Friday, April 12, 2019

The very high cost of very low cholesterol

Active surveillance is becoming a widely adopted alternative for some men with prostate cancer. Instead of having immediate treatment, men on active surveillance are monitored with periodic biopsies, physical exams of the prostate, and prostate-specific antigen (PSA) tests. Treatment begins only when the cancer shows signs of progression.

But is it safe to wait until then? A new study adds to growing evidence that the answer is yes, but only for men whose cancers fall into favorable risk categories.

The study is based on data gathered at Johns Hopkins Hospital, in Baltimore, Maryland, the site of a long-running active surveillance program. The authors studied nearly 1,300 men who were enrolled in active surveillance between 1995 and 2014. Most of the men had “very low-risk cancer,” meaning that their PSA levels weren’t excessively high at diagnosis and that only small amounts of low-grade cancer had been found in at most 2 cores of a standard 12-core biopsy. The rest were in a “low-risk” category, meaning that low-grade cancer had been detected in no more than 5 cores.

The men averaged 66 years of age at diagnosis. By the time the analysis was finished, 49 of the men had died, but only 2 of them from prostate cancer. The cancer-specific survival rates in both the very low-risk and low-risk categories combined exceeded 99% at both 10- and 15-year follow-ups, and the predominant cause of death by far was heart disease.

“These results affirm that men with favorable-risk cancer should be encouraged to consider active surveillance instead of treatment given the low likelihood of harm from their diagnosis,” said Dr. Jonathan I. Epstein, a professor of pathology, urology, and oncology at Johns Hopkins Hospital who led the study.

It’s important to point out that prostate cancer can get worse on active surveillance. During this study, 22% of the very low-risk men and 31% of the low-risk men eventually required treatment within 15 years. But by the time treatment was initiated, the men had been on active surveillance for an average of 8.5 years.

“Very low-risk men clearly make the best candidates for active surveillance,” Epstein said. “But in the case of low- and even intermediate-risk cancers, advanced age and other health problems can boost eligibility.”

Epstein added that some men may feel strongly that they don’t want to live with cancer, which can cause them to opt out of active surveillance in favor of treatment. “We’re trying to come up with strategies to help these men stay the course,” he said.

“The study adds important information about the growing practice of active surveillance for certain populations of men,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and Editor in Chief of “But we must also consider that we have no evidence of survival benefits from treatment in favorable-risk men either at the time that they’re diagnosed or when cancers progress on active surveillance. The benefits of treatment are hard to prove since favorable-risk prostate cancers typically will not be life-threatening during a man’s expected lifespan.” Think about it. Your brain is always “on.” It takes care of your thoughts and movements, your breathing and heartbeat, your senses — it works hard 24/7, even while you’re asleep. This means your brain requires a constant supply of fuel. That “fuel” comes from the foods you eat — and what’s in that fuel makes all the difference. Put simply, what you eat directly affects the structure and function of your brain and, ultimately, your mood.

Like an expensive car, your brain functions best when it gets only premium fuel. Eating high-quality foods that contain lots of vitamins, minerals, and antioxidants nourishes the brain and protects it from oxidative stress — the “waste” (free radicals) produced when the body uses oxygen, which can damage cells.

Unfortunately, just like an expensive car, your brain can be damaged if you ingest anything other than premium fuel. If substances from “low-premium” fuel (such as what you get from processed or refined foods) get to the brain, it has little ability to get rid of them. Diets high in refined sugars, for example, are harmful to the brain. In addition to worsening your body’s regulation of insulin, they also promote inflammation and oxidative stress. Multiple studies have found a correlation between a diet high in refined sugars and impaired brain function — and even a worsening of symptoms of mood disorders, such as depression.

It makes sense. If your brain is deprived of good-quality nutrition, or if free radicals or damaging inflammatory cells are circulating within the brain’s enclosed space, further contributing to brain tissue injury, consequences are to be expected. What’s interesting is that for many years, the medical field did not fully acknowledge the connection between mood and food.

Today, fortunately, the burgeoning field of nutritional psychiatry is finding there are many consequences and correlations between not only what you eat, how you feel, and how you ultimately behave, but also the kinds of bacteria that live in your gut.
How the foods you eat affect how you feel

Serotonin is a neurotransmitter that helps regulate sleep and appetite, mediate moods, and inhibit pain. Since about 95% of your serotonin is produced in your gastrointestinal tract, and your gastrointestinal tract is lined with a hundred million nerve cells, or neurons, it makes sense that the inner workings of your digestive system don’t just help you digest food, but also guide your emotions. What’s more, the function of these neurons — and the production of neurotransmitters like serotonin — is highly influenced by the billions of “good” bacteria that make up your intestinal microbiome. These bacteria play an essential role in your health. They protect the lining of your intestines and ensure they provide a strong barrier against toxins and “bad” bacteria; they limit inflammation; they improve how well you absorb nutrients from your food; and they activate neural pathways that travel directly between the gut and the brain.

Studies have shown that when people take probiotics (supplements containing the good bacteria), their anxiety levels, perception of stress, and mental outlook improve, compared with people who did not take probiotics. Other studies have compared “traditional” diets, like the Mediterranean diet and the traditional Japanese diet, to a typical “Western” diet and have shown that the risk of depression is 25% to 35% lower in those who eat a traditional diet. Scientists account for this difference because these traditional diets tend to be high in vegetables, fruits, unprocessed grains, and fish and seafood, and to contain only modest amounts of lean meats and dairy. They are also void of processed and refined foods and sugars, which are staples of the “Western” dietary pattern. In addition, many of these unprocessed foods are fermented, and therefore act as natural probiotics. Fermentation uses bacteria and yeast to convert sugar in food to carbon dioxide, alcohol, and lactic acid. It is used to protect food from spoiling and can add a pleasant taste and texture.

This may sound implausible to you, but the notion that good bacteria not only influence what your gut digests and absorbs, but that they also affect the degree of inflammation throughout your body, as well as your mood and energy level, is gaining traction among researchers. The results so far have been quite amazing.
What does this mean for you?

Start paying attention to how eating different foods makes you feel — not just in the moment, but the next day. Try eating a “clean” diet for two to three weeks — that means cutting out all processed foods and sugar. Add fermented foods like kimchi, miso, sauerkraut, pickles, or kombucha. You also might want to try going dairy-free — and some people even feel that they feel better when their diets are grain-free. See how you feel. Then slowly introduce foods back into your diet, one by one, and see how you feel.

When my patients “go clean,” they cannot believe how much better they feel both physically and emotionally, and how much worse they then feel when they reintroduce the foods that are known to enhance inflammation. Give it a try!

For more information on this topic, please see: Nutritional medicine as mainstream in psychiatry, Sarris J, et al. Lancet Psychiatry. 2015

The field of Nutritional Psychiatry is relatively new, however there are observational data regarding the association between diet quality and mental health across countries, cultures and age groups – depression in particular. Here are links to some systematic reviews and meta-analyses This likely isn’t a surprise to anyone who has been paying attention to the world around them, but a study just published in the journal Pediatrics shows that 44% of children under the age of 1 use mobile devices every day. By the age of 2, that jumps to 77%.

By age 4, half of the children in the study had their own TV — and three-quarters had their own mobile device. And these weren’t rich kids, either; the study was done at an urban, low-income practice in Philadelphia.

When the researchers asked parents about different situations where they let their children use the devices, here’s what they said:

    70% let the children use them so that they could do chores
    65% used them to keep their child calm in a public place
    58% used them while running errands
    29% used them to put their child to sleep

Now, as a parent, I totally see how having a smartphone can make all the difference when you are unexpectedly stuck in a boring place with a child who needs to be still and quiet. And it’s entirely possible that some of these kids are doing educational activities on their devices that will help them learn, or using Skype or FaceTime with a friend or relative.

But still, this is worrisome. As Dr. Dmitri Christakis, a pediatrician at the University of Washington who researches the effect of media on young children, said in a recent New York Times article, “Children need laps more than apps.” We’ve all been in situations where people are interacting with their phones and not each other. Dr. Jenny Radesky did a study where she watched families in fast food restaurants and found an unsettling number of parents paying more attention to their phone than their child. Interaction with adults is crucial for the brain development of children — and for building strong relationships. Interacting with devices simply can’t replace it.

When my children were young, if we were going anywhere they might need to be quiet or patient, I was always ready — with books, small toys, crayons and paper, and some games to play (I Spy, Guess What I’m Thinking, etc.) I don’t see too many parents doing this anymore. What I see is parents handing their child a tablet or a smartphone.

Only time will tell what effects this will have on children; we will need years to understand if or how it affects their brains and their relationships. While we wait, we should try to do what we know works well for both. So, parents — along with the smartphone, pack some crayons. And consider, before you turn on the iPad, putting your child in your lap and playing I Spy. You have probably heard about the new cholesterol-lowering drugs Praluent and Repatha, approved by the FDA within the last few weeks. Maybe you’ve even begun taking one of them yourself.

These drugs are miraculous in their ability to lower LDL (low-density lipoprotein cholesterol), the type that leads to heart disease. But this power comes at a great price — literally. Both drugs come at a yearly cost of around $14,600 per year.
The ripple effect of sky-high drug prices

Of course, people taking these drugs may not pay the full cost themselves — that will fall to their insurance company. Exactly how much a person would have to pay out of pocket depends on his or her particular health insurance plan, but many people could end up footing a considerable part of the bill. So, if your doctor prescribes one of these drugs for you, it is important to check with your insurance company about coverage before you start taking it.

But the prices of these drugs could still affect you, even if you don’t personally take one of them. If enough people enrolled in your particular health plan are prescribed one of these drugs, the total cost to your insurer could be high enough to trigger an increase in everyone’s premium.

The high price of the new cholesterol drugs is not unique. New drugs for hepatitis C, arthritis, and cancer (so-called “specialty drugs”) are also quite expensive, and together they are straining health care budgets — and offsetting the savings gained by the use of low-cost generic drugs.

Why are the new cholesterol drugs — and other specialty drugs — so expensive? In the U.S., drug companies can set prices based on whatever the market will bear. Unlike Canada and Europe, the U.S. government cannot set drug price controls, so our drug prices are usually higher than prices for the same drugs in those regions.

In fact, a new report from the Institute for Clinical and Economic Review (ICER), which analyzes the cost-effectiveness of new drugs, concluded that the cost of the new cholesterol drugs is way too high. ICER recommends a yearly price tag of $2,177.
What to do about the new cholesterol drug prices

While we don’t yet have proof that the new cholesterol lowering drugs will actually reduce rates of heart disease, for people who have an uncommon genetic form of high cholesterol (called familial hypercholesterolemia, or FH), they are a godsend. But for people who have the more common form of high cholesterol, there are other, much less costly options that should be tried first. Dietary change and regular exercise can help to bring cholesterol levels down, and inexpensive (generic) statin therapy remains the drug treatment of choice. A drug called ezetimibe (Zetia) may be added to a statin if the statin by itself is not completely effective.

Democratic presidential candidates Hillary Clinton and Bernie Sanders have both proposed legislation to control drug costs, but it is unlikely that such laws will be passed anytime soon. Until then, consumers need to be mindful of the prices of the drugs that doctors prescribe for them. Often, there are less expensive alternatives that should be considered first.

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