Posts Tagged ‘diabetes’

Diabetes And Urological Health

August 12, 2017

Andrew Siegel MD  8/12/17

Your taste buds may crave sugar (glucose), but the rest of your body sure doesn’t!

A common presenting symptom of undiagnosed diabetes is frequent urination because of the urine-producing effect of glucose in the urine. People with such urinary frequency will often consult a urologist (urinary tract specialist) erroneously, thinking that the problem is kidney, bladder or prostate in origin, when in actuality it is the sugar in the urine that is the source of the problem.

Because of this urinary frequency presentation of diabetes, urologists often have the opportunity to make the initial diagnosis and refer the patient for appropriate care. Similarly, many uncircumcised men who have foreskin problems–particularly when the foreskin becomes stuck down over the head of the penis and will not retract (phimosis)–have undiagnosed diabetes. A simple dipstick of urine in conjunction with the typical presenting symptoms of frequent daytime and nighttime urination and/or foreskin issues directs the proper diagnosis.

Diabetes has detrimental effects on all body systems, with the urinary and genital systems no exception. Today’s entry reviews the impact of diabetes on urological health. Many urological problems occur as a result of diabetes, including urinary infections, kidney and bladder conditions, foreskin issues and sexual problems.  Additionally, diabetes increases the risk of kidney stones. Although many of the same urinary issues that are present in diabetics commonly also occur with the aging process (in the absence of diabetes), the presence of diabetes hastens their onset and severity.  Diabetes can have catastrophic consequences including the following: heart disease, stroke, blindness, kidney failure requiring dialysis and vascular disease resulting in amputations.

Wickipedia public domain copy

Thank you, Wikipedia, for the above public domain image

Diabetes 101

Diabetes is a disease in which blood glucose levels are elevated. Glucose is the body’s main fuel source, derived from the diet.  Insulin, a hormone secreted by the pancreas, is responsible for moving glucose from the blood into the body’s cells so that life processes can be fueled. In diabetes, either there is no insulin, or alternatively, plenty of insulin, but the body cannot use it properly. Without functioning insulin, the glucose stays in the blood and not the cells that need it, resulting in potential harm to many organs.

Two distinct types of diabetes exist. Type 1 is an autoimmune condition in which the body’s immune system destroys insulin-producing cells, severely limiting or completely stopping all insulin production.  It is often inherited and is responsible for about 5% of diabetes. It is managed by insulin injections or an insulin pump.

Type 2 diabetes is caused by overeating and sedentary living and is responsible for 95% of diabetes. This form of diabetes is caused by insulin resistance, a condition in which the body cannot process insulin and is resistant to its actions. Anybody with excessive abdominal fat is on the pathway from insulin resistance towards diabetes.  Type 2 diabetes is a classic example of an avoidable and “elective” chronic disease that occurs because of an unhealthy lifestyle.

Sad, but true: Chances are that if you have a big abdomen (“visceral” obesity marked by internal fat) you are pre-diabetic. This leaves you with two pathways: the active pathway – cleaning up your diet, losing weight and getting serious about exercise, in which this potential problem can be nipped in the bud. However, if you take the passive pathway, you’ll likely end up with full-blown diabetes.

Common presenting symptoms of diabetes are frequent urination, thirst, extreme hunger, weight loss, fatigue and irritability, recurrent infections, blurry vision, cuts that are slow to heal, and tingling or numbness in the hands or feet.

Complications of diabetes occur because of chronic elevated blood glucose and consequent damage to blood vessels and nerves.  Diabetes accelerates atherosclerosis, a condition in which fatty deposits occur within the walls of arteries, compromising blood flow and the delivery of oxygen and nutrients to tissues. Diabetic “small blood vessel” disease can lead to retinopathy (visual problems leading to blindness), nephropathy (kidney damage leading to dialysis), and neuropathy (nerve damage causing loss of sensation).  Diabetic “large vessel disease” can cause coronary artery disease, stroke, and peripheral vascular disease.  Diabetes increases the risk of infections because of poor blood flow and impaired function of infection-fighting white blood cells.

Diabetes and the bladder

Many diabetics have urological problems on the basis of the neuropathy that affects the bladder.  These issues include impaired sensation in which the bladder becomes “numb” and the patient gets no signal to urinate as well as impaired bladder contractility in which the bladder muscle does not function properly, causing inability to empty the bladder completely.  Other diabetics develop involuntary bladder contractions (overactive bladder), causing urinary urgency, frequency and incontinence.

Diabetes and the kidneys

Diabetes is the most common cause of kidney failure, accounting for almost half of all new cases. Even with diabetic control, the disease can lead to chronic kidney disease, kidney failure and the need for dialysis or kidney transplantation.

Diabetes and urinary/genital Infections

Diabetics have more frequent urinary tract infections than the general population because of factors including improper functioning of the infection-fighting white blood cells, glucose in the urine (a delightful treat for bacteria) and compromised blood flow. Diabetics have a greater risk of asymptomatic bacteriuria and pyuria (the presence of white cells and bacteria in the urine without infection), cystitis (bladder infections), and pyelonephritis (kidney infections).  Impaired bladder emptying further complicates the potential for infections.  Diabetics have more serious complications of pyelonephritis including kidney abscess, emphysematous pyelonephritis (infection with gas-forming bacteria), and urosepsis (a very serious systemic infection originating in the urinary tract requiring hospitalization and intravenous antibiotics).  Fournier’s gangrene (necrotizing fasciitis) is a soft tissue infection of the male genitals that often requires emergency surgery (that can be disfiguring) and has a very high mortality rate.  Over 90% of patients with Fournier’s gangrene are diabetic. Diabetic patients also have an increased prevalence of infections with surgical procedures, particularly those involving prosthetic implants, including penile implants, artificial urinary sphincters, and mesh implants for pelvic organ prolapse.

Diabetes and the foreskin

Balanoposthitis is medical speak for inflammation of the head of the penis and foreskin. As mentioned previously, a tight foreskin that cannot be pulled back to expose the head of the penis (phimosis) can be the first clinical sign of diabetes in uncircumcised men. At least 25% of men with this problem have underlying diabetes.  It is common for these men to have fungal infections under the foreskin because of the risk factors of a warm, moist, dark environment in conjunction with the presence of glucose in the urine. The good news is that phimosis and fungal infections often respond nicely to diabetic control.

Who Knew? I learned from a patient of mine that this issue is referred to in slang as “sugar dick.”

Diabetes and sexual function

Sexual functioning is based upon good blood flow and an intact nerve supply to the genitals and pelvis.  Diabetics often develop sexual problems (in fact, diabetes is the most common cause of erectile dysfunction) because of the combination of neuropathy and blood vessel disease.  Men commonly have a reduced sex drive and have difficulty achieving and maintaining erections.  Diabetes increases the risk of erectile dysfunction threefold.  Diabetes has clearly been linked with testosterone deficiency, which can negatively impact sex drive and sexual function.  Because of the neuropathy, many diabetic males have retrograde ejaculation, a situation in which semen goes backwards into the bladder and not out the urethra.  Female diabetics are not spared from sexual problems and commonly have reduced desire, decreased arousal and sexual response, vaginal lubrication issues and painful sexual intercourse.

Diabetic management

With Type 2 diabetes it is vital to modify lifestyle, including dietary changes that avoid diabetic-promoting foods and replacement with healthier foods in order to have appropriate sugar control to help prevent diabetic complications. Diabetics should refrain from high glycemic index foods (those that are rapidly absorbed) including sugars and refined white carbohydrates and instead should consume high-fiber vegetables, fresh fruits, and whole-grain products.  Regular exercise is equally as important as healthy eating, and the combination of healthy eating, physical activity, and weight loss can often adequately address Type 2 diabetes.

When lifestyle measures cannot be successfully implemented or do not achieve complete resolution, there are different classes of medications that can be used to manage the diabetes. However, lifestyle modification should always be the initial approach, since lifestyle (in large part) caused the problem and is capable of improving/reversing it.  At times, when diet, exercise and drugs are unable to control the diabetes, bariatric (weight loss) surgery may be needed to control and even potentially eliminate the diabetes.

Bottom Line:  Diabetes is a serious chronic illness with potentially devastating complications. Type 1 diabetes is relatively rare and unavoidable, but is manageable with insulin replacement. Type 2 diabetes is epidemic and its prevalence has increased dramatically coincident with the expanding American waistline. It can be improved/reversed through integration of healthy eating habits, weight management, and exercise. Lifestyle modifications can be amazingly restorative to general, urological and sexual health and overall wellbeing. After all, our greatest wealth is health.

Wishing you the best of health,

2014-04-23 20:16:29

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Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

Amazon page for Dr. Siegel’s books

 

 

Getting Up At Night Gets Me Down: Nighttime Urinating

May 24, 2014

Blog #155

Getting up once to relieve your bladder during sleep hours is usually not particularly troublesome. However, when it happens two or more times, it can negatively impact one’s quality of life because of sleep disruption, daytime fatigue, an increased risk of fatigue-related accidents and an increased risk of fall-related nighttime injuries. Fatigue has a negative effect on just about everything, even influencing us to mindlessly eat.

Nocturia is the medical term for the need to awaken from sleep to urinate. One’s natural response is to think urinary bladder problem and seek a consultation with a urologist, the type of doctor who specializes in the urinary system. Although nocturia manifests itself via the bladder and much of the time is a urological issue, it is often not a bladderproblem. Rather, the kidneys are frequently culprits in contributing to the condition.

The kidneys are remarkable organs that can multitask like no other. They not only filter blood to remove waste products, but are also responsible for other vital body functions: They are in charge of maintaining the proper fluid volume within our blood stream. They regulate the levels of our electrolytes including sodium, potassium, chloride, etc. They keep our blood pH (indicator of acidity) at a precise level to maintain optimal function. They are key players in the regulation of blood pressure. Furthermore—and unbeknownst to many—they are responsible for the production of several important hormones: calcitrol (calcium regulation), erythropoietin (red blood cell production), and renin (blood pressure regulation). The kidneys regulate our blood volume by concentrating or diluting our urine depending on our state of hydration. When we are over-hydrated, the kidneys dilute the urine to rid our bodies of excess fluid, resulting in virtually clear urine. When we are dehydrated, the kidneys concentrate urine to preserve our fluid volume, resulting in very concentrated urine that can look as dark as apple cider.

Nocturia correlates with aging and the associated decline in kidney function and decreased ability to concentrate urine. Although having an enlarged prostate may certainly contribute to nocturia, it is obviously much more complicated than this since women do not have prostates and nocturia is equally prevalent in men and women. As simple as getting up at night to urinate sounds, it is actually a complex condition often based upon multiple factors that require careful evaluation in order to sort out and treat appropriately. When a urology consultation is sought, our goal is to distinguish between urological and non-urological causes for nighttime urinating. It often comes down to one of three factors: nighttime urine production by the kidneys; capacity of the urinary bladder; and sleep status. In the elderly population, excessive nighttime urine production is a factor almost 90% of the time.

Nocturia can ultimately be classified into one or more of 5 categories: global polyuria (making too much urine, day and night); nocturnal polyuria (making too much urine at night); reduced bladder capacity; sleep disorders; and circadian clock disorders (problems with our bio-rhythms). Global polyuria can result from excessive fluid intake from overenthusiastic drinking or from dehydration from poorly controlled diabetes mellitus (sugar diabetes). The pituitary gland within our brain manufactures an important hormone responsible for water regulation. This hormone is ADH—anti-diuretic hormone—and it works by giving the message to the kidneys to concentrate urine. Diabetes insipidus is a disease of either kidney origin—in which the kidneys do not respond to ADH—or pituitary origin—in which there is deficient secretion of ADH. In either case, lots of urine will be made, resulting in frequent urination, both daytime and nighttime. Medications including diuretics, SSRIs (selective serotonin reuptake inhibitors), calcium blockers, tetracycline and lithium may induce global polyuria.

Nocturnal polyuria may be on the basis of excessive fluid intake, especially diuretic beverages including caffeine and alcohol, a nocturnal defect in the secretion of ADH, and unresponsiveness of the kidneys to the action of ADH. Congestive heart failure, sleep apnea and kidney insufficiency may also play a role. Certain conditions result in accumulation of fluids in tissues of the body such as the legs (peripheral edema); when lying down to sleep, the fluid is no longer under the same pressures as determined by gravity, and returns to the intravascular (within the blood vessels) compartment. It is then subject to being released from the kidneys as urine. Such conditions include heart, kidney and liver impairment, nephrotic syndrome, malnutrition and venous stasis. Circadian clock disorders cause reduced ADH secretion or activity, resulting in dilute urine that causes nocturia.

Nocturia may also be caused by primary sleep disorders including insomnia, restless leg syndrome, narcolepsy, and arousal disorders (sleepwalking, nightmares, etc.)

There are numerous urological causes of reduced bladder capacity. Any abnormal process that occurs within the bladder can irritate its delicate lining, causing a reduced capacity: bladder infections, bladder stones, bladder cancer, bacterial cystitits, radiation cystitis, and interstitial cystitis. An overactive bladder—a bladder that “squeezes without its owner’s permission”—can cause nocturia. Some people have small bladder capacities on the basis of scarring, radiation, or other forms of damage. Prostate enlargement commonly gives rise to nocturia, as can many neurological diseases that often have profound effects on bladder function. Incomplete bladder emptying can give rise to frequent urination since the bladder is already starting out on a bias of being partially filled. This problem can occur with prostate enlargement, scar tissue in the urethra, neurologic issues, and bladder prolapse.

The principal diagnostic tool for nocturia is the frequency-volume chart (FVC), a simple test that can effectively guide diagnosis and treatment. This is a 24-hour record of the time of urination and volume of urination, requiring a clock, pencil, paper and measuring cup. Typical bladder capacity is 10–12 ounces with 4–6 urinations per day. Reduced bladder capacity is a condition in which frequent urination occurs with low bladder capacities, for example, 3–4 ounces per void. Global polyuria is a condition in which bladder volumes are full and appropriate and the frequency occurs both daytime and nighttime. Nocturnal polyuria is nocturnal urinary frequency with full and appropriate volumes, with daytime voiding patterns being normal.

Lifestyle modifications to improve nocturia include the following: preemptive voiding before bedtime, intentional nocturnal and late afternoon dehydration, salt restriction, dietary restriction of caffeine and alcohol, adjustment of medication timing, use of compression stockings with afternoon and evening leg elevation, and use of sleep medications as necessary.

Urological issues may need to be managed with medications that relax or shrink the prostate when the issue is prostate obstruction, and bladder relaxants for overactive bladder. For nocturnal polyuria, synthetic ADH (an orally disintegrating sublingual tablet) in dosages of 50-100 micrograms for men and 25 micrograms for women can be highly effective.

Bottom Line: Nocturia should be investigated to determine its cause, which may often in fact be related to conditions other than urinary tract issues. Nighttime urination is not only bothersome, but may also pose real health risks. Chronically disturbed sleep can lead to a host of collateral wellness issues.

Andrew Siegel, MD

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health; available in e-book (Kindle, iBooks, Nook) and coming soon in paperback.

www.MalePelvicFitness.com

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Sex and the Mediterranean Diet

February 1, 2014

Blog # 139

Sexuality is a very important part of our human existence, both for purposes of procreation as well as pleasure.  Although not a necessity for a healthy life, the loss or diminution of sexual function may result in loss of self-esteem, embarrassment, a sense of isolation and frustration, and even depression. Therefore, for many of us it is vital that we maintain our sexual health. Loss of sexual function further exacerbates progression of sexual dysfunction—the deficiency of genital blood flow that often causes sexual dysfunction produces a state of poor oxygen levels (hypoxia) in the genital tissues, which induces scarring (fibrosis) that further compounds the problem.  So “use it or lose it” is a very relevant statement when it comes to sexual function, as much as it relates to muscle function.

Healthy sexual function for a man involves a satisfactory libido (sex drive), the ability to obtain and maintain a rigid erection, and the ability to ejaculate and experience a climax. For a woman, sexual function involves a healthy libido and the ability to become aroused, lubricate adequately, to have sexual intercourse without pain or discomfort, and the ability to achieve an orgasm.   Sexual function is a very complex event contingent upon the intact functioning of a number of systems including the endocrine system (produces sex hormones), the central and peripheral nervous systems (provides the nerve control) and the vascular system (conducts the blood flow).

A healthy sexual response is largely about adequate blood flow to the genital and pelvic area, although hormonal, neurological, and psychological factors are also important.  The increase in the blood flow to the genitals from sexual stimulation is what is responsible for the erect penis in the male and the well-lubricated vagina and engorged clitoris in the female. Diminished blood flow—often on the basis of an accumulation of fatty deposits creating narrowing within the walls of blood vessels—is a finding associated with the aging. This diminution in blood flow to our organs will negatively affect the function of all of our systems, since every cell in our body is dependent upon the vascular system for delivery of oxygen and nutrients and removal of metabolic waste products.  Sexual dysfunction is often on the basis of decreased blood flow to the genitals from pelvic atherosclerosis, the accumulation of fatty deposits within the walls of the blood vessels that bring blood to the penis and vagina.

Sexual dysfunction may be a sign of cardiovascular disease. In other words, the quality of erections in a man and the quality of sexual response in a female can serve as a barometer of cardiovascular health. The presence of sexual dysfunction can be considered the equivalent of a genital stress test and may be indicative of a cardiovascular problem that warrants an evaluation for arterial disease elsewhere in the body (heart, brain, aorta, peripheral blood vessels).  The presence of sexual dysfunction is as much of a predictor of cardiovascular disease as is a strong family history of cardiac disease, tobacco smoking, or elevated cholesterol. The British cardiologist Graham Jackson has expanded the initials E.D. (Erectile Dysfunction) to mean Endothelial Dysfunction (endothelial cells being the type of cells that line the insides of arteries), Early Detection (of cardiovascular disease), and Early Death (if missed). The bottom line is that heart healthy is sexual healthy.

Many adults are beset with Civilization Syndrome, a cluster of health issues that have arisen as a direct result of our sedentary lifestyle and poor dietary choices.  Civilization Syndrome can lead to obesity, high blood pressure, and elevated cholesterol and can result in such health problems as diabetes, heart attack, stroke, cancer, and premature death.  The diabetic situation in our nation has become outrageous—20 million people have diabetes and more than 50 million are pre-diabetic, many of whom are unaware of their pre-diabetic state! It probably comes as no surprise that diabetes is one of the leading causes of sexual dysfunction in the United States.

Civilization Syndrome can cause a variety of health issues that result in sexual dysfunction.  Obesity (external fat) is associated with internal obesity and fatty matter clogging up the arteries of the body including the arteries which function to bring blood to the genitalia.  Additionally, obesity can have a negative effect on our sex hormone balance (the balance of testosterone and estrogens), further contributing to sexual dysfunction. High blood pressure will cause the heart to have to work harder to get the blood flowing through the increased resistance of the arteries. Blood pressure lowering medications will treat this, but as a result of the decreased pressure, there will be less forceful blood flow through the arteries.  Thus, blood pressure medications, although very helpful to prevent the negative effects of hypertension—heart attacks, strokes, etc.—will contribute to sexual dysfunction.  High cholesterol will cause fatty plaque buildup in our arteries, compromising blood flow and contributing to sexual dysfunction.  Tobacco constricts blood vessels and impairs blood flow through our arteries, including those to our genitals. Smoking is really not very sexy at all!  Stress causes a surge of adrenaline release from the adrenal glands. The effect of adrenaline is to constrict blood vessels and decrease sexual function.  In fact, men with priapism (a prolonged and painful erection) are often treated with penile injections of an adrenaline-like chemical.

A healthy lifestyle is of paramount importance towards the endpoint of achieving a health quality and quantity of life.  Intelligent lifestyle choices, including proper eating habits, maintaining a healthy weight, engaging in exercise, adequate sleep, alcohol in moderation, avoiding tobacco and stress reduction are the initial approach to treating many of the diseases that are brought on by poor lifestyle choices.  Sexual dysfunction is often in the category of a medical problem that is engendered by imprudent lifestyle choices.  It should come as no surprise that the initial approach to managing sexual issues is to improve lifestyle choices.  Simply by pursuing a healthy lifestyle, Civilization Syndrome can be prevented or ameliorated, and the myriad of medical problems that can ensue from Civilization Syndrome, including sexual dysfunction, can be mitigated.

In terms of maintaining good cardiovascular health (of which healthy sexual function can serve as a proxy), eating properly is incredibly important—obviously in conjunction with other smart lifestyle choices. Fueling up with the best and most wholesome choices available will help prevent the build up of fatty plaques within blood vessels that can lead to compromised blood flow. Poor nutritional decisions with a diet replete with fatty, nutritionally-empty choices such as fast food, puts one on the fast tract to clogged arteries that can make your sexual function as small as your belly is big!.

A classic healthy food lifestyle choice is the increasingly popular Mediterranean diet.  This diet, the traditional cooking style of the countries bordering the Mediterranean Sea including Spain, France, Greece, Cyprus, Turkey, Southern Italy, and nearby regions, has been popular for hundreds of years. The Mediterranean cuisine is very appealing to the senses and includes products that are largely plant-based, such as anti-oxidant rich fruits and vegetables, whole grains, nuts, seeds and legumes.  Legumes—including peas, beans, and lentils—are a wonderful source of non-animal protein.  Soybeans are high in protein, and contain a healthy type of fat.  Soy is available in many forms— edamame (fresh in the pod), soy nuts (roasted), tofu (bean curd), and soymilk. Fish and poultry are also mainstays of the Mediterranean diet, with limited use of red meats and dairy products.  The benefits of fish in the diet can be fully exploited by eating a good variety of fish.  Olive oil is by far the principal fat in this diet, replacing butter and margarine. The Mediterranean diet avoids processed foods, instead focuses on wholesome products, often produced locally, that are low in saturated fats and high in healthy unsaturated fats. The Mediterranean diet is high in the good fats (monounsaturated and polyunsaturated) which are present in such foods as olive, canola and safflower oils, avocados, nuts, fish, and legumes, and low in the bad fats (saturated fats and trans fats).  The Mediterranean style of eating provides an excellent source of fiber and anti-oxidants.  A moderate consumption of wine is permitted with meals.

Clearly, a healthy diet is an important component of a healthy lifestyle, the maintenance of which can help prevent the onset of many disease processes.  There are many healthy dietary choices, of which the Mediterranean diet is one.  A recent study reported in the International Journal of Impotence Research (Esposito, Ciobola, Giugliano et al) concluded that the Mediterranean diet improved sexual function in those with the Metabolic Syndrome, a cluster of findings including high blood pressure, elevated insulin levels, excessive body fat around the waist and abnormal cholesterol and triglyceride levels.  35 patients with sexual dysfunction were put on a Mediterranean diet and after two years blood test markers of endothelial function and inflammation significantly improved in the intervention group versus the control group. The intervention group had a significant decrease in glucose, insulin, low-density lipoprotein cholesterol (LDL—the “bad” cholesterol), triglycerides, and blood pressure, with a significant increase in high-density lipoprotein cholesterol (HDL—the “good” cholesterol).  14 men in the intervention group had glucose intolerance and 6 had diabetes at baseline, but by two years, the numbers were reduced to 8 and 3, respectively.

Why is the Mediterranean diet so good for our hearts and sexual health?  The Mediterranean diet is high in anti-oxidants—vitamins, minerals and enzymes that act as “scavengers” that can mitigate damage caused by reactive oxygen species.  Reactive oxygen species (also known as free radicals) are the by-products of our metabolism and also occur from oxidative damage from environmental toxins to which we are all exposed.  The oxidative stress theory hypothesizes that, over the course of many years, progressive oxidative damage occurs by the accumulation of the chemicals the accumulation of reactive oxygen species engender diseases, aging and, ultimately, death.  The most common anti-oxidants are Vitamins A, B-6, B-12, C, E, folic acid, lycopene and selenium.  Many plants contain anti-oxidants—they are concentrated in beans, fruits, vegetables, grain products and green tea.  Brightly colored fruits and vegetables are good clues as to the presence of high levels of anti-oxidants—berries, cantaloupe, cherries, grapes, mango, papaya, apricots, plums, pomegranates, tomatoes, pink grapefruit, watermelon, carrots, broccoli, spinach, kale, squash, etc.—are all loaded with anti-oxidants as well as fiber. A Mediterranean diet is also high in omega-3 fatty acids, a type of polyunsaturated fat present in oily fish including salmon, herring, and sardines.  Nuts—particularly walnuts—have high omega-3 fatty acid content.  Research has demonstrated that these “good” fats have numerous salutary effects, including decreasing triglyceride levels, slightly lowering blood pressure, and decreasing the growth rate of fatty plaque deposits in the walls of our arteries (atherosclerosis), thus reducing the risk of cardiovascular disease, stroke, and other medical problems. Mediterranean cooking almost exclusively uses olive oil, a rich source of monounsaturated fat, which can lower total cholesterol and LDL cholesterol while increasing HDL cholesterol. It is also a source of antioxidants including vitamin E.  People from the Mediterranean region generally drink a glass or two of red wine daily with meals. Red wine is a rich source of flavonoid phenols—a type of anti-oxidant—which protects against heart disease by increasing HDL cholesterol and preventing blood clotting, similar to the cardio-protective effect of aspirin.

The incorporation of a healthy and nutritious diet, such as the Mediterranean diet, is a cornerstone for maintaining good health in general, and vascular health, including sexual health, in particular.  The Mediterranean diet—my primary diet and one that I have incorporated quite naturally since it consists of the kinds of foods that I enjoy—is colorful, appealing to the senses, fresh, wholesome, and one that I endorse with great passion. Maintaining a Mediterranean dietary pattern has been correlated with less cardiovascular disease, cancer, and sexual dysfunction.  And it is very easy to follow.  It contains “good stuff”, tasty, filling, and healthy, with a great variety of food and preparation choices—plenty of colorful fresh fruit and vegetables, a variety of fish prepared in a healthy style, not fried or laden with heavy sauces, healthy fats including nuts and olive oil, limited intake of red meat, a delicious glass of red wine.  It’s really very simple and satisfying.  Of course the diet needs to be a part of a healthy lifestyle including exercise and avoidance of harmful and malignant habits including smoking, excessive alcohol, and stress.  So if you want a sexier style of eating, I strongly recommend that you incorporate the Mediterranean diet into your lifestyle.  Intelligent nutritional choices are a key component of physical fitness and physical fitness leads to sexual fitness.

Andrew Siegel, M.D.

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When Our Kidneys Go South

October 26, 2013

Andrew Siegel MD Blog #125

Our kidneys are paired, bean-shaped, fist-sized organs that work diligently and silently behind the scenes 24/7/365, filtering our blood free of toxins and waste products so that we can maintain a healthy existence. When they are working well, they are often taken for granted.  The renal arteries bring blood to the kidneys, the kidneys do their magic, and the cleansed and purified blood is returned into the renal veins, with the liquid waste—urine—excreted into the ureters that drain into the urinary bladder.

If the kidneys stop working properly, excessive fluid and toxic wastes build up rapidly, resulting in death within a matter of days to weeks. Death by kidney failure is described as “euphoric” because of the very abnormal blood chemistries and electrolyte disturbances that occur…not that death is something to be “giddy” about, but kidney failure just happens to be an easier, more peaceful way to exit the planet than many others.

Because of their critical importance to our healthy existence, it behooves us to take great care of these prized possessions, which nature gave us in duplicate. This “spare tire” is capable of sustaining life in the event of trauma, cancer requiring surgical removal, donating a kidney or other issues resulting in loss of one kidney.

The kidneys are multifunctional, not only filtering our blood to remove waste products, but also responsible for regulating fluid, electrolyte, acid-base balance and blood pressure.  They are in charge of maintaining the proper fluid volume within our blood stream. They regulate the levels of our electrolytes including sodium, potassium, chloride, etc. They keep our blood pH (indicator of acidity) at a precise level to maintain optimal function. They are key players in the regulation of blood pressure.  Furthermore—and unbeknownst to many—they are responsible for the production of several important hormones: calcitrol (calcium regulation), erythropoietin (red blood cell production), and renin (blood pressure regulation).

Kidney disease is a very common cause of serious illness with a prevalence of more than 25 million Americans. Each year approximately 110,000 new patients start dialysis treatments in the USA.  Kidney disease is responsible for nearly 100,000 American deaths annually. When the kidneys fail (end stage renal disease), the options are peritoneal dialysis, hemodialysis, kidney transplantation, or death. Peritoneal dialysis uses the peritoneal membrane that lines the abdomen as a filter to clear wastes and extra fluid from the body. Hemodialysis involves being hooked up to a machine that mimics the function of the kidneys; it requires three sessions weekly that take about 3-4 hours per session.

The unfortunate thing about kidney disease is that it typically causes few symptoms until it is advanced; however, simple tests are capable of detecting it.   Symptoms of kidney disease are non-specific and may include the following: fatigue; decreased energy; poor appetite; difficulty concentrating; insomnia; swollen ankles and feet; nighttime muscle cramping; puffiness around one’s eyes; dry and itchy skin; and the need for frequent urination, particularly at night

A definitive sign of kidney disease is the presence of protein in the urine, which is easily detectable on a urinalysis. Additionally, uncontrolled high blood pressure is highly suggestive of kidney disease, as is an elevated serum creatinine, detectable by a simple blood test.  Early detection is critical as it can help prevent kidney disease from progressing to kidney failure. The bottom line is that three simple tests can detect kidney disease:  blood pressure; serum creatinine; urine albumin (protein).

Under normal circumstances, the kidneys filter the blood, removing waste products and excessive fluid, returning into circulation the body’s important chemicals and constituents. When the filtration system is not working properly, one’s system is not cleared of the bad (waste products), resulting in electrolyte disturbances and proteinuria, a condition in which what is good for the body (protein) ends up being filtered out into the urine.

Risk factors for kidney disease are the following: African-American race; diabetes; high blood pressure; and family history of kidney disease.  The two leading causes of chronic kidney disease are hypertension and diabetes, responsible for about two thirds of cases.

Urologists are the specialists who deal with surgical kidney issues whereas nephrologists are the specialists who deal with medical kidney tissues including hypertension and impaired kidney function. If kidney disease is diagnosed, one will typically be referred to a nephrologist for further evaluation and management.  Nephrologists will typically measure the serum creatinine, and do blood and urine tests to assess the glomerular filtration rate, a quantitative test of kidney function.  Often a renal ultrasound is performed and in some cases it is necessary to do a renal biopsy to find the root cause of the kidney dysfunction

Treatment for progressive kidney disease includes interventions such as blood pressure control, often with the use of ACE inhibitors and angiotensin receptor blockers, and control of diabetes.   Nutritional interventions include dietary protein restriction that may slow the progression of chronic kidney disease.   High-protein intake can worsen the proteinuria and result in the accumulation of various protein breakdown products as a result of decreasing kidney function, which can cause toxic effects.

A truly unfortunate fact of life is that many of us are not responsible caretakers of our kidneys (or any of our other “precious physical valuables”); many seem to take better care of their automobiles than they do of their own health.  How many of us change our oil every 3000 miles, bring our cars in for regular service and proudly maintain shiny exteriors while at the same time neglecting our own health by living a harmful lifestyle.  This includes a sedentary existence, excessive stress, insufficient sleep and substance abuse—of alcohol, tobacco and food—with diets high in red and processed meats, sodium and fat laden concoctions, sugar-sweetened drinks, etc., and low in fruits, vegetables, legumes, nuts, whole grains, and low-fat dairy.  The result: obesity, high blood pressure, and elevated cholesterol, which oftentimes leads to diabetes, heart attack, stroke, cancer, and premature death. Sadly, the diabetic situation in our nation—often referred to as “diabesity”—has become epidemic and, as mentioned, is one of the leading causes of chronic kidney disease in the United States.

So how do we care for our kidneys?  The prescription for healthy kidneys is to maintain a healthy lifestyle and, if you have been neglectful in this department, to do a lifestyle remake through the following: good eating habits; maintaining a healthy weight; engaging in exercise; obtaining adequate sleep; consuming alcohol in moderation; avoiding tobacco; and stress reduction.  Additionally, being proactive by seeing a physician on a regular basis for “scheduled maintenance” is of paramount importance in order to detect kidney disease—or any other malady—as early as possible, no matter what the ivory tower pundits say about the ineffectiveness of annual physicals.

Bottom Line: Kidney disease is a debilitating—oftentimes deadly—condition, the risk for which can be greatly reduced by adopting a healthy lifestyle. Never neglect your health, for it is your greatest wealth. 

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

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Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe and receive notifications of new posts in your inbox.  Please feel free to avail yourself of these educational materials and share them with your friends and family.

Pancreatic Cancer

October 19, 2013

 Pancreatic Cancer 

Andrew Siegel, M.D.  Blog #124

The pancreas is a vitally important organ that serves dual roles: as an endocrine organ that produces hormones including insulin and glucagon and as an exocrine organ that secretes digestive enzymes that help the process of fat, protein and carbohydrate breakdown and digestion.  It is located deep within the upper abdomen and is divided into a head, body and tail.  The head lies within the concavity of the duodenum (the first part of the intestine).  The body runs behind the stomach and the tail touches the spleen.  The fact that it is such a deep-seated organ makes it virtually impossible to examine on a physical exam (unlike superficial organs such as the breasts or testicles) and pathological problems of the pancreas are identifiable only on sophisticated imaging studies of the abdomen.

Cancer of the pancreas is an incredibly lethal malignant tumor.  Approximately 45,000 Americans will be diagnosed with pancreatic cancer in 2013 and more than 38,000 will die from the disease, with a five-year survival rate of only about 5%.   The greatest challenge is that there are no early detection tests and, unfortunately, most patients who have early and localized disease have no recognizable symptoms such that most are not diagnosed until late in the disease—after the cancer has spread (metastasized).

In spite of the dismal prognosis, there has been recent progress in pancreatic cancer with surgery becoming safer and less invasive, the availability of new drug combinations that have been shown to improve survival, and advances in radiation that have resulted in less side effects. Significant strides forward have been made in the understanding of the genetics of pancreatic cancer, and unlocking the molecular basis of this horrific disease hopefully will translate into better treatment options.

The most common form of pancreatic cancer is invasive ductal adenocarcinoma.  The second most common type is a pancreatic neuroendocrine tumor; this is less aggressive than the ductal carcinomas, but still has a 10-year survival rate of only 45%. Some of the neuroendocrine tumors manufacture hormones such as insulin that produce clinical syndromes.

A combination of inherited and environmental factors contributes to the development of pancreatic cancer. The most common environmental risk factor is tobacco; smokers having a more than double the risk of pancreatic cancer as compared to non-smokers.  The good news is that smoking cessation will substantially reduce the risk.  Other risk factors are long-standing type II diabetes, increased body mass index, heavy alcohol consumption, and chronic pancreatitis.   A strong family history of pancreatic cancer puts an individual at significant risk.  BRCA2 gene mutations also increase the risk. Additionally, patients who have hereditary pancreatitis have a 60-fold increased risk; this is so substantial that some patients with this disease opt for a prophylactic removal of the pancreas.

Now for Molecular Biology 101:  Genes are inherited bits of information that code for proteins.  When genes become mutated, the proteins that the genes code for become dysfunctional.  One can think of genes as the written recipe for a particular meal and their product as the meal itself—when the recipe is changed (mutated) the resultant meal is defective.  In the case of the human body, the altered genes code for altered proteins that damage cellular function and replication in such a way as to alter the normal orderly process of cellular reproduction, resulting in unrestrained, disorderly cell replication, aka cancer.  Scientists have identified numerous genetic mutations responsible for cancers and they are named with bizarre combinations of letters and numbers—do not be daunted by their names as follow.

So, on a molecular level, cancer is caused by inherited and acquired mutations in genes. The sequencing of the genetic material of the pancreatic ductal adenocarcinomas has demonstrated that four specific genes are each altered in more than 50% of these cancers.  KRAS, an oncogene (a gene with the potential to cause cancer), becomes activated in 95% of pancreatic cancers—the protein coded for by this gene plays an important role in cell signaling, a complex system of communication that governs basic cellular activities and coordinates cell actions. The p16/CDKN2A gene, a tumor suppressor gene (a gene that protects a cell from cancer that, when mutated, would allow the cell to progress to cancer), becomes inactivated in 95% of pancreatic cancers.  The protein product of this gene plays an important role in the regulation of the cell cycle and its loss promotes unrestricted cell growth. The TP53 tumor suppressor gene is inactivated in 75% of pancreatic cancers. Loss of its function through mutation promotes pancreatic cancer through the loss of a number of critical cell functions.  The SMAD4 tumor suppressor gene has a protein product in the cell signaling pathway that when interfered with is associated with a very poor prognosis and widely metastatic disease. In addition to these 4 major genes, there are numerous other genes that are mutated in pancreatic cancer at lower frequencies.

Unfortunately, most pancreatic cancers do not cause specific symptoms and are not diagnosed in a timely manner. Typical non-specific symptoms include upper abdominal pain radiating to the back; unexplained weight loss; nausea; jaundice; clay colored stools; and in a small percentage of people, migratory thrombophlebitis (multiple blood clots appearing in a variety of veins). At times, it can present with diabetes, symptoms of pancreatitis, or depression. Diagnosis is predicated upon imaging tests including CT, MRI, and endoscopic ultrasound.  Standard cancer staging is stage I through stage IV, with stages I an II being localized, III being locally advanced, and IV being metastatic. In the absence of metastatic disease, the ability to surgically remove the cancer is predicated on the relationship of the tumor to the adjacent major blood vessels.

Pancreatic cancer is a complex disease and is best treated by a multidisciplinary team including a surgeon, medical oncologist, and radiation oncologist. In general, patients with stage I/II disease should undergo surgery followed by adjuvant therapy (chemotherapy and/or radiation).  Patients with stage III locally advanced disease should be treated with chemotherapy and/or chemo-radiation.  Patients with stage IV and good performance status may receive systemic therapy and those with poor health should be given supportive therapy.

The best chance of long-term survival of a patient with localized pancreatic cancer is surgical removal. However, because pancreatic cancer is often beyond the confines of the pancreas at presentation and due to the potentially negative impact of surgery on quality of life as well as the low chance of long-term survival, surgery is often non-curative. Certainly, the risk of local and systemic recurrence after surgery is very high.

Bottom Line: Pancreatic cancer is a wickedly lethal cancer.  In terms of minimizing one’s risk, avoid tobacco, obesity and heavy alcohol consumption. So, don’t smoke, eat a healthy diet, maintain a good weight, and be moderate with alcohol.  Despite the dismal prognosis, there have been recent advances on many fronts, particularly in terms of the genetics of the cancer, wherein the key to treating this miserable cancer most likely lies.

“Sometimes life hits you in the head with a brick. Don’t lose faith. I’m convinced that the only thing that kept me going was that I loved what I did. You’ve got to find what you love. And that is as true for your work as it is for your lovers. Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle. As with all matters of the heart, you’ll know when you find it. And, like any great relationship, it just gets better and better as the years roll on. So keep looking until you find it. Don’t settle.” 

Steve Jobs, who died of neuroendocrine cancer of the pancreas

Reference: Recent Progress in Pancreatic Cancer, Wolfgang, Herman, Laheru, Klein, Erdek, Fishman and Hruban

CA CANCER J CLIN 2013;63:318-348 September/October 2013

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe and receive notifications of new posts in your inbox.  Please feel free to avail yourself of these educational materials and share them with your friends and family.

Sugar Substitutes

October 12, 2013

Andrew Siegel, M.D.  Blog #123

For many of us who have a “sweet tooth,” sweet tastes are delightful and we actively seek them out in accordance with our evolutionary drives. The first bite of that sugary Cinnabon is pure bliss. The brain’s reward pathway squirts out the neurotransmitter dopamine and we get a jolt of near ecstasy—the mind-body connection in action. Hopefully, within a matter of minutes, leptin—our satiety hormone that regulates appetite—will counteract the dopamine, making subsequent bites less rewarding and stopping us from gorging.

Sugar is ubiquitous in our diets, not just in the places you expect it, but also “stealth” sugar in breads, crackers, pretzels, chips, salad dressings, sauces, etc.  If you read food labels you might be shocked about the presence of sugar in many unexpected destinations. Sugar (sucrose) is clearly unhealthy and processing and refinement “advances” have permitted its consumption in unreasonable, immoderate and unwarranted amounts, contributing to America’s expanding waistlines and derrières.  So what’s the skinny on sugar substitutes?  Are they helpful in terms of losing weight? Are they better for our dental health than sugar? Are they helpful for diabetics?  Do they have risks?

Sugar substitutes duplicate the sweetness of sugar, but without the caloric (energy) load. Natural sugar substitutes originate from nature and include the following: agave nectar; date sugar; fruit sugar concentrate; honey; maple syrup; and molasses. Synthetic substitutes are concocted by chemists in a lab and are known as artificial sweeteners.   There are 6 “super-sweet” high-intensity substitutes approved for use by the FDA. The super-sweet sugar substitutes are the following: stevia (Truvia); aspartame (NutraSweet; Equal); sucralose; neotame (manufactured by the NutraSweet company); acesulfame (Nutrinova); and saccharin (Sweet’N Low).  Aspartame is the most popular artificial sweetener in United States and sucralose is not far behind.

Sugar substitutes are widely prevalent in our food supply—in processed foods, baked goods, dietary foods, dietary soft drink beverages, powdered drink mixes, canned foods, jams and jellies, dairy products, toothpastes, chewing gums, sugar-free desserts such as ice cream, yogurts, and puddings, and in vitamins and medicines including cough drops.

In terms of weight loss, sugar substitutes can be an effective and attractive means of consuming less calories since the substitutes are non-nutritive and have virtually no calories, while retaining the sweet taste of food substances.    This is in contrast to sucrose that has 4 calories per gram.  Additionally, sugar substitutes are dental friendly, as they—unlike sucrose—are not fermented by the bacterial flora that lives on the teeth and thus do not produce acidy waste products that cause tooth decay.   Sugar substitutes can be effective for diabetics who have trouble regulating blood glucose levels since sugar substitutes do not elevate blood sugar levels the way sucrose does.

Sugar substitutes, while providing a sweeter taste than sugar, contain few or no calories, which is why using them has been thought to aid weight management. Our food-reward system plays a critical role in regulating eating behavior and controlling the number of calories consumed. When the tongue perceives sweetness, the brain expects a glucose infusion, which increases levels of dopamine and stimulates reward centers in the brain.  Without the energy kick provided by actual sucrose, sugar substitutes cannot fool our brains into feeling satisfied. Sugar imposters yield no such reward and cravings can persist and cause more rebound consumption than eating sugar in the first place.

The Food and Drug Administration (FDA) is the governmental body responsible for the regulation of sugar substitutes. Over the years, health concerns have been raised with respect to the use of substitutes and they have been the subjects of intense scrutiny. The general consensus is that there is no sound evidence that any of the substitutes approved for use in the United States cause serious health problems and that they are generally safe in limited quantities. However, there is ongoing and unsettled controversy regarding whether substitute usage is problematic in terms of health risks. We remain muddled in a debate about the health implications of substitutes and whether they might be linked to obesity, cancer, Alzheimer’s disease, ADD, autism, etc.  Search on the Internet and you will learn about the “conspiracy theories” concerning artificial sweeteners.

Saccharin (Sweet’N Low) was the first artificial sweetener, originally synthesized in 1879.  It is 400 times as sweet as sugar.  Although saccharin was previously considered hazardous when it was discovered to cause cancer in rats and carried a warning label, the warning label was subsequently repealed and saccharin has been removed from the hazardous list.  Cancer in laboratory rats has not been found to necessarily correlate with cancer in humans.

Aspartame (Equal; NutraSweet) was discovered serendipitously in 1965 when a scientist at Searle was working on a drug for peptic ulcer disease and spilled some of the chemical on his hand. He accidentally noted its sweet taste, and the rest is history.  It is 200 times as sweet as sugar and derives from 2 amino acids, aspartic acid and phenylalanine.  It is undesirable as a baking sweetener because, when heated, it breaks back down into its constituent amino acids.  It has sometimes been linked to headaches.

Stevia is a natural sweetener that is derived from the stevia plant; its leaves have been used as a sweetener in South America for centuries. It is 300 times as sweet as sucrose.  It was discovered by botanist Petrus Jacobus Stevus, which is why it was named Stevia.

Sucralose (Splenda) is a chemically modified form of sugar that was discovered in 1976 and is about 600 times as sweet as sucrose. It is stable when heated, so is appropriate for use in cooked foods.   Most of consumed sucralose passes out of the body unchanged, with only a small amount getting absorbed.

Neotame (from NutraSweet) is chemically similar to aspartame, but is significantly sweeter, being the sweetest of the group.  It is the only artificial sweetener deemed safe by the Center for Science in the Public Interest (CSPI).

Acesulfame is calorie-free and 200 times as sweet as sucrose; it is formed by adding potassium to aceto-acetic acid.  It is not metabolized by the body, but is excreted unchanged.  Because it is heat stable, it can be used in cooking and baking.

Sugar alcohols are carbohydrates that occur naturally in certain fruits and vegetables, but can also be synthesized.   They do contain calories but they are lower in calories than sucrose. They are used in many processed foods and household items including chocolate, candy, frozen desserts, chewing gum, toothpaste, mouthwash, baked goods and fruit spreads.

Bottom Line: The take-away message is “everything in moderation.” Whether you indulge in items sweetened with sugar derived from sugar beet or sugar cane, sugar alcohols, or any of the natural or artificial sweeteners, consumption should always be kept in check.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health, in press. Will be available in e-book and paperback formats in later 2013.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Not So Sweet on Sugar

September 14, 2013

Andrew Siegel  Blog #119

Nature is ever so clever—look at our human species—brilliantly evolved and adapted not only to survive, but also to thrive on this planet, breathing the air in the atmosphere, drinking the water and eating the bounty from the soils of the fertile earth.

Whenever clever nature provides us with a nutrient that is potentially unhealthy, it protects us 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.  If you ever tried to extract the sugar out of a sugar cane or sugar beet plant you would quickly find that they are fibrous and unyielding. If you want to derive calories from them, it requires great effort and you will likely end up quite frustrated.  It’s not unlike chewing on a stick of bamboo and trying to suck the sugar out—at best we will only get a few calories out of the whole endeavor and probably burn more calories than taken in with the effort.

Because of the collective intelligence of mankind, we are now easily able to remove the protective fiber matrix of the sugar cane or sugar beet and process the sugar into a pure, refined and powdery product.  This 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.  However, it is very difficult to beat nature in the long run, and though mankind may have won this battle, we are losing the war, because the consequences of excessive sugar consumption are potentially dire and grave.

Most humans love—if not crave—the taste of sugar. It activates pleasure pathways in our brain that reinforce the desire for its continued consumption and, in some of us, it behaves like addictive substances.  Even if one is extremely disciplined and rarely opens a packet or cube of sugar to sweeten their ice tea, chances are they nonetheless are consuming way too much sugar.  The typical American diet adds 25 or so teaspoons of sugar to our daily consumption.  This includes sugar from sugar cane and sugar beet sources as well as from the highly processed high fructose corn syrup (HFCS).  In one month, this inadvertent cumulative sugar consumption is equivalent to approximately 4 extra days of eating!

Sucrose—a.k.a. table sugar—is a combination of glucose and fructose.   All sugars are not the same.  After consuming glucose, it is absorbed by the small intestine and used as fuel by our cells, aided by the hormone insulin.   Any glucose that does not need to be used for immediate fuel is stored in the form of glycogen in our muscles and liver.   Fructose behaves differently than glucose. Insulin does not have an effect on fructose and after absorption it goes straight to our livers where it is mostly converted to fat.  Fructose does not cause the same amount of satiety as glucose does. Too much fructose leads to increased visceral fat and high blood lipid levels.

Fructose is the predominant sugar in many fruits, hence the term fructose. How do we explain the apparent paradox between fructose being a “bad” sugar, yet fructose being the main sugar in fruit, which is good for us? One difference between the fructose contained within fruit as opposed to that within a bottle of soda is that fruit fructose is natural and not created in a chemistry lab (i.e., high fructose corn syrup).  Additionally, the concentration of fructose in fruit is significantly less than that contained within the soft drink. Furthermore, the fructose in beverages is a source of “empty” calories—essentially liquid candy—as they do not contain health-promoting ingredients present in fruit including fiber, anti-oxidants, vitamins, minerals and other phyto-nutrients. Because of the fiber content of the apple, the sugars are slowly absorbed whereas the “naked” sugars in beverage form are rapidly absorbed, providing a “load” of fructose to the liver.  More than being just empty calories, fructose is a source of poisonous calories that promote obesity—think of fructose as fat.

Let’s do the math comparing an apple to a bottle of soda: An average-sized apple has about 80 calories: this includes 20 grams of sugar consisting of 4 grams of sucrose (equivalent to 2 grams fructose and 2 grams glucose), 5 grams of glucose, and 11 grams of fructose, for a total of 13 grams of fructose.  A 20-ounce bottle of soda has about 240 calories: this includes 60 grams of sugar all from HFCS (55% fructose / 45% glucose) for a total of about 35 grams of fructose. 

High fructose corn syrup is a gooey, liquefied sweetener that is abundant in processed foods and beverages. The typical American consumes an astonishing 50-100 pounds of HFCS per year! The derivation of HFCS is as follows: Corn is milled to cornstarch, a powdery substance that is then processed into corn syrup.  Corn syrup consists primarily of glucose. Through a complex chemical process, the glucose in the corn syrup is converted to fructose.  HFCS results from the mixing of this fructose back in with glucose in varying percentages to achieve the desired sweetness: 55% fructose/45% glucose ratio of HFCS is used to sweeten soft drinks; 42% fructose/58% glucose ratio of HFCS is used in baked processed foods.  

The processed food industry is quite enamored with HFCS for a number of reasons. First, it is cheaper than sugar because of huge corn subsidies and sugar tariffs.  Second, the liquid syrup lends itself to ready transportation in enormous storage vats within 18-wheelers, similar to how gasoline is hauled.  Third, fructose is incredibly sweet and does not crystallize or turn grainy when cold, as sugar can do.  Fourth, because HFCS is very soluble and retains moisture, it makes for softer and moister processed baked goods.  Fifth, it acts as a preservative that extends the shelf life of processed foods and helps to prevent freezer burn.  Finally, HFCS is a key ingredient in many processed junk foods, which are addictive and promote cravings and continued consumption.

There is a good reason why HFCS is so demonized: while HFCS may help “preserve” processed foods, it does not help “preserve” us!  In fact, a diet high in HFCS will help accelerate our demise. To reiterate an important fact: fructose is metabolized very differently from glucose.  Every cell in our bodies can metabolize glucose, but it is primarily the liver that metabolizes fructose. Fructose does not stimulate insulin release as does glucose, nor does it stimulate leptin (our satiety hormone).  Fructose, more readily than glucose, replenishes liver glycogen, and once the liver is saturated with glycogen, triglycerides (fats) are made and stored. So, too much HFCS and we end up with a fatty liver and body.  The bottom line is that HFCS ingestion pushes our metabolism towards fat production and fat storage, potentially leading to obesity, diabetes, elevated cholesterol, high blood pressure and cardiovascular disease.  HFCS should be thought of as a toxin, in precisely the same way that tobacco is dangerous to our health.  Unfortunately, sugar in the little packets that we use to sweeten our frappuccinos is really no better.

Bottom Line Tips: High fructose corn syrup and sugar are NOT our “friends,” so:

·      Don’t drink too many calories or sugars if possible: minimize sodas, sweetened ice tea, lemonade, fruit juices, sports drinks, etc.  Water or seltzer with lemon, lime or other fruit is so much healthier.  Go for the real fruit instead of the juice.  Easy on the alcohol because it is all carbs. Even milk has sugar in the form of lactose, (consisting of glucose and galactose, about 11-12 grams/cup.

·      Avoid processed yogurts that are laden with excessive amounts of sugar because of the processed fruit on the bottom.  You are much better off adding fresh fruit to plain yogurt.

·      Try to avoid snacking on candy, cookies, energy bars, etc., and instead munch on nuts, fiber-rich fruits and vegetables and whole grains, like popcorn.

·      Eat healthy cereals instead of those that are sugar-laden: steel-cut oats are so much healthier than Fruit Loops.

·      Beware of “alternative” sweeteners—brown sugar, honey, molasses, maple syrup are all more-or-less the same.

·      Read labels carefully since about 75% of packaged foods have sweeteners some that would surprise you, including sauces, salad dressings, breads, etc.

·      Bottom line: use sugar and alternative sweeteners in moderation

Coming soon: Artificial sweeteners

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health, in press and will be available in e-book and paperback formats in the Autumn 2013.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

What’s This Metabolic Syndrome I’ve Been Hearing So Much About?

August 18, 2012

Andrew Siegel, M.D.    Blog #71

 

The “metabolic syndrome” is a cluster of risk factors that are dangerous to your health.  These include visceral obesity as defined by waist circumference, elevated blood glucose level, high blood pressure, elevated triglycerides, and low HDL cholesterol (the good cholesterol).  Visceral obesity is a collection of fat within the abdomen as opposed to under the skin (subcutaneous fat).

When a patient walks into the office and the first thing observed is a protuberant and bulging belly, a siren goes off screaming “metabolic syndrome, metabolic syndrome, metabolic syndrome.”

If you have at least three of the following five risk factors, you have metabolic syndrome.  Those who have metabolic syndrome often develop cardiovascular disease and/or type-2 diabetes.

 Features of Metabolic Syndrome:

 

  • Elevated waist circumference: men > 40 inches; women > 35 inches
  • Elevated triglycerides: > 150 mg/dL
  • Reduced HDL (“good”) cholesterol: men < 40 mg/dL; women

< 50 mg/dL

  • Elevated blood pressure: > 130/85 mm Hg
  • Elevated fasting glucose (sugar): >100 mg/dL

One of every four Americans has metabolic syndrome. This syndrome is caused by insulin resistance—the body’s inability to properly process nutrients including sugars and fats because the pancreatic hormone insulin no longer works in an efficient manner to get nutrients into our cells.  The root cause of insulin resistance is too much waist and not enough movement.  Essentially, our well-engineered systems are “flooded” by taking in excessive calories.  Our bodies simply were not designed for chronic caloric overload, and the only people who can handle this caloric flooding are endurance athletes who burn the calories, such as Michael Phelps.

Triglycerides are the main fat in food and the bloodstream.  One in three adults have a fasting triglyceride level higher than 150; optimally, triglycerides should be under 100.  Even a non-fasting triglyceride level should not be that high, because no healthy person should ever develop an extremely high level even in response to a fatty meal.  Diets high in sugar are the major underlying cause of elevated triglycerides.

The good news is that lifestyle modification has a very positive impact on triglyceride level—it is very possible for triglycerides to decline as much as 30% based upon a diet with less calories, sugar, saturated fat and alcohol.  EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) are marine-derived omega fats that are capable of lowering triglycerides.  Fish contain these two omega-3 fats because they consume algae that are rich in them.   Exercise is an equally important component of lowering triglycerides, since it activates lipoprotein lipase, which breaks down triglycerides.

Ways To Avoid Metabolic Syndrome:

  • Lose excess weight to improve each of the five features of metabolic syndrome
  • Eat a diet with abundant fruit, vegetables, and fiber
  • Minimize saturated fats and refined carbohydrates
  • Minimize sugar: the American Heart Association recommends a maximum of 6 teaspoons daily for women and 9 for men, including the sugar in processed foods
  • Eat fatty fish high in EPA and DHA including salmon, herring, sardines, halibut and trout; if you don’t eat fish, take fish oil capsules
  • Exercise will facilitate weight loss and will improve every feature of metabolic syndrome

Andrew Siegel, M.D.

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

www.PromiscuousEating.com

Now available on Amazon Kindle

 

Diabetes and the Urologist

April 21, 2012

Andrew Siegel, M.D.   Blog #55

“Let food be your medicine and medicine be your food.”

Hippocrates

Many diseases and disabilities are related to the quantity and quality of the foods we eat and the amount of exercise we get or don’t get.  The most prevalent form of diabetes, Type 2, is a classic example of an avoidable disease that occurs because of lifestyle indiscretions. Type 2 diabetes is now occurring in epidemic proportions and, sadly, can have catastrophic consequences including: heart disease, strokes, blindness, kidney failure requiring dialysis and vascular disease resulting in amputations.  This disease has the capability of dramatically decreasing the quantity and quality of our lives.

There are over 25 million diabetics in the USA, and the incidence is rapidly spiraling upwards, particularly because of poor dietary choices and insufficient exercise.  Diabetes causes elevated blood glucose (i.e., sugar) and occurs on the basis of a defect in the body’s ability to produce the pancreatic hormone insulin or use the insulin (insulin resistance). The function of insulin is to regulate glucose and move it  into our cells so that it can be used for energy and metabolism.  When insulin is unavailable or the body has developed resistance to its effect, blood glucose levels rise uncontrollably with potential dire health complications.

Common presenting symptoms of diabetes are frequent urination, thirst, extreme hunger, weight loss, fatigue and irritability, recurrent infections, blurry vision, cuts that are slow to heal, and tingling or numbness in the hands or feet.  However, the most common symptom may unfortunately be…no symptom at all.

There are two distinct types of diabetes.  These were formally called juvenile diabetes and adult-onset diabetes, but because of the increasing incidence of obesity in children (such that children are now developing adult-onset diabetes), they have been renamed Type 1 and Type 2.  Type 1diabetes is not linked to obesity and is responsible for about 5% of diabetes.   It is an autoimmune condition in which the body’s immune system destroys its own insulin-producing cells, thus severely limiting or completely terminating all insulin production, and is often inherited. It is managed by insulin injections or an insulin pump. 95% of diabetes in the USA is Type 2 diabetes, also known as diabesity (diabetes caused by obesity). This form of diabetes is typically on the basis of insulin resistance, due predominantly to environmental factors including overeating and sedentary living.  Unlike Type 1, Type 2 diabetics produce plenty of insulin, but their bodies cannot process the insulin and are resistant to its actions. Anybody who has excessive abdominal fat is on the pathway from insulin resistance towards diabetes.

While Type 1 diabetes is treated primarily with insulin replacement, diet and exercise are also necessary for its management. With Type 2 diabetes, it is imperative to pursue a lifestyle modification, including dietary changes that avoid certain diabetic-promoting foods and replacement with healthier foods.  Diabetics should refrain from high glycemic index foods (those that are rapidly absorbed) including sugars and refined white carbohydrates and instead should consume high-fiber vegetables, fresh fruits, and whole-grain products.   Regular exercise is equally as important as good dietary habits, and the combination of healthy eating, physical activity, and weight loss can often adequately address Type 2 diabetes.  When lifestyle measures cannot be successfully implemented, there are different classes of medication that can be used to manage the diabetes, although lifestyle modification should always be the initial approach, since lifestyle (in large part) caused the problem and is capable of improving/reversing it.   At times, when diet, exercise and drugs have not been able to control the diabetes, bariatric (weight loss) surgery might be needed to control and even potentially eliminate the diabetes.

As a urologist (a urinary tract specialist), it is not uncommon for me to make the initial diagnosis of diabetes.  This is because diabetes often presents with urinary frequency, a symptom typically treated by urologists.  Sleep-disruptive nighttime frequency is a particularly disturbing symptom and is often a major complaint that brings patients into my office.  Because diabetes causes high levels of blood glucose, this results in glucose in the urine, which causes a diuretic effect (lots of urine production).  In fact, earlier this week a patient came in complaining of new onset of significant urinary frequency; his urinalysis on dipstick showed glucose (normally there should be no glucose in the urine) and his serum glucose was over 400 (normally < 100).  He was promptly sent to his internist for management of Type 2 diabetes.

Additionally, many uncircumcised men who present to my office with foreskin problems have diabetes.  In fact, when a man has foreskin issues such as the foreskin being stuck down over the head of the penis and is not able to be pulled back (phimosis), the first thing I do is to dipstick the urine for glucose.

Aside from urologists having the occasion to make the initial diagnosis of diabetes, we also have ample opportunity to treat many diabetic patients because of the urological problems that can occur as a result of the diabetes, including urinary infections, bladder conditions, and sexual problems such as erectile dysfunction. Additionally, recent studies have indicated that diabetes greatly increases the risk of kidney stones. Although many of these symptoms are common with the aging process in the absence of diabetes, the presence of diabetes hastens them, causing earlier onset and increased severity of these issues.

In general terms, the complications of diabetes occur because of damage to blood vessels and nerves.  Diabetes accelerates atherosclerosis, a condition in which fatty plaques get deposited within the walls of arteries, compromising blood flow and the vital delivery of oxygen and nutrients to tissues. Diabetic “small blood vessel” disease can lead to retinopathy (visual problems leading to blindness), nephropathy (kidney damage leading to dialysis), and neuropathy (nerve damage causing loss of sensation in the hands and feet). Diabetic “large vessel disease” can cause coronary artery disease, stroke, and peripheral vascular disease.  Diabetes increases the risk of infections because of poor blood flow and impaired function of the infection-fighting white blood cells.  It is important to know that diabetic control can lower the chances of the early onset and severity of the aforementioned problems.

Many diabetics have urological problems on the basis of neuropathy that affects the bladder.  These issues include impaired sensation in which the bladder becomes “numb” and the patient gets no signal to urinate and impaired bladder contractility in which the bladder muscle does not function properly, causing inability to empty the bladder completely.  Other diabetics develop involuntary bladder contractions (overactive bladder), causing such symptoms as urgency, frequency and incontinence.  The good news here is that there are effective, non-invasive means of managing diabetic voiding dysfunction.

Diabetics have many more urinary tract infections than the general population because of many factors including improper functioning of the infection-fighting white blood cells, glucose in the urine (a delightful treat for bacteria) and compromised blood flow to the kidneys and bladder.  Diabetics have a greater risk of asymptomatic bacteruria and pyuria (the presence of white cells and bacteria in the urine without a frank infection), cystitis (bladder infections), and pyelonephritis (kidney infections).  Impaired bladder emptying further complicates the potential for infections.  Diabetics have more serious complications of pyelonephritis including kidney abscess, emphysematous pyelonephritis (infection with gas-forming bacteria), and urosepsis (a very serious systemic infection originating in the urinary tract requiring hospitalization and intravenous antibiotics).  Fournier’s gangrene (necrotizing fasciitis) is a soft tissue infection of the male genitals that often requires emergency surgery (that can be very disfiguring) and has a very high mortality rate.  Over 90% of patients with Fournier’s gangrene are diabetic.  Diabetic patients also have an increased prevalence of infections with surgical procedures, particularly those involving prosthetic implants, such as penile implants, artificial urinary sphincters, and mesh implants for pelvic organ prolapse.

Satisfactory sexual functioning is predicated upon good blood flow and an intact nerve supply to the genitals and pelvis.  Diabetics often develop sexual problems because of the combination of neuropathy and blood vessel disease.  Men commonly have a reduced sex drive and have difficulty achieving and maintaining erections.  Diabetes has clearly been linked with testosterone deficiency that can worsen libido and sexual function.  Because of the neuropathy, many diabetic males have retrograde ejaculation, a situation in which semen goes backwards into the bladder and not out the urethra.  Female diabetics are not spared from sexual problems either and commonly have reduced desire, decreased arousal, and vaginal lubrication issues.

In summary, diabetes is a serious chronic illness with potentially devastating complications. Type 1 diabetes is relatively rare and unavoidable, but is eminently manageable with insulin replacement. Type 2 diabetes is now epidemic and its prevalence has increased dramatically coincident with the expanding American waistline. Type 2 is avoidable and can be improved/reversed through integration of healthy eating habits, weight management, and exercise.

Many people—myself included—do not relish seeing doctors, because such visits can be frightening, invasive, and sometimes uncomfortable.  It is a simple fact that healthy people do not need to consult doctors very often, aside from routine “wellness” visits.  The corollary is if you don’t want to see doctors very often, stay healthy.  To stay healthy you need the right lifestyle—avoiding tobacco, maintaining a satisfactory weight, eating healthy foods and drinking in moderation, avoiding stress, and getting plenty of exercise as well as adequate sleep. If your lifestyle is not up to par, remember that it is never too late to change. Your health is ultimately your own responsibility, but as doctors, it is our responsibility to help educate you and guide you towards the pathway of healthy habits and lifestyle—there is simply no magic bullet other than this.  Lifestyle modifications can be amazingly restorative to your health and overall well being.  And simply put, there is absolutely nothing else that transcends being healthy.

A special thank you to diabetes specialist Joseph Giangola, M.D. for reviewing and editing this blog entry.

Andrew Siegel, M.D.

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

www.PromiscuousEating.com

Now available on Amazon Kindle

Male Obesity Causes Low Testosterone With Potentially Dire Medical Consequences

July 30, 2011

Testosterone (T) is an important male sexual hormone that promotes the physical changes that commence at the time of puberty including pubic, axillary and facial hair, deepening voice, prominent Adam’s apple and increased bone and muscle mass.  Throughout adulthood, testosterone helps maintain libido, masculinity, sexuality, and youthful vigor and vitality.  The lion’s share of testosterone is manufactured in the testicles, although a small percentage is made by the adrenal glands.

There is a gradual decline in T that occurs with the aging process—approximately a 1% decrease each year after age 30. The decline will occur in most men, but will not always be symptomatic. Symptoms of low T may include one or more of the following:  fatigue, irritability, depression, decreased libido, erectile dysfunction, ejaculatory dysfunction, decreased energy and sense of well-being, loss of muscle and bone mass, increased body fat, abnormal lipid profiles. Essentially, low T can accelerate the aging process.

Obesity can have a pivotal role in the process leading to low T. Fat is not just fat—it is a metabolically active endocrine organ that does not just protrude from our abdomens in an inert state.  Fat produces pro-inflammatory factors, hormones and immune cells—including cytokines—which function to inhibit T production in the testicles and the release of hypothalamus and pituitary hormones that govern the release of T.  Low T is present in about half of obese men.   Fat has an abundance of the hormone aromatase, which functions to convert T to the female hormone estrogen (E).  The consequence of too much conversion of T to E is the potential for gynecomastia, aka breast enlargement or alternatively, man boobs.

There is a strong relationship between low T and metabolic syndrome.  Metabolic Syndrome is defined as having three or more of the following: high blood glucose levels; abdominal obesity; high fats (triglycerides); low levels of the “good” cholesterol (HDL); and high blood pressure. If we have a substantial amount of belly fat, then by definition we have insulin-resistance, a condition in which our pancreas works overtime in order to make more and more insulin to get glucose into our cells.  This is a precursor to diabetes, cardiovascular disease and all the havoc they can wreak.  Those with metabolic syndrome have a much-increased risk of cardiovascular disease and type 2 diabetes.

Bottom line:  Abdominal obesity—an accumulation of fat in our midsections—not only is unattractive from a cosmetic standpoint, but can have dire metabolic consequences that can unequivocally affect the quality and quantity of our lives. Obesity in males often promotes low levels of the all-important male hormone testosterone, which can have a number of detrimental effects on our sexuality, bone and muscle health, energy, well-being, etc.  The good news is that by losing the abdominal fat, all of the potentially bad consequences can be reversed.

Andrew Siegel, M.D.

http://www.PromiscuousEating.com for information on Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship With Food

http://www.youtube.com/incontinencedoc for educational videos on low T and a variety of other urological and wellness subjects