Posts Tagged ‘obesity’

“Doc, My Penis Is Shrinking”

October 8, 2016

Andrew Siegel MD  10/8/16

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Image above: Roman copy of Apollo Delphinios by Demetrius Miletus at the end of the second century (Attribution: Joanbanjo (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)%5D, via Wikimedia Commons)

Not a day goes by in my urology practice when I fail to hear the following complaint from a patient: “Doc, my penis is shrinking.” The truth of the matter is that the penis can shrivel from a variety of circumstances, but most of the time it is a mere illusion—a sleight of penis, if you will. Weight gain and obesity cause a generous pubic fat pad, the male equivalent of the female mons pubis, which will make the penis appear shorter and retrusive. However, penile length is usually intact, with the penis merely hiding behind the fat pad, the “turtle effect.” Lose the fat and presto…the penis reappears. Having a plus-sized figure is not such a good thing when it comes to size matters, as well as many other matters.

Factoid: It is estimated that with every 35 lbs. of weight gain, there is one-inch loss in apparent penile length.

The 9-letter word every man despises: S-H-R-I-N-K-A-G-E, immortalized by Jason Alexander playing the character George in the Seinfeld series. Jerry’s girlfriend Rachel catches a glimpse of naked George after he has stepped out of a swimming pool. Suffice it to say that George’s penis was in a “non-optimized” state. George tries to explain: “Well I just got back from swimming in the pool and the water was cold.” Jerry makes the diagnosis: “Oh, you mean shrinkage” and George confirms: “Yes, significant shrinkage.”

Penis size has not escaped our “bigger is better” American mentality where large cars, homes, breasts,  buttocks and mega-logos on shirts are desirable and sought-after assets. The pervasive pornography industry–where many male stars are “hung like horses”– has given the average guy a bit of an inferiority complex.

Factoid: The reality of the situation is that the average male has an average-sized penis, but in our competitive society, although average is the norm, average curiously has gotten a bad rap.

Adages concerning penile size and function are common, e.g., “It’s not the size of the ship, but the motion of the ocean.” Or even better, as seen on a poster in a gateway while boarding an airplane: “Size should never outrank service.” The messages conveyed by these statements have significant merit, but nonetheless, to many men and women, size plays at least some role and many men have concerns about their size. Whereas men with tiny penises may be less capable of sexually pleasing a woman, men who have huge penises can end up intimidating women and provoking pain and discomfort.

Leonardo Da Vinci had an interesting take on perspectives: “Woman’s desire is the opposite of that of man. She wishes the size of the man’s member to be as large as possible, while the man desires the opposite for the woman’s genital parts.”

Penile Stats

As a urologist who examines many patients a day, I can attest to the fact that penises come in all shapes and sizes and that flaccid length does not necessarily predict erect length and can vary depending upon many factors. There are showers and there are growers. Showers have a large flaccid length without significant expansion upon achieving an erection, as opposed to growers who have a relatively compact flaccid penis that expands significantly with erection.

With all biological parameters—including penis size—there is a bell curve with a wide range of variance, with most clustered in the middle and outliers at either end. Some men are phallically-endowed, some phallically-challenged, with most somewhere in the middle of the road. In a study of 3500 penises published by Alfred Kinsey, average flaccid length was 8.8 centimeters (3.5 inches). Average erect length ranged between 12.9-15 centimeters (5-6 inches). Average circumference of the erect penis was 12.3 centimeters (4.75 inches). As with so many physical traits, penis size is largely determined by genetic and hereditary factors. Blame it on your father (and mother).

Factoid: Hung like a horse—forget about it! The blue whale has the mightiest genitals of any animal in the animal kingdom: penis length is 8-10 feet; penis girth is 12-14 inches; ejaculate volume is 4-5 gallons; and testicles are 100-150 pounds. Hung like a whale!

Factoid: “Supersize Me.” In order to make their genitals look larger, the Mambas of New Hebrides wrap their penises in many yards of cloth, making them appear massive in length. The Caramoja tribe of Northern Uganda tie weights on the end of their penises in efforts to elongate them.

“Acute” Shrinkage

Penile size in an individual can be quite variable, based upon penile blood flow. The more blood flow, the more tumescence (swelling); the less blood flow, the less tumescence. “Shrinkage” is a real phenomenon provoked by exposure to cold (weather or water), the state of being anxious or nervous, and participation in sports. The mechanism in all cases involves blood circulation.

Cold exposure causes vasoconstriction (narrowing of arterial flow) to the body’s peripheral anatomy to help maintain blood flow and temperature to the vital core. This principle is used when placing ice on an injury, as the vasoconstriction will reduce swelling and inflammation. Similarly, exposure to heat causes vasodilation (expansion of arterial flow), the reason why some penile fullness can occur in a warm shower.

Nervous states and anxiety cause the release of the stress hormone adrenaline, which functions as a vasoconstrictor, resulting in numerous effects, including a flaccid penis. In fact, when the rare patient presents to the emergency room with an erection that will not quit, urologists often must inject an adrenaline-like medication into the penis to bring the erection down.

Hitting it hard in the gym or with any athletic pursuit demands a tremendous increase in blood flow to the parts of the body involved with the effort. There is a “steal” of blood flow away from organs and tissues not involved with the athletics with “shunting” of that blood flow to the organs and tissues with the highest oxygen and nutritional demands, namely the muscles. The penis is one of those organs from which blood is “stolen”—essentially “stealing from Peter to pay Paul” (pun intended!)—rendering the penis into a sad, deflated state. Additionally, the adrenaline release that typically accompanies exercise further shrinks the penis.

Cycling and other saddle sports—including motorcycle, moped, and horseback riding—put intense, prolonged pressure on the perineum (area between scrotum and anus), which is the anatomical location of the penile blood and nerve supply as well as pelvic floor muscles that help support erections and maintain rigidity.  Between the compromise to the penile blood flow and the nerve supply, the direct pressure effect on the pelvic floor muscles, and the steal, there is a perfect storm for a limp, shriveled and exhausted penis. More importantly is the potential erectile dysfunction that may occur from too much time in the saddle.

“Chronic” Shrinkage

Like any other body part, the penis needs to be used on a regular basis—the way nature intended—in order to maintain its health. In the absence of regular sexual activity, disuse atrophy (wasting away with a decline in anatomy and function) of the penile erectile tissues can occur, resulting in a “de-conditioned,” smaller and often temperamental penis.

Factoid: If you go for too long without an erection, smooth muscle, elastin and other tissues within the penis may be negatively affected, resulting in a loss of penile length and girth and negatively affecting ability to achieve an erection.

Factoid: Scientific studies have found that sexual intercourse on a regular basis protects against ED and that the risk of ED is inversely related to the frequency of intercourse. Men reporting intercourse less than once weekly had a two-fold higher incidence of ED as compared to men reporting intercourse once weekly.

Radical prostatectomy as a treatment for prostate cancer can cause penile shrinkage. This occurs because of the loss in urethral length necessitated by the surgical removal of the prostate, which is compounded by the disuse atrophy and scarring that can occur from the erectile dysfunction associated with the surgical procedure. For this reason, getting back in the saddle as soon as possible after surgery will help “rehabilitate” the penis by preventing disuse atrophy.

Peyronie’s Disease can cause penile shrinkage on the basis of scarring of the erectile tissues that prevents them from expanding properly.  For more on this, see my blog on the topic:

https://healthdoc13.wordpress.com/2015/05/23/peyronies-disease-not-the-kind-of-curve-you-want/

Medications that reduce testosterone levels are often used as a form of treatment for prostate cancer. The resultant low testosterone level can result in penile atrophy and shrinkage. Having a low testosterone level from other causes will also contribute to a reduction in penile size.

Are There Herbs, Vitamins or Pills That Can Increase Penile Size?

Do not waste your resources on the vast number of heavily advertised products that will supposedly increase penile size but have no merit whatsoever.  Realistically, the only medications capable of increasing penile size are the oral medications that are FDA approved for ED. Daily Cialis will increase penile blood flow and by so doing will increase flaccid penile dimensions over what they would normally be; the erect penis may be larger as well because of augmented blood flow.  Additionally, for many men this will restore the capability of being sexually active whereas previously they were unable to obtain a penetrable erection, thus allowing them to “use it instead of losing it” and maintain healthy penile anatomy and function.

Is Penile Enlargement Feasible Through Mechanical Means?

It is possible to increase penile size using tissue expansion techniques. The vacuum suction device uses either a manual or battery-powered source to create a vacuum in a cylinder into which the penis is placed. The negative pressure pulls blood into the penis, expanding penile length and girth. A constriction ring is placed around the base of the penis to maintain the erection. The vacuum is used to manage ED as well as a means of penile rehabilitation and is also used prior to penile implant surgery to increase the dimensions of the penis and allow a slightly larger device to be implanted than could be used otherwise. It can also be helpful under circumstances of penile shrinkage.

vsd

Vacuum Suction Device

The Penimaster Pro is a penile traction system that is approved in the European Union and Canada for urological conditions that lead to shortening and curvature of the penis. In the USA it is under investigation by the FDA. It is a means of using mechanical stress to cause penile tissue expansion and enlargement.

penimaster

Penimaster Pro

What’s The Deal With Penile Enlargement Surgery?

Some men who would like to have a larger penis may consider surgery. In my opinion, penile enlargement surgery, aka, “augmentation phalloplasty,” is highly risky and not ready for prime time. Certain procedures are “sleight of penis” procedures including cutting the suspensory ligaments, disconnecting and moving the attachment of the scrotum to the penile base, and liposuction of the pubic fat pad. These procedures unveil some of the “hidden” penis, but do nothing to enhance overall length. Other procedures attempt to “bulk” the penis by injections of fat, silicone, bulking agents, tissue grafts and other implantable materials. The untoward effects of enlargement surgery can include an unsightly, lumpy, discolored, painful and perhaps poorly functioning penis. Realistically, in the quest for a larger member, the best we can hope for is to accept our genetic endowment, remain physically fit, and keep our pelvic floor muscles well conditioned.

What’s Up With Penile Transplants?

The world’s first penis transplant was performed at Guangzhou General Hospital in China when microsurgery was used to transplant a donor penis to a recipient whose penis was damaged beyond repair in an accident. Subsequently, there have been several transplants done for penile trauma.  Hmmm, now here is a concept for penile enlargement!

What To Do To Avoid Shrinkage issues?

  • Accept that cold, stress and athletics will cause temporary shrinkage
  • Be aware that cycling and other saddle sports can cause shrinkage as well as erectile dysfunction: wear comfortable and protective shorts; get measured for a saddle with an appropriate fit; frequently rise up out of the saddle, taking the pressure off the perineum
  • Eat a healthy diet and stay physically active to maintain a lean physique
  • Use it or lose it: stay sexually active
  • Do pelvic floor exercises (a.k.a. Man Kegels): visit http://www.MalePelvicFitness.com
  • “Rehab” the penis to avoid disuse atrophy after radical prostatectomy: oral ED meds, pelvic floor muscle training, vibrational stimulation, vacuum suction device, penile injection therapy; consider “pre-hab” before the surgery
  • Seek urological care for Peyronie’s disease

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

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

http://www.TheKegelFix.com

E-book available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback available via websites. Author page on Amazon:

http://www.amazon.com/Andrew-Siegel/e/B004W7IM48

Apple iBook: https://itunes.apple.com/us/book/the-kegel-fix/id1105198755?mt=11

Trailer for The Kegel Fix

https://www.youtube.com/watch?v=uHZxoiQb1Cc 

Co-creator of the comprehensive, interactive, FDA-registered Private Gym/PelvicRx, a male pelvic floor muscle training program built upon the foundational work of renowned Dr. Arnold Kegel. The program empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance weights, this program helps to improve sexual function and to prevent urinary incontinence: www.PrivateGym.com or Amazon.  

In the works is the female PelvicRx DVD pelvic floor muscle training for women.

Pelvic Rx, Vacuum Suction Devices and many other quality products can be obtained at http://www.UrologyHealthStore.com. Use promo code “UROLOGY10” at checkout for 10% discount. 

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How To Raise Your Testosterone, Naturally

September 3, 2016

Andrew Siegel MD  9/3/2016

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(CDC/Amanda Mills from Public Health Image Library)

Two weeks ago, my entry was about the medication Clomid–a nice alternative to testosterone replacement therapy. What about a non-pharmacological, natural approach to raising testosterone levels?

Testosterone (T) is produced mostly in the testes, although the adrenal glands also manufacture a small amount. T has a critical role in male development and physical characteristics. It promotes tissue growth via protein synthesis, having “anabolic” effects including building of muscle mass, bone mass and strength, and “androgenic” (masculinizing) effects at the time of puberty. With the T surge at puberty many changes occur: penis enlargement; development of an interest in sex; increased frequency of erections; pubic, axillary, facial, chest and leg hair; decrease in body fat and increase in muscle and bone mass, growth and strength; deepened voice and prominence of the Adam’s apple; occurrence of fertility; and bone and cartilage changes including growth of jaw, brow, chin, nose and ears and transition from “cute” baby face to “angular” adult face. Throughout adulthood, T helps maintain libido, masculinity, sexuality, and youthful vigor and vitality. Additionally, T contributes to mood, red blood cell count, energy, and general “mojo.”

The amount of T made is regulated by the hypothalamus-pituitary-testicular axis, which acts like a thermostat to regulate the levels of T. Healthy men produce 6-8 mg testosterone daily, in a rhythmic pattern with a peak in the early morning and a lag in the later afternoon.  Low T levels can be low based upon testicular problems or hypothalamus/pituitary problems, although the problem most commonly is due to the aging testicle’s inability to manufacture sufficient levels of T. T levels gradually decline—approximately a 1% decline each year after age 30—sometimes giving rise to symptoms. These symptoms may include the following: fatigue; irritability; decreased cognitive abilities; depression; decreased libido; ED; ejaculatory dysfunction; decreased energy and sense of well-being; loss of muscle and bone mass; increased body fat; and abnormal lipid profile. A simple way to think about the effect of low T is that it accelerates the aging process.

Lifestyle factors are strongly associated with variations in testosterone (T) levels, with healthy lifestyles correlating with higher levels of T and unhealthy lifestyles with lower levels.  Some physicians regard T level as a laboratory marker of male physical health.

One of the key factors responsible for some of the decline in T that accompanies aging is excessive body fat. In fact, there is an inverse relationship between obesity and T levels, with increased body mass index (BMI) correlating with decreased T.

Factoid: Every 5-point increase in BMI translates to a 10% dip in T–an equivalent decline as would typically occur with 10 years of aging.

Fatty tissue – particularly visceral abdominal fat (the “beer belly”) – contains an abundance of metabolically active factors and hormones including aromatase, an enzyme which functions to convert T to the female sex hormone estrogen. Men with large bellies consequently are often found to have lower T levels and higher estrogen levels, which can result in “emasculation” with loss of sex drive, diminished erections, the disturbing loss of penile length and the presence of gynecomastia (man boobs)

Factoid: In addition to the decline in T, for every 35 lb. weight gain there is a 1-inch loss in apparent penile length because of the pubic fat pad that hides the penis.  

The good news is that weight loss will increase T levels and is capable of improving all of the aforementioned signs and symptoms. This has been demonstrated with all means of  weight loss, ranging from caloric restriction to bariatric surgery.

Another important lifestyle factor associated with variations in T levels is the extent of one’s physical fitness. Exercise is clearly associated with higher T levels. The degree of potential increase in T is related to both the quantity and quality of exercise. In general, the more time invested in moderate intensity exercise, the greater the increase in T.  As important as aerobic exercise is for health, resistance exercise is superior in terms of increasing T.

Bottom Line:  To optimize your T level, maintain a healthy weight and engage in an exercise program emphasizing resistance training.  If you are obese and sedentary, it is likely that you have low T, a situation that can be reversed with a modification to a healthier lifestyle. 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at TheKegelFix.com

Author page on Amazon: http://www.amazon.com/Andrew-Siegel/e/B004W7IM48

Apple iBook: https://itunes.apple.com/us/book/the-kegel-fix/id1105198755?mt=11

Trailer for The Kegel Fix: https://www.youtube.com/watch?v=uHZxoiQb1Cc 

Co-creator of the comprehensive, interactive, FDA-registered Private Gym/PelvicRx, a male pelvic floor muscle training program built upon the foundational work of renowned Dr. Arnold Kegel. The program empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance weights, this program helps to improve sexual function and to prevent urinary incontinence: www.PrivateGym.com or Amazon.  

In the works is the female PelvicRx DVD pelvic floor muscle training for women.

Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

On Beer Bellies, Heart Disease And Sexual Function

July 30, 2016

Andrew Siegel MD  7/30/16

fat

 

A bit of fat is good…but not too much

Having some fat on our bodies is not a bad thing, as long as it is not excessive. Fat serves a number of useful purposes: it cushions internal organs; it provides insulation to conserve heat; it is a means of storing energy and fat-soluble vitamins; it is part of the structure of the brain and cell membranes; and it is used in the manufacturing process of several hormones.

All fat is not created equal…It’s all about location, location, location.

Not all fat is the same. It is important to distinguish between visceral fat and subcutaneous fat. Visceral fat–also referred to as a “pot belly” or “beer belly”– is internal fat located deep within the abdominal cavity. Subcutaneous fat–also known as “love handles,” “spare tires,” “muffin top,” or “middle-age spread”–is superficial fat located between the skin and the abdominal wall. In addition to the physical distribution of the fat being different, so is the nature of the fat. Although neither type is particularly attractive, visceral fat is much more hazardous to one’s health than subcutaneous fat since it increases the risk of heart disease, diabetes and metabolic disturbances. Subcutaneous fat is inactive and relatively harmless and generally does not contribute to health problems.

Factoid: A beer belly is called a beer belly for good reason. One of the real culprits in cultivating visceral fat is drinking liquid carbs, whether they are sweetened beverages (sodas, iced tea, lemonade, sports drinks, etc.), fruit juices such as orange, grapefruit, grape, cranberry, etc., or alcoholic beverages. These liquid carbs have no fiber and are essentially pre-digested, stimulating an insulin surge and rapid storage as fat. It is always better to eat the fruit rather than drink the juice, since the fruit is loaded with fiber that fills you up and slows the absorption process and contains abundant phytonutrients. You would have to eat 3 oranges to get the same sugar and calorie load as drinking a glass of OJ, and it is hardly possible to do that.

Visceral fat essentially is a metabolically active endocrine “organ” that does way more than just create an unsightly protrusion from our abdomens. It produces numerous hormones and other chemical mediators that have many detrimental effects on all systems of our body. So, fat is not just fat. Visceral fat ought to have a specific name, as do other endocrine organs (thyroid gland, adrenal gland, thymus gland, etc.). This name should convey the dangerous nature of this “gland.” I suggest “die-roid” gland because of its dire metabolic consequences, including risk of diabetes, cardiovascular disease, low testosterone, erectile dysfunction (ED) and premature death.

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

Factoid: Anybody with a big belly is pre-diabetic, if not diabetic already.

“Metabolic syndrome” is a cluster of risk factors that are dangerous to one’s health. These include visceral obesity as defined by waist circumference (men > 40 inches; women > 35 inches), elevated blood sugar (> 100 mg/dL), high blood pressure (> 130/85 mm), elevated triglycerides (>150 mg/dL) and low HDL cholesterol (the good cholesterol): (men < 40 mg/dL; women < 50 mg/dL).

Sexual dysfunction

Beer belly and metabolic syndrome are highly associated with low testosterone and poor erection and ejaculation function. The fatty tissue present in obese abdomens contains abundant amounts of the enzyme aromatase, which converts testosterone to estrogen—literally emasculating obese men. So, visceral fat can steal away our masculinity, male athletic form and body composition, mojo, strength, as well as the ability to obtain and maintain a good quality erection.

ED serves as a good proxy for cardiac and general health. The presence of ED is as much of a predictor of heart disease as is a strong family history, tobacco smoking, or elevated cholesterol. The British cardiologist Graham Jackson expanded the initials ED to mean: Endothelial Dysfunction (endothelial cells being the type of cells that line the insides of arteries); Early Detection (of heart disease); and Early Death (if missed).

Factoid: The penis can function as a “canary in the trousers.” Since the penile arteries are generally rather small (diameter of 1- 2 mm) and the coronary (heart) arteries larger (4 mm), it stands to reason that if vascular disease is affecting the tiny penile arteries and causing ED, it may affect the larger coronary arteries as well—if not now, then at some time in the future. In other words, the fatty plaque that compromises blood flow to the smaller vessels of the penis may also do so to the larger vessels of the heart and thus ED may be considered a genital “stress test.”

“Fatal retraction”

While the penis can genuinely shrink for a variety of reasons, most of the time it is a mere illusion—a sleight of penis. Obesity causes a generous pubic fat pad that will make the penis appear shorter. However, penile length is usually intact, with the penis merely hiding or buried behind the fat pad, the “turtle effect.” Lose the fat and presto…the penis reappears. Yet another reason to remain lean!

Trivia: It is estimated that for every 35 lbs. of weight gain, there is a one-inch loss in apparent penile length.

What does this all mean?

  • Visceral fat is a bad, metabolically-active form of fat that is highly correlated with metabolic syndrome, diabetes, heart disease and sexual dysfunction.
  • ED often occurs in the presence of “silent” heart disease (no symptoms) and serves as a marker for increased risk for heart disease (as well as stroke, peripheral artery disease and death) often occurring 3-5 years before heart disease manifests. Early detection of ED provides an opportunity to decrease the risk of heart disease and the other forms of blood vessel disease.  ED has a similar or greater predictive value for heart disease as do traditional factors including family history, prior heart attack, tobacco use and elevated cholesterol. The greater the severity of the ED, the greater the risk and extent of heart disease and blood vessel disease.
  • Intensive lifestyle intervention has the potential for reversing visceral obesity, metabolic syndrome and sexual dysfunction. This lifestyle intervention involves achieving a healthy weight, losing the belly fat, healthy eating, regular exercise, smoking cessation, moderation of alcohol intake, stress management, etc.
  • The good news about visceral fat is that it is so metabolically active that with the appropriate lifestyle measures it can readily melt away, as opposed to subcutaneous fat, which is tenacious and can be virtually impossible to lose.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at TheKegelFix.com

Author page on Amazon: http://www.amazon.com/Andrew-Siegel/e/B004W7IM48

Apple iBook: https://itunes.apple.com/us/book/the-kegel-fix/id1105198755?mt=11

Trailer for The Kegel Fix: https://www.youtube.com/watch?v=uHZxoiQb1Cc  

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.  In the works is the female PelvicRx pelvic floor muscle training DVD. 

Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

Sleep Apnea: Bad For Your Health (General, Sexual & Urinary)

February 6, 2016

Andrew Siegel MD   2/6/16

guy-32820_1280

(Thank you Pixabay for image)

This is an important topic, an issue that the medical community is just getting wind of (pardon the pun) with respect to how common a problem it is and how significant its consequences are. Obstructive sleep apnea (OSA) negatively affects all aspects of health, including sexual and urinary function. Many patients with OSA present with urological symptoms that are not genital/urinary in origin, their root cause being the OSA.  When the OSA is treated, the urological symptoms improve dramatically. 

Obstructive sleep apnea (OSA) is a chronic medical disorder that adversely affects one’s sleep, health and quality of life. It is characterized by repeated complete or partial interruptions of breathing during sleep due to mechanical obstruction of the upper airway passage. Muscle relaxation during sleeping—including those muscles that support the tongue and throat—results in the soft tissues in the throat sagging and collapsing under the force of gravity, pulling the airway closed and causing intermittent suffocation. This reduces or halts breathing and causes below-normal levels of oxygen in the blood, giving rise to insomnia and restless sleep with frequent awakenings. OSA sufferers wake up fatigued and have excessive daytime sleepiness, which correlates with an increased chance of motor vehicle accidents, “fatigue” eating and sleep deprivation-related cognitive impairment and mood disturbances.

OSA is present in about 25% of men and 10% of women in the USA. It is more prevalent with aging and with obesity.  Snoring in a loud and exaggerated fashion is typical, and snorting and gasping for air is characteristic. Other manifestations of OSA are a dry mouth and throat and abnormal daytime breathing patterns–particularly loud, shallow mouth breathing. It is not uncommon for those with OSA to have anatomical irregularities, including a thick neck, enlarged tonsils and palate and jaw abnormalities.

Obesity and OSA share much in common, both chronic diseases that give rise to serious medical issues affecting quantity and quality of life. OSA results in hypoxia (lack of oxygen supply), an unhealthy state since every cell, tissue and organ in our body depends upon oxygen to fuel proper function. A spectrum of serious medical issues can result, including headache, impaired glucose metabolism/type 2 diabetes, depression, chronic kidney disease, peripheral neuropathy, glaucoma and cardiovascular disease. OSA is detrimental to endothelial cell function, the specialized cells that line arteries, and OSA-related cardiovascular disease includes high blood pressure, heart attack, stroke, congestive heart failure, arrhythmia and atrial fibrillation. OSA increases the risk of premature mortality.

OSA is associated with urological issues including decreased sex drive, low testosterone levels, sexual dysfunction in both men and women, overactive bladder and frequent nighttime urinating (a.k.a. nocturia).

OSA and Urination

Many with OSA have urinary symptoms because of the OSA and not because of problems with their bladder, prostate, kidneys, etc. They often end up in a urologist’s office because their primary symptoms are urinary. The two most prevalent urinary issues associated with OSA are nighttime urination and overactive bladder.

Nocturnal urine production by the kidneys is based upon many factors including fluid intake as well as the production of certain hormones. The two key hormones involved are anti-diuretic hormone (ADH) and atrial natriuretic peptide (ANP). ADH is a pituitary hormone that regulates water excretion by the kidney, restricting urine production so that humans maintain their blood volume. ANP is the opposite—a diuretic that increases water excretion by the kidney, causing abundant urine production, as well as inhibiting ADH.

Here is what happens with OSA: Vigorous efforts to breathe against an obstructed airway result in negative pressures in the chest. This increases the volume of venous blood that returns to the heart, causing distension of the right heart chambers (atrium and ventricle). The heart responds to this distension as a false sign of fluid volume overload, with a hormonal response of secreting ANP. As a result of the ANP secretion, high volumes of urine are produced during sleep, resulting in sleep-disruptive nocturia. There may be as many as 6 or more nighttime awakenings to urinate. When OSA is treated it results in a significant improvement, if not complete resolution, of the sleep disruptive nocturia.

In contrast to nocturia, overactive bladder is more of a daytime issue. Its symptoms include the sudden and urgent desire to urinate (a.k.a. “gotta go”), urinating frequently, and possibly urinary leakage (urgency urinary incontinence). The cardinal symptom of OAB is urgency, the sudden and compelling desire to urinate that is difficult to postpone. Studies have shown a direct relationship between the severity of OSA and the severity of OAB symptoms.

 OSA and Sex

Sexual issues are common among men and women with OSA. Men typically experience a loss of interest in sex, low testosterone and difficulties obtaining and maintaining erections.  Women can experience a loss in sex drive and other symptoms of female sexual dysfunction.  Neurological testing of patients with OSA-related erectile dysfunction has shown an absent or impaired bulbo-cavernosus reflex, which is a measure of pelvic floor muscle response to sexual stimulation. The extent of impairment is directly proportional to the severity of the OSA. Essentially, this is peripheral neuropathy—nerve damage that negatively affects sexual function.

 Diagnosing OSA

Despite growing awareness of OSA, 90% of those with the disorder are undiagnosed and untreated. The diagnosis is made with overnight sleep studies, performed under the care of a pulmonologist, an internist who specializes in lung problems. This study records sleep stages, heart rhythm, leg movements, breathing patterns and oxygen saturations. OSA is defined as a complete cessation of airflow lasting more than 10 seconds (apneic episodes). The degree of OSA is based upon the number of episodes per hour of breathing cessation:

  • Mild OSA: 5-15 apneic episodes per hour
  • Moderate OSA: 15-30 apneic episodes per hour
  • Severe OSA: more than 30 apneic episodes per hour

As an alternative to overnight sleep studies that require an overnight stay in a sleep lab, home sleep testing machines are now available.

Treating OSA

Since many with OSA carry the burden of extra pounds–which contributes in a major way to the problem–the first-line treatment is lifestyle improvement. This includes healthy eating, weight loss, exercise, smoking cessation, etc. Additionally, alcohol and other sedative medications (that can further interfere with breathing) should be avoided. Positional therapy–avoiding the supine position and instead sleeping upright–can be helpful as well.

Continuous positive airway pressure (CPAP) is the most common and effective treatment for OSA and is considered the gold standard. This is an apparatus that maintains the airway and airflow, preventing apnea and the negative consequences of lack of oxygen. The problem with CPAP is that it is a somewhat cumbersome device that some people tolerate poorly. Alternatively, oral appliances that are fitted by a dentist can be effective, are less cumbersome than CPAP and do not require an electrical source. A procedure under investigation is the implantation of a hypoglossus nerve stimulators, which can help prevent some of the involved muscles from sagging and causing obstruction. On occasion, surgery such as uvulo-palato-pharyngoplasty performed by an ear/nose/throat surgeon is needed to help alleviate the obstructed breathing passage.

Bottom Line: OSA causes reduced levels of oxygen in the blood and therefore diminished oxygen supply to all cells in the body. Oxygen is vital for cellular function, and similar to the mechanical choking of one’s neck from OSA, so the cells, tissues and organs of the body “choke” in response to insufficient oxygen. The symptoms of OSA are due to the collateral damage from this lack of oxygen with impaired nerve and blood vessel function being particularly detrimental. Many urological issues can develop as a result of OSA, including sleep-disruptive nighttime urination, overactive bladder and altered sexual function. Fortunately, OSA is a treatable condition.

A shout-out to my friend and dentist extraordinaire who has expertise on OSA and the use of oral appliances:  Warren Boardman, DDS, Bergen County Center for Snoring, Sleep Apnea & CPAP Intolerance, 75 Chestnut Street, Ridgewood, NJ, 07450, 201-445-4808

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

Are You A Kidney Stoner? Update On Technological Advances

January 30, 2016

Andrew Siegel MD 1/30/16

Continuing on the theme of technological advances in medicine, today’s entry is on innovations in the diagnosis and management of kidney stones. Kidney stones cause excruciating pain, on par with the most painful human experiences– childbirth, broken bones, gout and impaired blood flow to organs.  Kidney stones are a common affliction with about 10% of Americans having experienced their misery. The good news is that most will pass spontaneously, without the necessity for surgical intervention. The other welcome news is that if surgery is required, it is minimally invasive—open surgery for kidney stones has virtually gone by the wayside.

What’s new in the world of kidney stones?

  1. Our recognition that lifestyle factors are major risks
  2. New and improved imaging techniques
  3. Technological refinements in surgical management
  4. Medical “expulsive” therapy to help stone passage

It is now well understood that although there are many causes of kidney stones, lifestyle factors are of paramount importance. This includes body weight, dietary habits and the quantity of fluids consumed. The prevalence of stone disease has DOUBLED in the last 15 years, paralleling the epidemic of obesity and type II diabetes. The more obese you are, the more likely it is that you will experience a kidney stone and the more difficult it will be to effectively treat it. Why is this so?  Obesity has metabolic consequences including increased urinary excretion of calcium, oxalate and uric acid (all common stone constituents); additionally, the obese population tends to consume excessive protein and salt, further increasing stone formation risk.  Another key risk factor is not consuming sufficient volumes of fluid to maintain a well hydrated state.

The diagnostic tools used to evaluate kidney stones have advanced considerably. Years ago, the imaging choice was intravenous urography (a series of x-rays taken after injecting contrast in a vein), which has been supplanted by unenhanced abdominal computerized tomography (CT) urography, a more sophisticated means of visualizing the anatomy of the urinary tract that does not use contrast (thus avoiding the potential risks of contrast) and has recently evolved further in terms of reduced radiation exposure. It precisely pinpoints the size and location of the stone and the extent of the obstruction. It provides insight into the mineral composition of the stone and also images the other organs in the abdomen and pelvis aside from the urinary tract.

IMG_1630

CT image of patient with stones circled in red in the lower poles of both kidneys, yellow arrow points to right kidney, blue arrow to left kidney.

In terms of stone evaluation, ultrasonography affords the advantage of less expense and no radiation, but is not on a par with CT imaging in terms of diagnostic capability.

sono kidney stone

Ultrasound image of kidney with stone circled in red; blue arrows point to border of kidney.

Minimally invasive techniques to manage kidney stones are now the norm.  Shock wave lithotripsy uses fourth generation machines that generate and focus external shockwaves at the stone.  This procedure is done under sedation, using fluoroscopy (real-time x-ray imaging) to image the stone, resulting in fragmentation of the stone into pieces that can be passed. Ureteroscopy and laser lithotripsy, done under general anesthesia, is a procedure in which a narrow lighted instrument is passed up the ureter (tube connecting the kidney to bladder) to directly visualize the stone and a laser fiber is used to pulverize the stone into pieces.  This procedure has benefited from miniaturized telescopes with increased flexibility, improved optic lens systems and fiber-optic light sources as well as advances in laser technology.

Medical expulsive therapy is now routinely used to help facilitate the passage of the stone or stone fragments. Alpha-blocker medications including Flomax, Uroxatral and Rapaflo, traditionally used to improve urinary symptoms due to prostate enlargement, are utilized “off label” to help relax the smooth muscle of the ureter and aide stone passage.

Groans, moans and other symptoms

Colicky pain results when a stone gets lodged in the ureter during the process of passage. Because of excruciating pain and the inability to find a comfortable position, stones frequently result in a visit to the emergency room. Other typical symptoms are sweating, nausea and vomiting, blood in the urine and urinary urgency and frequency. In the emergency department patients are usually hydrated intravenously, given pain medications and undergo CT imaging. Most kidney stones can be managed on outpatient basis with patients sent home on pain medication, an alpha-blocker medication and a strainer to capture the stone.

Will my stone pass?

Whether a stone will or will not pass is dependent upon factors including stone size, shape, and ureteral anatomy. 70% of stones less than 5 mm and 50% of those between 5–10 mm will pass, given sufficient time. The smoother and less irregular they are, the more easily they will pass. Passage is also influenced by the internal diameter of the ureter and the nuances of ureteral anatomy. Once a stone passes into the urinary bladder, passage out the urethra (tube from the bladder out) is usually rapid and painless.

Why do stones form?

Kidney stones form when minerals normally dissolved in the urine crystallize into solid particles. It starts out as a tiny “grain” that grows because the stone is bathed in mineral-rich urine that laminates mineral deposits around the grain. This crystal formation often occurs during periods of dehydration, typically prompted by summer heat, exercise, saunas, hot yoga, diarrhea, vomiting, being on bowel prep for colonoscopy, etc. Another big culprit is excess Vitamin C, which is converted into oxalate, one of the components of calcium oxalate stones, the most common stone variety.  Vitamin C is not stored in the body and any excess ends up in the urine in the form of oxalate. Other stone promoting factors are excessive dietary protein, fat and sodium intake. Inflammatory bowel disease and previous intestinal surgery increase the risk for stones.  Urinary infections with certain bacteria can promote stone formation. Parathyroid gland issues and high serum calcium levels increase one’s risk. Some stones have a genetic basis.

When to intervene?

If a stone does not pass in a reasonable amount of time and causes continued symptoms, it will require active intervention. Aside from unremitting pain, other reasons for intervention are unrelenting nausea and vomiting with dehydration, larger stones that are not likely to pass, significant obstruction of the kidney, a high fever from a kidney infection that does not respond to antibiotics, a solitary kidney and certain occupations that cannot risk impaired functions such as airline pilots.

What about recurrent stones?

Although the majority of people with a kidney stone will have only one isolated episode, about 35% will experience recurrent episodes. Because of the possibility of recurrence, it is important to identify the underlying metabolic causes in order to implement prevention strategies. For this reason it is important to analyze the mineral content of the stone and certainly for recurrent stones, to collect urine for 24 hours to do a metabolic evaluation.

Strategies to reduce your risk for stones

  • Healthy lifestyle (healthy diet and body weight, exercise, etc.)
  • Stay well hydrated (make sure your urine looks more clear than amber)
  • Consume citrate (high levels in citrus, particularly lemons), which is an inhibitor of stone formation
  • Avoid excess Vitamin C
  • Avoid high protein diets
  • Avoid excessive salt (kidneys tend to reabsorb sodium and compensate by excreting calcium in the urine)

 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

Eating Yourself Limp

January 2, 2016

Andrew Siegel MD   1/2/16

Central_Obesity_008.jpg

Today’s entry is on the topic of how overeating and obesity affect one’s manhood and vitality (this holds true for female sexual function as well).  While optimal sexual function is based on many factors, it is important to recognize that our food choices play a definite role. What we eat—or don’t eat—impacts our sex lives.  It’s a new  year– a fresh start–and time for many resolutions, which often involve weight loss and a healthier lifestyle.  Yet another benefit of becoming leaner and fitter is improved sexual function. 

Sexuality is an important part of our human existence. Healthy sexual function involves a good libido, the ability to obtain and maintain a rigid erection and the ability to ejaculate and experience a climax. Although not a necessity for a healthy life, diminished sexual function can result in loss of self-esteem, embarrassment, a sense of isolation and frustration and even depression.

Sexual functioning is complicated and dependent upon a number of systems working in tandem– the endocrine system (which produces hormones); the central and peripheral nervous systems (which provide nerve control); the vascular system (which conducts blood flow); and the musculo-skeletal system (specifically the pelvic floor muscles that help maintain the high blood pressures in the penis necessary for erectile rigidity).

Sexual function is a good indicator of underlying cardiovascular health. A healthy sexual response is largely about blood flow to the genital and pelvic area. The penis is a marvel of engineering, uniquely capable of increasing its blood flow by a factor of 40-50 times over baseline, this surge happening within seconds and responsible for the remarkable physical transition from flaccid to erect. This is accomplished by relaxation of the smooth muscle within the penile arteries and erectile tissues. Pelvic muscle engagement and contraction help prevent the exit of blood from the penis, enhancing penile rigidity and creating penile blood pressures that far exceed normal blood pressure in arteries. For good reason, Gray’s Anatomy textbook over 100 years ago referred to one of the key pelvic floor muscle as the “erector penis.”

Blood flow to the penis is analogous to air pressure within a tire: if there is insufficient pressure, the tire will not properly inflate and will function sub-optimally; at the extreme the tire may be completely flat. Furthermore, slow leaks (that often occur with aging and failure of the smooth muscle within the penile arteries and erectile tissues to relax) promote poor function.

Just as your car suffers a decline in performance if it is dragging around too much of a load, so you penis will function sub-optimally if you are carrying excessive weight. Obesity steals your manhood and reduces male hormone levels. Abdominal fat converts the male hormone testosterone to the female hormone estrogen. Obese men are more likely to have fatty plaque deposits that clog blood vessels–including the arteries to the penis–making it more difficult to obtain and maintain good-quality erections. Additionally, as your belly gets bigger, your penis appears smaller, lost in the protuberant roundness of your large midriff and the abundant pubic fat pad.

Remember the days when you could achieve a rock-hard erection—majestically pointing upwards—simply by seeing an attractive woman or thinking some vague sexual thought? Chances were that you were young, active, and had an abdomen that somewhat resembled a six-pack. Perhaps now it takes a great deal of physical stimulation to achieve an erection that is barely firm enough to be able to penetrate. Maybe penetration is more of a “shove” than a ready, noble, and natural access. Maybe you need pharmacological assistance to make it possible.

If this is the case, it is probable that you are carrying extra pounds, have a soft belly, and are not physically active. When you’re soft in the middle, you will probably be soft where it counts.  A flaccid penis is entirely consistent with a flaccid body and a hard penis is congruous with a hard body. If your is penis difficult to find, if you have noticed man-boob development, and your libido and erections are not up to par, it may be time to rethink your lifestyle habits.

Healthy lifestyle choices are of paramount importance towards achieving an optimal quality and quantity of life. It should come as no surprise that the initial approach to managing sexual issues is to improve lifestyle choices. These include proper eating habits, maintaining a healthy weight, engaging in exercise, adequate sleep, alcohol in moderation, avoiding tobacco and minimizing stress.

Eating properly is incredibly important, obviously in conjunction with other smart lifestyle choices. Maintaining a healthy weight and fueling up with wholesome and natural and real foods will help prevent weight gain and the build-up of harmful plaque deposits within blood vessels. Healthy fuel includes vegetables, fruits, legumes, nuts, whole grains and fish. Animal products—including lean meats and dairy—should be eaten in moderation. The Mediterranean-style diet is an excellent one for minimizing both sexual dysfunction and heart disease. Poor dietary choices with meals full of calorie-laden, nutritionally-empty selections (e.g., fast food, processed foods, excessive sugars or refined anything), puts one on the fast tract to obesity and clogged arteries that can make your sexual function as small as your belly is big.

Bottom Line: If you want a “sexier” lifestyle, start with a “sexier” style of eating that will improve your overall health and make you feel better, look better and enhance your sexual function.  Smart nutritional choices are a key component of sexual fitness. If you are carrying the burden of too many pounds, now is the perfect time to start on the pathway towards better health and reversing the sexual dysfunction that has been brought on by poor lifestyle choices. 

Wishing you a healthy, peaceful, happy (and sexy) 2016,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. Coming soon is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Author of Promiscuous Eating: Ending Our Self-Destructive Relationship With Food: http://www.PromiscuousEating.com

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

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.

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.

My Blood Pressure Ordeal

July 6, 2013

Andrew Siegel, MD  Blog #111

I consider myself to be a very fit person—for the most part, I eat a very healthy diet with abundant fruits and vegetable and avoid processed, fast and junk foods, don’t smoke, drink alcohol very moderately, and exercise religiously and aggressively.  I’m 5’9” tall and weigh 155 lbs., so I’m not carrying around much body fat.  Nonetheless, in spite of my healthy lifestyle, I was diagnosed with hypertension this year.  I am a strong believer in the mind-body connection and initially attributed my blood pressure issue to the incorporation of electronic medical records into my urology practice, a frustrating and tedious experience that has added hours of time to my workday and much grief and hassle to my life.  That stated, it is difficult to hide from one’s genetics—I have a bunch of family members with high blood pressure, including my younger sister who is a vegetarian and avid cyclist and runner who truly could not be any leaner or in any better physical shape.  But it really irks me that I know many obese and sedentary individuals who do not have blood pressure iss

Earlier this year, I was in Florida with my brother, cousin, and brother’s friend for an extended weekend golf and tennis excursion. We went to the Publix supermarket where we chanced upon one of those free blood pressure machines that you stick your arm in and presto, in a few moments you have a blood pressure reading.   Suffice it to say that among the four of us, I lost the blood pressure contest!   I wrote it off to the stressful week that I had had, but at a visit to my dentist several weeks later, the elevated blood pressure was confirmed.  Suffice it to say that I was not pleased with this news.

You are probably aware that high pressure within the arterial walls (hypertension) contributes to many serious ailments including the following: coronary artery disease; aneurysms; stroke; congestive heart failure; and kidney disease.  These cardiovascular diseases are the leading causes of death in the USA. So it behooves anyone with high blood pressure to get it treated, pronto.

I saw my internist and was prescribed medication called Diovan, which I started immediately.  It controlled my blood pressure nicely, but I experienced some side effects, so I returned to my doctor and I recommended to him a trial of a different class of medication called a beta-blocker.   This is typically not a first-line drug for hypertension and is often used for people with cardiac problems.   It works by decreasing the heart rate and contractility (the ability of the heart muscle to squeeze out blood).   This class of medication generally has a calming effect and I thought that because of my rather “energetic” style and persona, it might have a beneficial effect beyond managing the high blood pressure. Beta-blockers are sometimes used by people before public speaking, work on tremors of the hand, and have a general blunting/“take off the edge” effect.  I have some early morning insomnia and thought that this might help with that as well.

The medication was effective in normalizing my blood pressure.   However, it did “knock” me down a few notches.  I experienced fatigue in the late afternoon that was new to me.  More disturbing was that it was more difficult for me to exercise when it required major exertion.   When working out, I became short of breath and tired much more readily than previously. I’m a recreational cyclist and have always enjoyed bike riding since my earliest days of childhood.  I observed that I was having trouble keeping up with my cycling buddies and that hills—previously one of my strengths—were suddenly particularly difficult.  Understand that I’m going to be 58 years old on my next birthday, so I thought that my age might have finally caught up with me a bit, but I also questioned what role the beta blocker was playing.

My old heart rate monitor that I typically use when I cycle was not working properly so I headed out to Campmor and picked up a new one.  It is basically a chest strap that detects one’s heart rate that is displayed on a wristwatch. It is a very helpful device when cycling that helps one stay in the proper zone of heart rates to assure the appropriate level of exertion.   For example, I know that my maximum heart rate is 160 and a level of 125–140 is a comfortable heart rate for an endurance ride. When I start heading above 145, I begin experiencing shortness of breath and need to tamp down the exertion if I want to maintain the endurance.  I learned all of this when I attended Chris Carmichael hill cycling camp, located in Asheville North Carolina where I went a number of years ago with my cycling buddies to learn the proper techniques of attacking hills.

So I put on my new heart monitor and went out on a hilly ride.  Much to my surprise, my maximum heart rate was now 125, being 160 under normal circumstances.   At 115, I started experiencing shortness of breath; 110 was a comfortable rate.  I was astonished by the profound effect the beta-blocker had my heart rate.

Understand that beta-blockers do not just work on heart rate but also on contractility.  The term “stroke volume” refers to the amount of blood that the heart pumps out with one beat. Beta-blockers reduce both heart rate and stroke volume.   The ability to succeed in aerobic sports such as cycling and running is contingent upon satisfactory cardiac output to provide oxygen and nutrients to our cells. Cardiac output is the product of heart rate and stroke volume. So, cardiac output goes way down on a beta-blocker and clearly explains my sub-normal performance with highly exertion physical sports.

I saw my internist yet again, stopped the beta-blocker, and started an alternative medication—the same one that my sister is on—that has no cardiac effects. I went on a bike ride in Fort Lee Park and Route 9W with my sister and friends and noticed a dramatic subjective improvement in my cycling performance, more in line with my typical cycling functioning of previous years.  This was just one day after getting the beta-blocker out of my system. Objectively, my maximum heart rate was 140, much improved over the 125 on the beta-blocker, but still not up to the 160 that was typical for me.  On my next ride, my maximum heart rate was back to normal and my cycling performance was fully back to days of old.  I was back!  I’m very happy to say that age is not catching up with me—yet.

Bottom Line: The morals of the story are several: 

1.    High blood pressure usually causes no symptoms whatsoever and must be sought after, so get your blood pressure checked periodically even if you’re feeling great

2.    Do not assume that because you are in great physical shape, exercise regularly, are not overweight, are a non-smoker and have a healthy diet, that you are immune from high blood pressure, which is often genetic despite a very healthy lifestyle

3.    Be wary of beta-blockers if you are an endurance exercise enthusiast.   Apparently what I experienced does not happen to everybody, but it was quite profound with me.  

4.    Don’t tell your doctor what to prescribe you even if you are a doctor!  Physician—do not treat thyself; let your internist provide their sage input regarding management of medical problems.

 

 

Andrew Siegel, M.D.

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

Available on Amazon in paperback or Kindle edition

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.

Kidney Cancer (“Renal Cell Carcinoma”) Part II

June 29, 2013

Andrew Siegel, MD  Blog #110

This blog is dedicated to my friend Shira Litvin, host and producer of “Best In Health Radio” (www.BestInHealthRadio.com), who recognized the critical importance of this disease and prodded/begged/nagged/coerced me to address this subject.

(Continued from last week)

Conventional urological teaching is that a solid mass in the kidney is a cancer until proven otherwise. However, not all solid kidney masses are cancers. It is possible to have a kidney tumor that is benign, e.g., an “oncocytoma” or an “angiomyolipoma.” Kidney cancer needs to be distinguished from the much more common kidney cyst.   A kidney cyst is a sac containing fluid that is within the kidney or attached to the kidney. They are very common, occurring in about 50% of adults over 50 years of age and can be quite variable in size. Most have the appearance of water balloons, are benign, and rarely evolve into a problem.  A simple cyst has a thin wall and no subdivisions (referred to as “septa”), calcifications, or solid components.   If a cyst has septa, calcifications, or wall thickening, it is known as a “complex” cyst and generally needs to followed carefully and regularly and perhaps operated upon.   On occasion, a kidney cancer can be a malignant cystic mass, although most kidney cancers are solid (containing tissue) as opposed to kidney cysts (containing fluid).

Most kidney cancers occur on the basis of sporadic mutations in kidney cells during the process of cellular replication. Cancer begins when kidney cells acquire mutations in their DNA. The mutations direct the cells to grow and divide rapidly and in unchecked fashion, with the accumulating abnormal cells forming a mass.  Ultimately, these cells can extend beyond the kidney and some cells can break off and spread (metastasize) to remote parts of the body, including the bones, chest, liver and brain. Tobacco and obesity have been established as environmental risk factors for kidney cancer.

There are genetic/familial forms of kidney cancer including von-Hippel-Lindau disease and familial papillary renal cell carcinoma.    In general, hereditary forms of kidney cancer occur at an earlier age than those that occur on the basis of mutations.  Furthermore, with the hereditary forms of kidney cancer, it is not uncommon to have multiple kidney tumors present, sometimes present in both kidneys. Certain populations are particularly high risk for kidney cancer.  People with end-stage-kidney disease (renal failure) who are on dialysis are in this group as are those with familial/hereditary kidney cancer.  Those with tuberous sclerosis have a propensity for developing kidney cancers.

Many kidney tumors have a very rich blood supply. Interestingly, some kidney cancers can give rise to a strange set of symptoms known as “paraneoplastic syndromes,” in which symptoms remote from the kidney occur, making the diagnosis confusing.  These syndromes can be high blood pressure; anemia; high red blood cell count; high calcium levels in the blood; elevated liver function tests; fever; etc.

Kidney cancers are commonly referred to as renal cell carcinomas-RCC. They can be “staged” to demonstrate the extent of the disease by using imaging studies including CT or MRI. Stage I means confined within the capsule of the kidney; Stage II invades the fatty envelope surrounding the kidney; Stage III involves the lymph nodes in the region; Stage IV is distant spread of tumor.  Prognostic factors include stage, size, nuclear grade (a description based on how abnormal the tumor cells and the tumor tissue look under a microscope), and histological sub-type of cancer.  In general, the lower the stage, the smaller the size, the lower the grade all portend a better prognosis.

In terms of sub-types of kidney cancer, clear cell RCC is the most common form, accounting for about 70% of those with renal cell carcinoma.  When seen under a microscope, the cells that make up clear cell renal cell carcinoma look very pale or clear. Papillary RCC is the second most common subtype.  These cancers form little finger-like projections (papillae). Pathologists refer to this as chromophilic because the cells take up certain dyes and appear pink under the microscope. Chromophobe RCC accounts for about 5% of kidney cancers.  The cells of these cancers are also pale, but are much larger, and this particular kind of kidney cancer has the best prognosis.

The treatment of early, localized kidney cancer is surgical.  Years ago, this meant complete removal of the kidney.  This is still the case with a large cancer or a central one that affects the key blood supply, but in many cases it is possible to do a “partial” nephrectomy and spare kidney tissue.  Nowadays, this is often done using laparoscopy with robot assistance.  Not all kidney masses need to be removed as some can be observed and if they do not change in size or character over time, it is unlikely malignant.  Thermal ablative therapies are also possible for smaller kidney masses—using either heat (radiofrequency waves) or cold (cryosurgery) placed directly into the mass via CT guidance.  It is often possible to biopsy the mass prior to the ablative therapy using a fine needle via CT guidance.  Kidney tumors in general respond poorly to radiation therapy and chemotherapy, but there are numerous effective alternative therapies for advanced disease including immunotherapy including and targeted therapies.  

Targeted therapies are drugs that interfere with the growth of cancer cells at a molecular level.  These drugs interfere with cell growth, prevent cell replication, or disrupt the blood supply to the cancer cells. Sorafenib and Sunitinib disrupt the blood supply, depriving the tumor of oxygen and nutrients; Temsirolimus and Everolimus block blood supply as well as interfere with cell growth; Pazopanib and Axitinib are additional targeted medications.

Bottom Line: What to do to try to minimize risk and make an early diagnosis of kidney cancer?

·      Stay fit and healthy by eating well and exercising regularly

·      Avoid tobacco

·      Avoid obesity

·      Avoid kidney failure (renal failure) as kidney cancer is much more prevalent in patients on dialysis.  The two leading causes of kidney failure are diabetes and high blood pressure, often but not exclusively on the basis of poor lifestyle choices. Diabetes and high blood pressure frequently respond well to a lifestyle “angioplasty” including weight loss, exercise and healthy eating habits.  If they do not respond to lifestyle optimization, they can most often be managed well with medications.

·      Don’t ignore symptoms that persist and are not normal for you: blood in the urine; flank pain; etc.

·      Although controversial, a non-invasive screening sonogram (ultrasound) of the abdomen can easily pick up an early kidney tumor as well as a host of other problems (liver, gallbladder, spleen, pancreas, aorta, bladder, prostate, ovaries, uterus).  Although it may not be cost-effective for a population at large, if it is you or a loved one who has a potential serious problem picked up, then it is certainly more than cost-effective!

Andrew Siegel, M.D.

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

Available on Amazon in paperback or Kindle edition

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.