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Ross Walker
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Breast cancer: What hurts and what helps

Thursday, August 17, 2017

By Ross Walker

One in eight women in Australia will be diagnosed with breast cancer at some stage during their lifetime. There are around 17,600 cases of breast cancer diagnosed on a yearly basis. Breast cancer is the most common cause of (non-skin) cancer in women and the second most common cause of cancer death.

Why has the incidence of breast cancer increased?

The incidence of breast cancer has increased significantly over the past few decades and the obvious question is why? Firstly, there has been significant publicity over the past decade about the genetics of breast cancer. There has been much media attention around the decision of Angelina Jolie to undergo a preventative bilateral mastectomy because of the detection of the BRCA 1 gene, after her mother previously died from the condition. This is only one of a number of genes present in women which may increase breast cancer risk. This, however, does not explain the increased incidence over the past few decades.

Diabesity

Firstly, let us examine what hurts. One of the key and well-accepted factors in the increased incidence of breast cancer is the modern epidemic of diabesity i.e. a combination of diabetes and obesity. Around 50% of Australian women are currently either overweight or obese. Until we can address this issue by engaging the public in better lifestyle practices, we will continue to see cardiovascular disease, diabetes (and all its complications) and many common cancers as a result.

Alcohol consumption

The second issue which I have addressed in the past is that of alcohol consumption and breast cancer. There is no doubt that there is a link between even a daily glass of alcohol and breast cancer, but as I have stated, I believe this is far too simplistic. Mediterranean data clearly shows that low-dose consumption of red wine in combination with a high-quality diet (and the Mediterranean lifestyle) actually assists in reducing the risk for both cardiovascular disease and cancer.

I believe that when a poor-quality Western diet is combined with alcohol consumption, problems start to arise. Interestingly, the Nurse’s Health study showed that nurses living in the affluent New England region, who consumed low-dose alcohol but also took a daily multivitamin, had no increased risk for breast cancer. The New England region of America typically consumes a better diet than say, for example, the southern states. This also would have been a significant factor. Regardless, it is irresponsible for any doctor to encourage people to drink alcohol but, if you choose to do so, I would strongly suggest you combine your alcohol consumption with the Mediterranean diet and lifestyle program, along with a daily multivitamin.

Lack of physical activity

Again, in keeping with our modern society, is that of physical inactivity. Not only is there a clear link between being overweight and breast cancer but being inactive can also lead to these scenarios.

Xenooestrogens

Finally, I believe a major factor in the increased incidence of breast cancer is what is known as xeno-oestrogens. These are the synthetic oestrogens found ubiquitously in our modern society in all manner of synthetic substances such as plastics, aluminium cans and many other common household products.

Young children and even babies in utero are being exposed to these substances in some form, and one of the unintended consequences is that immature breast tissue is being flogged with oestrogen-like substances from a very early age. Couple this with the delay in a woman becoming pregnant, which is happening on a more significant basis in our modern world, which markedly increases the risk for breast cancer.

The female breast exposed to excessive doses of oestrogen throughout its lifetime is much more prone to developing breast cancer. The combination of these commonly-used household products and food containers, along with synthetic oestrogens used to prevent pregnancies and to treat the symptoms of menopause, are also major factors.

What helps?

So, after this somewhat depressing lot, we must ask ourselves the question - what helps? Following on from this argument is the obvious factor of early pregnancy. The shorter the time between the onset of puberty and your first baby markedly reduces the risk for breast cancer. As we were all designed to be hunter-gatherers living a short life of somewhere between 30-40 years, with young girls going through puberty in their early teens and having babies soon after (with the grandmothers being in their late 20s or early 30s helping look after the child), in a very simple top-of-the-food-chain life.

Clearly in our modern world, teenage pregnancy is still unacceptable and many women are delaying pregnancies to establish a career. Although this may seem to be a good idea, it does come with significant health consequences.

Healthy lifestyle principles

There is also very strong work to show healthy lifestyle principles, such as consuming high doses of fruit and vegetables, regular physical activity and minimising alcohol intake, are clearly linked to lower rates of breast cancer. You may be surprised to know that there is a World Breastfeeding Week, when it was announced that 18 studies of breastfeeding showed that for every five months a woman breastfeeds, there is a reduced breast cancer risk of around 2%. There are a number of proposed reasons as to why this occurs, but suffice to say the statistics are very clear. The strong suggestion is that a woman should breast feed for at least six months and interestingly, 80% of mothers start breastfeeding but by six months only 50% continue. It is my feeling that if women can breastfeed, that they should do so for somewhere between 6-12 months.

Early detection

The most comforting statistic from this entire discussion is that the current 5-year survival rates for breast cancer are 90%, which is attributed to early detection through excellent screening programs, along with much better management programs. Another very important statistic is that one in three breast cancers could be avoided by greater attention to the aforementioned lifestyle factors. It is a very simple message, “they’re your breasts, look after them”.

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Overdiagnosis and overtreatment

Thursday, August 10, 2017

By Ross Walker

A recent report published in the Journal of the Royal Society of Medicine by three cardiologists, including my friend Dr Aseem Malhotra, has presented a stunning exposé around creating diseases out of non-diseases.

I am a strong advocate for appropriate screening for common diseases, but the main problem here is over interpreting the results and, just as worrying, excessive investigation of incidental findings. This report has detailed the fact that in the United Kingdom alone, cardiovascular disease accounts for more than 10% of all in-patient episodes for men, with spending on the disease just under £7 billion in the period 2012/2013, which accounted for around 6% of the total NHS budget.

Excessive prescription and overinvestigation

The report highlighted the problems with the excessive prescription of cardiac medications, along with over investigation and unnecessary medical procedures, such as coronary stenting. Interestingly, a review performed in New York State a few years ago by an independent body reviewing coronary angiography (a dye study of the coronary arteries, looking for significant blockages) suggested that around 65% of the coronary angiograms performed in that state of America were unnecessary.

Coronary stenting, where a small, hollow metal tube is placed in a blockage in a coronary artery, is a highly effective treatment for acute coronary syndromes, such as heart attack. There is a disturbing, cynical phrase known as the “oculodilatory” reflex, which is basically where an interventional cardiologist sees a blockage on an angiogram in a person with stable or no symptoms and routinely stents the blockage, regardless of whether it was proven to be causing any problems.

The report also covered recent publicity in the media around screening for, and treating, coronary artery disease. There was also a rather disturbing comment describing coronary calcium scoring as an invalidated screening tool in an asymptomatic population. This is where I am at odds with the authors. The appropriate use of coronary calcium scoring in asymptomatic people can prevent the excessive prescription of statin drugs to people where the drugs are unnecessary.

In the November edition of the Journal of the American College of Cardiology, a study was published where 5000 people were screened for ten years, over the age of 50. 77% of the people in the trial fitted the US criteria to be on a statin. Half of the 77% had a zero coronary calcium score and their heart attack rate was so low that the conclusion of the trial was that statins were unnecessary in that population. There have been thousands of patients screened with coronary calcium score, showing clearly that this is the most predictive test for coronary artery disease, and in my opinion, should be used in the asymptomatic population. It is my suggestion that all males over 50 and all females over 60 have coronary calcium scoring. If they have zero or low scores, they should be reassured. Lifestyle practices should be reinforced for all people.

The true non-disease here is that of hypercholesterolaemia. I see so many people on a weekly basis saying to me, “Doctor, I’ve got cholesterol and my doctor wants me to take a statin”. We’ve all got cholesterol and if we didn’t, we’d be dead. The real question here is whether the particular cholesterol issue for that patient is spilling into the walls of their arteries, causing the build-up of fat, inflammatory tissue and calcium, and thus increasing the risk for heart attack over the next 5 to 10 years. The coronary calcium score is easily the best way to determine this risk and is certainly not, in any way, invalidated.

The real concern here is how any of this information is used and misused by the medical profession. I am completely against the use of intravenous CT Coronary Angiography as a screening tool for heart disease. This is completely invalidated, with no science to support its use. Often, people have this test performed and are told they have serious blockages in their arteries requiring a coronary angiogram and stenting. This, in my view, is where the unworried-well become the worried-unwell and become overinvestigated and overtreated.

The simple algorithm I use in my practice is based around age, risk factor profile (which includes a review of the entire lipid or fat profile), hypertension, cigarette smoking, all aspects of metabolic syndrome and family history, along with the appropriate use of coronary calcium scoring, the variety of important blood markers, and stressed echocardiography only for people who are in the highest-risk category. This allows me to reassure people that they do not need chronic drug therapy if they are low-risk, but I may be able to prevent significant coronary events for those who are high-risk.

I believe it is vital for us to have the debate about over-investigation, over-diagnosis and over-treatment but let’s not “throw out the baby with the bathwater”.

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Thinking - your brain needs it!

Thursday, August 03, 2017

By Ross Walker

Cogito ergo sum - I think, therefore I am. This famous phrase was made by the French philosopher, René Descartes in 1644. In so many ways, the way we think defines us. The quality of your life is often defined by the quality of your thinking. My daughter, Dr Ali Walker, has recently published her first book - “Get Conscious - How to overcome overthinking”. Yes, many of us overthink, but without good-quality, well-crafted thinking, many of us live in misery.

Maintaining high-quality thinking, otherwise known as cognition, is vitally important as we age. Unfortunately, as we age, too many people across the globe are succumbing to the ravages of dementia. In Australia, there are just over 413,000 people living with some form of dementia, making it the second leading cause of death after cardiovascular disease. Around 1.2 million people in Australia are involved in the care of someone with dementia. 1 in 10 people older than 65 have some form of dementia.

There are so many questions around dementia and its most common cause, Alzheimer’s disease, which remain unanswered. Is it preventable? Can it be treated? Can it be reversed? Are there any effective treatments etc., etc.?

There are certainly no magic bullets for the prevention, management and possible reversal of dementia, but there are definitely some promising advances.

I reported over 12 months ago, the results of the pilot study of the MEND program where 10/11 patients with varying degrees of Alzheimer’s disease demonstrated some degree of reversal. There have been a number of new and old drugs trialled with varying degrees of promise. There are increasing studies around various aspects of lifestyle showing improvement in thinking and other negative factors demonstrating impairment of thinking.

Three new trials have reinforced prior studies around these aforementioned lifestyle factors. The long quoted “use it or lose it” concept has been reinforced with a recent study of 17,000 people over age 50, showing those who regularly performed word puzzles, typically crosswords, scored much better on tests of attention, reasoning speed and memory accuracy, compared with those who didn’t do crosswords.

The much maligned, naughty indulgence of enjoying a few pieces of chocolate has been recently demonstrated to improve thinking, attention, processing speed, verbal fluency and working memory. So, the next time you enjoy a couple of pieces of chocolate (and especially dark chocolate), see it as therapy.

But, what about certain lifestyle and environmental factors that may have negative, long-term consequences on our thinking ability? There are the obvious toxins that are clearly linked to cognitive decline such as poor diets, cigarette smoking, excessive and prolonged alcohol consumption, inactivity, poor sleep and, of course, the chronic use of illegal drugs in any form, including marijuana, which should not be confused with medical cannabis.

But, a recent study has looked at the effect of so-called “smart phones”, which may be seen as a distinct oxymoron. This study looked at 800 regular smartphone users and conducted an experiment with the phone switched to silent mode. The owner was exposed to one of three circumstances:

1) The phone was in sight and within reach

2) The phone was nearby but out of sight

3) The phone was not in the room with the owner

Participants were then tested for various aspects of cognitive ability requiring a high level of concentration, involving an assessment of working memory and functional fluid intelligence. These tests are designed to assess an individual’s ability to store and process new information, along with a person’s ability to consider and solve new problems.

It appears that the mere presence of the smart phone is such a distraction that it affects a person’s ability to concentrate on the task at hand. There was a gradation of effect based on the proximity and presence of the phone. The more dependent and closer the person was to their phone, the greater the negative effect on cognitive performance.

The major question here is, “is this just an acute effect of the study or does it have long term consequences?”

A quote that has often been attributed to Albert Einstein stated, “I fear the day that technology will surpass human technology. The world will have a generation of idiots”.

In our complex, time poor and often very stressful world, it is vitally important we look after our greatest asset, ourselves. Clearly, one of the major factors here is the quality of our thinking, which is very much housed in our brain. You are only given one brain and therefore you should use it wisely.

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Can air pollution increase the risk of dementia?

Thursday, July 27, 2017

By Ross Walker

I have stated on repeated occasions that I believe the major problem on the planet is over-population. Until some authoritative world body addresses this issue, I suspect that, as a species, we only have somewhere between 50-100 years left. One of the major consequences of overpopulation is the overcrowding of urban areas and large cities, purely because this is where better facilities and infrastructure are available.

Another major consequence of so many people being squeezed into a relatively small space is air pollution. In Mumbai, where there are 24 million people living in a very concentrated area, the traffic and pollution are unmanageable. When I visited, it took two hours to drive 15km and I spent more time in the car than I did in meetings.

The health effects of pollution

Over the past decade, there have been a number of disturbing reports about the health effects of air pollution. One of the major culprits appears to be the fine particles (PM 2.5). These are particles that are around 30 times smaller than human hair and are very easily inhaled. They can be absorbed into the bloodstream. There appears to be a strong link with exposure to PM 2.5 and chronic lung conditions, heart disease, cancer and now, according a recent and very disturbing report, a major factor in the generation of Alzheimer’s disease.

The study

A recent study analysed the data from the Women’s Health Initiative Memory Study, looking at 48 US states and just under 3,650 women (aged between 65 and 79) who did not have dementia at the start of the study.

All women had their cognitive function assessed on an annual basis and the results of the study were very clear and very disturbing. It appears that those women who had the highest exposure to PM 2.5 compared with those with the lowest exposure had an 81% greater risk of global cognitive decline, along with a 92% increased risk for developing not only Alzheimer’s disease, but all other forms of dementia.

When analysing all of the data, it appears that air pollution is the probable cause for around 20% of dementia cases. I have often said, it’s your genes that load the gun and your environment that pulls the trigger. In this situation, it certainly appears to be the case.

There is a particular genetic abnormality that is quite common known as ApoE4. The women who had one copy of the ApoE4 gene had a much higher risk of developing Alzheimer’s disease, especially when they were exposed to air pollution. 

Interestingly, this study was also replicated in mice comparing those with the ApoE4 gene and those mice without the gene. Both groups were exposed to the equivalent of significant air pollution and the study showed exactly the same results as the Women’s study.

It has been estimated that one in eight deaths around the world are linked now to air pollution, whereas one in four deaths in China appear to be related to this increasing and worrying scourge. Although many people are debating the concerns around air pollution, it doesn’t appear that there is much action happening to reduce this increasing, and concerning, problem. 

The answer is clear, we need to bring in fair and reasonable strategies to start reducing the world’s population. It appears from all accounts that we can sustain the planet with a population of around 4 billion, but we’re rapidly approaching the 8 billion mark. Clearly, maintaining the health of the population is not sustainable if we continue in this fashion.

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Prevention is better than cure

Thursday, July 20, 2017

By Ross Walker

A recent report, co-funded by the Heart Foundation, Kidney Australia, Alzheimer’s Australia, the Australia Health Promotion Association and the Foundation for Alcohol Research and Education, is titled “Preventive health: how much does Australia spend and is it enough”?

It is estimated that $27 billion annually is spent in Australia treating chronic disease, which accounts for around a third of our annual health budget. But, Australia currently spends around $2 billion a year on prevention, ranking us 16th out of 31 OECD countries for per capita expenditure. This accounts for around 1.3% of Australian healthcare expenditure.

It is estimated that around 50% of Australians suffer some form of chronic disease, being responsible for 83% of all premature deaths in Australia and around 66% of the total burden of disease.

In my opinion, there are many reasons why much lip service is given to preventative health, but little action follows as seen in the report. Firstly, to examine the medical profession’s role in all of this, there is little emphasis placed on preventive health during the training of student doctors. The vast majority of their critical time is spent in hospitals dealing with very sick people with established diseases. There is little emphasis in medical courses on preventative measures, the variety of lifestyle factors and integrative techniques combining the evidence based aspects of pharmaceutical therapy, medical procedures and operative therapy, along with the proven aspects of complementary medicine.

Modern medicine is currently being practised by having the ambulance parked at the bottom of the cliff waiting for people to fall off and instead of fixing the rails at the top of the cliff, i.e. prevention. What we do in medicine is build faster ambulances. I make the analogy that this is like the financial world waiting for people to go bankrupt and then they give them financial advice.

Practising doctors are overloaded and time poor. Doctors are certainly not rewarded for spending time with patients discussing the vital aspects of prevention. When a person with clear lifestyle issues such as obesity, cigarette smoking or the excessive use of alcohol, to name three key areas, is given a pill for cholesterol-lowering or blood pressure (and told in one sentence to lose weight, give up smoking and cut back their alcohol intake), the perception is the pills will do the job and they can continue the variety of forms of self-abuse.

Until the remuneration system is rearranged for doctors, rewarding the profession for spending time with patients and not for churning them through as quickly as possible, nothing will change in this area.

At a government level, more is needed in the “carrot and stick” department, again legislating to reduce the costs of healthy, fresh foods, and to increase the cost for processed packaged foods, takeaway foods, the introduction of a sugar tax and continued heavy regulation of alcohol and cigarettes.

Also, more needs to be done to encourage people to exercise, move more and spend less time sitting at work and at home. These initiatives do need to come at a government level.

I also believe life insurance and health insurance companies should be rewarding clients for healthy behaviour with financial incentives based on a variety of health parameters.

Another issue, which is not really considered, is that of convenience. Around 10 years ago, I wrote a book titled “Diets Don’t Work”. One of the chapters in that book was, “Convenience is killing us”. One of the great paradoxes of life is that what seems good and fun at the time, and is easily accessible, is typically bad for you, which I believe is clear and obvious in our modern world.

Most importantly, however, is personal responsibility. With our modern, overloaded, time poor world, each individual needs to examine their day-to-day activity and behaviour. Basically, in life we have three choices - protection, life maintenance and urges. The protection aspect is obvious in that if you are in any sort of danger, you need to bring in steps to protect yourself from that danger. But, for most of the day, most of us living in the modern world are not at any acute risk from violence or abuse and thus we’re left with life maintenance or following our urges.

Life maintenance involves focusing on the five keys of good health:

  1. Quitting all addictions
  2. 7-8 hours of good quality sleep
  3. Eating less and eating more naturally
  4. 3-5 hours of testing exercise per week
  5. Happiness, peace and contentment

Following our urges is clearly the opposite of these five keys. Not suppressing urges can then lead to addictions. Whether this is ongoing cigarette smoking, consuming too much alcohol or using illegal drugs to the increasing pervasive urge of dependency on electronics. Rather than cultivating a good quality sleep habit, there is the urge to check messages and emails in the middle of the night. There is the urge to spend too much time sitting in front of the television, rather than exercising. There is the urge to overeat, or even munch on unnecessary food, while you are watching television.

With our urge-focused society, it is no wonder we’re seeing rampaging ‘diabesity’ and ongoing addictions.

Rather than laying the blame on poor government spending, inadequate medical emphasis on prevention, or even shifting all of this back onto the individual, I believe we require a global societal approach to shift from the current disease based medical model to a prevention focus at each level of society.

The first aspect here is to start the discussion, and thank goodness for reports such as the one explored in this article and others, such as the Obesity Initiative from the Royal Australasian College of Physicians. Hopefully, with the increasing emphasis on preventive health, we will start to see a reduction in the carnage from chronic illnesses.

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Contraceptive Microchip

Thursday, July 20, 2017

by Ross Walker


In my opinion, all major crises on this planet are linked to one key issue – whether you consider pollution, terrorism, conflicts between nations and communities, unemployment, government’s inability to offer and maintain basic services such as health, education, transport and all other infrastructure – in my view, it all comes down to the central fact that there are far too many people on the planet.
 
Dan Brown’s latest novel, “Inferno”, addresses this issue and, of course, it is a novel, but I believe we need to start the important discussion regarding overpopulation.  Some commentators and experts in the area believe that if we are to sustain the necessary resources to maintain life on this planet indefinitely, we need to keep the human population at four billion or below.  When I checked recently, the current population was 7,247,780,000 people and rising rapidly. 

Clearly, the growing world population is at a crisis level and some World bodies such as the United Nations, needs to debate this issue, or in my opinion, the human species will probably be extinct within the next one hundred to two hundred years, if that.
 
Thus, I was delighted to hear Bill Gates has partnered with the Massachusetts Institute of Technology in Boston to develop a contraceptive microchip which lasts for sixteen years.  This small microchip can be inserted beneath the skin in the buttocks, abdomen or upper arm and can be switched off remotely if the woman wishes to conceive.  It should be available for general use in 2018 and the Gates Foundation is trying to establish worldwide services in vaccination, contraception and improving the nutrition and accommodation for many people in the third world. 

As I have stated, if we do not start looking at the major issue of overpopulation, I do not have great hope for the long term future of the human species.  As Albert Einstein once said “we cannot solve our current problems with the same thinking we used to create them”. 

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Weight loss - is it all about calories?

Thursday, July 13, 2017

There is no doubt that to lose weight you have to take in less calories than you burn off every day. But, this is not as simple as eating less food and doing more exercise. New evidence is now emerging that it is not just what you eat but also when you eat.

Firstly, let us consider “Calories in”. “Calories in” is everything that goes in your mouth apart from water consumed in an inert container. All “calories in” have the potential of contributing to weight gain although, to take the example of an apple, the number of specific calories in an apple is actually less than the amount needed to metabolise the combination of nutrients found in the apple itself. Therefore, consuming an apple gives you a negative calorie balance which is therefore a help in losing weight. When you consider macronutrients, 1g of fat contributes nine calories, 1g of carbohydrates and protein each contribute four calories. But, a significant carbohydrate load leads to more insulin release, which tends to lay down more fat than the equivalent amount of fat and protein.

Fluid also has to be entered into the equation. If you consume water in an inert container such as a glass or a stainless-steel bottle, then this is not contributing to your calorie intake. Many people these days, however, consume water in a plastic bottle which leeches a vast array of, at times, quite damaging chemicals into the water which can significantly affect metabolism and contribute to weight gain.

Most people, however, also consume other forms of fluid such as tea, coffee, alcohol, juices, milk and the ubiquitous soft drinks, whether sugar sweetened or artificial. Alcohol, for example, contributes seven cal per gram and when you add in the sugar added to the alcoholic beverage, there is a significant caloric intake with each standard alcoholic drink consumed. For example, I saw a patient a few months ago who had significant abdominal obesity. His wife supported his comments that he did not eat much but he went on to tell me that he consumed a bottle of wine on a daily basis which in itself gives him close to 1000 cal per day before he puts anything else in his mouth.

To focus on soft drinks, the amount of sugar in the sugar sweetened beverages is anywhere between 8-12 teaspoons per can and recent work has demonstrated that the artificially sweetened drinks contribute to an equivalent amount of weight gain despite the fact that the artificial sweeteners allegedly carry no calories.

Then we must look at calories out or in other words the energy we burn on a daily basis. There are 3 components here which include exercise, movement and metabolism. Unfortunately, the system is more geared to sin than it is penance. If you go for a brisk half an hour walk, you burn 300 cal. If you have a small piece of chocolate cake you are taking in 300 cal.

Another big issue is that of prolonged sitting. It is now estimated that the average person living in modern society sits for 11 h/day and this is associated with a whole host of health issues from musculoskeletal problems, cardiovascular disease, high blood pressure and even cancer and, of course, the increasing weight gain we see across the board in our society. Last comes the thorny and often misunderstood concept of metabolism. Metabolism is basically the day-to-day functioning of each cell in our body contributing to existence. To maintain normal balance requires a very finely tuned system involving energy production by a component of the cell - the mitochondria, along with thousands of various proteins which have a variety of functions within the body. The complex process of metabolism consumes a significant amount of energy on a daily basis and in fact over a 24-hour period the average person burns around 1500-1600 cal daily before any exercise or movement.

But, the human being is not like a car. With the car, you put the fuel in and you can use the petrol when you need it. With our bodies, if you do not burn the fuel within a few hours of ingestion, it gets laid down as fat.

Now, to discuss the best studied diet, the Mediterranean diet. It is far too simplistic to look at the food that is ingested. In fact, it is the Mediterranean lifestyle that contributes significantly to their good health. They have a large breakfast of fresh fruits and whole grains and burn off any extra carbs in the hot Mediterranean sun in the morning. They have their biggest meal at lunchtime which typically involves pasta and a couple of glasses of wine (typically red wine). The carbs and alcohol make them sleepy and they have an afternoon sleep typically lasting around one hour and then burn off any extra carbs in the hot Mediterranean sun in the afternoon. In the evening, they have a small meal and go to sleep.

In Western society, we have a small breakfast and small lunch and typically snack throughout the day and have a huge evening meal and sit down for a few hours and watch television and then go to sleep. As we are not burning off any of the fuel taken in from our evening meal, it gets laid down as fat. Another major issue is the increasing sleep problems experienced by many people in modern society. 30% of adults experience some form of insomnia along with the very common sleep apnoea. As the body works on a 24 hour cycle, our so-called circadian rhythms are significantly affected by poor sleep as are many of the normal hormonal secretions throughout the day and can certainly affect our metabolism in a deleterious fashion.

Over the past decade, there have been increasing comments about the timing of eating. It appears that one of the bad habits of the modern world is to delay eating until late in the evening, which appears to have a profound effect on metabolism. Prolonged delayed eating can lead to weight gain, increasing insulin and cholesterol levels and negatively affect fat metabolism and the hormonal markers implicated in heart disease, diabetes and many other health issues.

Professor Namni Goel, a professor of psychology in the division of sleep and chronobiology at the University of Pennsylvania has performed a very elegant study on nine healthy weight adults subjecting them to two different conditions over an eight week period. The first involved daytime eating of three meals and two snacks between 8AM to 7PM with a two-week washout in between. This was followed by delayed eating including the same amount of meals and snacks and identical calories, but staggered to between 12 midday to 11PM. Sleep was kept constant throughout the study.

A variety of measurements were performed including weight, the respiratory quotient, which looks at indirect measurement of metabolism, along with a number of hormonal markers. The study clearly showed that delayed eating led to a gain in weight, metabolising fewer fats and more carbohydrates, increasing levels of insulin, glucose, cholesterol and triglycerides.

The well-known hormone, Ghrelin, stimulates appetite and this peaked earlier in daytime eating along with Leptin which induces the feeling of satisfaction when you eat, peaked later. Therefore, eating earlier keeps you satisfied for longer and prevents excessive eating in the evening.

Therefore, weight gain and weight loss is not a simple question of how much we eat and how much we move but clearly also involves the very complex concept of metabolism. This is not a fixed parameter for each individual but can significantly be affected by many factors including age, genetics, the amount of food consumed, the type of food and now, when we eat as well.

As the father of medicine, Hippocrates, has been often quoted as saying, "Let food be thy medicine and medicine be thy food". Although this is a very important comment, it is clearly not that simple.

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Is low dose alcohol safe?

Thursday, July 06, 2017

by Ross Walker

For many years, the battle between the proponents of temperance and the alcohol industry has raged on. Both sides have used medical evidence to support its case. There are not too many people on either side who would suggest that heavy drinking has any benefits apart from filling the coffers of the people who sell alcohol.

Heavy drinking, defined as the regular consumption of four or more standard drinks on a daily basis or intermittent binging, which is five or more drinks during one particular drinking session, is definitely associated with a vast majority of health issues. These typically involve the liver, the brain, the heart and a significant increased cancer risk for a variety of cancers. The World Health Organisation has suggested that 5% of the global burden of disease and injury was directly related to alcohol.  

But, the age-old three questions are

1) Is all alcohol harmful?

2) Is there a safe dose?

3) Is any particular type of alcoholic beverage beneficial to the health?

I have recently written my view on the low-dose alcohol and breast cancer association and since that article, two studies have emerged expressing concern in regard to low or moderate consumption of alcohol. The third study relates to indiscretions of youth and later health issues.  

The first study, in my view, does answer the question about the safety of alcohol during pregnancy. The study performed in Australia and Belgium examines 415 children born as part of the AQUA study - (Asking questions about alcohol in pregnancy study). The study reviewed the alcohol consumption of 1600 women. As a sub-study, the offspring of some of these women were examined at one year old and related the findings to the maternal alcohol consumption during pregnancy. The children underwent 3D imaging of the face to detect any variations in facial features based on the mother’s alcohol consumption.

Low-dose alcohol consumption was defined as less than 20 g on any one occasion and less than 70 g per week. Moderate dose was defined as 21 to 49 g per occasion and less than 70 g per week and high dose was defined as more than 50 g on any occasion. 15 g is a schooner of beer, 150 mL of wine and a standard 30 mL nip of spirits. When compared to women who did not consume any alcohol during pregnancy, there were definite variations in the nose, lips and eyes of children born to mothers who consumed alcohol.

The second study was 30-year data from the Whitehall II study which followed British civil servants. This particular sub-study looked at 550 healthy men and women with an average age of 43. Consuming more than 30 units per week of alcohol, which is the equivalent of around 10 pints of strong beer or 10 large glasses of wine, was definitely associated with damage to part of the brain known as the hippocampus, which is intricately associated with memory. But, consuming 14 to 21 units per week was also associated with the degree of hippocampal atrophy and problems in the white matter of the brain and also language fluency.

The final study, performed in Sweden, was a 27-year study looking at the drinking habits of young men and women and followed their risk for disease as they age. The study began at age 16 and found that binge drinking in younger age, only in women was associated with increased risk for higher blood sugar levels after age 40. This was independent of weight, blood pressure or cigarette smoking. There was not the same association with males. High blood sugar was only associated with weight and BP.

Although studies such as these cannot be extrapolated completely to every individual, they do raise concerns about society’s increasing exposure to alcohol. I have always been a strong supporter of the consumption of low-dose alcohol, which I would define as somewhere between 1-3 glasses most days of the week, but only when combined with a healthy diet, such as the Mediterranean diet, and the daily consumption of a high-quality multivitamin.

Also, not considered in any of the studies, is the reason why people consume alcohol in the first place. Many people consume alcohol for social reasons or to enhance the flavour of food, in the case of wine. But, a number of people also consume alcohol for more pervasive reasons such as stress management, loneliness or to relieve feelings of anxiety and depression. Could it also be that the people in the studies who are not alcoholics and therefore not consuming alcohol to excess had higher stress levels thus contributing to disease? Regardless, the studies do highlight the importance of not only choosing your poison wisely, but also choosing the dose of your poison. Although it is often said, all things in moderation, it is also very important to look at the setting of the moderation i.e., the other factors in your life which may be leading to this particular behaviour. 

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Aspirin for all?

Thursday, June 29, 2017

By Ross Walker

One of the most common questions I am asked, especially in people over the age of 50 is, ‘Should I be taking aspirin every day as a preventative?’ Although aspirin has been available for many years and has a very strong evidence base, as with all pharmaceuticals, there are some concerns around its widespread use.

Many studies over the years have shown around a 25% reduction in cardiovascular disease, including heart attack and stroke. Over the past decade, there have been a number of studies suggesting a reduction in the risk and recurrence of many common cancers.

Recent studies have suggested around a 20% reduction in breast cancer and breast cancer metastasising. In some studies, there have been suggestions of up to a 50% reduction in colon cancer. One study has suggested a reduction in chronic liver disease with the regular use of aspirin. It is not known whether this is specific for aspirin, or whether this pertains to all antiplatelet agents such as the commonly used clopidogrel.

So, with all of this very positive information in support of the regular use of low-dose aspirin as a preventative, should not all of us over the age of 50 be taking this? Well, unfortunately, it is not that simple. I would estimate that around 10% of the population are prone to easy bruising and bleeding and this certainly becomes more prominent as we age. Many of my patients on chronic aspirin, or clopidogrel therapy, have the tell-tale subcutaneous blotches of this treatment. Mind you, I do have a number of patients who are not on this therapy and still have these subcutaneous blotches caused by fragile capillaries beneath the skin, as we age.

Probably somewhere between 5-10% of people who take any form of aspirin, including the enteric-coated low-dose aspirin, may still suffer reflux and other forms of heartburn as a consequence of this therapy. This is not the case with clopidogrel. Aspirin is also associated with chronic inflammation in the stomach, and people who take regular aspirin do have higher rates of gastrointestinal bleeding, intracranial bleeding and, of course, increased bleeding if there is any trauma involved.

A recent study from the Oxford vascular group followed just under 3200 patients for around 10 years. These patients all had some vascular event, such as a transient ischaemic attack, ischaemic stroke or heart attack and were treated with mainly aspirin after the event. For patients under the age of 65, the rates of significant bleeding requiring admission to hospital was 1.5% but these rates increased significantly with patients over age 75, increasing to 3.5%. In patients over 85, the rates were 5%. It was a significant concern that in the patients who did suffer a major bleed, whether it be gastrointestinal or intracranial, the rates of disability and death thereafter increased 10 times higher than those who had not suffered a similar fate.

It may well be that those people who suffered the aforementioned haemorrhages had more fragile capillaries and thus were more prone to bleeding. This, in itself, may be a marker for a poor prognosis and the bleeding was yet just another manifestation of a more fragile population. But, it does raise the question as to who should, and who should not, be taking low dose aspirin. Although I do not believe there are any clear-cut answers, it would be my suggestion that if you have already had a proven vascular event, have a high coronary calcium score or known significant carotid atherosclerosis, then aspirin or clopidogrel should be part of your long-term preventative management. If you have a strong family history particularly of breast or colon cancer, then low-dose aspirin would probably be of benefit as well.

But, if you have a prior history of any form of significant bleeding, bruise easily, or have a strong family history of bleeding, then it is probably better to avoid aspirin or clopidogrel as a preventative. If you have a history of prior peptic ulceration, reflux or any significant upper gastrointestinal symptoms you should certainly have a strong conversation with your treating doctors.

Thus, should aspirin be a key aspect of preventative strategies for all people? Certainly not.

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Can you die of a broken heart?

Thursday, June 22, 2017

By Ross Walker

Although there are many romantic notions about people dying from a broken heart, the evidence is actually quite striking that this is a strong possibility, with specific medical conditions arising in this situation.

Less likely to follow healthy lifestyle principles

Firstly, and most obviously, a person with a broken heart is less likely to follow important lifestyle principles, which are commonly associated with reduced risk for cardiovascular disease.

These include:

1. Quitting all addictions;

2. Getting good-quality sleep;

3. Eating less and eating more naturally;

4. Doing three to five of exercise per week; and

5. Cultivating peace and happiness.

What the studies say

Secondly, there are a number of studies linking the acute release of hormones such as adrenaline and cortisone – typically seen during times of stress – and the generation of an acute coronary syndrome, such as heart attack, unstable angina and even sudden cardiac death.

Acute stressful situations, such as a broken heart, may be associated with the rupture of fatty plaques, and thus, a subsequent heart attack.

There are also a number of studies linking chronic anxiety, depression and loneliness with acute coronary syndromes.

There have also been a number of studies showing much higher rates of death in the three years after a person suffered significant bereavement following the passing of their lifelong partner.

Finally, there is the well-known Takotsubo syndrome, which is severe constriction of the coronary circulation during times of stress. This has been specifically called the broken-heart syndrome.

If an angiogram is performed at the time of presentation with chest pain and shortness of breath, there are no blockages but the circulation is in constriction and resolves once the stress has settled.

How can a broken heart affect your mental health?

People suffering from a broken heart do have much higher rates of depression and anxiety. Depression is felt to be due to a reduction in brain serotonin levels, the so-called ‘happy hormone’, which controls our mood.

If a situation such as a broken heart arises, there is a strong possibility that serotonin levels are affected and depression may occur. Closely linked to a feeling of depression is that of anxiety, probably through the same mechanism.

How a broken heart affects your happy hormones

Apart from the direct effect on serotonin, there are other happy hormones that may be affected as well. Oxytocin is the love hormone, vital for bonding between couples and also parents with their children. If these bonds are broken for any reason, this may have a direct effect on oxytocin levels.

Dopamine is the “pleasure chemical” released from the nucleus accumbens in the brain. When you have a broken heart, it is certainly hard to experience pleasure and therefore the normal secretion of dopamine will be affected.

How a broken heart affects your social life

Because of the profound effects of a broken heart on all aspects of life, many people in this situation prefer to avoid social situations. Although superficial interactions are of no value in this situation, staying close to other important, supportive people may ease the suffering somewhat.

Being held and comforted by important members of your family and close friends is an important part of healing the horrible wounds experienced when your heart is breaking.

However, superficial interactions with people who make ridiculous comments like “time heals all wounds, you’ll meet someone else again soon” or the worst comment, “there are plenty of fish in the sea” are completely unhelpful and, in fact, make the situation worse.

Sudden weight changes

The major way a broken heart may affect your weight is through the combination of reduced attention to maintaining a healthy lifestyle and hormonal abnormalities that arise in this situation, which I referred to above.

Sudden changes of weight in any situation always puts a strain on the body’s normal processes. The body is always trying to achieve homeostasis, which is basically metabolic balance. Any strain on the body changes this balance and can precipitate acute health issues.

Tips for coping with a broken heart

1) Strangely, the most important tip I can give in this situation is to feel and accept the pain. You are supposed to feel bad when your heart is broken and often, by not trying to fight this emotion, the dreadful feelings will ease somewhat.

2) Stay close to the people who genuinely care about you, rather than those who dish out ridiculous platitudes (some of which I mentioned above). People who will hold you, care for you and let you cry on their shoulder.

3) Sleep is important and difficult to achieve under these circumstances. It doesn’t hurt you or your body to take, for a short period of time, gentle pharmaceutical sedatives before bed. There are also a variety of more natural anti-anxiety treatments, e.g. Withania and Kava, which also may be of some benefit.

4) If you have any specific medical symptoms such as chest pain, palpitations or shortness of breath, you still should seek medical attention because a broken heart can lead to more serious health issues.

5) Finally, if your symptoms and feelings persist well beyond a few weeks, it is important to have a strong relationship with a trusted medical practitioner who can help you through this period.

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