Is Fish Healthy? Yes, But Don't Ask Dr. Neal Barnard For An Unbiased Answer

On Friday March 8, 2013, Dr. Neal Barnard, a physician, author and president of PCRM, an organization dedicated to perpetuating veganism among other things, appeared on the Dr. Oz show to promote his new book about preventing Alzheimer's. During the episode, he made a statement that no one should eat fish if they wanted to avoid Alzheimer's. Even Dr. Oz was surprised by Dr. Barnard's complete repudiation of fish in human diets. 

Personally, I was shocked. How could anyone make such a statement, given the preponderance of evidence supporting the health benefits of certain fish, let alone a medical professional?  So I contacted Dr. Barnard to seek further clarification of his controversial position.  He was kind enough to respond and I offer below his full response so that you can reach your own conclusions.

My initial query:

"I am writing for clarification regarding a statement that Dr. Barnard made on the Dr. Oz show this past Friday March 8, 2013. During the show, Dr. Barnard stated emphatically that in order to prevent Alzheimer’s, one should completely avoid fish consumption of any kind. I am hoping you could provide me with any citations of peer-reviewed studies that support his conclusion as my own review of the literature does not support such a statement, particularly in regards to wild Alaskan salmon and other such fish rich in omega-3s and low in saturated fat."

His response:
"Dear Dr. Charlap:

Thank you for being in touch about fish. The question is a good one and one that I’m sure many patients will raise, too. Let me share my perspective. It’s certainly true that, compared with beef fat or chicken fat, fish oils have less saturated fat and more omega-3 fatty acids. In some studies, people who favored vegetable oils and/or fish have had a reduced risk of dementia, compared with people who focused on meatier fare. So that is all to the good. However, as a group, people who eat fish have more weight problems and have a higher risk of diabetes, compared with people who skip animal products altogether. In this regard, let me attach diagrams from two large epidemiologic studies, one in the US and the other in Europe. As you’ll see, the greatest benefit comes from plant-based diets, rather than meat-based or fish-based diets. [Added by me: The studies showed very minimal differences between the vegans and those who ate the unspecified fish.] As you know, excess body weight and diabetes can both increase Alzheimer’s risk. So, for people following a healthful plant-based diet, fish is really a step in the wrong direction. [Added by me: None of the science he produced made this connection. This is just his own hypothesis.  The facts are that studies show, as he even quotes above, that fish consumption decreases cognitive decline, which is obviously the opposite of dementia.]

Here are the numbers: Atlantic salmon is about 40 percent fat, as a percentage of calories. Chinook salmon is around 50 percent. Most of that is not “good” fat. That is, only about 15 to 30 percent of the fat in fish is omega-3, depending on the species. The other 70 to 85 percent is a mixture of saturated and various unsaturated fats. Since every fat gram holds nine calories, fatty fish can easily add to your waistline. You may wish to informally survey your patients about their fish consumption and their weight. You’ll often find that fatty fish set them back.

Of course, fish consumption in general has been controversial for other reasons. Mobile shellfish (eg. lobster, crab, shrimp) are very high in cholesterol—higher than beef, ounce for ounce—and also contribute contaminants, including neurotoxic metals. [My note: For an excellent review of the risks versus benefits of consuming fish with contaminants (see article titled: Fish Intake, Contaminants and Human Health, Evaluating the risks and benefits at http://www.myprorenal.com/images/media/Primarypreventionfishoil.pdf). The conclusion of this paper was, and I quote directly from the study, "Potential risks of fish intake must be considered in the context of potential benefits. Based on strength of evidence and potential magnitudes of effect, the benefits of modest fish consumption (1-2 servings/wk) outweigh the risks among adults..."] I think you could argue that salmon is somewhat better than some other fish species on both fronts, but even so, it does contribute cholesterol and animal fat, along with a varying load of contaminants, none of which is necessary.

So, the bottom line is that a person following a healthy plant-based diet—which has proven so helpful for heart disease and diabetes, and now appears to also apply to Alzheimer’s prevention—would not be expected to derive any additional benefit by adding fish.  Not surprisingly, in the Blue Zones—areas where people live the longest—fish is not a large part of the diet. That applies to Okinawa and Sardinia, just like the other regions. The diet staples come from plant sources. 

Let me make one other observation. You’ll discover that some patients—and even some doctors—become quite emotional about food prescriptions and get bent out of shape if one questions the value of nuts, fish, olive oil, red wine, or some other product. It pays to step back and recognize that we all have the health of our patients in mind. Just as doctors seek second opinions and don’t expect complete concordance in every conclusion, the same is true in nutrition. So it’s good to take a deep breath, keep our lines of communication open, and see where emerging evidence leads us.

I hope this is helpful information. I wish you the very best in your work. 
Neal D. Barnard, MD"

My response:


Hi Dr. Barnard,

Thank you for your prompt response. I have had the pleasure to hear you speak at the American College of Preventive Medicine conference in 2012 and found your talk to be informative. My understanding is that you fully advocate on behalf of a vegan diet and so I can appreciate your position about fish in general. However, I was very concerned to hear you on the Dr. Oz show create a negative link between fish and Alzheimer’s disease. Since you did not differentiate between types of seafood, this was particularly alarming as my knowledge suggests that fish like wild Alaskan salmon may offer specific benefits in preventing or delaying the onset of dementia, including Alzheimer’s. See some of the studies listed at end of this email.

Accordingly, as I am always eager to increase my knowledge and that of my readers/patients, I sought you out for clarification. 

Therefore, please indulge me as I pull out certain quotes from your response for further clarification and comment.

You wrote, “However, as a group, people who eat fish have more weight problems and have a higher risk of diabetes, compared with people who skip animal products altogether.”

In response, I ask if you have any credible studies that support that those who eat wild fish like Alaskan salmon, halibut, lake trout, etc. have more weight problems and a higher risk of diabetes?  I reviewed the two studies you cited and they do not differentiate between types of seafood. As you know, farm raised salmon is a far less nutritional fish than wild salmon as it includes more saturated fat, less omega-3s, less Vitamin D, etc.  Therefore, if you have any specific fish studies that look at particular types of fish in comparison to non-fish eaters, I would appreciate it if you could forward them to me.  I contend that in the absence of such studies, it is a rush to judgment to state that consuming fish leads to Alzheimer’s when studies, as even you cited to me in your response, show an explicit decrease in cognitive loss due to fish consumption.

Furthermore, you wrote, “Here are the numbers: Atlantic salmon is about 40 percent fat, as a percentage of calories. Chinook salmon is around 50 percent. Most of that is not “good” fat. That is, only about 15 to 30 percent of the fat in fish is omega-3, depending on the species. The other 70 to 85 percent is a mixture of saturated and various unsaturated fats.”

As discussed above, it is important to differentiate between wild and farm raised salmon as farm-raised Atlantic salmon has far more than double the saturated fat of wild Atlantic salmon and nearly four times the saturated and total fat of wild Alaskan pink salmon. In addition fat in the pink variety represents far less than the 40% of the total calories of fish that you cite.

You wrote, ”Of course, fish consumption in general has been controversial for other reasons. Mobile shellfish (eg. lobster, crab, shrimp) are very high in cholesterol—higher than beef, ounce for ounce—and also contribute contaminants, including neurotoxic metals. I think you could argue that salmon is somewhat better than some other fish species on both fronts, but even so, it does contribute cholesterol and animal fat, along with a varying load of contaminants, none of which is necessary.”

Let me start with the point you make that “none of it is necessary.”  This is not an accurate statement, as omega-3s are not the only valuable fat in wild salmon. For example, nervonic acid, one of the monounsaturated fats in salmon, plays a valuable role in the biosynthesis of myelin, a key component as you know, of our nervous system.  Again, while certain predatory fish like tuna, and many of the crustaceans tend to absorb the ocean’s pollutants, wild salmon from Alaska and certain lake trout which are non-predatory fish tend to contain few contaminants.  Besides, as you are well aware, many plants are victims of pesticides and other pollutants equal in their potential devastation to human health as anything found in the ocean, and yet you didn’t declare on national television that people equally avoid them like you said about all fish. 

You also wrote, “So, the bottom line is that a person following a healthy plant-based diet—which has proven so helpful for heart disease and diabetes, and now appears to also apply to Alzheimer’s prevention—would not be expected to derive any additional benefit by adding fish.  Not surprisingly, in the Blue Zones—areas where people live the longest—fish is not a large part of the diet. That applies to Okinawa and Sardinia, just like the other regions. The diet staples come from plant sources.”

Again, I am not sure of the source of your information, but in Okinawa fish is a large part of the diet although the diet contains many plant based foods, By the way, not only do the Sardinians eat fish, but they also eat meat and drink goat’s milk all while tracing their men’s extraordinary longevity back to the Bronze Age.

In conclusion, I feel that you do not offer a compelling case due to the lack of scientific support against fish like wild Alaskan salmon as part of one’s diet. If you have further studies that you think would be relevant, I ask that you forward them to me as soon as possible. As a courtesy, I will not publish until Sunday to give you ample time to response.

As for my patients, I advocate eating such fish as wild salmon every other day and have witnessed reversal of hemoglobin A1cs from mid 7s to below 6, cholesterols from 300s to low 100s, and 50+ pound weight loss.  My personal transition to such a diet enabled me to drop 25 pounds to below a 25 BMI and keep it off, while also weaning myself off of statins. Therefore, as you wrote, I agree that “it’s good to see where emerging evidence leads us.” However, I hope you agree that it’s not prudent to suggest to people that emerging evidence supports a conclusion unfounded by the facts, some of which are cited below.
“Emerging evidence” to consider about the benefits of fish:

1.     J Nutr Health Aging. 2011 Aug;15(7):551-4552.

Consumption of fish and Alzheimer's disease.
Newton W, McManus A.
Source
Centre of Excellence Science Seafood and Health, Curtin Health Innovation Research Institute, Curtin University.
http://www.ncbi.nlm.nih.gov/pubmed/21808933

2.     Nihon Rinsho. 2011 May;69(5):953-63.

[Dementia and lifestyle-related diseases in Japanese aging society].
[Article in Japanese]
Iwamoto T.
Source
Toshihiko Iwamoto: Department of Geriatric Medicine, Tokyo Medical University.
http://www.ncbi.nlm.nih.gov/pubmed/21595287

3.     J Nutr Health Aging. 2011 Jan;15(1):25-31.

High dietary and plasma levels of the omega-3 fatty acid docosahexaenoic acid are associated with decreased dementia risk: the Rancho Bernardo study.
Lopez LB, Kritz-Silverstein D, Barrett Connor E.
Source
Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, California 92093, USA.
http://www.ncbi.nlm.nih.gov/pubmed/21267518

4.     Arch Neurol. 2010 Jun;67(6):699-706. doi: 10.1001/archneurol.2010.84. Epub 2010 Apr 12.

Food combination and Alzheimer disease risk: a protective diet.
Gu Y, Nieves JW, Stern Y, Luchsinger JA, Scarmeas N.
Source
The Taub Institute for Research in Alzheimer's Disease and the Aging Brain, Columbia University, New York, NY, USA.
http://www.ncbi.nlm.nih.gov/pubmed/20385883

I can produce many more studies if you are interested.  The bottom line is that certain fish, like those rich in omega-3s and low in other saturated fats, play a critical role in health promotion, including Alzheimer’s prevention, and to suggest otherwise, is to ignore the “emerging facts.”
I mean no disrespect in my response and I trust you will accept it in the spirit intended, which is for all of us to identify the best dietary answers for ourselves, our families, our patients, and the community at large.
I look forward to your response.

To your health,

Steve
  
His response:

"Hi, Steven,

You have the same access that I do to published studies. See what you find. If you can find a study that shows that people who habitually add fish to the diet are as slim and healthy as vegans, I’d love to see it. The epi studies mostly characterize fish-eaters as a group, and they don’t do as well.

All the best,

Neal 

My final response:


"Hi Neal,

Please find seven studies below that clearly show major health benefits associated with fish consumption.

As you know, there are no head to head studies between vegans and vegans who eat fish. While we can agree to disagree on which is better, I ask you to use caution in the future in telling people that all fish is bad for them because I hope you agree, there are clear benefits in consuming certain non-predatory, wild fish rich in omega-3s, antioxidants such as astathanxin (although no conclusive studies), Vitamin D, Vitamin B12, lean protein, etc. Consuming such fish eliminates the need to supplement with Vitamin B12.  I trust you agree that it is always best to get vitamins from nature than from a pill produced in a factory

1. Kromhout D, Bosschieter EB, de Lezenne Coulander
C. The inverse relation between fish consumption and
20-year mortality from coronary heart disease.
N Engl J Med. 1985;312:1205-1209.

2. Burr ML, Fehily AM, Gilbert JF, et al. Effects of
changes in fat, fish, and fibre intakes on death and
myocardial reinfarction: diet and reinfarction trial
(DART).
Lancet. 1989;2:757-761.

3. Daviglus ML, Stamler J, Orencia AJ, et al. Fish con-
sumption and the 30-year risk of fatal myocardial
infarction.
N Engl J Med. 1997;336:1046-1053.

5.Albert CM, Hennekens CH, O’Donnell CJ, et al. Fish
consumption and risk of sudden cardiac death.
JAMA.1998;279:23-28

6. Morris MC, Evans DA, Tangney CC, Bienias JL,
Wilson RS. Fish consumption and cognitive decline with
age in a large community study.
Arch Neurol. 2005;62:1849-1853.

7. He K, Song Y, Daviglus ML, et al. Fish consump-
tion and incidence of stroke: a meta-analysis of co-
hort studies.
Stroke. 2004;35:1538-1542.

In conclusion:

Now you have a well reasoned perspective of pure veganism versus a vegan diet combined with certain fish. Personally, until proven otherwise, I continue to advocate for the inclusion of wild fish like salmon in one's diet on a regular basis (every couple of days) for optimal health. You now have the available facts and both sides of the debate; you be the judge.

The Main Reason You Can't Lose Weight is EXACTLY What You Think!

Most businesses hope for repeat customers; weight loss businesses bank on it. Following New Year's, every single year, thousands of resolutions to lose weight are made and broken. If you have dieted once, chances are you have done it many times. You've tried the programs, read the books, watched the shows, took the pills, had the injections, and maybe even spoke to your doctor about your desire to lose weight.

Perhaps, you've even enjoyed some success, only to find yourself slipping again. But despite your best efforts, every time you look in the mirror or get out of a chair, you know you are carrying around more weight than is good for you. You are probably ready to throw your hands up in disgust and give up. Or maybe you will keep watching Dr. Oz hoping that one of his far flung schemes or pill of the day may actually work for you. Don't! The problem of losing weight and keeping it off is clearly a challenging one and difficult predicaments need good solutions. So what's a person to do?

From the inception of MDPrevent, I have believed that psycho-social issues are at the forefront of most people's inability to lose weight and keep it off. Some eat too much or choose the wrong foods because of stress, poor sleep, anxiety, depression, comfort, loneliness, etc. There are many reasons, and sometimes they even combine. Either way, if you don't deal with them, they keep plaguing you.

That's why one of the first professionals I added to my team was a health psychologist. Patients who want to lose weight once and for all find seeing a psychologist trained in such matters to be a godsend. Why? The answer comes from the psychologists themselves.

A new survey of psychologists confirms that dieters should pay attention to the role emotions play in weight gain and loss if they hope to succeed.

According to the American Psychological Association, the survey, conducted by the Consumer Reports National Research Center, queried over 1,300 licensed psychologists about how they dealt with clients’ weight and the challenges of losing weight. The strategies psychologists cited as essential to losing weight and keeping it off, was "understanding and managing the behaviors and emotions related to weight management." The doctors believed this was essential to forty-four percent (44%) of their clients who wanted weight loss. "Survey respondents also cited “emotional eating” (43 percent) as a barrier to weight loss, and included "maintaining a regular exercise schedule" (43 percent) and "making proper food choices in general" (28 percent) as keys to shedding pounds.

In general, gaining self-control over behaviors and emotions related to eating were both key, indicating that the two go together."

Among the 306 respondents who provide weight loss treatment, 92% reported helping a client “address underlying emotional issues related to weight gain.” More than 70 percent identified cognitive therapy, problem-solving and mindfulness as "excellent" or "good" weight loss strategies. In addition, motivational strategies, keeping behavioral records and goal-setting were also important in helping clients to lose weight and keep it off, according to survey results. Cognitive therapy, one of the clinical approaches often used by psychologists, helps people identify and address negative thoughts and emotions that can lead to unhealthy behaviors. "Mindfulness allows thoughts and emotions to come and go without judging them, and instead concentrate on being aware of the moment."

The full survey results are reported in the February 2013 issue of Consumer Reports Magazine.^®

Now clearly, psychologists telling the surveyors that their efforts to ensure their clients keep losing weight is somewhat self-serving, and I would be a ‘doubting Thomas’ myself if I didn't see the difference a psychologist can make. By the way, it’s not just the psychologists with whom I work that make a difference.  I recently sat with a friend from out of state who has enjoyed over a one-hundred pound weight loss. When we sat down to discuss his formula, the secret sauce is that he has been working with a psychologist.  My only concern in listening to him was that some of the foods he was eating to lose weight are not the healthiest.  Also, he would have been better off to consult with a nutritionist or registered dietitian to make sure that he was both losing weight and eating health promoting foods. Not all weight loss is healthy and ultimately what's the point of losing weight only to get sick?

Therefore, I recommend that if you can afford to see both a registered dietitian and a psychologist to lose weight, there is no better combination. If you have Medicare, nutritional consultations for weight loss are 100% covered under a program called Intensive Behavioral Therapy for Obesity if your body mass index (BMI) is above 30.

Last year, MDPrevent was the largest provider of such services in the State of Florida. If you can get to our office in Delray Beach, I welcome you do so (561-807-2561).  If not, consult with your local primary care physician or cardiologist to identify who is offering this service near your home.  Even if you don’t have Medicare, you can still give us a call so we can let you know what your insurance company will cover.

It turns out that the key to losing weight may really be in your head and we can help you use that knowledge to unlock a healthier, higher energy, and more enjoyable life.     

So stop wasting your time and money on programs whose results usually don't last and address once and for all the real problem: your emotional health.

What Was Once Black Is Now Bright

Fifty years ago, a TV show that ran from 1958 to 1963 came to an end. Some of you may remember its iconic closing narration: "There are eight million stories in the Naked City. This has been one of them." Every week, Naked City, a police crime drama, focused on unique stories about criminals and their victims. To me, barely past the toddler stage, the show demonstrated how even though there are so many different people, each has his or her own story. 

"You are the best psychologist I ever met with" said my patient to me yesterday. "You are the first one to tell me not to focus on what has gone wrong, but rather to recognize the good that it represents." Although I am not a psychologist, I know one thing for sure. Harboring negative thoughts and being stuck in the past, even the recent past, serves no purpose.  

The patient, a lady in her late 80s, conveyed in all sincerity that she felt like she had recently been tested by G-d just as he had tested Job in the Bible. Her tale included a string of failed refrigerators that had forsaken her--at least that's the way she saw it. There is little doubt that a refrigerator is a vital appliance in Florida. This lady's refrigerator broke, then the replacement broke, then the next replacement also broke, and finally the last one worked. It took great effort to resolve the problem. She had to make multiple calls to the store that sold her the refrigerators, to the manufacturer's of the refrigerators, and she had to live without refrigerated food for an extended period of time before the problem was resolved. She truly felt like she had been through an ordeal equal to a biblical epic.

I am sure she expected me to empathize with what she had endured. But I didn't. Instead I marveled at it.  "Do you realize," I asked her "how amazing it is that at your age you were able to handle this entire situation on your own without the help of others?" It was a testament to the fact that older people, particularly those that hope to live to their 90s and beyond, can handle difficult situations with wisdom and aplomb duly earned over many years. I applauded the patient's efforts and reminded her that seventy-five percent of people over the age of 90 live independently and she had earned her stripes and showed her mettle to count herself among them. Suddenly, instead of thinking woe unto me, she was beaming at her masterful response to her latest life challenge.

In classical psychology, patients and their doctors often focus on what is wrong. In 'positive psychology,' the up and coming field which some call "the science of happiness,' the emphasis shifts to what works. Having read my share of 'positive psychology' books, I applied one of its simple lessons to my 'oy vey' patient.  Together, we shifted her paradigm from the perspective of a personal travail to one of a sense of accomplishment. What was once black was now bright. 

I wish it was so easy to help all my patients. But to paraphrase the Naked City, "there are many stories and this has been one of them."  I hope in reading this anecdote, you recognize its fundamental lesson: perspective means everything. What's your perspective on life? Come see me and let's explore it together.

(561) 807-2561.

How Much Exercise Does One Need?

Everyone agrees that physical activity is a key part of a healthy lifestyle. Yet, there is no absolute consensus as to what is the best form of such activity and how much activity provides the most benefit. For example, does one need to set aside specific time for exercise each day or does a physically active lifestyle such as gardening or playing golf suffice? Before, I share a new study that may shed some light on this question, let's just review some basic information.

There are four types of exercise: endurance, strength, balance and flexibility. By endurance, we mean what is commonly referred to as cardio or aerobic. By strength, we often refer to anaerobic or weight bearing. All four forms of exercise confer specific benefits for healthy living. But how much do we really need and what are the benefits?  Is 60 minutes better than 30 minutes and 90 minutes better than 60? Is it better to do more intensive exercise for a shorter period of time or less intensive for a longer duration? Is endurance better or more important than strength? The answers depend on what your goal is. If your goal is longevity than the answer may be different than if your goal is to have more pronounced muscles.

For many years, doctors have been more comfortable prescribing medication than an exercise routine. That may be about to change. A new study from the Harvard School of Public Health now offers doctors specific exercise prescriptions. In the study led by I Min Lee, a professor of medicine at Harvard Medical School, researchers analyzed data of more than 650,000 people older than 40 who were followed for an average of ten years.

Here's what they found:
1. Subjects that completed the equivalent of 75 minutes of brisk walking each week--roughly 11 minutes per day--lived 1.8 years longer than those who did not exercise at all.
2. Subjects that completed the equivalent of 150 minutes (as federally recommended) of brisk walking each    week--roughly 22 minutes every day or 30 minutes five days a week day--lived 3-4 years longer.
3. The benefits plateaued at about 43 minutes of brisk walking a day.

The noted gains applied to people at all weight levels, including the obese. This means that even if weight was not lost, the benefits of exercise were still realized.

The researchers focused on brisk walking because it is the most commonly reported exercise, but any moderate intensity exercise, from riding a bike, doing gardening and yard work, running around with the kids, would be just as good. The only requirement is that you get your heart rate beating to a level where speaking is still comfortable, but singing becomes difficult (that means hard for you to sing, not for people to hear you sing.)

The researchers also concluded that those who engage in more vigorous exercise, say running or playing basketball, enjoyed the same gains but in half the time. In other words, the benefits of vigorous exercise plateaued at 21.5 minutes per day for the more intense exercisers. In fact, a previous study showed that women who exercise 60 consecutive minutes a day actually burned fewer calories over the entirety of the day than those who only exercise for 30 minutes. Combining the two studies, we can extrapolate that too much exercise may be counterproductive. That said, moving around all day, as opposed to sitting for large parts of it, is known to confer many benefits.  From my perspective, I advise patients in general to do five minutes of moderate activity for about eight or nine hours during the day. I believe, although it has not yet been proven scientifically, that this will confer the most benefit.  As always, follow the advice of your physician who knows your personal medical history and limitations.

This new study is not the final say on exercise as it only addressed longevity, but it offers an excellent guideline for improving your longevity. As other recent studies have shown, exercise may also help prevent dementia and even cancer. So if you have been sitting reading this blog, may I suggest you now get up and get moving. It will probably extend your life.

Dr. Oz and Asprin: Is He Being Irresponsible?

Do not, and I repeat do not, stop taking aspirin prescribed by your physician (Dr. Oz on TV is not your physician) based on what you read here today. Today's blog highlights why it is a huge mistake to take medical advice from any doctor, including Dr. Oz, who does not personally know your medical history.

On a recent episode of The Dr. Oz Show, Dr. Oz spoke about aspirin -which he calls the Miracle Over The Counter Drug. As he has done multiple times before, Oz recommended that everyone take two baby aspirins every day. He prefaced his recommendation based on a video stream of medical conditions that he claims benefit from aspirin therapy. Heart attacks, strokes, arthritis, etc. were on the list. He highlighted aspirin's anti-inflammatory benefits and the role it may play in cancer prevention (a topic obviously dear to my heart). He did not, however, cite any of the side effects of aspirin therapy. He did not mention the risk for bleeds, easy bruising, ulcers, asthma, macular degeneration, etc. Aspirin can wreak havoc if used inappropriately and he gave no hint of such dangers. In my opinion, this is irresponsible and unprofessional behavior, worthy of revocation of his medical license.

Why am I so strident in my feelings?  Personal experience. First, I use to take aspirin and developed an ulcer from it. It took months of suffering, an eventual endoscopic procedure to make the diagnosis, and months of drug treatment to cure it. Anytime I take a baby aspirin, my nose begins to bleed the next day. Obviously, aspirin and I do not agree. But I am not alone. Aspirin and other anti-platelet drugs are known to cause bleeding and be corrosive to the esophagus and stomach linings. In fact, aspirin, a member of the non-steroidal anti-inflammatory (NSAIDS) class of drugs, has been cited as one of the top four categories of drugs responsible for emergency room visits and hospitalizations. (By the way, on a subsequent episode Oz cited the potential harms caused by NSAIDS, but did not make a single reference to aspirin.)  Many patients who take aspirin note the easy skin bruising that develops.

Another one of my family members has a condition where aspirin therapy triggers an asthmatic attack.  This well known syndrome is a triad that includes aspirin, asthma, and a nasal polyp.

A number of recent studies have shown a correlation between aspirin therapy and the development of age-related macular degeneration, an eye condition with very poor treatment options.

The bottom line is that a daily aspirin has both associated benefits and risks and no one should initiate therapy with out first consulting a physician who can help you calculate your risks and benefits.

But what gets me really upset about Oz's pronouncements is that he not only fails to identify potential risks to an unwary audience, but he goes so far as to recommend two baby aspirins instead of one despite the paucity of evidence to support his stand. Don't take my word for it. Quoted below is information from the United States Preventive Services Task Force, which gives aspirin therapy prescribed by a physician its highest recommendation. But here's what it writes about the dose:

"The optimum dose of aspirin for preventing cardiovascular disease events is not known. Primary prevention trials have demonstrated benefits with various regimens, including dosages of 75 and 100 mg/d and 100 and 325 mg every other day. A dosage of approximately 75 mg/d seems as effective as higher dosages. The risk for gastrointestinal bleeding may increase with dose."

Two baby aspirins represent 162 mg.

Not good enough for you? Here's the Mayo Clinic's weigh in on the topic quoted directly from their website:

"Should you take a daily aspirin?

You shouldn't start daily aspirin therapy on your own in an effort to prevent a heart attack. Your doctor may suggest daily aspirin therapy if:

• You've already had a heart attack or stroke
• You haven't had a heart attack, but you have had a stent placed in a coronary artery, have had coronary bypass surgery, or you have chest pain due to coronary artery disease (angina)
• You've never had a heart attack, but you're at high risk of having one
• You're a man with diabetes older than 50, or a woman with diabetes older than 60

Although aspirin has been recommended in the past for certain groups of people without a history of heart attack, there's some disagreement among doctors about this approach. Guidelines are changing and have varied between organizations. The bottom line is that before taking a daily aspirin you should have a discussion with your doctor."


Still want another opinion? Here's an excerpt from a gastroenterologist writing in The New York Times:

"February 1, 2010, 11:42 am

A Hidden Danger of ‘an Aspirin a Day’

By THE NEW YORK TIMES

Dr. Neena S. Abraham, a gastroenterologist at the Michael E. DeBakey V.A. Medical Center and associate professor of medicine at the Baylor College of Medicine in Houston, recently took readers’ questions about ulcers, a potentially life-threatening condition increasingly tied to Nsaid pain relievers. Here, Dr. Abraham discusses the potential dangers of taking a daily baby aspirin, which doctors often recommend for those at high risk of heart disease.
An Underappreciated Risk of an Aspirin a Day
By Neena Abraham, M.D.
If your physician has suggested you take aspirin to reduce your risk of heart disease, it is important to remember that even small doses of daily aspirin — including “baby aspirin,” at a dose of 81 milligrams daily — can increase your risk of ulcers and bleeding. It is important to remember that all Nsaids, including over the counter aspirin, have the potential to damage the tissue of the gastrointestinal tract. Damage can occur anywhere, from mouth to anus.
Over-the-counter doses of aspirin, or buffered or enteric coated aspirin preparations, do not eliminate the risk of developing an Nsaid-related ulcer. Your risk for bleeding is still two- to four-fold greater than if you were not taking the aspirin product at all.
This risk increases in magnitude as the dose of the aspirin increases. Some studies have suggested that one-third of aspirin-induced ulcers are related to over-the-counter aspirin use. The excess ulcer bleeding risk associated with aspirin use is estimated at 5 extra cases per 1,000 patients per year.
However, it is important to remember that your risk of aspirin-induced ulcer will further increase if you have high-risk features such as:

• being older than 60,
• having a history of gastric or duodenal ulcer,
• having active Helicobacter pylori infection (the bacterium linked to ulcers),
• taking aspirin at the same time as you take full strength Nsaids (such as ibuprofen, Motrin and naproxen), anticoagulants (such as warfarin) or antiplatelet agents (such as clopidogrel or ticlopidine); or taking aspirin if you are a chronic steroid user.

Aspirin is not a nutritional supplement — it is a medication with real risks and side-effects, so it should not be taken without explicit cardiovascular risk assessment by your physician.
If you and your doctor determine that the benefit of taking aspirin to prevent heart disease exceeds the risk of gastrointestinal bleeding, ensure you are only taking the minimum dose of aspirin required for cardiovascular risk reduction (in the United States, that is a dose of 81 milligrams a day).
If you have high-risk features for aspirin and Nsaid-induced ulcers, as discussed above, discuss with your physician the appropriateness of taking a stomach protecting medication, such as a proton-pump inhibitor. It may also be important to be tested and treated for H. pylori infection to minimize your risk of ulcer formation."

The bottom line is that aspirin therapy may be indicated for certain, if not many patients, under the right set of circumstances. But is it for everyone? Absolutely not. Do you need two baby aspirins? No good evidence to support that position. Should Dr. Oz be telling a national television audience to start aspirin therapy without consulting a physician, and to take two, not one baby aspirins when they do? You be the judge.

I say shame on you, Dr. Oz.

Which Routine Medical Tests and Treatments Should You Avoid?

Often when you go to a doctor with a problem, you expect tests and a prescription. Such actions are not always the best course of action and can sometimes be counterproductive. Unnecessary tests can lead to more expensive, time-consuming, stressful, and sometimes painful tests with side effects that could have been avoided. Medications have side effects and if you don't need a drug, you shouldn't take it.  But how do you know which tests to avoid?

Choosing Wisely^® is an initiative of the American Board of Internal Medicine Foundation to help physicians and patients engage in conversations to reduce overuse of tests and procedures, and support physician efforts to help patients make smart and effective care choices.

A new list of tests and treatments to avoid was released last week. The entire list is listed below with links to the sites.

I find the lists to be very thoughtful and well developed. That doesn't mean that they are gospel or infallible. Physicians must continue to use their clinical judgment to make the right decisions for their patients. I hope the information provided makes you a smarter patient, one capable of asking the right questions from your doctor to get the best care for you or a loved one. Avoiding unnecessary tests and treatments is as important as receiving the right ones. It is worthwhile to familiarize yourself with all the tests so if you ever find yourself in a situation where such a test is being recommended for you or a family member, you are more knowledgeable and better prepared to decide.

Patient-Friendly Resources from Specialty Societies and Consumer Reports:

link: http://www.choosingwisely.org/doctor-patient-lists/

• Allergy tests: When you need them and when you don't
• Bone-density tests: When you need them...
• Chest X-rays before surgery: When you need them...
• Choosing pain relievers with kidney disease/heart problems
• Chronic kidney disease: Making hard choices
• Colonoscopy: When you need it...
• EKGs and exercise stress tests: When you need them...
• Hard decisions about cancer
• Heart tests before surgery : When you need an imaging test...*
• IgG replacement therapy: When you need it...
• Imaging stress tests: When you need them...
• Imaging tests for a headache: When you need them...
• Imaging tests for lower-back pain: When you need them...
• Imaging tests for ovarian cysts: When you need them...
• Pap tests: When you need them...
• Spirometry for asthma: When you need it...
• Stress tests for chest pain: When you need an imaging test...*
• Testing after heart procedures: When you need a nuclear stress test...*
• Treating heartburn and GERD
• Treating sinusitus: Don't rush to antibiotics

Here's a couple of examples.

Bone-density tests: When you need them...

When you need them—and when you don’t

Download PDF It’s worth getting a bone-density test if you’re older or have other risk factors for weak bones, because without it the first sign of osteoporosis is usually a broken bone. But if you’re not at higher risk, you should think twice about the test. Here’s why:
The test usually isn’t necessary in younger people without risk factors for weak bones.
Many women and some men are routinely screened for weak bones with an imaging test called a dual-energy X-ray absorptiometry (DEXA) scan. If it shows that you have outright osteoporosis, the results can help you and your doctor decide how to treat the problem, usually with drugs. But many people learn they have only mild bone loss, a condition known as osteopenia, and for them the risk of fracture is often quite low.
It can pose risks.
A DEXA scan isn’t likely to harm you directly. But a diagnosis of osteopenia can lead to treatment with such drugs as alendronate (Fosamax and generic), ibandronate (Boniva and generic), and risendronate (Actonel, Atelvia, and generic), which pose numerous risks. Those include thigh fractures; throat or chest pain; difficulty swallowing; heartburn; and more rarely, bone, eye, joint, and muscle pain; bone loss in the jaw; and possibly abnormal heart rhythm. In addition, there is little evidence that people with osteopenia get much benefit from the drugs. Other types of osteoporosis drugs are linked to risks such as blood clots, heart attacks, strokes, and serious infections.
It can be a waste of money.
A DEXA scan costs about $132, according to HealthcareBlueBook.com. Though that isn’t as expensive as some tests, any money spent on unnecessary tests is money wasted. In addition, a month’s supply of generic alendronate costs $38 to $70. Fosamax, the brand-name version, costs $125 to $148. People often take the drugs for years and sometimes indefinitely.
So when is the test warranted?
Women should have their bone density measured at age 65. Men 70 and older might also want to talk with their doctor about the test. Women younger than 65 and men 50 to 69 should consider it if they have risk factors such as a fracture from minor trauma, rheumatoid arthritis, a parent who had a hip fracture, or a history of smoking, heavy drinking, or long-term use of corticosteroid drugs. Whether you need a follow-up bone-density test depends on the results of the initial scan.

Treating heartburn and GERD

Use Nexium, Prilosec, and related drugs carefully

Download PDF If you have heartburn, or a feeling of burning pain in your upper abdomen or lower chest, you might be tempted to try a powerful drug such as Nexium, Prevacid, or Prilosec. Those drugs, called proton pump inhibitors (PPIs), can be good choices for severe or frequent heartburn. But in most cases PPIs aren’t necessary. And when they are, consider using the lowest dose necessary for as short a time as possible. Here’s why:
You might not need a PPI.
A PPI can help if you have heartburn more than twice a week for several weeks, or a condition called gastroesophageal reflux disease (GERD). But studies suggest that up to 70 percent of people taking a PPI were never diagnosed with GERD. Instead, they might have less serious heartburn, which can often be eased with dietary and other lifestyle changes and, if necessary, antacids like Rolaids and Tums or another class of medication, known as H2 blockers, such as Pepcid AC and Zantac.
The drugs can pose risks.
High doses of PPIs, and taking them for a year or longer, has been linked to an increased risk of bone fractures. Long-term use might also deplete magnesium blood levels, which, in turn, can trigger muscle spasms, irregular heartbeats, and convulsions. Another complication of long-term use is an intestinal infection called Clostridium difficile that can lead to severe diarrhea, fever and, in rare cases, death. PPIs can also interact with other medications. For example, omeprazole (Prilosec) can reduce the blood-thinning effect of the drug clopidogrel (Plavix), which can increase the risk of heart attack and even death. Esomeprazole (Nexium), and the H2 blocker, cimetidine (Tagamet), might also interact with Plavix in that same way.
PPIs cost more.
A month’s supply of a prescription strength PPI could cost you about $100 to $300 more than you would pay for antacids or an H2 blocker. A low-dose, over-the-counter PPI such as Prilosec OTC or store-brand or generic version, costs less than the prescription options, but still runs about $10 more a month than the other heartburn drugs.
When should you consider a PPI?
Talk with a doctor if you have heartburn at least twice a week for several weeks, if you often regurgitate food into your throat, or if your heartburn is not relieved by lifestyle changes and antacids or H2 blockers. When a PPI is necessary, start with a low dose of omeprazole or Prilosec OTC (15 mg) or Prevacid 24HR (15 mg). If symptoms improve, consider taking a break after a few weeks. To reduce the risk of rebound heartburn, gradually lower your dose, try taking it every other day, or take an antacid.


One final thought. The next time you think that all doctors want is to make more money, think of the many doctors involved in forming these lists for the sole purpose of sparing patients from the costs and hardships of wasteful testing and treatments. The medical profession is not perfect and it has its problem practitioners, but concerted efforts like these give me hope for a better tomorrow.

Alcohol and Cancer

My last blog titled "Can Breast Cancer Be Prevented?" offered few clues if prevention is even possible. The reason for the lack of insight was because there are a very limited number of even close to conclusive studies available.  Therefore, imagine my delight, when yesterday a new study comes along that may shed light on a well known dietary factor that may lead to breast and other forms of cancer such as mouth, throat, esophagus, liver, colon, and rectum. That factor is alcohol.

If you are among those who think that drinking alcohol, even in moderation, poses no risks, a new report finds that alcohol is to blame for one in every 30 cancer deaths each year in the United States.
According to the study's researchers, the effects of alcohol consumption are even more pronounced with breast cancer, with 15 percent of those deaths directly related. Even worse, drinking in moderation doesn't help because 30 percent of all alcohol-related cancer deaths are linked to drinking 1.5 drinks or less a day. Quoting one of the researchers, "Alcohol is a cancer-causing agent that's in "plain sight," but people just don't see it." Study author Dr. David Nelson, director of the Cancer Prevention Fellowship Program at the U.S. National Cancer Institute added, "As expected, people who are higher alcohol users were at higher risk, but there was really no safe level of alcohol use."

Published online Feb. 14 in the American Journal of Public Health, the study sought to determine the risks related to drinking and cancer.  The study involved the compilation of data from various sources, including the 2009 Alcohol Epidemiologic Data System, the 2009 Behavioral Risk Factor Surveillance System and the 2009-2010 National Alcohol Survey. Both women and men were affected by alcohol with alcohol-related cancer deaths in men, accounting for about 6,000 deaths each year. The researchers estimated that each alcohol-related cancer death accounted for an average of 18 years of potential life lost.

According to the report, previous studies have shown drinking is a risk factor for cancers of the mouth, throat, esophagus, liver, colon, rectum and, in women, breast cancer, and one expert was noted on Medline to weigh in, stating that the findings in this study are consistent with what has been shown before.
 
So does this mean you shouldn't drink alcohol, even in moderation? Before I answer, let me tell you my bias. I don't like alcohol and I never did. I've never had more than two drinks in my life at one time and I can say with pride that I've never been inebriated (maybe a little tipsy). Nevertheless, I'm not completely buying this study. Here's why. There is no doubt that alcohol is a toxin, poorly tolerated by several organs such as the brain, liver, etc.  It does not, however, rise to the level of causing cancer like cigarettes that are said to kill over 100,00 each year.

The reasons that alcohol may lead to cancer deaths are not well understood even by researchers.  Some studies claim that alcohol may actually be good for the heart in moderation. No one, including me advocates that one should start drinking if they aren't already in order to prevent heart disease. No one, including me can say with certainty that alcohol isn't causing cancer. I have a problem with studies that don't show cause and effect. It's not that I don't quote them often because they sometimes are the best we have and that's the problem.

My real problem is these one off studies based on compilation of data. Like I wrote in my last blog, we need to shift our research focus to figuring out more definitively what works and what doesn't work when it comes to our health and not rely on retroactive gathering of statistics. For the moment, it's the best we have so it's probably wise not to ignore it; but, I look forward to the day when we know for sure.

In the interim, if you are one of those people who are cancer-phobic, and I wish more were, my recommendation is to really limit your alcohol consumption to special occasions and to limit your consumption to one glass of alcohol (three ounces or less) when such occasions arise. My apologies to those who consume one glass or more regularly with dinner--the numbers are simply not in your corner. In fact, the researchers say their findings suggest there's no safe amount of alcohol when it comes to certain types of cancer.

Update 5.13.13.  A new meta-analysis study, a study that looks at multiple other studies to reach a conclusion, shows again that even moderate alcohol consumption ups the risk for developing breast cancer.