Doc,

I’ve seen a lot of tv commercials for men who have trouble or a feeling of urgency to urinate. If my PSA is low, what do you think is the most likely cause and what course of action do you suggest?

Its time to reflect and I give Thanks for being blessed with such a wonderful family and staff:

Ginny L my indispensable nurse who works tirelessly to help our patients in every way possible and always with a smile and a chuckle
Rebecca my office manager of twenty five years who does all those behind the scenes things that make our office the best there is
Ginny C with the best phone manner on the planet
Regina our medical assistant who helps in so many ways
Our new addition nutritionist Rick who has taught us so much about the role of diet in treating and preventing illness
Our talented phlebotomist and Redskins Aficionado Chase
Cindy who keeps everything so well organized
Brendan and Erin the most wonderful son and daughter – in–law anyone could ask for
Daughter Michele my medical alter ego and newly board certified surgeon! Now working tirelessly mastering the trade of vascular surgery at Emory
To wife Nancy, the wind behind my sails
And of course you our wonderful patients
Have a Happy Holiday. We will see you back on Monday

Almost all the publicity on the recent guidelines from the American Heart Association has centered on the use of statins.  However a whole section was devoted to “Life Style Changes”.  A group of experts reviewed the literature from 2001 onwards and concluded that aerobic physical activity such as brisk walking for 40 minutes at a time done 3 to 4 times per week will reduce blood pressure on average by 2 to 5 points systolic (the higher number) and 1 to 4 points diastolic (the lower number).  Though that might not seem like a lot for many people it can be the difference between going on blood pressure medicines or having to increase the dose to get to goal.

Similarly, moderate physical activity will lower LDL (lousy cholesterol) by 3-6 mg.  More intensive physical activity results in further decreases.  The effects on HDL or good cholesterol is less clear.

Importantly, dietary changes such as more fruits, vegetables, nuts, whole grains. and low fat products, in conjunction with exercise and weight loss, all help make for a healthier heart.

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“All good things must come to an end…” Well, hopefully not completely…

While it is true that my 4-month fellowship in Tanzania “has come to an end” it is with the greatest of hope that the foundations in which accomplishments were achieved are sustainable and will continue to foster even greater successes in the months and years to come.

Supporting PSI the last few months has been one of the most life changing and rewarding experiences. PSI has established a new Health Services department that will focus primarily on supporting the franchise clinics with additional services to assist the people and communities of Tanzania. Health Services will work to educate, train, and develop providers in clinics to offer high quality health services; and will continue to work to insure those high quality standards are maintained.

Previously, PSI was supporting Family Planning services. During my tenure here, we have launched cervical cancer prevention and treatment programs, as well as programs for prevention of childhood illnesses. Near the end of my fellowship, PSI began launching a third additional service to provide safe Post Abortion Care. Implemented programs will heavily impact morbidity and mortality in women and in children under the age of five.

As I return home to the United States, I search my memories and experiences to define what the past four months have meant. All the superlatives come to mind “life changing”, “unbelievable”, “amazing”, “eye opening”, but what do those terms mean? For me, they serve as a springboard to advocate the need for improved health services in underdeveloped communities. To drive home this point, I go back to a heart wrenching fact I learned while I was here and I posted in an earlier blog. Tanzania is a country of 43 MILLION PEOPLE. It is twice the size of California, yet the country has ONE HOSPITAL that provides chemotherapy treatments… and this is merely just one example of the need to improve access to life saving medical care; unfortunately, there are so many more.

I want to thank Pfizer for the opportunity to become a part of the Global Health Fellows program. Without corporations who are truly dedicated to social responsibility, the path to identifying the tremendous need for support would be much more difficult to navigate. As Pfizer continues to develop medications and develop its people who can develop innovative strategies, there will be continued hope for UNDER developed nations.

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The new guidelines are a joint effort of the American Heart Association, the American College of Cardiology, and the National Heart, Lung, and Blood Institute to revamp guidelines on how to reduce heart disease and stroke risk.  Though most of the press coverage has been about cholesterol guidelines it is important to emphasize that half the report was devoted to lifestyle modifications and the importance of us collectively and individually getting our weight down.  The reports well document that our collective lack of physical activity, the kinds of foods we are eating, and the quantity of foods we are eating is greatly contributing to the epidemic of diabetes and vascular disease we are seeing as evidenced by heart attacks, sudden death, and stroke.

The reports solidify the safety and role of statins in reducing cardiovascular disease.  The statin class of medications have been with us now for four decades and this report widens the audience of people who should consider them.

When patients have asked me over the years about the safety of statins I have half jokingly suggested that they should be in the drinking water.  Though we are not yet to the point where anyone is advocating putting these medications in the drinking water – in some parts of the world there has been serious talk  of giving everyone a “poly pill” of statin, aspirin, and blood pressure lowering medicine with the expectation that cardiovascular disease would dramatically drop.

In regards to cholesterol the report recommends that everyone with known heart disease and everyone with diabetes be on a statin, regardless of their cholesterol numbers.  Furthermore, every one with an LDL “lousy” cholesterol of 190 or more be on a statin, and everyone at increased risk for heart disease consider being on a statin.  How do you know if you are at increased risk?  One way is to use the excel spread sheet calculator they have created and vetted http://static.heart.org/ahamah/risk/Omnibus_Risk_Estimator.xls

If your risk of having a heart attack, dropping dead, or having a stroke is greater than 7.5% over the next ten years it is recommended that you too be on a statin.

The panels of experts who wrote the reports tired to review and critique the world’s vast literature on these issues and to consolidate and come up with sensible recommendations.  Their effort is admirable.  It is by no means the last word and will be updated regularly.  In future posts I will be exploring some of issues and controversies discussed in the reports including more about lifestyle and weight loss measures, concerns about statins causing diabetes, what to do about people who are intolerant of statins, management of elevated triglycerides, the role of heredity in heart disease, and how newer modalities such as the VAP profile may fit in.

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Trans fats are fats that get hydrogen atoms added to their structure (a carbon chain). Food chemists started ‘hydrogenating’ fats as a way of keeping vegetable oil-containing foods from going rancid. This was done for two reasons: because consumers basically don’t like chemical preservatives being added to their foods; and because the food companies were too cheap to use natural preservatives (like vitamin E or fat-soluble vitamin C). Food which contained these fats included crackers, cookies, chips, and other products that had to sit on shelves for a long time. The American food supply became, in effect, a ‘living laboratory’ to test the effects of these fats on a large population, long before these should have been tested for safety in humans.

Hydrogenating fats makes them more saturated, which was one clue that they might not be so good for us. The second came from studies in mice, which found that trans fats messed with key processes involved in fat metabolism. Those of us who were reading these studies knew what was coming, but not when it would arrive. After studies in human populations found evidence of higher risks for heart disease, clinical studies in human volunteers followed. These found that trans fats raised our bad (LDL) cholesterol more than even saturated fats did. Even worse, while saturated fats raise both bad and good (HDL) cholesterol, trans fats lower HDL. The experiment is now over, and the score is still: Food companies 1, American consumers, zero.

Rick Weissinger, MS, RD, LDN, CPT
Author, WHAT THE EXPERTS SAY ABOUT FOOD AND CANCER
Co-author, NUTRITION GUIDE FOR CLINICIANS, editions 1 and 2
Web site: www.idomnt.com

As part of our new cardiovascular risk assessment (the VAP test) we are analyzing not just the amount of LDL or “lousy” cholesterol in the blood but also the pattern of the LDL.  Pattern “A” refers to large fluffy particles which are less damaging to blood vessels vs pattern “B” which refers to smaller and denser particles that tend to stick around longer and are more damaging to blood vessels.  If you have a pattern “B” then you are twice as prone to have a heart attack or die suddenly from your heart disease.  Heredity plays a role in which pattern you have but the good news is that lifestyle changes such as increased exercise and weight loss can help move those with pattern “B” to pattern “A”  Simple changes in diet as advised by our nutritionist Rick, and certain medications can all play a beneficial role.

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