Archive for February, 2012

Tobacco Keeps Me Way Too Busy As A Urologist

February 25, 2012




Blog # 47       Andrew Siegel, M.D.

To paraphrase Dr. David Katz—the master levers of our medical destiny are our fingers, forks and feet: fingers that may or may not bring cigarettes to our lips; forks that may or may not bring healthy food to our mouths; feet that may or may not participate in exercise and fitness pursuits.  The negligent use of our fingers, forks and feet is the leading causes of premature death and conversely, the appropriate use of them is capable of preventing 90% of diabetes, 80% of cardiovascular disease and 60% of cancers.

Bottom line:  Most everyone is knowledgeable about the role of tobacco in contributing to cardiovascular disease, stroke, lung cancer and emphysema.  However, the complications of tobacco abuse go way beyond the heart and the lungs; physicians in every medical and surgical specialty bear witness to the havoc that tobacco wreaks on every system in our body.  As a urologist, I am on the front lines of the deleterious and deadly effects of tobacco. Tobacco has clearly been linked to several urological cancers as well as numerous other non-malignant conditions. Tobacco is a major factor in the occurrence of bladder cancer, kidney cancer, sexual dysfunction, and infertility in both men and women.  Smoking cessation can help reverse these serious issues.

Bladder cancer is an incredibly prevalent cancer.  It is the 4th most common cancer in men and the 8th most common cancer in females.  It is highly correlated—hugely so—with the use of tobacco.  Cigarette smoking is the number one environmental cause and greatest risk factor for bladder cancer.  Cancer-causing chemicals known as carcinogens get inhaled into the smoker’s lungs, are absorbed into the bloodstream and are filtered by the kidneys, from where they pass into the urinary bladder.  In the bladder, these carcinogens have prolonged, direct contact time with the bladder lining, where they induce changes that ultimately can become malignant.  There is a many-year “latency period” from the time of exposure of the carcinogens to the actual occurrence of cancer—often several decades.  So the smoking that you did in your teens and twenties can come back to haunt you in your forties and fifties.

Continuing to smoke leads to worse bladder cancer outcomes compared to patients who discontinue tobacco use. Ongoing smoking after the diagnosis of bladder cancer greatly increases the risk of morbidity and mortality, treatment-related complications, recurrence of the cancer and the development of a second malignancy.  Smoking cessation will diminish all of the aforementioned consequences.  It is estimated that elimination of smoking could decrease the overall incidence of bladder cancer by 50%.

Prostate cancer is the most prevalent cancer in men and keeps our office bustling with patients.  Although smoking does not increase the risk of being diagnosed with prostate cancer, men who smoke at the time of prostate cancer diagnosis have an increased risk of recurrence and death from prostate cancer and also face an increased overall mortality from cardiovascular disease. Conversely, those who quit smoking at least a decade before the diagnosis of prostate cancer was made have mortality similar to those who never smoked.

Smoking is also strongly correlated with both male and female sexual dysfunction.  Anything that compromises blood flow to the genitals is going to interfere with sexual function, and the chemicals in tobacco do a marvelous job at constricting blood flow.  Approximately 40% of men with erectile dysfunction are smokers.  There is a direct relationship between the quantity of smoking and the extent of sexual dysfunction. Smoking cessation will help restore lost function, but tobacco takes its toll as former smokers have been shown to be at an increased risk of developing sexual dysfunction later in life.

Smoking adversely affects the reproductive system in both sexes.  As compared to non-smokers, the semen of smokers demonstrates poorer parameters, particularly sperm motility. Thus, sperm from smokers has reduced potential for fertilizing an egg.   Females who smoke have a higher prevalence of fertility issues including an increased risk of ectopic pregnancy and fare poorer than non-smokers when assisted reproductive techniques are needed.  Women who smoke during pregnancy increase their risk for bearing male children born with undescended testicles. Smoking has also been associated with increased risk of acquiring HIV infection, HPV infection, invasive cervical cancer, and pelvic inflammatory disease.

An estimated six trillion cigarettes are smoked worldwide every year.   It is not only the smokers who suffer the ill effects of tobacco use.  The health of individuals exposed to smokers is also at risk due to second-hand smoke. Second-hand smoke is a mixture of the smoke given off by a cigarette, pipe or cigar and the smoke exhaled into the air we breathe from the lungs of smokers.   Second-hand smoke is involuntarily inhaled by non-smokers and can linger in the air for hours after tobacco products have been extinguished.  There is no safe level of second-hand smoke, and even brief exposure can be harmful. Second-hand smoke clearly is associated with serious diseases and is responsible for shortening life spans. Second-hand smoke has been classified by the Environmental Protection Agency as a cause of cancer in human beings, causing approximately 3,000 lung cancer deaths and about 50,000 cardiac deaths in non-smokers in the United States annually.  Second-hand smoke is particularly harmful to young children, being responsible for hundreds of thousands of respiratory tract infections in those under 18 months of age.

There at least 43 carcinogens and more than 300 polycyclic aromatic hydrocarbons in second-hand smoke, as well as many other toxins including arsenic, carbon monoxide, lead, cyanide, DDT, formaldehyde and polonium 210. Polonium 210—a highly toxic radioactive poison that was brought to the attention of the public because of its use in the poisoning of a former KGB agent—is inhaled along with the tar, nicotine, cyanide, and other chemicals.

Smoking is a vile, incredibly harmful, self-destructive and miserable habit and addiction.  It is the single greatest cause of illness and premature death in modern society.  Every cigarette that is smoked can be thought of as another nail in one’s coffin.

Years ago, smoking was an excusable habit simply because we didn’t know any better.  It was thought of as a sophisticated, glamorous and sexually alluring and was so glorified on television, in magazines, and in Hollywood on the silver screen.   Magazine advertisements depicted physicians smoking and one slogan went so far as to state: “More doctors smoke Camels than any other cigarette.”   Even my father, a physician, smoked; however, as soon as he caught wind of the fact that smoking was dangerous to his health, he stopped immediately.

The greatest irony is that there are many smokers who have a pervasive fear of terrorism and potentially pandemic bacterial and viral illnesses such as avian bird flu, mad cow disease, SARS, anthrax, West Nile virus, etc.  What they fail to realize is that the cocktail of carcinogenic chemicals entering their lungs and bloodstream via smoking and being delivered to every single cell in their body can be thought of as little terroristssuicide bombers if you will, that can and certainly will ultimately wreak havoc on their health and their lives.  Smoking really is just a form of slow, voluntary suicide.  While we do not have a great deal of control over terrorist acts or deadly pandemics, we certainly have the ability to live a smart lifestyle that avoids self-destructive behavior such as smoking.

What truly is a source of amazement to me are the smoking lounges in the airports.  Glassed in like fish in an aquarium, these ridiculous-appearing humans are puffing away in unison, garnering not only the ill benefits of first-hand smoke, but also second-hand, third-hand, and every other permutation imaginable!  A motley group of men and women collectively inhaling and exhaling, hacking and choking within this absurd observatory, with plumes of smoke floating around like clouds—this glass menagerie is a showcase for the folly of humankind.

This folly is certainly aided and abetted by Big Tobacco. In 2006, a federal judge named Gladys Kessler ordered strict new limitations on tobacco marketing, sticking it to the cigarette manufacturing companies for their disingenuous behavior and forcing them to stop labeling cigarettes with deceptive descriptors including “low tar,” “light,” or “natural.”  The tobacco industry was shown to have “marketed their lethal product with zeal, with deception, with a single-minded focus on their financial success and without regard for the human tragedy or social costs that success exacted.”  She further stated that “cigarette makers profit from selling a highly addictive product that causes diseases leading to a staggering number of deaths per year, an immeasurable amount of human suffering and economic loss, and a profound burden on our national health care system.”

The WHO (World Health Organization) estimates that by the year 2020, cigarettes will be responsible for the deaths of 10 million people annually.   Cigarettes killed 100 million people in the period between 1900 and 2000, and we’re on track for nearly a billion tobacco-related deaths for the 21st century.  About half of all smokers will die of smoking-related diseases. Habitual smoking decreases general life expectancy by an average of 8-12 years. Many smoking-related deathsare not pleasant and quick deaths, but are often protracted and associated with significant suffering.

There is a magic pill—inexpensive, readily available, free of side effects and safe for all ages—that taken daily will reduce the risk of getting any major chronic disease by 80% or so. This pill is called healthy lifestyle, and if you don’t have it in your medicine cabinet yet, it would make all the sense in the world to acquire it.


Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

 Now available on Amazon Kindle


For my educational video on bladder cancer:


The Guevedoces: How An Intersex Genetic Defect Led To A Blockbuster Class Of Medicines

February 18, 2012

Blog #46   Andrew Siegel, M.D.

In the early 1970’s, a Cornell endocrinologist by the name of Julianne Imperato conducted an expedition to the Dominican Republic to investigate reports of a community where children who were thought to be “girls” at birth turned into “boys” at puberty.  In this remote area, these intersex children—biological males with a normal male chromosomal make-up (46 XY) who have female-appearing genitals—surprisingly develop male genital anatomy at the time of puberty. The very interesting tale of the guevedoces (literally, “penis at 12 years”) and how an understanding of their genetic defect led to the development of a commonly used medication is the subject of this week’s blog.

In Salinas, an isolated village of the southwestern Dominican Republic, 2% of the live births in the 1970’s were guevedoces.  These children who appeared to be girls at birth, developed a penis, testicles and all of the typical male physical characteristics at the time of puberty.  Most guevedoces were found to be descendants of a single common ancestor, Altagracia Carrusco.  Their underlying pathology was shown to be deficiency of an enzyme known as 5- alpha reductase (5AR).  This enzyme is responsible for converting the male hormone testosterone into dihydrotestosterone (DHT), the more potent, active form of testosterone.

During uterine gestation, DHT is essential for the development of normal male external genitals.  In the absence of DHT in utero, the external genitals develop as female.  However, internally the gonadal tissue is that of the male.  The guevedoces have feminized external genitals, a short “vagina,” undescended testicles and an absent uterus.  With the testosterone surge at puberty, the tiny penis– that was thought to be a clitoris–develops into a normal-size, functional penis; at the same time, the testicles, previously not within the scrotal sac, descend into the scrotum, and other usual male characteristics develop in terms of libido, musculature, voice change, etc.  For the duration of their lives, the guevedoces resemble other Dominican men in all respects except that they have scanty beard growth, never develop acne, their prostate glands remain small and they never develop baldness.

The discovery of this congenital 5-alpha reductase (5AR) deficiency in this small enclave of the Dominican Republic helped transform my field of urology from a largely surgical specialty into a discipline that became enabled to offer effective drug treatments and minimally invasive procedures for prostate and urinary conditions.  The clinical findings of the guevedoces led Merck researchers in the 1970’s to work on the development of a drug that would replicate the effects that the 5AR deficiency had on the adult guevedoces population. Pharmaceutical scientists reasoned that if 5AR could be inhibited after the external genitalia were fully formed and mature, then a medication to shrink the prostate, relieve urinary symptoms and treat baldness and acne might be developed.  The legacy of the guevedoces became a class of drugs known as 5 alpha-reductase inhibitors (5ARIs), the “prostate pills.”  Finasteride, the original 5ARI, was approved in 1992.  Dutasteride followed, and the treatment approach to prostatic obstruction was forevermore changed.  Aside from prostate shrinkage and symptomatic relief of urinary symptoms, this class of drugs is an effective treatment for male pattern baldness.

I do not believe in medications unless there is a compelling reason to use them and the benefits outweigh the potential side effects. The 5ARIs are genuine winners with a terrific reward/risk ratio and not only do I endorse them and prescribe them liberally, but I personally start my mornings with a dose of Finasteride.   The 5ARIs cause prostate atrophy and alter the natural history of benign prostate hyperplasia, BPH (prostate enlargement), improving the typical urinary symptoms that the aging male is prone to.  They help prevent a situation where a male cannot urinate (acute urinary retention) and requires emergency placement of a catheter and also help prevent the need for prostate surgery.  The 5ARIs are very useful to control blood in the urine that is of prostatic origin, a not uncommon manifestation of BPH.  Studies have shown that these medications confer a risk reduction for prostate cancer, so urologists often employ the 5ARIs for men at high risk: those with a family history; those with very elevated PSA levels; and those with prior prostate biopsies showing pre-malignant findings.   Men on 5ARIs will have a decrease in prostate specific antigen (PSA) to about 50% of baseline and this is factored into ongoing PSA testing.  Another utility is that if the PSA does not drop to 50% of baseline, it is suspicious that an underlying prostate cancer may be an issue.  Additionally, the shrinkage of the BPH as a result of these medications will make the digital rectal exam more sensitive to finding abnormalities that can help make an early diagnosis of prostate cancer.  Most recently, the 5ARIs have been shown to delay prostate cancer progression in men with low-risk, localized prostate cancer. Finally, the 5ARIs promote hair growth, particularly for men with hair loss at the crown of their heads.

The safety record of the 5ARIs deserves mention, as they are intended for long-term use. Aside from a relatively low incidence of sexual dysfunction—difficult to distinguish from the declining erectile capabilities that occur with aging—the 5ARIs are among the most benign treatments for any chronic condition.  Another rather inconsequential result of 5ARIs is that they cause a decrease in ejaculate volume as a result of the prostate atrophy.  5ARIs do not cause major side effects while still depriving the prostate of stimulation because inhibiting 5AR results only in lowering the concentration of DHT within the prostate gland, leaving serum testosterone levels normal or even slightly elevated.

My own tale:

A number of years ago, within a few day period of time, both my wife and father independently noticed and related to me that I had sunburn on the crown of my head.  This did not appeal to my sense of vanity!   I tried topical Minoxidil (Rogaine) but it was ineffective, so I started Propecia (Finasteride 1mg) every morning.  Lo and behold, about six months later, I was startled to find that my exposed scalp was not so exposed any more. It worked slowly, but within a couple of years after starting the Propecia, the vertex of my head had a full regrowth of hair.  No kidding!

When the Veterans Administration report came out demonstrating that the risk of prostate cancer diminished 25% with Finasteride use, this cinched it—particularly insofar as my father had been diagnosed with prostate cancer at age 65.  This is a drug that fixes my bald spot, shrinks my prostate, and helps prevent prostate cancer for which I have a positive family history. This was truly a win-win situation, a real no- brainer.  I will share with you a little insider information—a significant number of urologists and other physicians avail themselves of this class of medications for all of the reasons just stated.  It is truly a medication worth taking.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

Now available on Amazon Kindle

Refined Foods: Not So Fine For Us

February 11, 2012


Blog # 45   Andrew Siegel, M.D.=



Nature is ever so clever—look at our human species—amazingly engineered, evolved and adapted not only to survive, but also to thrive on this planet.

Whenever nature provides us with a nutrient that is potentially unhealthy, it protects us does by limiting our access to that nutrient.  Take, for example, sugar—also known as sucrose or alternatively, 50% glucose/50% fructose—clearly unhealthy and a key contributor to the obesity epidemic.  The major sources are sugar cane and sugar beets.  Did you ever try to get the sugar out of a sugar cane or sugar beet plant?  They are fibrous and unyielding and if we want to derive calories from these, it will require great effort and we will likely end up frustrated.  It’s like chewing on a stick of bamboo!

However, because of the collective intelligence of mankind—standing on the shoulders of giants, if you will—we are now able to easily remove the protective fiber matrix and process the sugar cane or sugar beet into a pure, refined and powdery product.   This process enables unrestricted access to the sugar and allows many “naked” calories to be easily consumed in a short time period. That is NOT the way nature intended, but humankind has prevailed over nature. Processing has allowed us to cheat nature by refining sugar, permitting consumption in immoderate and unhealthy amounts, contrary to nature’s design.

Now lets move on to a discussion about the processing of grains—specifically wheat, since these amber waves of grain are one of the staples of the American diet. However, this same line of thought is relevant to other grains including rice, corn, rye, oats, barley, etc.  The bottom line is that processing leaves us with a very refined product—not unlike sugar—again cheating nature’s “natural” protective mechanisms.  Unfortunately, when we cheat nature, we ultimately cheat ourselves.

Wheat needs to be processed to make it available and accessible to us. Threshing is the means whereby the chaff  (the wheat husk) is separated from the wheat kernel, the diamond of wheat.  Highly efficient milling enables the wheat kernel to be separated into the following three components—the bran: the outer covering of the wheat kernel; the germ: the embryo or sprouting section; and the endosperm: the source of the white flour that contains starch and protein.

White flour has the bran and germ removed, resulting in a pure, highly refined powder as opposed to whole-wheat flour that contains the bran and germ. By removing the fiber-rich bran and germ, the resulting product has a longer shelf life and makes for lighter and fluffier breads, as opposed to the darker, coarser, heavier breads made from the whole-grain wheat.

The removed bran and germ—the wholesome and healthy components of the wheat kernel—are often used to produce animal and poultry feed.   Interestingly, the farm animals are fed the wholesome, slow-digesting grain components and us humans end up with the refined and unhealthy component!  Go figure!  In fact, the nutritionally depleted and deficient processed white flour needs to be fortified with vitamins and minerals to replace those that were lost with refining, hence the term “enriched” wheat flour.

What is the problem with enriched wheat flour?  Simply, wheat grain that is hulled and stripped of the bran and germ results in a pulverized, super-fine, silky-white powder. This highly refined substance is very similar in appearance to cocaine or heroin. This pre-chewed, pre-digested, melts-in-your-mouth, adult baby food equivalent is absorbed extremely rapidly and is promptly transformed into glucose; it is not unlike getting an injection of intravenous glucose into one’s bloodstream.  Insulin levels (remember that insulin is our “fat” hormone) surge in response and any glucose that does not need to be immediately used as fuel gets stored as glycogen in our muscles and liver and when that is maximized, any excess glucose gets stored as fat.

This quick fix of sugar is not particularly filling because of the absence of fiber; it is a short-lived satisfaction that begs for more consumption, establishing a vicious cycle. The result is a push in the direction of weight gain, insulin-resistance, obesity, diabetes and heart disease. Furthermore, the refined product does not induce the “thermic effect” that many more substantive foods do, in which the body’s metabolism increases because of the energy expenditure it takes to digest a wholesome, fiber-rich product.

In contrast to the refined, enriched wheat flour product, whole-wheat flour is made by grinding up the entire wheat kernel. “Whole” refers to all three grain components used—bran, germ, and endosperm.  Whole-wheat flour is brown in color and textured, as opposed to the silky-white enriched wheat product. Whole wheat is very nutritious because the bran and germ components contain abundant fiber, protein, calcium, iron and other minerals. Because of the fiber, absorption and glucose transformation occur in a slow, gradual and well-regulated fashion. Whole wheat is filling, satisfying and substantive and literally sticks to your ribs.  Whole-wheat adds heaviness to breads or to whatever recipe it is used for and requires more flour to obtain the same volume of bread as white flour. Whole-wheat has a shorter shelf life than white flour because of its higher oil content—the source of the oil being the wheat bran, and the oil being a healthy one.  Products containing oil will go rancid faster than products that do not contain oil.  Whole-wheat flour is more expensive than white or enriched wheat flour.  It is easy to understand why the Industrial Food Complex is enamored with enriched wheat flour.

Now let’s go way beyond mere processing and separation of a natural product into its components and get into a real chemistry experiment—high fructose corn syrup (HFCS).  HFCSis a sugar substitute that is derived from corn via a complicated chemical process. Corn is milled to produce cornstarch, a powdery derivative. The cornstarch is processed into corn syrup, which contains glucose. Glucose is converted to fructose by using a process developed in the 1970’s by food scientists in Japan. Glucose is then added back in differing percentages to the fructose to achieve the desired sweetness. 55% fructose HFCS is used to sweeten soft drinks and a 42% fructose HFCS is used in baked goods. HFCS is abundant in processed foods and drinks.

Why does the Industrial Food Complex adore HFCS?  It is less costly than sugar because of corn subsidies and sugar tariffs. It is easy to transport as the viscous syrup lends itself to huge storage vats within trucks.  Fructose is the sweetest of all naturally occurring carbohydrates and does not crystallize or turn grainy when cold, as sugar can do in cold drinks such as iced tea. Because HFCS is highly soluble, its use makes for softer products and its ability to retain moisture allows for moister and better textured baked goods. Finally, it acts as a preservative to help prevent freezer burn as well as maintain the freshness and extend the shelf life of processed foods.

While HFCS may help preserve processed foods, it does not help preserve us; in fact, I would describe HFCS as killer sweetener.  It’s not just about the “naked” calories of the refined, fiber-less carbohydrate but is all about the fructose, which can be thought of as “poisonous” carbohydrate that has unique and distinct properties.  Fructose is remarkably similar to a carbohydrate that is very familiar to all of us—ethanol, a fermented sugar that is an acute toxin to the brain. However, fructose can only be metabolized by the liver and not by the brain, so in the words of Dr. Robert Lustig, fructose is “alcohol without the buzz.”   While ethanol is an acute toxin, fructose can be thought of as a chronic toxin. The “beer belly” from alcohol is not unlike the “soda belly” seen in those who overindulge in products containing HFCS.

Fructose is metabolized entirely differently from the way glucose is.  Every cell in our body can metabolize glucose, but only the liver can metabolize fructose. Fructose does not stimulate insulin release, as does glucose.  Fructose does not stimulate thesecretion of our satiety hormone leptin, nor suppress our hunger hormone ghrelin, so that foods containing fructose, unless couched in fiber, do not fill us up and curb our appetites. Fructose much more readily than glucose replenishes liver glycogen, and once the liver is saturated with glycogen, triglycerides (fats) are made and stored. Thus, HFCS ingestion can readily lead to obesity, elevated cholesterol, fatty liver, hypertension, insulin resistance and metabolic syndrome. The bottom line is that excessive HFCS ingestion pushes our metabolism towards fat production, and it doesn’t take eating that much processed food to cross the excessive HFCS threshold.

Fructose is the predominant sugar in many fruits, hence the name fructose. The difference between this sugar contained within a piece of fruit as opposed to that within a bottle of cola is that fruit fructose is natural (not created in a chemistry lab) and the amount is significantly less than the load contained within the soft drink. Additionally, the fruit fructose is accompanied by a substantial amount of fiber, anti-oxidants, and other phyto-nutrients, all health-promoting ingredients not present in the cola.


Bottom line:  Resonate with nature and literally think “outside the box,” can, package, bottle, etc., by eating whole, natural foods and not their refined by-products. Whole and real foods do not require a label because what you see is what you get. Leave the chemistry experiments to the chemistry lab and not for our consumption. Processing is a necessity to make some foods accessible to us, so read food and nutritional labels as carefully as you would read the ingredients in a medication, because when it comes down to it, food is medicine. The best diet is the “anti-processed-atarian” diet.  Your body will thank you.



Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

Gluttony, Sloth, & Cardiac Care or Healthy Lifestyle & Wellness

February 4, 2012

Blog # 44   Andrew Siegel, M.D.


February is American Heart Month, so I put my heart into this narrative about this amazingly engineered, all-important organ that serves us tirelessly and relentlessly. Like our pet canines, this organ requires to be  well fed, to be exercised, and to be given tender loving care.  Be kind to it and it will return the favor big time.

Two hundred years ago, the following words on angina pectoris (chest pain from coronary artery occlusion) from John Warren, M.D. were published in the very first issue of the New England Journal of Medicine and Surgery:

The disease itself is excited more especially upon walking up hill,

and after a meal; that thus excited, it is accompanied with a sensation,

which threatens instant death if the motion is persisted in;

and that on stopping, the distress immediately abates, or altogether subsides.


Two centuries later, we are infinitely wiser regarding the diagnosis and management of heart disease, yet unfortunately this illness is more prevalent than ever.  The saddest aspect of this is that coronary artery disease is largely a preventable and avoidable problem.  Every day, many hearts are broken because of the premature and unnecessary demise of loved ones who succumb to cardiac disease. It is my heart’s desire that we become better caretakers of ourselves and avoid the 600,000 deaths to heart disease and 130,000 deaths to strokes that occur every year in the USA.

Cardiovascular disease (CVD), including heart disease and stroke, is the number one cause of death in the USA and other industrial countries.  The only year since 1900 in which CVD was not the leading cause of death was in 1918, the year of the influenza pandemic.  CVD is also the leading cause of death in every region of the world except for sub-Saharan Africa.  The burden of CVD is increasing because of our longer life spans, continued tobacco use, physical inactivity, unhealthy food consumption, obesity, high blood pressure, elevated LDL cholesterol and prevalence of type 2-diabetes.

The following paragraph is a brief historical perspective of some of the important medical advances with respect to the management of heart disease.  The 50-year cardiovascular Framingham study (1948-1998) linked high blood pressure and high cholesterol with angina and heart attacks and originated the novel concept that coronary artery disease and its complications could be prevented.  The advent of the coronary care unit (CCU) vastly decreased the death rate of patients admitted with acute heart attacks by provided sophisticated monitoring with electrocardiograms, closed chest cardiac massage, and external defibrillation (using electric paddles to shock the heart back into a normal rhythm).   Cardiac catheterization and coronary arteriography lead to the birth of cardiac surgery and coronary revascularization (coronary artery bypass).  The field of interventional cardiology enabled balloon angioplasty revascularization of occluded coronary arteries without the need for cracking one’s chest open, using access through a thigh artery.  Cardiac stents, initially metal and currently drug eluting, were developed to prevent coronary re-occlusion.  Statin medications to lower LDL-cholesterol levels and many new and potent cardiac drugs have provided significant advances.  Implantable pacemakers and implantable pacemaker-ventricular defibrillators have further improved the prognosis of those suffering with cardiovascular disease. Sophisticated tests including echocardiograms, treadmill tests, isotope stress tests, Holter monitoring, and computerized tomography of the heart are readily available to help pinpoint the precise cardiac diagnosis.

Despite all of the aforementioned incredible technological advances, coronary artery disease remains highly prevalent and is a major widow-maker and widower-maker.  Why?  It’s really very simple—those all-important, tiny blood vessels that provide the lifeline of blood flow of oxygen and nutrients to that vital organ that pumps our blood 24/7/365 get blocked with fatty plaques.  With clogged coronary arteries, when increased demand is placed on our life-sustaining pump, not enough oxygen can get delivered through the compromised coronary arteries and we develop angina and possibly sustain damage to the heart muscle (a myocardial infarction or heart attack) or its electrical conduction system (an arrhythmia).  Tragically, this compromise to our heart and blood vessels is too often self-induced through bad eating habits, physical inactivity, and the use of tobacco.

To quote the insightful and poetic Dr. David Katz who says it all:

“We are all offspring of predecessors who lived in a world where calories were relatively scarce and hard to get, and physical activity constant, arduous and unavoidable. We now live in a world where physical activity is scarce and hard  to get, and calories constant, effortless and unavoidable.

Atherosclerosis is the process that gives rise to the fatty plaques in our arterial walls that compromise blood flow to our organs.  Atherosclerosisis a chronic arterial inflammation that develops slowly, gradually and progressively over many years.  It happens in response to the biological effects of risk factors.  It begins with changes in the endothelial cells, the unique cells that line arteries.  When subjected to these risk factors, endothelial cells change their permeability and allow white blood cells and LDL cholesterol entrance into the cells.  The risk factors include the following:

  • high blood pressure within the arteries
  • oxidative stress from free radicals (highly reactive molecules known as free radicals are created as a consequence of how our body reacts with oxygen; these interact with other molecules within cells and cause oxidative damage)
  • biochemical stimuli (chemicals from tobacco, high levels of bad fats like LDL cholesterol in the blood, food toxins)
  • inflammatory factors

The presence of white blood cells and LDL cholesterol within the endothelial cells gives rise to a cascade of chemical reactions that causes proliferation of both endothelial and smooth muscle cells and the formation of plaques.  Plaques lead to symptoms by restricting flow through the arteries involved, or alternatively, by provoking clotting that interrupts blood flow.  If the plaque ruptures, more clotting will occur at the site of the disruption, perpetuating the restricted flow, and additionally, the ruptured plaque can travel and jam other blood vessels.  LDL cholesterol is clearly a major culprit and atherosclerosis occurs in direct proportion to LDL levels.

Occlusion of the coronary arteries is a big deal because damage of the blood flow to the heart—the most important organ in our body—is a major concern.  However, it is important to know that the process of atherosclerosis is by no means unique to the heart—it is just that the effects of atherosclerosis on the heart—including angina, heart attacks, arrhythmias and death—are ever so dramatic.  It is critical to realize that if you have atherosclerosis in your coronary arteries, you can bet you have it in every artery in the body—including the aorta and those arteries providing blood to the brain, kidneys, intestines, legs, genitals, etc.  This can give rise to strokes or transient ischemic attacks, kidney disease, pain in the abdomen after meals, pain in the legs when walking, sexual dysfunction, etc.  Suffice it to say that intact blood flow to transport oxygen and nutrients to every cell in our body is our lifeline and we don’t want it compromised.

It is nothing short of wonderful that the medical fields of cardiology and cardiovascular surgery have become so evolved and sophisticated and that we have the medical and surgical resources to manage CVD so well.  Countless lives and loved ones have been saved from premature deaths.  That being the case, I must make an appeal from the bottom of my heart for preventive and pre-emptive measures that can keep the disease away and the cardiac team at bay.  Nature and nurture have roles in CVD and we can’t do a thing about the genetic blueprint that we inherited from our parents that can predispose us to CVD, but we do have incredible power to shape our health destiny with our lifestyle.  In my heart of hearts, I can assure you the truth and the validity of the following statement: Genes load the gun, but lifestyle pulls the trigger.  Even if genetics has been unkind to you, you have the authority and choice to pull the trigger, keep your finger on the trigger, or withdraw your finger from the trigger.

Prostate cancer is the number one cancer in men and one that I spend a great deal of my time managing and treating. Can you guess what the leading cause of death is in prostate cancer patients?  If your answer was prostate cancer, you are wrong.  The leading cause of death in men with prostate cancer is CVD.  After CVD, cancer happens to be the second leading cause of death in the USA and in most developed countries.  Most of our knowledge regarding lifestyle and dietary change for CVD prevention applies to cancer prevention as well.  One of the most dramatic reductions in both CVD and cancer has been through smoking cessation.   A heart-healthy diet and lifestyle will contribute to health improvements in every part of our human anatomy, whether it is the heart, colon, prostate or genitals.

As individuals, we must take responsibility for our health and make every effort towards maximizing our fitness and well-being.  We are the stewards of our own health destiny—no one else is.  Yes, we have physicians, sophisticated diagnostic tests, medications and surgery to help us when things go south, but simply by being smart and living a healthy lifestyle, we can avoid personal grief and the grief of our families.

Please take the following advice to heart:

Pearls to keep your heart ** healthy:

  1.  No smoking or tobacco
  2.  Maintain a healthy weight
  3.  Eat a healthy diet: nutrient-dense, non-processed, whole foods; lean protein including seafood which is abundant in heart-healthy omega-3 fats; eat meat and dairy sparingly (use fat-free dairy products); fruits, vegetables and legumes; nuts and seeds; whole-grain carbohydrates
  4.  Exercise daily: walking is great, but try to get some exercise that makes you sweat, breathe hard and gets your heart pumping. Exercise is all about adaptation. Our hearts and bodies are remarkably adaptable to the “stresses” that we place upon them, whether they be vigorous exercise or sitting on the couch.   
  5.  See a medical doctor for periodic health check-ups: don’t take better care of your car than you do of yourself!
  6.  Minimize and manage stress
  7.  Know your blood pressure and cholesterol levels and maintain them at healthy levels

 ** And every other organ in your body as well.


Heartfully Yours,

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food