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Thursday, December 30, 2010

First Looks -- Hottest Tips

The Top Health Priorities:

1. The Lifestyle 5:

    a. 0 cigarettes (i.e, no smoking, or quit now)
    b. 5 servings of fruits and/or vegetables every day.
    c. 10 minutes of relaxation (any healthy way that you unwind) every day
    d. 30 -- BMI < 30. See below.
    e. 150 -- minutes of exercise (walking will do) every week.

            You can prevent:
91% of type 2 diabetes (the adult type)
83% of heart disease
                3. 78% reduction in hypertension
70% reduction in stroke
                5. 50% reduction in heart failure
36-68% reduction in cancer.
and          7. a 40-69% reduction in deaths from any cause.

                You do not need to get a chronic disease!

2. The Top Killers
    a. Know your  blood pressure and make it less than 140 / 90 mm Hg
    b. Know your cholesterol--the good (HDL), the bad (LDL), and the ugly (triglycerides):
            Aim for an LDL < 100 mg/dL

    c. Know your BMI.
            Aim for < 30. Heart disease and other causes of death increase over  30.

    d. If you have diabetes, follow the ABC(DEF)'s
            A. make you hemoglobin A1c < 7% (a blood test)
            B. Blood pressure < 140/90
            C. Cholesterol: LDL < 100  (a blood test)
            D. mDrD (a measure of kidney function): check it every 6 months (takes a blood test)
            E. Eye checks every other year or as advised by your ophthalmologist
            F.  Foot exam every day at home; every visit to the doctor.

    e. Mental Health: Living is hard. Depression, anxiety, stress, grief, and loss all happen. At times we get overwhelmed.
            Be aware that how you feel affects your health.
            Talk about it (and it will feel better immediately)
            If it is severe, ask your doctor about medication.

    f. Excess alcohol or drugs:
            1. if you're a man and drink more than 4 servings of alcohol on any one occasion or drink more than 14 servings in a week, you may be at risk from alcohol.
            2. If you're a woman and drink more than 3 servings of alcohol on any one occasion or drink more than 7 servings in a week, you may be at risk from alcohol.

3. Cancer Prevention:

    a. The lifestyle 5 prevent more cancer than any (or all) screening tests.
    b. Self assessment of your own risk can do much of the work:

Self-Assessment of Cancer Risks
    Cancer is a concern to everyone. This is especially true if someone in your family or among your close friends has had cancer. The general risk of developing cancer in the US is about 0.4% per year. For the most part interventions against cancer and various attempts to prevent the different kinds have had only equivocal effectiveness. In fact, none of them have yet to be proven to actually increase life-expectancy. This is an area in which it is particularly important to be an informed consumer. Essential in order to do anything intelligent to mitigate your personal cancer risk is to systematically appraise your personal situation and determine what factors may put you at increased risk for specific cancers.
    A wonderfully practical article on this topic appeared in the British Medical Journal
.1 There Janusz Jankowski and Emma Boulton presented a systematic approach to assessing personal cancer risk with respect to a variety of cancers using an alphabet-based memory aid--ABCDEFGHIJK. The point is, unless you are at specifically increased risk of developing a specific cancer, there is little point in aggressive general cancer screening technology.

Alcohol consumption
> 3 units a day: predisposes to squamous cancers, especially cancer of the bladder and esophagus.
Body Mass Index > 25 and certainly > 30: predisposes to all solid cancers. If you don’t know your BMI, see the free calculator at: .
Cigarette smoking at any level (even passive smoking): predisposes to bladder cancer, lung cancer, head and neck cancer, esophageal cancer, and oropharyngeal cancers.
Diet, especially one that is high in fat: predisposes to all solid cancers.
Exercising < 30 minutes a day: predisposes to all solid cancers.
Family history of cancer: (in at least one first degree relative (e.g., brother, sister, mother, father, son, daughter) and at least 3 people in two or more generations): predisposes to inherited cancer syndromes, including breast cancer, colorectal cancer, diffuse gastric cancer, ovarian cancer, prostate cancer, and uterine cancer.
Genital health (sexually transmitted infections): predisposes to cervical cancer and penile cancer.
Health promoting drugs that may decrease global cancer risks (but need a careful risk benefit analysis): colonic adenomas can be treated with los dose aspirin but can have serious side effects; hormone replacement therapy is linked with breast cancer)
Intense sunburn: predisposes to melanoma.
Job related factors: lung cancer (exposure to asbestos and particulates), skin cancer (contact with arsenic)
Known disease associations: colorectal cancer has predisposing mucosal pathology–adenomas, celiac disease, ulcerative colitis.

    The actions they recommend for physicians at the time of a routine check-up are:

1. Review history for any symptoms of cancers of concern (e.g. bleeding in the rectum, altered bowel habits, weight loss)
2. Educate the patient that early investigator of cancer symptoms increases the chances of cancer being successfully treated, but that most of such symptoms are not in fact due to cancer.
3. Emphasize the importance of a good diet. A patient should eat at least 5 portions of fruit and vegetables each day and cut down on fat, salt, and added sugar.
4. Explain that many cancers are preventable through lifestyle modification. Help the patient strategize as to what modification to tackle first–smoking, exercise, dietary modification, or alcohol consumption.
5. If the patient is serious about lifestyle modification, counsel about the advantages and options of various support methods for assisting behavioral change.
6. Offer objective advice about the risks of medical interventions such as x-rays, Pap smears, endoscopic examinations (sigmoidoscopy, colonoscopy, endoscopic esophagoscopy, gastroscopy and duodenoscopy (EGAD)), mammography, Pap smears and additional interventions (e.g. ThinPrep, HPV testing), and fecal occult blood testing (FOBT). The authors state, “Most people asking about the risk of cancer won’t develop it, and in about 10% of people anxiety levels will be raised needlessly
7. Provide as much objective (non-cancer society and non-specialty society sponsored) information and web-links as appropriate.

[1. Jankowski J, Boulton E. 10-Minute Consultation: Cancer Prevention. British Medical Journal 2005; 331: 618

 What to know about cancer screening tests:

1. Lung cancer: No need to screen. Just don't smoke or, if you do, quit.

2. Colon cancer: At age 50, the risk of colon cancer in a man is about 50/100,000 and in women it is even less;  the risk steadily increases to about 150 cases per 100,000 at age 75.  Screening with stool blood tests or sigmoidoscopes/colonoscopes only prevent about 15% of colon cancer-related deaths. This is far less (and far more expensive) than you can prevent by not smoking, a health lifestyle, a healthy diet, vitamin D, and an aspirin a day. I frankly advise against routine colon cancer screening with our current tests.

3. Breast cancer: An average-risk woman's general risk of breast cancer is 1-3% for each decade after age 50. Whether or not you get screened, modern treatment cures about 50% of all breast cancers. Screening with mammography prevents between 10-15% of all breast cancer deaths and carries the risk of having to get a breast biopsy when you don't really need it. Screening is currently recommended by the national expert group (the United States Preventive Services Task Force, USPSTF) every other year between age 50 and 75. Multiple studies have shown that regular breast self-exam by women does not lower cancer risk. If you are going to get a mammogram, you do not need an exam by your physician (unless you feel a lump).

4. Cervical cancer: Pap smears are recommended for women starting 3 years after the onset of sexual activity and can stop at age 65 if the preceeding Pap smears have been normal. A finding of High-Grade Squamous Epithelial Lesion (HSIL) on a Pap smear specimen requires further evaluation. Such evaluation is optional for other findings. If you ever have an abnormal Pap smear result, be sure you understand exactly what the abnormality is and be sure to always tell each new doctor about it.

5. Prostate cancer: About 50% of men will have some degree of cancer in their prostate by age 65;  very, very few will ever die of it. There is no good test for screening for those who are likely to die from their prostate cancer. The PSA blood test is popular, but most of the abnormal tests are false. There is very little evidence that screening for prostate cancer leads to lower prostate cancer mortality than just simply waiting and doing nothing. The inventor of the PSA test has called it's generaliozed use (in the New York Times) one of the great public health disasters of the modern era--a huge cost for almost no benefit. I frankly recommend against any kind of prostate cancer screening.

NOTE:  The positions articulated above derive from my review of the medical evidence over 30 years. Nonetheless, almost all of these remain controversial. What is described above reflects my informed opinion. This does not necessarily mean that it is the right advice for you. If you have had a friend or family member affected by cancer, talk to your doctor about what is available to lower your risk.

The routine annual blood tests that I recommend:
    1. A blood count (CBC): a routine periodic check for anemia is a good idea. Low red blood cell counts lead to fatigue and low energy and can be a sign of other serious diseases.
    2. A cholesterol panel: For the simplest screen, a single test for total cholesterol is adequate. For a better screen, you can measure the total cholesterol, good cholesterol (HDL), and "bad" cholesterol (LDL), and these can be obtained without a need to be fasting.  For the best screen, get a total cholesterol, good cholesterol, bad cholesterol, and triglycerides, but for triglyceride testing you need to be fasting.
    3. A single test for kidney function (creatinine [MDRD]). Kidney disease is becoming more common and does not have any symptoms, so it is good to check.
    3. For adults over 50 and any adult with a BMI over 30 or with high blood pressure, I recommend a hemoglobin A1c test to screen for diabetes.
    4. A single test of liver function (ALT). An abnormal ALT is a good marker for liver inflammation,whether it is from drugs or medications, infectious hepatitis, alcohol, or fatty deposits.
    5. A single test of your thyroid function (TSH). Low hormone levels are associated with fatigue and weight gain; high levels are associated with osteoporosis and heart rhythm disturbances.
    6. A test of your vitamin D level. Adequate levels of vitamin D are becoming increasingly recognized as associated with lower risk for heart disease and cancer, as well as of bones, muscle, joints, and even for mental function (prevention of dementia in the elderly). It is a partial assessment of nutrition as well as of sun exposure.