Soy: Beneficial or Harmful?

A common question in my practice revolves around soy. Should you consumed or avoid it, especially for women who have breast cancer risk factors? It is a valid question, and the medical research has begun to debunk the myth that soy is detrimental.
The form of soy is important; soy from food seems to be safe, but soy in high supplement form has shown mixed results.
Why are patients worried? Soy contains phytoestrogens (plant estrogens). The thought is that phytoestrogens have similar effects as estrogen produced by humans or other animals.
However, the story is complex: soy actually may help prevent breast cancer and its recurrence. It may also have other positive health effects.

Breast Cancer Impact
The Shanghai Breast Cancer Survival Study, an over 5,000 patient observational trial that followed patients for a median of 3.9 years, has had resounding effects on the way we think of soy in relation to breast cancer.
The population consisted of women who had already had one occurrence of breast cancer that was in remission. The women who consumed the most soy from food, measured as soy isoflavones or soy proteins, had a 32 percent reduction in a second occurrence of breast cancer and a 29 percent reduction in breast cancer mortality, compared to those who consumed the least.
This inverse relationship was seen in both estrogen receptor-positive and estrogen receptor-negative women. It is more difficult to treat estrogen receptor-negative women; therefore, making these results even more impressive.
A 2008 meta-analysis suggested that soy decreases breast cancer risk on a dose-dependent curve; for every 10 mg of soy isoflavones daily, there was a 16 percent reduction in breast cancer risk.

Soy and soy isoflavones may help improve cognitive function in postmenopausal women. This effect was seen only in women who increased their soy intake before age 65. There may be a “critical window” of therapeutic opportunity in early stages of post-menopause where soy has the greatest impact.
Soy is not the food with the greatest phytoestrogens, flaxseed is. In a randomized control trial, a daily flaxseed bar did no better at reducing vasomotor symptoms in postmenopausal women, such as hot flashes, than a fiber placebo bar. This took the study’s authors by surprise; preliminary studies had suggested the opposite.
Reinforcing these results, another trial failed to show any beneficial effect of soy isoflavones on menopausal symptoms or on preventing bone loss.

Lung Cancer Treatment and Prevention
Soy isoflavones help to boost the effect of radiation on cancer cells by blocking DNA repair in these cells. They also protect surrounding healthy cells with an antioxidant effect. Soybeans contain three powerful components, genistein, daidzein and glycitein, that provide this effect.
Pretreating lung cancer patients, may promote better outcomes.
The risk of lung cancer was also shown to be reduced 23 percent in one meta-analysis of 11 trials. In subset data, when analysis was restricted to the five highest quality studies, there was an even greater reduction: 30 percent.

Soy may have modest effects in reducing cholesterol levels. Interestingly, people who convert a soy enzyme to a substance called equol, an estrogen-like compound, during digestion were considered the only ones to benefit; however, one study showed that equol non-producers also benefited with a reduction in LDL “bad” cholesterol.
The equol producers maintained their HDL “good” cholesterol whereas the non-producers saw a decline.
What does all of this tell us? Soy is most likely beneficial for men and women alike, even in those with a risk of breast cancer. It does not mean we should eat a soy-based diet, but rather have soy in moderation – on a daily basis, perhaps. It is best to eat whole soy, not soy isolates.
Also, soy supplements are not the same as foods that contain soy, so it is best to consume soy in foods.

Examining the Annual Check-up

Over the past 18 months, many have had to – or elected to – forgo an annual physical exam. Does it matter? It’s a good question, one that’s not new to the pandemic era.
If an annual medical exam means lots of expensive diagnostic tests and invasive procedures, it may be time to put it to pasture. However, if it fosters a physician-patient relationship and allows for a partnership in prevention and treatment of diseases, then this alone may be a good reason to keep it.
So what are its pros and cons?

The cons
One of the downsides may be that it does not save lives. According to a Cochrane meta-analysis of 16 studies, an annual physical exam had no benefit related to mortality risk and morbidity (disease) risk.
The report went on to say that it did not have an effect on overall mortality, nor on cancer survival and/or cardiovascular mortality. The authors noted that primary care physicians may already be treating patients at high risk for diseases.
Another potential negative is that certain diagnostics, such as prostate-specific antigen screenings to test for prostate cancer, could be harmful.
The results of a meta-analysis presented at the European Cancer Conference show that routine screening for prostate cancer in the general, symptom-free male population may have more detrimental effects than benefits — a high PSA may lead to unnecessary invasive procedures, such as biopsies and prostatectomies (removal of the prostate).
Side effects could be impotence and infection and could result in hospitalization. The author acknowledged that there have been two large studies on PSAs, one touting the benefits and the other showing increased harm. This assessment may be the tiebreaker.

The pros
Not all diseases show symptoms, especially in the earlier stages. Examples include hypertension (high blood pressure) and chronic kidney disease. It is also an opportunity to discuss mental health. And, of course, there is the importance of lifestyle discussions.

Chronic Kidney Disease
Chronic kidney disease (CKD) causes more deaths than prostate or breast cancer. According to the Centers for Disease Control and Prevention, one in five patients with high blood pressure has chronic kidney disease, and most are undiagnosed.
Early to moderate stages of the disease without symptoms can only be identified through blood tests and urinalysis.
Detecting CKD early may be the key to halting its progress and preventing end-stage kidney disease resulting in dialysis. Without the annual exam, we may miss this opportunity.

Like CKD, there are frequently no symptoms to detect high blood pressure until it is too late. According to a study in the British Medical Journal, high blood pressure may be responsible for almost half of all heart attacks and a quarter of premature deaths in the U.S.
To reduce the risk of this “silent killer,” a study in the Annals of Internal Medicine suggests lifestyle modifications. In a meta-analysis, involving 54 small, randomized controlled trials, aerobic exercise had significant benefits in reducing blood pressure.

One of the most effective ways to know a patient is with a thorough discussion of history that identifies intangibles that may not show up in numbers, including mental health.
A presentation at the 26th European College of Neuropsychopharmacology Congress showed it is not what patients say, but how they say it that may be most important.
Short essays identified that those who were mildly depressed used significantly more verbs in the past tense than the present (100 versus 2.6 percent) and used less complex sentences, compared to the healthy control patients.
Ultimately, the success of an annual medical checkup is the physician’s approach. With a strong focus on a thorough history, rather than a predominance of diagnostic testing leading to invasive procedures, there is little downside.

Tackling Sjogren’s Syndrome

If you are a tennis fan, you’re probably aware that Venus Williams was diagnosed with Sjogren’s Syndrome in 2011. Her diagnosis came on the heels of typical quality of life symptoms of the disease, which include dry eyes, dry mouth, profound fatigue, and painful joints.
Sjogren’s is one of the more common autoimmune diseases in the U.S., and 90 percent of sufferers are women. With autoimmune diseases, the immune system attacks cells, tissues and organs of the body.

How is Sjogren’s diagnosed?
There are two types of Sjogren’s, primary and secondary. Venus Williams has primary Sjogren’s, the focus of this article. Secondary is caused by other autoimmune diseases.
Physicians diagnose primary Sjogren’s by its symptoms and blood tests that show two particular autoantibodies – anti-Ro/SS-A and anti-La/SS-B – in the blood. However, these autoantibodies are also found in Lupus and rheumatoid arthritis. In addition, clinicians perform eye and dental tests.
This is a diagnosis of exclusion, so it’s important to rule out Lupus and other autoimmune diseases before providing a Sjogren’s diagnosis.

Unfortunately, there are no known cures, so treatment involves management of symptoms as they occur. NSAIDs, such as ibuprofen and aspirin, can be used to manage inflammation. Corticosteroids can also be employed to manage disease flares, but should only be used for a short time, because of their significant side effects.
The two most common symptoms are dry eyes and dry mouth. These can be treated systemically (with oral medication), topically and/or with lifestyle adjustments. Humidity may help with dry eyes, and drinking plenty of water may help with dry mouth.
Dry eyes result from a deficiency in tear production. Therefore, this symptom can be treated with artificial tears or lubricants, in consultation with an ophthalmologist. If this doesn’t work, then punctual occlusions, an uncomplicated procedure that prevents the loss of tears, can be done by an ophthalmologist. Ocular (topical) 0.05 percent cyclosporine may be beneficial for moderate to severe dry eye.
Dry mouth needs to be treated to avoid increased cavities that occur without saliva. An effective treatment to increase salivary flow may be as simple as sucking on dried fruit, such as nectarines or peaches. A trial with 100 patients found that Maltose lozenges, which contain malic acid found in apples and pears, three times a day may increase salivary secretions. Participants experienced an improvement in both the dry mouth and dry eye symptoms. Eating these fruits directly might be beneficial as well.
An oral medication that has shown statistically significant result in trials is pilocarpine. This drug appears to stimulate the aqueous secretions that are beneficial for both dry mouth and eyes. The limiting factor for this drug is the side effects, which include sweating, abdominal pain, flushing and increased urination.
Immunosuppressive drugs, like hydroxychloroquine, address the underlying immune function issues. However, there are significant side effects of suppressing the immune system, including opportunistic infections.

Alternative treatments
Unfortunately, many supplements have shown mixed results. However, N-acetyl cysteine (NAC) in a very small randomized clinical trial showed improvement in eye symptoms with a dose of 200 mg three times a day. Another small randomized clinical trial showed that LongoVital, a combination of herbal-based tablets with vitamins, significantly increased saliva production and anti-inflammatory effects.
Vitamin D deficiency is seen commonly in Sjogren’s and other autoimmune diseases, so raising Vitamin D levels may have immunomodulatory effects, reducing inflammation.

Autoimmune diseases such as Sjogren’s tend to cluster and run in families. Diagnosis and treatment involve a multidisciplinary approach, including a primary care physician, rheumatologist and ophthalmologist.
The Sjogren’s Syndrome Foundation appears to be a valuable resource and support network for those who suffer from this disease.
This disease has robbed many of their quality of life. Don’t hesitate to seek treatment if you have similar symptoms.

Alternative to the little blue pills

Erectile dysfunction (ED) is a very common problem with a stigma. In fact, I have had several patients who resisted telling me they suffered from this malady. Because it can be a symptom of other diseases, it is crucial that you share this information with your doctor.
ED affects approximately 1 in 10 men on a chronic basis. If it occurs less than 20 percent of the time, it is normal; whereas if it occurs more than 50 percent of the time, there is a problem that requires therapy, according to the Cleveland Clinic.
There are oral medications for ED. Its prevalence has led pharmaceutical companies to saturate the airwaves. Approved medications include Viagra (sildenafil, or the “little blue pill”), Cialis (tadalafil) and Levitra (vardenafil).
These drugs work by affecting the endothelium, or inner layer, of blood vessels and causing vasodilation, or enlargement, which increases blood flow to the penis.
Unfortunately, this does not solve the medical problem, but it does provide a short-term fix.
ED’s prevalence increases with age. In a multinational MALES study, ED affected 8 percent of those aged 20 to 30 and 37 percent of 70 to 75 year olds. What was surprising was that advanced age had the least association with ED, increasing the odds by only 5 percent.
So, what contributes to the rest of the increase as we age? Disease processes and drug therapies.

Disease processes
Chronic diseases significantly contribute to ED – and ED may be a harbinger of disease. Typical contributors include metabolic syndrome, diabetes, high blood pressure, cardiovascular disease and obesity.
In the Look AHEAD trial, ED had a greater than two-fold association with hypertension and a three-fold association with metabolic syndrome. In another study, ED was associated with a 2.5-times increase in cardiovascular disease.
In a randomized clinical trial (RCT), patients with ED had significantly more calcification, or atherosclerosis, in the arteries when compared to a control group. They were more than three times as likely to have severe levels of calcification. They also had more inflammation, measured by C-reactive protein.

Medications contribute
About 25 percent of ED cases are thought to be associated with medications, such as antidepressants; NSAIDs, such as ibuprofen and naproxen sodium; and hypertension medications.
Unfortunately, the most common antidepressant medications, SSRIs, have the greatest impact on ED of all antidepressants.
The California Men’s Health Study, with over 80,000 participants, showed that there was an association between NSAIDs and ED, with a 38 percent increase in ED in patients who use NSAIDs on a regular basis.
The authors warn that patients should not stop taking NSAIDS without consulting their physicians.
Also, high blood pressure drugs have a reputation for causing ED. A meta-analysis of 42 studies showed that beta blockers have a small effect, but thiazide diuretics (water pills) more than doubled ED, compared to placebo.

Prevention & Treatment
The Mediterranean-type diet has been shown to treat and prevent ED, thus improving one’s health and sex life at the same time. It is the green leafy alternative to the little blue pill.
The foods are rich in omega-3 fatty acids and high in monounsaturated fats and polyunsaturated fats, as well as in fiber. Components include whole grains, fruits, vegetables, legumes, walnuts, and olive oil.
In two RCTs lasting two years, those who followed a Mediterranean-type diet saw improvements in their endothelial functioning. They also had reduced inflammation and decreased insulin resistance.
In another study, men who had the greatest compliance with the Mediterranean-type diet were significantly less likely to have ED, compared to those with the lowest compliance. Even more impressive was that the group with the highest compliance had a 37 percent reduction in severe ED versus the low compliance group.
Therefore, it is important to bring ED to the attention of physicians. There are very effective lifestyle alternatives to oral medication that provide positive overall health effects, while also helping patients eliminate medications that contribute to ED.

Epigenetics: environment & genes

There has been a pervasive thought in both biology and medicine that humans are limited by their genes. It’s true that traits like height and eye color are dictated by the genes you inherit. You can’t manipulate your eye color, for example, without contact lenses.
Diseases also have a genetic component. So, are we are locked in by our genes, as far as disease goes? Not necessarily. Most chronic diseases are influenced by a combination of genes and environment. This means that your family history of cancer or diabetes, for instance, does not necessarily mean that you are highly likely to get the disease.

Epigenetics is a burgeoning field with a potentially powerful impact on preventing and treating chronic diseases. Literally, it means “above the gene.” In other words, epigenetics regulates gene expression, or the turning on and off of genes, based on our behavior and environmental factors. This can have beneficial or detrimental effects.
It does this through transcription factors – proteins that bind to genes and determine whether they are expressed or suppressed. There are at least 2,000 transcription factors. Examples of some of the more researched transcription factors include NF-kB, increasing oxidation and inflammation; p53, a tumor suppressor; and NRF-2, an antioxidant response.
However, epigenetics does not alter the DNA sequencing of the gene itself. This differentiates it from gene therapy, which is a more complicated process that has thus far eluded medicine, with a few exceptions.

The biochemistry behind epigenetics
Environmental factors, such as diet, toxins, drugs and exercise affect which transcription factors are up-regulated or down-regulated and then, in turn, the genes that are turned on or off. For instance, vitamin D may have an effect on over 200 genes.
To date, cancer is the disease most extensively studied. Cells can be transformed into cancer cells due to down-regulation of tumor suppression genes and expression of oncogenes, pro-cancer genes. The opposite is also true. Epigenetics can cause tumors to either proliferate or be suppressed, depending on environmental influences.

Dietary factors
Diet plays a central role in determining whether cancer develops. There are bioactive compounds in foods that bind to the transcription factors.
Examples of dietary agents that can interfere with the development of tumors in cancer and activate tumor suppressor genes include spices, such as curcumin (turmeric); genistein, a polyphenol found in soybeans; tea polyphenols, highest in green tea; resveratrol, found in grapes, peanuts and blueberries; and sulforaphanes, found in cruciferous vegetables like broccoli. This is not an exhaustive list.
There was a study published in the Journal of Thoracic Oncology demonstrated the benefits of soy in the treatment of non-small cell lung cancer, the most common type. The soybeans increased the sensitivity of cancer cells to the radiation, allowing for their destruction.
Soybean isoflavones help to boost the effect of radiation on cancer cells by blocking the enzyme APE1/Ref-1, which inhibits DNA repair in these cells. They also protect surrounding healthy cells with an antioxidant effect.
The soy isoflavones also had an inhibitory effect on transcription factors NF-kB and HIF-1 alpha. These are examples of factors that induce oncogenes (pro-cancer cells) to be up-regulated, or turned on. Interestingly, in previous studies, soy pills with genistein were used to help destroy cancer cells, but the author suggests that soybeans themselves, with multiple bioactive compounds, are more effective.
Cancer prevention and treatment is but one of the effects of epigenetics. It has also been shown to have potentially beneficial effects in cardiovascular disease, diabetes and allergies. It may even have a direct role in longevity or an indirect role, by preventing chronic diseases such as cancer, obesity and diabetes.
Thus, our health outcomes are not predetermined, and the wonderful news is that we have much more control than we once thought.

Heart attack risks & calcium

Mothers have been telling us for decades to drink our milk to have strong bones. They are not necessarily wrong; calcium from diet is essential. However, what about calcium from supplements?
Many people, especially women after menopause, take calcium supplements as a preventive measure to reduce the chances of osteoporosis. Patients who have osteoporosis are instructed to take calcium to prevent fracture.
In a meta-analysis, 1200 mg of calcium plus 800 mg of vitamin D resulted in preservation of bone mineral density at the hip and spine. In fact, there was a 12 percent reduction in the risk of fracture in patients taking this combination.
The demographics included people over the age of 50. So, you can understand why patients would readily use calcium supplements.

Is it possible that calcium supplementation is dangerous?
A meta-analysis that looked at five randomized control trials in 2007, showed that calcium taken without vitamin D may increase the risk of a heart attack. Patients who had a heart attack had calcification (hardening) of the coronary arteries. The average dose of calcium supplementation was approximately 1000 mg.
In the treatment group, there was a 31 percent increase in incidence of heart attack, compared to the placebo group. The authors recommended at the time that most of your calcium come from diet.
I agree that it is important to take calcium and vitamin D together; vitamin D helps with the absorption of calcium. However, high levels of calcium may interfere with vitamin D’s functioning.
Still, a study published in the British Medical Journal in 2011 illustrated that calcium with vitamin D increased the risk of a heart attack by about 20 percent. The authors analyzed data from the Women’s Health Initiative, with over 20,000 participants.
The most damaging impact to calcium supplementation is the authors’ conclusion that for every 1000 people taking calcium for five years, regardless of vitamin D intake, there would be an increase of six heart attacks or strokes, but prevention of only three fractures.
This may mean that the risks outweigh the benefits with calcium supplementation. The study used 1000 mg of calcium and 400 IUs of vitamin D. The conclusion of the authors is that patients should get most of their calcium from diet.

What are the different types of calcium supplementation?
The two common types are calcium carbonate and calcium citrate. Calcium carbonate is less expensive, found in products like Tums, and it has a higher propensity to cause the most common type of kidney stone, calcium oxalate stones.
Calcium citrate is better absorbed. Therefore, I recommend to my patients, if they take calcium, it should be calcium citrate.

What is the optimal dose of calcium?
We see all varying doses of calcium on pharmacy shelves. The body absorbs <500 mg of calcium most effectively at one time, according to the Institute of Medicine. Therefore, it is best to target this amount. Also, the studies above showed an increase in heart attack with 1000 mg of calcium supplementation. Where should we get most of our calcium?
Even though it is not completely clear what to do about calcium supplementation, there is a recurrent theme of recommending dietary calcium. Interestingly, there was a study that showed that a diet rich in calcium, but not in vitamin D or dairy, lowered risk of death due to ischemic heart disease.
Foods that are naturally high in calcium include soybeans and vegetables, such as kale and bok choy. High levels of sodium and protein cause decreased levels of calcium.
There is definitely value in supplementing vitamin D in patients who are insufficient or deficient, but most people, including those with osteoporosis or osteopenia, may not have low levels of calcium. So, if patients have normal levels, there is no need for them to take calcium supplements.

Seven Factors for Preventing Heart Disease

What if I told you that you could practically eliminate your chances of getting heart disease? The risk of mortality from heart disease has decreased by 30 percent over the last few decades, which is impressive. However, before we start celebrating, it is still the number one cause of death in the U.S. – in 2019, heart disease was responsible for one in four deaths.

The Seven Factors
The good news is that several key studies examine ways to reduce heart disease risk factors. If we improve seven key modifiable risk factors, the chance of heart disease goes down to about one percent.
These seven factors are smoking, body mass index, physical activity, diet, total cholesterol without medication, blood pressure without medication and fasting blood glucose without medication.
What did the researchers find?
In one study, researchers found that we are doing best with smoking cessation. The prevalence of nonsmoking ranged from 60-90 percent, depending on demographics. On the other hand, Healthy Diet Scores were not very good; from 0.2 to 2.6 percent of participants achieved ideal levels. Obviously, diet is an area that needs attention. This observational study involved 14,515 participants who were at least 20 years old.
How many participants actually reached all seven goals? About one percent. This means we have the ability to alter our history of heart disease dramatically. There is also a direct relationship between the effort you apply to attain these goals and your outcome of reduced risk.
In another study, those who had an optimal risk factor profile at age 55 were significantly less likely to die from cardiovascular disease than those who had two or more risk factors. These differences were maintained through at least age 80.
The lifetime risk of fatal heart disease or a nonfatal heart attack in the optimal group was less than one percent for women and 3.6 percent for men. In terms of sex differences, men were ten times less likely and women were eighteen times less likely to die from heart disease if they were in the optimal risk stratification group.
This was a meta-analysis of 18 observational studies with more than 250,000 participants.

Dietary Approaches
Several diets have shown dramatic results in preventing and treating heart disease, such as the Ornish, DASH (Dietary Approaches to Stop Hypertension), Mediterranean-type, and Esselstyn diets.
These diets all have one thing in common: they rely on nutrient-dense, plant-based foods. Both the Ornish and Esselstyn diets showed reversal of atherosclerosis in studies and, as we know, atherosclerosis (plaques in the arteries) is the foundation for heart disease.

Exercise’s Effects
For the most beneficial effects on preventing heart disease, both the ACSM (American College of Sports Medicine) and the US Department of Health and Human Services recommend that most Americans get at least 30 minutes of moderate aerobic exercise five times a week, for a total of 150 minutes, or 75 minutes of vigorous aerobic exercise per week.
Moderate aerobic exercise includes brisk walking, as demonstrated in the Women’s Health Initiative, a large observational study. This study showed a 28 to 53 percent reduction in heart disease risk in women ages 50 to 79.
Resistance training is also very important. The Health Professionals’ Follow-up Study showed at least 30 minutes a week resulted in a 23 percent heart disease risk reduction, and running for only 60 minutes resulted in a 42 percent risk reduction.
Interestingly, although medications may be important for people who have high levels of blood pressure, cholesterol and glucose, they do not get you to the lowest risk stratification. Lifestyle modification is the only way to approach ideal cardiovascular health.
Thus, if we worked on these factors to achieve the appropriate levels, this disease would no longer be at the top of the list for mortality.

Is a calorie just a calorie?

Summer weather has arrived, and many are considering the best way to lose their “pandemic weight gain.” In terms of weight loss, a calorie may be a calorie. However, in terms of its effect on body composition, disease modification and prevention, this may not be true.

A low-carb, high-protein and high-fat diet
A study published in the Journal of the American Medical Association (JAMA) showed that a low-carbohydrate, high-protein diet was more effective at burning calories after initial weight loss than other diets.
Twenty-one young, obese and overweight adults were given a 12-week period to lose 10 to 15 percent of their body weight. They were then put on three different diets and assessed over a four-week period with each: a low glycemic index diet, a low-fat diet and a very low-carbohydrate diet.
The diet that seemed to show the most benefit for maintaining weight loss was the very low-carbohydrate diet, which was high in protein and high in fat – an Atkins-type diet.
This diet lowered the resting energy expenditure the least, meaning that the body burned calories more efficiently. Patients expended 300 more calories on this low-carbohydrate diet than on the low-fat diet and 150 more calories than on the low glycemic index diet.
Why did the low-carbohydrate diet show the best results for maintain weight loss and burning more calories? Jules Hirsch, M.D., former emeritus physician in chief at Rockefeller University, responded in the New York Times when the study was published.
His background included 60 years of obesity research, and he believed that the difference seen with the Atkins-type diet was due to water loss. He wrote that, while weight loss is dependent on the traditional formula – the number of calories consumed minus the number of calories burned on a daily basis – diets’ compositions do affect patients’ overall health.

Low-carb, high-protein diet negative effects
Interestingly, another study published in the British Medical Journal the same week as the JAMA study showed a potentially increased risk of cardiovascular disease with a low-carbohydrate, high-protein diet. This was a prospective trial involving 43,396 Swedish women with a 15.7-year duration.
There was a four percent increase in risk for every 10 percent increase in protein or, as the authors point out, for every additional boiled egg consumed. This is a modest, yet harmful, effect.
Low-carb, high-protein diets have also shown an increased risk of kidney stones. There was a doubling of uric acid levels and a significant increase in calcium levels in the kidney over a six-week period. The study was small, 10 participants, and short in duration.
However, it does make you think that low-carb, high-protein diets from animal sources may not be the best option for overall health.

Does protein source matter?
Interestingly, another study showed that a low-carb, high-protein diet may vary in its effects, depending on the protein source. If high protein levels and fat came from animal sources, then there was an increased risk of death from heart disease and cancer, 14 and 28 percent respectively.
However, if the protein and fat came from plant sources, such as nuts and beans, the risks of all-cause mortality and mortality from cardiovascular disease were decreased by 20 and 23 percent, respectively. The study was a meta-analysis of the Nurses’ Health Study, with over 85,000 women, and the Physician’s Health Study, with approximately 45,000 men, both long-term studies.
No one will argue that weight loss is important, especially for those patients who are obese. However, when choosing a diet, it is important to consider also its effectiveness for disease treatment and prevention.
Diets that are considered to be most effective are those that are plant-based and nutrient-rich. Why lose weight for vanity, when you can lose weight and gain health at the same time?

Alcohol: Risks and benefits

Alcohol is one of the most widely used over-the-counter drugs, and there is much confusion over whether it is beneficial or detrimental to your health. The short answer: it depends on your circumstances, including your family history and consideration of diseases you are at high risk of developing.
Several studies have been published – some touting alcohol’s health benefits, with others warning of its risks. The diseases addressed by these studies include breast cancer, heart disease and stroke.

Breast Cancer Impact
In a meta-analysis of 113 studies, there was an increased risk of breast cancer with daily consumption of alcohol. The increase was a modest, but statistically significant, four percent, and the effect was seen at less than one drink a day. The authors warned that women who are at high risk of breast cancer should not drink alcohol or should drink it only occasionally.
It was also shown in the Nurses’ Health Study that drinking three to six glasses a week increases the risk of breast cancer modestly over a 28-year period. This study involved over 100,000 women. Even a half-glass of alcohol was associated with a 15 percent elevated risk of invasive breast cancer.
The risk was dose-dependent, with one to two drinks per day increasing risk to 22 percent, while those having three or more drinks per day had a 51 percent increased risk.
If you are going to drink, a drink several times a week may have the least impact on breast cancer. According to an accompanying editorial, alcohol may work by increasing the levels of sex hormones, including estrogen, and we don’t know if stopping diminishes the effect, although it probably does.

Stroke Effects
On the positive side, the Nurses’ Health Study demonstrated a decrease in the risk of both ischemic (caused by clots) and hemorrhagic (caused by bleeding) strokes with low to moderate amounts of alcohol. This analysis involved over 83,000 women.
Those who drank less than a half-glass of alcohol daily were 17 percent less likely than nondrinkers to experience a stroke. Those who consumed one-half to one-and-a-half glasses a day had a 23 percent decreased risk of stroke, compared to nondrinkers.
However, women who consumed more experienced a decline in benefit, and drinking three or more glasses daily resulted in a non-significant increased risk of stroke. The reasons for alcohol’s benefits in stroke have been postulated to involve an anti-platelet effect (preventing clots) and increasing HDL (“good”) cholesterol. Patients shouldn’t drink alcohol solely to get stroke protection benefits.

Heart effects
In the Health Professionals follow-up study, there was a substantial decrease in the risk of death after a heart attack from any cause, including heart disease, in men who drank moderate amounts of alcohol compared to those who drank more or were non-drinkers.
Those who drank less than one glass daily experienced a 22 percent risk reduction, while those who drank one-to-two glasses saw a 34 percent risk reduction. The authors mention that binge drinking negates any benefits.

Alcohol in Moderation
Moderation is the key. It is very important to remember that alcohol is a drug that does have side effects. The American Heart Association recommends that women drink up to one glass a day of alcohol. I would say that less is more.
To get the stroke benefits and avoid the increased breast cancer risk, half a glass of alcohol per day may be the ideal amount for women. Moderate amounts of alcohol for men are up to two glasses daily, though one glass showed significant benefits.
Remember, there are other ways of reducing your risk of these maladies that don’t require alcohol. However, if you enjoy alcohol, moderate amounts may reap some health benefits.

Treatment Choices for Reflux Disease

Gastroesophageal reflux disease is one of the most commonly treated diseases. It is sometimes referred to as heartburn, although this is more of a symptom. In line with this, proton pump inhibitors (PPIs) have become one of the top-10 drug classes prescribed or taken in the United States.
The class of drugs called PPIs includes Prevacid (lansoprazole), Prilosec (omeprazole), Nexium (esomeprazole), Protonix (pantoprazole) and Aciphex (rabeprazole). Several of these medications are now available over-the-counter (OTC), rather than by prescription.
When they were first approved, they were touted as having one of the cleanest side-effect profiles. This may still be true, if we use them correctly. They are intended to be used only for the short term. This can range from 7 to 14 days for over-the-counter PPIs to 4 to 8 weeks for prescription PPIs.

Long-term use dangers
While PPI pre-approval trials were short-term, not longer than a year, many physicians put patients on these medications for decades. And the longer people are on them, the more complications arise. Among potential associations with long-term use are chronic kidney disease, dementia, bone fractures and Clostridium difficile, a bacterial infection of the gastrointestinal tract.

Chronic kidney disease
In two separate studies, results showed that there was an increase in chronic kidney disease with prolonged PPI use. All of the patients started the study with normal kidney function.
In the Atherosclerosis Risk in Communities (ARIC) study, there was a 50 percent increased risk of chronic kidney disease, while the Geisinger Health System cohort study found there was a 17 percent increased risk.
The first study had a 13-year duration, and the second had about a six-year duration. Both demonstrated modest, but statistically significant, increased risk of chronic kidney disease.
As you can see, the medications were used on a chronic basis for years. In an accompanying editorial to these published studies, the author suggests starting with diet and lifestyle modifications as well as a milder drug class, H2 blockers.

Bone fractures
In a meta-analysis of 18 observational studies, results showed that PPIs can increase the risk of hip fractures, spine fractures and any-site fractures. It did not make a difference whether patients were taking PPIs for more or less than a year.
They found increased fracture risks of 58, 26 and 33 percent for spine, hip and any site, respectively. It is not clear what may potentially increase the risk; however, it has been proposed that it may have to do with calcium absorption.
PPIs reduce acid, which may be needed to absorb insoluble calcium salts. In another study, seven days of PPIs were shown to lower the absorption of calcium carbonate supplements when taken without food.

Magnesium absorption
PPIs may have lower absorption effects on several electrolytes including magnesium, calcium and B12. In one observational study, PPIs combined with diuretics caused a 73 percent increased risk of hospitalization due to low magnesium.
A significant reduction in magnesium could lead to cardiovascular events. Diuretics are commonly prescribed for high blood pressure, heart failure and swelling.
The bottom line is that it’s best if you confer with your doctor before starting PPIs. You may not need PPIs, but rather a milder medication, such as H2 blockers (Zantac, Pepcid).
Even better, start with lifestyle modifications including diet, not eating later at night, raising the head of the bed, losing weight and stopping smoking, if needed, and then consider medications.
If you do need medications, know that PPIs don’t give immediate relief and should only be taken for a short duration: 7 to 14 days, according to the FDA, without a doctor’s consult, and 4 to 8 weeks with one.

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