An Apple A Day

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 is because I was already aware of our ignorance in this way (as well as in some many others), that I see mostly good in the controversy. It is another blow against erroneous assumptions. Sometimes it is necessary stir things up. Personally, having had decades of experience as a lightning-rod for narrow-minded criticism, it is nice to see someone else saying the right thing, accepting that it will be unpopular. I dedicated my medical textbook on homeopathy “to those with the courage to ask questions”, both because it is a rare quality in medicine and because it is essential to fundamental progress.

The universal assumption has been that cancers must be treated, or they will kill you. We have so much data, on so many cancers, refuting this facile falsity, that there is no excuse for sticking our heads in the sand. We urgently need to recognize our previous ignorance and move forward to answer the vital question of when treatment for cancer is needed and for whom.

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 goal. Lowering perfectionistic expectations about female bodies was my expectation, not raising expectations about male bodies. We are moving towards an unhappy and disordered equality.

Columnist Richard Cohen, commenting on the latest Bond film, pointed out the irony that Daniel Craig’s Bond supposedly suffers weakness and disability of age, while the film simultaneously lingers on his hyper-perfect body. They are now marketing the “Daniel Craig” workout, so that we can ALL achieve a similarly imperfect body????? Thanks?

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 toilet.

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 it out on other populations.

Amazingly, we have now built up research evidence ranging from the basic sciences (cellular and physiological changes) to clinical trials of old and young, fat and thin, trained and out of conditioned individuals. The bottom line: It’s all good.

In only two to three weeks of 2-4 short sessions of HIIT each week, just about every measure we have of fitness improves, often markedly so. It also improves blood tests associated with long-term risk of heart disease, diabetes, cancer and Alzheimer’s. Also, forget the long, slow activity and the “fat burning” heart rate zones you see posted on exercise equipment. HIIT gets fat burning better than low intensity exercise, and keeps it going for hours after your workout ends.

One of the incontestable failings of age is that our maximal oxygen uptake drops year after year, beginning in our late 20s. We just don’t have the aerobic capacity we used to. HIIT has been shown now to improve oxygen uptake, the most essential fuel for our cells, regardless of age, gender or previous fitness.

This is all great news, but it gets better. HIIT, with the rest intervals between the intense exertion intervals, is unlike the sprint training you might have endured long ago, and not just because it is less unpleasant. The only research comparing HIIT to that sprint-sprint-sprint-till-you-drop torment, shows that HIIT actually works better. Yay!

With one exception, I cannot remember any similar wave of research on a specific treatment. That one exception, vitamin D, is an almost perfect comparison. The evidence suggests vitamin D levels are linked to improvements in nearly every human health trouble. Similarly, HIIT does almost everything we have learned that exercise can do. Although there are fewer studies of HIIT than vitamin D, the quality of evidence might actually be even stronger than the vitamin D studies to date, because the of the way HIIT studies can be designed (intervention versus observation).

Okay, so how do you do it? Very simple. Warm up a few minutes (5-10). Then alternate working hard and easy. How long? The easiest way is probably to go hard for a minute and then easy for one minute, repeating that cycle a total of 10 times. Some studies used a four minute hard interval followed by three minutes of easy, for a total of four cycles. We do not know if some duration will prove to be better than another. All the studies, using whatever interval, show that it works. Consequently, I’d say it is up to you.

My son, for example, lives in a high rise building in a big city. He wanted to work out climbing stairs as he does not have any cardio equipment and gyms are extremely expensive where he lives. The plan we worked out was for him to climb up for 4 minutes, which gets him near the top of the 30 stories, take the elevator back down then do it three more times.

You can walk, going faster and then slower. You can do the same with swimming cycling or whatever activity you prefer.

How hard is hard? 90% of your maximal heart rate. Maximal heart rates are very scientific but they can be annoying to use as a measure, because you have to monitor your heart rate and figure out what 90% of MHR is for you. Maximal heart rate is different for different people, men versus women and it changes with age. It also differs by what you are doing.

My advice is to do this by how hard it feels to you. 90% = panting. Go hard enough so that you are breathing heavily and then go easy. As you go through the cycles, you will probably learn that, keeping your effort at the same level of intensity, you are going at a slower pace. That is fine. Do not try to maintain the same pace unless you feel about the same level of exertion. The point is your effort, how it feels to you. Do not thrash yourself. Start out being careful not to push yourself too much, and as you do it for a while you can get a better sense of what your limits are. You do need to approach those limits, to push yourself, to get the maximum benefit from this. If you have any questions about this, please come in to talk about your individual circumstance.

I will add that there are some HIIT regimens that make the hard exertion interval much longer than the easy, recovery interval. I do not like that for anyone who is not already quite fit.

My own experience with HIIT may be of interest. In years past I trained in this way to build fitness, partly because it was closer to the most demanding physical work I did. Refereeing semipro men’s soccer games, at times sprinting to keep up with athletes 20 years younger than I, was not at all like jogging for an hour or two. More recently, as problems leading to my knee surgery became increasingly troublesome, I dropped all of my longer aerobic sessions. My knee just would not tolerate them. I experienced much of the same energized but relaxed sensations of the longer aerobic work, but with considerably less pain in my knee. One conclusion from this is that HIIT can have an important role to play when a person has a chronic or acute joint problem, limiting the stress his/her body can endure.

Many medications are available only by prescription (unless you own a computer or travel to another country). That is because of the risks that accompany their use. When drugs become available we tend to believe that availability is some sort of certification that they are safe, and weak compared to prescription meds. Not true.

Recent news that daily use of aspirin lowers the risk of a number of cancers (especially esophagus, colon, rectum and lung) is another example of apparently wonderful information that is not, if you know enough. Seems great, doesn’t it? Take a safe drug and prevent some very nasty diseases. Shouldn’t I be taking it anyway, because it prevents heart attacks and strokes?

Here comes the buzz kill. Other studies, larger and more carefully designed, have not found this effect. Also, studies have found that taking aspirin does not prevent a first heart attack or stroke, as we had thought it would. It might be a good idea for that purpose in some middle-aged individuals, and probably is for those who have already had a heart attack or stroke. Finally, recent data shows that daily aspirin doubles the risk of macular degeneration, already one of the most common causes of age-related blindness.

Aspirin used to be routinely given to infants with fever. Then we learned that this could lead to (potentially fatal) Reyes Syndrome. I have never liked using it in this circumstance, because fever is generated by the body in its effort to make itself an unpleasant place for bacteria and viruses to live. Squashing the fever squashes the immune response and, as research shows, prolongs illness.

Ibuprofen, (aka ADVIL, MOTRIN, MUPRIN, RUFEN) seems like a good choice to so many. Inflammation is “bad”, so anti-inflammatory is then good.

Ibuprofen is the leading cause of impaired kidney function in the US. Years ago a kidney specialist told me she would not see a new patient for kidney trouble until the patient had been off ibuprofen entirely for at least a month, because dropping the kidney-imparing ibuprofen fixed 75% of the patients sent to her.

Ibuprofen markedly increases the risk of the most serious problem commonly seen in marathon runners. Their kidneys slow down from the exertion. Taking ibuprofen makes it worse. Their sodium drops and they can die. Not good.

Many athletes take ibuprofen before engaging in their sport. Ironically, ibuprofen increases damage to muscles and soft tissue because “inflammation” is one aspect of the healing process. At the medical meeting of physicians working with endurance athletes before the Marine Corps Marathon last fall, I was delighted to find myself in the company of others who shared my dislike for ibuprofen. We discussed its harms at length, as well as the muscle damaging effects of statin drugs. I loved it.

Is Tylenol, the “safer choice”. Not really. Starting from the very beginning of my medical training I spent a great deal of time working as an Emergency Room Physician. One of my first ER shifts I took care of a teenaged girl who was upset and, crying out for help, took an overdose of Tylenol, believing it was safer than aspirin. By the time she arrived in the ER, she had changed her mind and was feeling fine. She did not realize that, although , in the coming days her life was at risk due to the delayed, liver toxicity of acetaminophen/tylenol.

Following the recognition of the link between aspirin and Reye’s Syndrome, everyone switched to Tylenol. Now many think that the rise in childhood asthma, which began at the same time, is not a coincidence.

Remember, there is no “free lunch” biologically or otherwise. The best medication is no medication. Taking care of yourself, minding the essential health habits, will do far more to help you live well and happily than any medication. There is a place for drugs but they are only pharmacological band aids.