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.”

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.