Posts Tagged ‘tobacco’

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

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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.

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.

Bladder Cancer

February 2, 2013

Bladder Cancer

Andrew Siegel, MD  Blog #92

 

Bladder cancer is such a common public health problem that I thought it would be worthy of an educational blog.  Few people realize that its occurrence is more highly linked to tobacco than is lung cancer.

In the USA, the incidence of bladder cancer has increased greatly over the last few decades, with more than 60,000 new cases diagnosed each year.  It is the fourth most common cancer in men and the eighth in women. With the exception of skin cancers, bladder cancers are the most frequently recurring cancer, with up to 70% of patients experiencing recurrence.  The occurrence of bladder cancer increases with age and is three times more common in men than women.  80% of newly diagnosed individuals are 60 years of age or older.  At present, about 20% of patients die each year, but when the disease is diagnosed and treated in the early stages, the chances of survival are excellent, highlighting the importance of a timely and accurate diagnosis.  More than 90% of newly diagnosed bladder cancers are urothelial cell carcinomas  (cancers originating from the unique lining of the urinary tract).

The majority of patients with newly diagnosed bladder cancer have superficial cancer that involves the very inner layers of the bladder wall.  About 20% have invasive disease that involves the deeper layers of the bladder wall.  The remaining 5% present with metastatic disease, defined as spread beyond the confines of the bladder.

The highest prevalence of bladder cancer is in industrialized nations.  Cancer-causing agents (carcinogens) are most often responsible for bladder cancer.   Bladder cancer is highly associated with tobacco smoking—even if one stopped smoking years ago, the risk is related to the quantity of tobacco smoked over the years.  The carcinogens that are present in tobacco are absorbed through the lungs into the bloodstream and are filtered through the kidneys directly into the bladder, where their prolonged contact time with the lining of the bladder leads to cancerous changes.   Certain occupations are at higher risk for bladder cancer because of exposure to chemicals—these include: hairdressers, painters, machinists, printers, and those who work with dyes, textiles, rubber, leather, and petrochemicals.

Bladder cancer most commonly manifests with blood in the urine, either visible or microscopic (seen only under microscopic magnification).  It may also cause irritative lower urinary tract symptoms including urgency, frequency, discomfort with urinating, and urinary leakage.

The evaluation for blood in the urine includes imaging, cytology, and cystoscopy.  Imaging tests are means of visualizing the anatomy of the urinary tract, typically through ultrasound, computerized tomography (CT), or magnetic resonance imaging (MRI).  Cytology is a microscopic inspection of a urine sample by a pathologist for the presence of abnormal or cancerous cells that slough off the lining of the bladder, similar to a Pap smear done to screen for cervical cancer.  Cystoscopy is a visual inspection of the entire lower urinary tract (bladder and urethra) using a tiny, flexible, lighted instrument attached to a camera and monitor.

When a bladder tumor is identified on cystoscopy, attention is directed to the number of tumors present, their size, location within the bladder, and physical appearance.  A papillary appearance consists of fronds (finger-like projections floating in the bladder) with a narrow attachment to the bladder lining versus a sessile appearance, in which the tumor appears solid and is widely attached to the bladder lining.

Once a bladder tumor is recognized, it needs to be removed and sent for pathological evaluation.  This is performed under general or spinal anesthesia via cystoscopy, using an electric loop which is used to remove the area of concern as well as cauterize (use electricity to coagulate tissue) the underlying and adjacent tissue, both to stop bleeding and further destroy tumor cells.

The biopsed tissue is carefully examined by a pathologist, who will provide valuable information regarding malignancy vs. benignity, the type of tumor, depth of tumor, and grade of tumor.   Again, the vast majority of bladder tumors are urothelial cancers, referring to the cells that line the bladder.  A minority of bladder tumors are squamous cell cancers or adenocarcinomas.   Depth refers to the degree that the cancer is growing into the bladder wall.  Bladder cancers are broadly categorized into superficial and deep.  Superficial tumors are largely confined to the bladder lining and superficial layers and do not penetrate the muscle layer of the bladder, whereas deep tumors have “roots” that penetrate the muscular wall of the bladder.  Tumor grade refers to how much the microscopic appearance of the cancer deviates from the microscopic appearance of healthy bladder cells.  Low-grade cancers are similar in cellular appearance to normal bladder cells and generally behave in an indolent (slow) fashion versus high-grade cancers that can often behave aggressively.  Other factors of prognostic importance are the number of tumors present, the size of the tumors, and their physical characteristics.

In general, the best prognosis is for a solitary, small, superficial, low-grade papillary tumor and the worst prognosis is for multi-focal (originating from many different areas of the bladder), large, invasive (deep), sessile, high-grade tumors.

The biopsy information will enable the staging of the bladder cancer, a means of classifying the cancer.  It is extraordinarily unlikely for a superficial cancer to cause lymph node or distant spread, these events occurring with much greater likelihood with more deeply invasive cancers.

Staging of bladder cancer is as follows:

  • Ta: Superficial cancer is found only in polyps (papillary) on the surface of the inner lining of the bladder.
  • Tis: Carcinoma-in-situ. Tumor is found only in flat lesions on the surface of the inner lining of the bladder.
  • T1: Tumor is found in the connective tissue below the lining of the bladder but has not spread to the bladder muscle.
  • T2: Tumor has spread to the muscle layer deep to the lining of the bladder.
  • T3a: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer as identified under microscopic examination.
  • T3b: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer and is capable of being identified without a microscope.
  • T4: Tumor has spread to the prostate in men and to the uterus or vagina in women, or to the pelvic or abdominal wall in either gender.

Superficial cancers are usually managed with cystoscopy, with regular “surveillance” due to the high predilection for recurrence.  It is imperative to have frequent check-ups (every 3 months for the first year after initial diagnosis), consisting of periodic urinalysis, urine cytology, imaging, and cystoscopy.  If surveillance does not demonstrate any recurrences, the interval between follow up can gradually be increased (to every 6 months in the 2nd year; if there are no recurrences, to an annual check-up).  If a recurrence is found, treatment must be repeated and the surveillance frequency then starts anew with the every 3-month cycle.

To help prevent recurrence, under certain circumstances it is beneficial to use a medication that is instilled in the bladder on a weekly basis—this is especially useful when many tumors are present, in the presence of a high-grade tumor, or cancers that have recurred.   It is particularly useful for carcinoma-in-situ (CIS), a variant of bladder cancer that is very superficial, flat, yet of a high-grade pathological nature.  The medication of choice is tuberculosis vaccine—BCG (bacillus Calmette Guerin), which is a live, attenuated (weakened) form of tuberculosis bacteria!

Muscle-invasive cancers most often need to be treated with a major surgical procedure involving either partial or complete removal of the urinary bladder.  In the circumstance that the entire bladder needs to be removed, the ureters (tubes that conduct the urine from the kidneys to the bladder) need to be diverted to a piece of intestine that is either attached to the skin to a collection bag (ileal conduit) or attached to the urethra (neo-bladder or “reconstructed” bladder).  At times, in lieu of surgery, chemo-radiation can be utilized (a combination of radiation therapy provided by the radiation oncologist and chemotherapy provided by the medical oncologist).

Bladder cancer often behaves as two separate types of diseases—one that typically presents as multiple, superficial papillary tumors that have a tendency to recur but are not lethal (similar to many skin cancers), versus another, more deadly form characterized by high-grade, non-papillary, muscle-invasive tumors that have a tendency to metastasize.  Fortunately, the vast majority of bladder cancers are the superficial type.

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

For an educational video on bladder cancer that I have done, please go to the following link: http://www.youtube.com/watch?v=WvEOcCzw2gQ

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Heart Attacks Among My Fit Friends

July 7, 2012

Andrew Siegel, M.D.    Blog # 65

 

My good buddy V. had a heart attack a few weeks ago. He is a urologist in his mid 50’s, a non-smoker of medium build, and an avid recreational cyclist who puts in several hundred miles every week. If it wasn’t for his company and support, I would never have completed the 3 hour challenging bike ascent up Mt. Mitchell (elevation 6683 feet) in Asheville, North Carolina a few years ago.

After some intense cycling, he was taking a breather to wait for one of his cycling partners to catch up with the rest of the group when he developed extreme left shoulder pain and unrelenting sweating.  The unremitting pain was of intensity unlike any that he ever experienced, and in the ambulance in route to the hospital he gazed at his own EKG seeing the classic findings of a myocardial infarct.  He was given morphine for pain, nitroglycerin, aspirin and oxygen and after arriving in the ER was rapidly whisked to the cardiac catheterization lab.  He was found to have a complete occlusion of the right coronary artery and it wasn’t until a wire was passed through the occlusion that he felt dramatic pain relief.  After a stent was placed in the occluded artery, he was sent to the coronary care unit for monitoring.  He was discharged the following day on numerous medications and prescribed rest, time off work, and a specialized diet; he was also admonished to stop exercising until he finishes a program of cardiac rehabilitation.

When I spoke to him, he was extremely depressed about the situation, never having previously had any symptom of heart disease.  He had survived a life-threatening event, going from no medications to seven and having to severely restrict the physical activities that brought him so much pleasure.  To repeat, he was not overweight, not a tobacco user, and did not have high blood pressure, although his cholesterol ran on the high side of normal.  He did not have any family history of heart disease.  He had been a strong recreational cyclist for many years. He never paid attention to his diet because of his fast metabolism and vigorous exercise regimen, which always left him at a healthy weight.  V. is Italian and loves pasta, cheese and meat dishes and has always eaten anything and everything that he wanted.

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Now for the story of A., my good friend from surgical internship:  He became a heart surgeon and practiced in the Midwest for many years, but has recently relocated to the Southeast, where he is the Chief Medical Officer of a hospital.  Like V., A. was always in tip-top shape, a non-smoker and a running enthusiast.  As interns and surgical residents, we spent countless hours running the hills of the north shore of Long Island and each ended up having sibling chocolate Labrador Retrievers as pets.

A few years ago, several hours after a vigorous workout in his home gym, he was relaxing in the living room with his wife. As he stood up, he crumpled to the floor, obviously having passed out.  His wife found him to be pulseless and not breathing. Fortunately she was a RN and managed to maintain her composure and promptly initiated CPR after calling 911.  She continued the cardio-pulmonary resuscitation until the emergency team arrived.  When hooked up to a cardiac monitor he was found to be in a very abnormal rhythm called ventricular fibrillation.   After he was shocked, his heart resumed normal rhythm and he started breathing spontaneously.  Angiography in the hospital demonstrated severe coronary artery disease, and he underwent angioplasties and several stent placements.

A. was of average weight, a non-smoker, and a compulsive exerciser; however,  he had a strong family history of cardiac disease and never paid much attention to his diet. I recall his fondness for ice cream and his not uncommon consumption of a pint of Hagen-Daz at one sitting.

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The point that I wish to make is that maintaining a good weight, avoiding tobacco and pursuing regular exercise is not always enough for vitality and a healthy heart.  Particularly when there is a family history of heart disease, but also as a general health axiom, all efforts must be put in place to stem cardiovascular disease, the number one cause of death in the United States.  In addition to maintaining a good weight, avoiding tobacco and exercising, healthy eating is an indispensable and essential part of the effort—a sine qua non.

The quality and quantity of what we eat play an essential role in determining our health destiny.  The following is an excerpt from The Huffington Post written by Dr. David Katz entitled “Un-junking Ourselves.”  Although the subject of Dr. Katz’s discussion is a child, it is relevant to adults as well.

Think about a child — or former child — you love. This should be pretty easy for any parent, grandparent, aunt, uncle, or just about anybody else who has known a kid or ever been one.

Now, think about that child’s growth from year to year and ask yourself: What were they growing out of? What was the construction material? Matter can’t be constructed out of nothing — it comes from somewhere. If a child’s head is four inches higher off the floor this year than last year, then that four-inch platform of extra kid was built out of… something. What?  Food and nothing else. Food is the construction material — the only construction material — for the growing bodies of children we love.

We are, no doubt, all familiar with the expression “you are what you eat,” but given how most of us eat, it’s quite clear we don’t take it very seriously. And for some pretty good reasons. The human machine, and human fuel tank, are stunningly forgiving. We can throw almost anything in the tank, and run reasonably well for decades. We can’t build a machine fractionally so accommodating.

And, of course, we don’t look like what we eat. We eat donuts, and don’t sport big holes through our middles. We eat French fries, and don’t sprout French fry antennae. But you can’t judge what we are made of by what we look like, any more than you can judge a book by its cover — or a house by its paint. Our houses are, often, made mostly of wood — but look nothing like trees. Trees are cut down and, if you will, “digested” in a timber mill to produce wood that is turned into lumber. The lumber is then used to build houses that look nothing like the trees. But if that lumber is rotten, the house in question may look all right at first — but it will fare quite badly when the first big storm comes along. The quality of a house is rooted in the quality of its construction materials.

Ditto for us. The growing body of a child is built out of food. Nutrients are extracted from food, just as wood is extracted from trees. Rotten wood makes rotten houses. Rotten food makes… sick kids. The kids may look, and even feel, fine for a while. But every cell their bodies build depends on the quality of the available construction material it is offered. Every muscle fiber, every enzyme, every brain cell, every heart cell, every hormone. Maybe not right away — but eventually, rotten construction material catches up with us all.

No one I know throws any old junk into the tank of a car they hope will run well for the foreseeable future. No one I know willingly builds a home out of junk, or of rotten wood. But food is the one and only building material for the growing body of a child you love. How’s “junk” sounding now? And, by the way, every one of us adults is turning over literally hundreds of millions of cells daily. These need to be replaced, along with spent enzymes, hormones, neurotransmitters and the like. Where do WE get the construction material for this job? Think about it.  Right you are.

Bottom Line:  In the quest for fitness, vitality and health, it is necessary to maintain a healthy weight, exercise regularly and avoid tobacco. These efforts are important, but not sufficient to avoid cardiovascular disease; an essential additional factor is what we eat.  The quality of the foods that we ingest for fuel, metabolism and tissue rejuvenation are of great importance in terms of vitality and avoiding fatty plaque deposition in our arteries and cardiovascular disease.  It comes down to a largely plant-based diet with an abundance of different fruits and vegetables, whole grains, legumes, and lean protein sources.  Meat and dairy, unrefined carbohydrates, sugars, processed, junk and fast foods need to be consumed in moderation.  We literally are what we eat and the plaque lining our arteries is a reflection of our cumulative diet over our lifetime.  While genetics and luck are beyond our control, our lifestyle—including what or what not we decide to use as human building blocks—is well within our domain.  Today in my office, I skipped the Carvel ice cream cake and grabbed a Granny Smith apple instead…just not worth it!

My two friends are literally lucky to be alive as many are not so fortunate and succumb to cardiovascular disease.  A., being a cardiac surgeon and having put his event well behind him, has adapted well to his situation.  V. is currently somewhat depressed and is suffering from a form of post-traumatic stress disorder that not uncommonly follows the occurrence of a heart attack.  It behooves all of us to try to avoid potential life-threatening cardiac issues by maintaining a good BMI, eating healthy, exercising and avoiding tobacco.  We need to be especially vigilant when there is a strong family history and/or elevated cholesterol and under these circumstances, proactive cardiology care is certainly warranted.  Family history or not, it makes the utmost sense to keep in mind that “we are what we eat.”

Andrew Siegel, M.D.

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

www.PromiscuousEating.com

Available on Amazon Kindle

Tobacco Keeps Me Way Too Busy As A Urologist

February 25, 2012

 

 

 

Blog # 47       Andrew Siegel, M.D.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Andrew Siegel, M.D.

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

 Now available on Amazon Kindle

www.PromiscuousEating.com

 

For my educational video on bladder cancer:

http://www.youtube.com/watch?v=WvEOcCzw2gQ

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

February 4, 2012

Blog # 44   Andrew Siegel, M.D.

 

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

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

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

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

which threatens instant death if the motion is persisted in;

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

Please take the following advice to heart:

Pearls to keep your heart ** healthy:

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

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

 

Heartfully Yours,

Andrew Siegel, M.D.

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

www.PromiscuousEating.com