate of widespread, life-threatening breast cancer Improved breast cancer survivor rates are the result of more effective treatment, not screening 1/3 of the diagnoses of cancer by mammogram were needless, consequently - 1.3 million women have undergone treatment for breast cancers that would never have caused harm Unneeded treatment causes significant harm. The Hippocratic Oath begins with the admonition, “First, do no harm”. The obvious conclusion is that we need to find better ways to determine which cancers need to be treated and which do not. The reaction of much of the medical community has been highly emotional. It has not been reasoned and scientific, like we pretend to be. I admit that I have enjoyed the controversy for a few reasons. Welch’s points are valid, but carry frightening implications about our ignorance. Maybe it...

Strength Training, Health and Body Image

A large new study of adolescents in the Minneapolis area surprised and excited the study authors and a writer for the New York Times. They found that many of the girls and over 1/3 of the boys were doing things (changing eating patterns, exercising, taking protein drinks or using steroids) to improve their body composition. The highest rates were seen among the boys on sports teams and girls who were obese. Just under 6% admitted using steroids, which is probably an underestimate because people often do not admit “bad” behaviors in surveys. The researchers and the NYT writer interpreted their findings negatively– “cause for concern” the authors concluded. More careful consideration of the data leads to different conclusions. The article overemphasized the unhealthy potentials of these behaviors. Certainly individuals who are overweight or more serious athletically SHOULD be more serious about taking care of their bodies, including building muscle mass. The conclusions of this study were overblown, reflecting both a lack of understanding of proper diet and a hypersensitivity to body image issues. The CDC estimates that over 1/3 of American teens are overweight or obese (significantly less than their parents). It is very clear that the most effective ways to reach a healthier weight is through physical activity and dietary improvement, especially by boosting protein intake. I would add that it is even more evident that weight is far, far less important than is body composition (ie, the ratio of muscle to fat). Athletes need strength training, both to enhance performance and to prevent injury. Strength training also builds muscle and speeds up metabolic rate, each improving body composition. Considering the realities of American health in general and the health of adolescents, I am generally pleased by these findings. When I was 12 or 13 I was overweight. Ken Cooper’s book, AEROBICS, came out. I read it, changed my eating patterns, began a program of vigorous exercise, lost weight, learned the power of healthy lifestyle, grasped my ability to control my own life and eventually became the doctor I am today. The use of steroids is very concerning and we need to do more about that. The researchers and NYT writer apparently had biases which led to their skewed interpretation of the study data. Although less extreme, I do share some of their concern, particularly the issue of male body image. I have always supported the ideal of gender equality. This is not, however, the path I envisioned taking us towards that...

Be careful what you swallow

A study was just published with exclamatory headlines warning about vitamin D and calcium raising the risk of kidney stones. They studied the blood and urine of 163 healthy, postmenopausal women for a year. Investigators gave the women from 0-4,800 iu of vitamin D and raised their calcium to 1,200 - 1,400 mg/day. 1/3 of the women had high levels of urinary calcium and some had elevated blood levels. That would seem scary, except it isn’t. First, no one actually had a kidney stone or other trouble. More important to me is a much bigger study, involving more than 10 times as many women over a 10-20 times longer time span, also showing no kidney stones and no otherwise unaccounted for calcium elevations on blood work. That bigger study is my clinical practice. Maybe this is because I insist that my patients drink enough water. Dehydration is the major factor leading to kidney stones and calcium is notoriously insoluble. It may also be another example of our ignorance about calcium metabolism. For decades, the standard medical advice for patients who had a common calcium-based kidney stone was to avoid calcium. Then someone actually did a study instead of just making it all up, and found that low calcium intake was associated with INCREASED risk of kidney stones. Another contradictory example can be seen in the disease called hyperparathyroidism. More common than once thought, people with hyperparathyroidism have high calcium levels which can potentially become lethal. Many feared that giving these patients vitamin D would make things worse. Turns out that taking vitamin D does not raise calcium levels in patients with hyperparathyroidism. In fact, in many of these patients, taking vitamin D lowers calcium and helps the patient otherwise. Bottom line - get as much calcium as you can from food, use calcium supplements to make up for what you can’t eat, take lots of vitamin D (targeting a blood level over 50) and DRINK enough WATER so that your urine just slightly tints the water in your...

High Intensity Intermittent Exercise - Fast, Efficient, Fun and Effective

As you probably know, exercise may well be the single most important health habit. Drinking water, eating well, using supplements properly, avoiding toxins, sleeping, working on your attitude and relationships are all also vitally important. However, even beyond its power to prevent and treat disease, exercise may well provide the greatest wellbeing boost of any of the essential health habits. Whether exercise is “number one” or not, it is huge though, and getting people to exercise can be an equally huge problem. The number one obstacle for most people is time. Sure, our heritage is to be physically active all day long, sometimes vigorously so. Just as we are omnivorous eaters, consuming just about anything, our bodies need all kinds of physical activity and thrive on the greatest diversity. We need to work on our muscular strength (especially as we get old). We need aerobic activity to strengthen our heart and lungs. Flexibility and balance are also necessary. Our bodies, including our brains, need all of this physical activity, but where can one find the time? Like many in sports medicine, I am very excited about recent discoveries about one form of exercise that can shorten your time commitment, while simultaneously providing you with even greater benefits than those long, slow, time-consuming physical activities pursued by so many. This magical form of exercise is called High Intensity Intermittent/Interval Training (HIIT). Many of you will recall the crushingly intense sprint work your coach or PE teacher used to train/punish you with long ago. HIIT is a bit like that, but NOT torturous. In fact, when patients in intensive care with heart disease where given a choice of walking on a treadmill or a HIIT workout, the great majority preferred HIIT. That’s right, ICU patients encouraged to engage in a workout that would seem to be a good way to kill them off. I am almost as impressed by the fact that these latest studies using very sick hospitalized patients were approved by human subjects committees, as I am with the remarkable impact of the HIIT regimens. When the first studies came out on this approach less than 10 years ago, they were small but impressive, conducted on young, often already well-conditioned athletes. HIIT seemed like it might prove to be a way for these athletes to kick up their fitness after a layoff, or in the lead up to a big competition. After more and more results came in, showing how efficacious this approach could be, researchers decided to try...