The Experts

Dr Ross Walker
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Paraplegics walking again?

Thursday, November 15, 2018

Around a month ago, I gave a talk in Beijing on the Future of Medicine. One of the key points to this talk was the future of bionics and also of stem cell therapy. I suggested the strong possibility of people with spinal injuries being able to regrow new nerves in the damaged spinal-cord, allowing them to walk again.

A recent report from Switzerland published in two journals Nature and Nature Neuroscience, using electrical stimulation is bringing medicine closer to this extraordinary breakthrough. Three men with cervical spine injuries from years previously have been able to walk again with this new technique. Even more extraordinary was the fact that they could still move their legs once the electrical stimulation used as treatment was switched off.

Proprioception is the sense of body position and it appears that this is vital when using electrical stimulation. The electrical stimulation must have the right combination of the very precise location of the damaged nerves and also precise timing of pulses, which do not interfere with proprioception.

This new technique, known as the STIMO method, uses what is known as burst stimulation to have robust control over the activity of motor neurones. It basically mimics what occurs naturally in the spinal cord when motor neurones are stimulated. After five months, voluntary muscle control was improved and the three men involved in the study showed no fatigue in the leg muscles and were walking hands-free for more than a kilometre during the rehabilitation process. It appears that these very intensive sessions triggered what is known as “activity dependent plasticity” in the nervous system and thus reorganised nerve fibres. Strangely, this appeared present even when the electrical stimulation was switched off.

A spinal cord injury is clearly one of the most devastating conditions that can affect any human being and can occur at any age. Well over a third of these types of injuries are related to motor vehicle accidents, just over 30% from falls, 14% from violence and 8% from sports and other recreational activities. Any new therapies available for this condition are, of course, vitally important and major breakthroughs. With the giant leap forward in computing over the past few decades, the ability to develop smaller devices with much greater accuracy and fidelity, we will see electromagnetic therapy in its various forms becoming more prominent in medicine.

Whether it be some form of regenerative medicine, such as stem cell therapy, or these huge advances in electrical stimulation, any treatment that allows previously wheelchair bound people to walk again can be considered close to a miracle.


Can cancer be detected by a blood test?

Thursday, November 08, 2018

In most cases a few decades ago, a diagnosis of cancer was a death sentence. For the last few decades, however, there have been enormous strides in the management of most forms of cancer. The standard treatment up to recently has been extensive surgery, chemotherapy and radiotherapy. Improvements in all three areas have seen much better treatments available for most cases of cancer. But, over the past decade, there have been enormous advances in the personalised management of cancer. Creating a vaccine from a person’s own tumour is an extremely promising new technique. Also, Immunotherapy is now becoming widely used, where a person’s own immune system specifically targets the cancer. It’s a little known fact that cancer cells have almost an invisible shield around them, making them undetectable by the immune system. Many of these new immunotherapy techniques literally punch holes in the shield, allowing the immune system to recognise the malignant cells. Also, as part of immunotherapy, the immune cells and, in particular, the T cells, are being altered and enhanced in their ability to detect and kill cancer cells.

But there’s no doubt that the best management of cancer is prevention and coming a close second is early detection. Regarding preventative strategies for cancer, following solid and well-established lifestyle principles is always the most important. The most obvious example here is clearly do not smoke. 80% of lung cancers are directly related to cigarette smoking and if smoking was not freely available, we would see the rates of lung cancer plummet.

We’ve heard for many years the benefits of good diet to prevent heart disease but this is also the case for cancer. People having two to three pieces of fruit per day and three to five servings of vegetables per day have the lowest rates of heart disease and cancer in the community, as one example of good nutrition preventing common diseases.

We now have many excellent, well-validated scanning techniques that can detect early cancers and also some reasonable blood tests that give us a good pointer to the presence of a cancer. Early detection remains vitally important and recently a potential huge breakthrough came from the University of Bradford in the United Kingdom, which has developed in conjunction with the medical industry, a technique known as IMSTAR Pathfinder system, which generically detects the early presence of any cancers.

The theory is that when you are healthy, your body is in maintenance mode and your cells are in balance. The presence in the body of cancer, even at its early stage, puts the body into stress mode and the immune cells, which are our body’s defence system, are one of the most stressed parts of the body. Even though an immune cell may not be able to recognise an early cancer because of the shield around the cell that I previously mentioned, the cancer still releases toxic chemicals into the blood stream, which induces this immune stress. This new technique subjects white cells to UV light and detects damage to DNA. The cells appear that they have almost a comet like tail, whereas people without cancer do not have this appearance on their white cells. This has been shown to detect early cancers in over 95% of cases and is normal in close to 100% of people who do not have cancer.

Once this has been proven with more research, this should be commercially available at some stage over the next few years. Imagine a situation where you go to a doctor for your routine check-up and as part of your normal blood work, this test is also performed. The detection of an early cancer could then lead to much less extensive early management and cure. The future of medicine is clearly very exciting.


Blood pressure down, lung cancer risk up?

Thursday, November 01, 2018

A recent study published in the British medical Journal from McGill University in Canada reviewed 1 million people in the UK who were commenced on blood pressure treatment between 1995-2015. These people were all adults and were followed for just over 6 years on average. During this time 8,000 people were diagnosed with lung cancer.

Over the past decade, the most commonly prescribed blood pressure treatments are ACE inhibitors (e.g. Coversyl, Tritace or basically any blood pressure treatment whose generic name ends in pril) and angiotensin receptor blockers (e.g. Micardis, Atacand or any blood pressure treatment whose generic name ends in sartan).

The conclusion of this trial was that ACE inhibitors increased lung cancer risk, when compared to angiotensin receptor blockers (ARBs) by 14% in people who have taken these treatments for at least 5 years. When they examined the data in patients treated for more than 10 years, this risk increased by 31%. Well, you may say, the game is over. These drugs should never be prescribed again!

Although from the data, this looks rather obvious, it is important to put statistics into some sort of perspective. These numbers of 14% and 31% are what is known as relative risk. The raw data, in fact, states that the risk of lung cancer in people taking ARB’s is 1.2 cases per person thousand years studied. The risk of lung cancer in people taking ACE inhibitors is 1.6 cases per thousand person years studied. This would be pushed up to 2 cases per thousand person years studied in people taking ACE inhibitors for a prolonged period of time.

To use the same analysis, a relatively recent review of people taking Viagra showed a similar slight increase in risk for melanoma compared with those who did not take Viagra. But other recent studies have emerged suggesting that in people with heart disease who took Viagra, there was a 30% reduction in further heart attack, heart failure and cardiac death and another recent study in mice suggested a 50% reduction in bowel cancer in the mice treated with Viagra.

Another important question to ask here is how can a blood pressure treatment possibly increase lung cancer risk. ACE inhibitors increase two chemicals known as bradykinin and substance P within the body and especially within the lung. Both chemicals are associated with the growth and proliferation of cancer. Therefore, it could be that if you have an existing small cancer and these treatments have been prescribed, it may make the cancer grow and spread more easily. Interestingly, it takes one cancer cell 9 years to become a 2 cm tumour and then without treatment within 6 months that 2 cms has become 2 kg worth of tumour. I therefore do not believe that these drugs cause cancer, rather if you have an existing cancer, it may exacerbate its growth and proliferation.

Thus, we should be rather wary of sensationalist headlines presented by journalists who do not properly understand statistics. But hypertension is a chronic condition and needs chronic, lifelong therapy, which typically includes pharmaceutical therapy. ACE inhibitors have been around for over 30 years and ARB’s a decade less. It is much more common for a person with treated hypertension to avert a stroke or heart attack or the increasing problem of kidney damage than the very minimal risk for developing a cancer. Although this study was adjusted for cigarette smoking, age, body mass index, alcohol and a prior history of lung disease, there are numerous other factors that make it very difficult to control, such as exposure to air pollution and occupation that can also affect lung cancer risk.

Under the circumstances, should everyone be switching from ACE inhibitors to ARB’s? I think not. If people are concerned, the efficacy of both sets of drugs is rather similar but if someone has been on these treatments for years without any issues whatsoever, I would not overreact but purely discuss this with your doctor. Because the efficacy and mode of action of both drugs is relatively similar, I will probably switch my practice to prescribing ARB’s over ACE inhibitors whereas, prior to this study, I was more inclined to use ACE inhibitors first, as they have been around 30 years and there was no data suggesting any harm. Studies such as this are precisely the reason why science is important and why we always should be trying to manage medical conditions, if possible, initially with lifestyle changes and non-pharmaceutical therapy.


Are vitamins just expensive pee?

Thursday, October 11, 2018

Osteoporosis is incredibly common. To quote the osteoporosis Australia website, there is an estimated 1.2 million people living in Australia with the condition and a further 6.3 million people with low bone density. Although postmenopausal women are at the greatest risk for osteoporosis, well over 20% of males over the age of 50 suffer the condition as well. For postmenopausal women, there is around a 2% per year bone loss for several years after the onset of menopause.

The Osteoporosis website also states that low calcium and vitamin D levels are strong risk factors for osteoporosis. The website suggests that adults require around 1,000 mg per day of calcium, which increases to 1,300 mg per day for women over 50 and men over 70. The website also states that low vitamin D levels, due to lack of sun exposure, may imply you are not getting enough vitamin D, which your body needs to absorb calcium. The website doesn’t mention that vitamin D is intricately involved in many aspects of calcium metabolism, not just absorption.

There are other risk factors for osteoporosis, including corticosteroid therapy for many inflammatory conditions, low hormone levels in both men and women, thyroid disease, malabsorption (the most common being coeliac disease) along with the number of chronic inflammatory conditions and medications.

The most important lifestyle risk factor is physical inactivity, closely followed by smoking, excessive alcohol intake and extremes of weight, either too thin or obese.

In a recent edition of Lancet Diabetes and Endocrinology, a large meta-analysis was published of 81 randomised, controlled trials asking the question: does vitamin D prevent bone fractures and improve bone mineral density in adults? The study involved just over 53,500 people and all the studies were for less than five years. The conclusion of the meta-analysis was that vitamin D had no effect on preventing bone fractures or improving bone mineral density in adults.

This study will prompt many people in conservative medicine to suggest that this is more evidence that vitamin supplements are of no value and trot out the age old argument that all supplements do is give you expensive urine.

Interestingly, a few years back, there was a large meta-analysis of calcium supplementation involving 100 studies, asking the same question as the vitamin D meta-analysis. Again, this study showed no benefits for the use of oral calcium supplements for the prevention of bone fracture or the improvement in bone mineral density. But, most endocrinologists and conservative doctors are still recommending calcium supplementation, despite the suggestion in some studies (although I must state this has been refuted in other studies) that oral calcium supplementation increases heart attack rate by around 30%.

So, is this the end of vitamin D supplementation? Should we purely return to 15 minutes of sunlight during the nonburning times on a daily basis?

I would like to make some very important points regarding this well-done meta-analysis.

1. There is no doubt from a significant number of trials that there is a clear link between low vitamin D levels and a number of medical conditions, including osteoporosis, cardiovascular disease, cancer, multiple sclerosis, type II diabetes, depression and asthma.

2. There is also no doubt that around 30% of the Australian population have vitamin D levels below the recommended range. Because Australia is the skin cancer capital of the world, we have embraced the slip slop slap message and therefore a significant minority of the population does not have adequate vitamin D levels

3. Many of the trials, not just in the osteoporosis area but also for the vast majority of common diseases, study people over the age of 50, although in the trial in question, people as young as 18 were included. Regardless, many of the people in these trials already have established disease or are at high risk for the condition once these trials begin.

4. I have stated on numerous occasions previously that vitamin supplementation in any form can not be seen as the same as pharmaceutical therapy. I constantly make the analogy that pharmaceutical therapy is like a high-performance motorcar, taking you from A to B very quickly but with the potential of crashing and killing yourself or possibly sustaining a major injury and thus the vital need for stringent road rules, seat belts and high-tech safety equipment within the car. Vitamin supplementation is more like a bicycle that gets you from A to B much slower but you also get some exercise along the way, the road rules are less rigid and all you really need to do is wear helmets and be careful of drivers. Pharmaceutical therapy has very strong, relatively immediate effects, whereas supplements are purely that, supplements to a healthy lifestyle, taking much longer to be effective, with minimal side effects, in most cases.

Therefore, we can not apply the same rules of randomised controlled trials, which are vital for pharmaceutical drugs, to supplements because, in my view, it takes many years for the supplements to have a benefit. It is my view that if it is demonstrated that supplements do have an effect on the surrogate markers of risk and disease, this is enough justification for their use for all the reasons I have detailed above. 

5. Now, here’s where the problem arises. Homo sapiens are a very disappointing lot, who are not particularly good at compliance. If I prescribe any medication or supplement to a group of people, after 12 months, only 50% are continuing to take the therapy. It is my view that vitamin supplementation does have benefits when you look at the long-term observational trials (because no company can afford to perform randomised controlled trials that go for 10 to 20 years). There is a significant and consistent benefit from the use of certain supplements over this time. This is very true for multivitamins and fish oil, which don’t appear to have any benefits until the trials are performed for 10 years and beyond, as seen from recent randomised controlled trials of short-term supplements, which showed no benefits whatsoever for the treatment or prevention of cardiovascular disease.

I’m not suggesting that there is absolute proof that the long-term ingestion of Vitamin D does have a benefit for osteoporosis but what I am saying is that all the indirect evidence to date points to the fact that being deficient in Vitamin D is associated with a number of diseases, and that well monitored low-dose vitamin D is harmless and, in my view, should be used by a significant proportion of the population.

This large meta-analysis, although well performed with proper statistical analysis, does not answer any questions about whether vitamin D should or should not be used. I for one will continue to take 1,000 I.U. of Vitamin D on a daily basis and will continue to do so, not just for my bones, but for the health of the rest of my body.


The hippy hippy shake up

Thursday, October 04, 2018

There is no doubt that the definitive, evidence-based treatment for severe knee or hip osteoarthritis is a joint replacement. All other therapies are aimed at either reducing inflammation or pain. As yet, we don’t have effective treatments to rebuild cartilage, thus giving a person a new joint is the current best approach.

But we need to ask the question: Is this a cure all? The answer is a definite “No”. The reality is that there is a small but definite failure rate for both hip and knee replacements. Although I am not an orthopaedic surgeon, I see a number of patients who have gone through hip or knee surgery who are left with chronic issues thereafter. Many people, although universally informed by the surgeon involved, do not realise that there is a long rehabilitation process, which requires effort and time after the procedure.

There is also no doubt that weight loss and exercise are two of the most important treatments for osteoarthritis, whether you do or do not have surgery. Maintaining muscle and ligament strength around the joint is vital in all patients, regardless of whether they have had an operation.

A recent article from the British Journal of Sports Medicine looked at a younger group of people age between 18-50 who underwent arthroscopic hip surgery between 2004-2013. Medical records were collected for 12 months before and 24 months after surgery. Rather than focus on the result of the surgery on the affected joint, the researchers looked at other health issues that may arise in conjunction with the surgery, comparing the presence before and then the occurrence after the surgery had occurred.

Very concerningly, there appeared after the procedure to be an 84% increase in mental health disorders, 166% increase in chronic pain, 57% increase in substance abuse, 71% increase in cardiovascular disease, 86% increase in metabolic syndrome (this is the tendency to diabetes, hypertension, cholesterol issues and abdominal obesity), 132% increase in arthritis in other joints and 111% increase in sleep problems.

The explanation for all these issues is suggesting that the long recovery time after this procedure leads to an inability to exercise, a loss of purpose, inability to work — with the combination of all these factors leading to weight gain, poor sleep and the need for pain killers. The psychological effects of all the above are clearly striking. It certainly appears that we need a much better and coordinated approach for people undergoing significant surgery. 

Whether it be orthopaedic surgery, the increasingly common bariatric surgery, cardiac surgery or any forms of operation, if these procedures are elective, it appears to me that prehab is probably just as important as rehab. With prehab, I am of course referring to assessing and managing all potential physical, emotional and mental disorders prior to subjecting people to serious surgeries.

All the potential complications of surgery need to be explained to the patients, along with their close relatives and support prior to, during the hospital stay and after discharge needs to be very comprehensive and extensive. I believe if there is a total rethink in how we approach these issues, we will see less of these very serious complications arising as a consequence of doctors intervening in the variety of chronic, disabling conditions.

As I say very often, the commonest cause of death and disability in the world is cardiovascular disease, closely followed by cancer. Unfortunately, it appears that the third commonest cause of death and disability is modern healthcare. Although, in many cases, this is unavoidable as the underlying condition treated would probably have either killed the patient or made their life a complete misery without treatment, surely there is a better approach?

Many intrusive surgeries are such a major intervention with so many potential negative consequences, involving the team care approach well before the surgery will be the answer. Fortunately, this is now happening in many instances, but the information I presented above is very disturbing when you consider the vast and increased complication rates after surgical procedures.


Is watching sports a health hazard?

Thursday, September 27, 2018

With the football finals all around us, the question is: is all this excitement and/or disappointment worth the effort? A number of medical studies have suggested, over the past few years, a degree of caution when being a spectator in the variety of sports available across the world. These studies have focused on the potential cardiovascular risks of watching sports.

The Canadian Journal of Cardiology published a study looking at people watching hockey games. Interestingly, they compared watching the game on television, live at the game and then compared this to the cardiac effects of vigorous exercise. It appears that watching a hockey game on television increases your heart rate around 78% and this effect is maintained for 39 minutes after the game. Interestingly, watching the game live increases your heart rate 110%, with the effects lasting for 72 minutes. When this is compared with vigorous exercise, the heart rate effects only last for 13 minutes once the exercise is completed.

This study was performed with people without a history of heart disease and also showed during the rising heart rate there were increased markers for inflammation and constriction of arteries related to adrenaline release associated with the stimulation of watching a sporting event.

During the recent World Cup, the now ubiquitous Apple Watches show a marked increase in heart rate whilst the games were being played.

Before the era of Apple watches, there had been analysis of a variety of World Cup soccer events. During a penalty shootout in 1996 in the game between France and the Netherlands, which was won by France, on that day there were 14 more deaths from cardiovascular disease in Dutch men compared with the usual average. In the 1998 Argentina versus England World Cup penalty shootout that was won by Argentina, there was a 25% increase in cardiovascular admissions to English hospitals.

Conversely, when France hosted and won the World Cup, there was a 33% reduction in heart attack across France around the time of the victory.

In the 2006 World Cup, where Italy beat Germany, German men were 2.66 times more likely to suffer an acute coronary event compared with the non World Cup times. Around this time in the greater Munich area, there were 4,279 patients admitted with a cardiovascular condition, just under half of whom had known heart disease. This occurred especially within two hours of kick off. It appears clearly that the stress of watching your team lose is related to a marked increase in cardiovascular risk and also cardiac rhythm disturbances such as atrial fibrillation.

Strangely, there did appear to be another effect of the World Cup. When Germany hosted the World Cup in 2006, nine months after the event, there was a 30% increase in births. This phenomenon has been coined, “Soccer Euphoria”.

It doesn’t appear that adrenaline is released with excitement (this fact the medical profession has known for years) but the happy hormones released when your team wins appears to negate any deleterious effects from the adrenaline. But, when your team loses, clearly you lose the protective effect of happy hormones because, clearly, you are unhappy.

It has been suggested the deleterious health effects are also associated with an increased consumption of alcohol, cigarettes, fast foods laden with salt and synthetic chemicals not to mention lack of sleep, all contributing to acute cardiovascular risk.

With all this evidence about the potential risks of sporting events, especially in people with existing cardiovascular disease, you must ask yourself the question: is it really worth the risk? I suspect most people who love their sport will say- of course it is!


An aspirin a day…

Thursday, September 20, 2018

I’m often asked the question by patients and callers on my various radio segments as to whether they should be taking low dose aspirin on a daily basis to prevent heart attack and stroke. In fact, the evidence from secondary prevention trials (aspirin taken by people who have already had cardiovascular disease) suggests a reduction in recurrent events by around 25%.

Evidence over the last decade has also suggested up to a 30% reduction in a variety of common cancers in people who take daily aspirin. But, the primary prevention trials (people who do not have established disease) have produced quite variable results with some studies suggesting a possible benefit and others showing none at all.

The New England Journal of Medicine recently published the ASPREE trial. This was a trial of 19,000 people over the age of 70 with a follow up period on average just under five years, performed in Australia. All people were free of cardiovascular disease, dementia and considered healthy at the start of the trial and at the end of follow up there was no benefit in terms of reduction of cardiovascular disease and dementia from taking aspirin 100 mg daily compared with the placebo group.

This trial demonstrated an increase in significant bleeding and thus the conclusion of the trial is that aspirin should not be given as preventative therapy for people over the age of 70. This message is consistent with the other trials in younger people, which again did not show any dramatic benefit.

So, who should be taking aspirin? I believe the evidence to date support the use of low-dose aspirin in all people with established cardiovascular disease such as heart disease and stroke or people with very strong risk factors for heart disease, along with a high coronary calcium score. This is, of course, excluding people who are allergic to aspirin or have had a past history of significant gastrointestinal or cerebral bleeds. Aspirin (even the low-dose variety with a protective coating) is also associated with a significant increased risk for gastrointestinal reflux.

Thus, it is important to realise that aspirin is not a magic bullet although has been proven to be highly effective as a blood thinning agent for people with established disease. But, as with all aspects of medicine, one size does not fit all and if anyone reading this article does have established cardiovascular disease and has had no problems from the use of chronic aspirin therapy, it is important that you do not misinterpret this evidence thinking that there is no benefit for you. The message is purely for people without a history of cardiovascular disease or not at a particularly strong risk for this condition. As far as taking aspirin as a prevention for common cancers, although there is weak evidence, I do not believe the medical profession should be encouraging patients to use this for all the reasons I have said above.

As with all aspects of medicine, it is much more important to focus on key lifestyle principles than to believe that pharmaceutical therapy is the panacea that will keep you living for many years without disease.


The rise of the super bug

Monday, September 17, 2018

Every year in the United States alone there are around 23,000 deaths related to drug resistant bacteria. Two million people are infected on a yearly basis in America with some form of drug resistant bacteria.

Most of us have heard of golden staph, better known as methicillin resistant staphylococcus aureus but there are, in fact, more scary bacteria that hardly make news in the public arena, despite the fact that medical and nursing staff in hospitals throughout the world are battling these infections on a daily basis.

The bacteria that causes typhoid fever, salmonella typhi, which affects 21 million people across the globe on a yearly basis, is becoming increasingly resistant to standard antibiotics.

It may shock you that the world’s leading infectious disease is Tuberculosis, killing 1.7 million people per year and often requiring a combination of four antibiotics for six months to eradicate the bacteria. It Is estimated that now 13% of cases are multiresistant to antibiotics.

Multi resistant Klebsiella pneumoniae has a 50% death rate once the infection becomes blood-borne. The bacteria pseudomonas aeruginosa is resistant to the vast majority of commonly used antibiotics.

The mostly forgotten (by the public) sexually transmitted disease, gonorrhoea, has now developed a super resistant strain to all but one antibiotic.

A common skin organism, staphylococcus epidermidis, has become an increasing problem for the elderly or those people with immune disorders, especially if there have any prosthetic materials such as joints, catheters or heart valves.

All forms of super bugs are spreading like wildfire especially in places such as intensive care units where strong antibiotics are often used as a routine in very ill patients.

Many infectious diseases researchers are working furiously to find new ways to attack these deadly bacteria including the development of new, stronger antibiotics; changing older antibiotics to become more powerful; the use of bacteriophages-which are viruses that only attack bacteria. These are some techniques that are being trialled at present.

A recent study combined 4-5 existing antibiotics in one treatment (similar to how Tuberculosis is treated currently) found using over 18,000 different combinations of these antibiotics were highly effective in treating a multi resistant form of E.Coli.

Regardless, the large variety of drug resistant bacteria are increasing and becoming more virulent with many experts in the field predicting at some stage over the next 10 to 15 years we will enter the post antibiotic era where we purely have no treatments to combat these issues.

Hopefully, Science will find the right answers because if not, we will be living in a vastly different world to the one we know today.


Is booze a poison or a tonic?

Thursday, September 13, 2018

With so many of the contradictory health messages over the years, you’d be forgiven for being sceptical and somewhat confused. The latest study published in the Lancet adds more to this confusion, suggesting the only safe intake of alcohol is none whatsoever. The introduction to the study suggests that alcohol is responsible for 3 million deaths around the planet on a yearly basis and is the leading cause of death for people in the 15 to 50 age group, causing around 12% of deaths especially in males.

This study analysed 592 separate reports analysing 28 million people. Understandably, intake of alcohol varies between countries with a rather healthy place like Denmark having over 95% of the adult population consuming alcohol on a regular basis, whereas Muslim countries, such as Bangladesh and Pakistan, have an expected less than 1% of people who consume alcohol regularly.

The study took people who were non-drinkers, compared to those who consumed only one alcoholic drink per day over a 12-month period. The analysis suggested that for every daily alcoholic beverage consumed there was a 0.5% increase in the health problems related to alcohol consumption. In real terms, over the course of a year, the 23 separate health problems related to alcohol consumption were increased from 914/100,000 for the abstainers from alcohol to 918/100,000 for those who drink one alcoholic beverage daily (hardly earth shattering statistics to strike fear in the hearts and other organs of light drinkers).

The variety of health problems included cardiovascular disease and diabetes, a variety of cancers, liver & pancreatic disease, neurological disorders, a variety of infections, along with accidents and violence.

I’d like to take a somewhat different view of these statistics and the entire issue of alcohol consumption. Firstly and most importantly, no one benefits from the excessive consumption of alcohol, apart from people who own hotels or liquor stores. There is no doubt that the regular consumption of four or more standard drinks per day for a male and half that for a female is associated with increasing health problems, such as those mentioned above. Therefore, we should not see the evidence that consuming low dose alcohol may have some benefit as an excuse for heavy or binge drinking.

Secondly, it is my opinion that it isn’t just the alcohol but “who the alcohol is hanging around with” that contributes to the health disorders. What I am inferring here is that you can’t consume an unhealthy diet and expect two glasses of alcohol will afford you some health benefit. For example, if you look at the data from areas of America where a poor diet is consumed, there is no benefit from consuming alcohol and a possible detriment. But, for example, in a more affluent area such as Boston, The Male Physician’s trial demonstrated around an 80% reduction in sudden cardiac death associated with the consumption of one glass of red wine on a daily basis. The Copenhagen Heart study, clearly performed in Denmark where there is a very high proportion of drinkers, demonstrated a 50% reduction in heart disease and cancer when two glasses of red wine were consumed with a healthy Danish diet. The Lyon Heart study, of 36,000 Frenchmen over 12 years showed exactly the same result.

Again, staying with the Harvard data from the Boston area from the Nurses Health study, again suggested that even one glass of alcohol daily can increase the risk for breast cancer. This risk, however, was negated by taking a daily multivitamin on a regular basis for 15 years and beyond.

Finally, it is also important to ask why people consume alcohol? Many people use alcohol as an antidepressant or sedative to numb the pain of a difficult life. Could it be that the alcohol in these people is purely a marker for a mental health disorder and not the actual cause of the problem, thus also increasing the risk for physical disease-a well known association?

Food and alcohol are at the centre of many of our celebrations in life. With around 70% of Australian males and around 50% of females overweight or obese, could it be more that the obesity interacts poorly with the alcohol contributing to all the health problems mentioned above?

I was recently asked the question as to whether grape juice had the same benefits as red wine? The reality is that the polyphenols (strong plant chemicals) in grape juice are in a very complex, polymeric form and therefore are more difficult to absorb. When wine is fermented, these polyphenols are converted to a more monomeric form and are more easily absorbed. I therefore believe the combination of the reduced absorption of polyphenols and the sugar content of grape juice makes it less healthy than the low dose consumption of wine. Red wine, especially, has very concentrated polyphenols, that is, in my view, the evidence for the health benefits in low doses in people who also consume a healthy diet and take a daily multivitamin.

There will always be people with a vested interest either way who will condemn any alcohol consumption on the one hand and those who for other reasons will want to promote the health benefits of alcohol consumption, often playing down the social and health problems created by overuse. As with most issues in life, I believe the answer lies somewhere in the middle and am yet to be convinced that the low-dose, responsible intake of alcohol causes harm and in my view this low dose consumption does have a weak health benefit when combined with all the other aspects of a healthy lifestyle.


Is coffee going to kill you?

Thursday, September 06, 2018

The most commonly used addictive drug in the world is coffee. A few decades ago, coffee was maligned as a substance that should be taken in low doses, if at all, because of the potential for deleterious effects, especially on the heart. But, over the past decade there is increasing evidence for a variety of health benefits when the ingestion of coffee is studied in populations.

But, with the advent of nutrigenetics, which looks at the science of the variety of genetic variations on dietary responses and nutrigenomics, which is the role of nutrients in gene expression, the position on coffee has clearly changed and is very much in the one size does not fit all category.

The human genome contains around 25,000 genes that code for around 150,000 proteins in the body. Logically, you would think that one gene codes for one protein but because of subtle movements in the DNA machinery, different proteins can be created depending on the position of DNA at the time. There are around 60 genes that dictate cardiac risk and in regard to the interaction between coffee and the cardiovascular system, there are four major genes that determine an individual’s response to coffee.

These genes include

1) CYP1A2




The actual designation of the genes is not really important unless you are a geneticist but it is important to realise firstly with CYP1A2 that there are two possibilities. One variation of this gene indicates that you are a fast metaboliser of caffeine and this is associated with reduced cardiovascular risk. The second variation of the gene indicates you are a slow metaboliser of caffeine, which is associated with a higher cardiovascular risk.

The second and third, AD genes, if the rather common mutations are present, then having a double espresso coffee will markedly increase your blood pressure. If however, you do not have these gene mutations, then coffee will have minimal effect on your BP.

Finally, COMT, which affects circulating and locally released adrenaline like hormones, if you have the genetic variation that gives you low activity in this enzyme system, then you will metabolise caffeine slowly and thus there is an increase in acute coronary events.

The bottom line with this discussion is that when genetic testing becomes more widespread, it is important that you have an understanding of your own personal mutations and if you are a coffee drinker with one of the riskier gene mutations, I would strongly suggest you switch to decaffeinated coffee. A standard cup of coffee purchased in a café as around 100 mg of caffeine. Decaffeinated coffee has only 8 mg and therefore the risk of any interactions with these abnormal genes is markedly reduced by drinking decaffeinated coffee.

With our increasing understanding of genetics, in the not too distant future (and, in fact there many good high quality genetic services already offering these tests), we will be able to gain a much better understanding of which nutrients are suited to a particular genetic make up and also which nutrients may affect your own particular gene expression. The same will be true for pharmaceutical drugs where there are already some basic tests available to gauge response to commonly used medications.

Until recently, the only way to determine your response to a particular food or medication is to trial the pill, test the benefits and assess the potential side effects. Fortunately, with these increasing advances in genetic screening, we are much closer to the vitally important field of personalised medicine.

Dr Walker is on the board of Imagene, a company that provides genetic screening services.



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