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Dr Ross Walker
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An aspirin a day…

Thursday, September 20, 2018

I’m often asked the question by patients and callers on my various radio segments as to whether they should be taking low dose aspirin on a daily basis to prevent heart attack and stroke. In fact, the evidence from secondary prevention trials (aspirin taken by people who have already had cardiovascular disease) suggests a reduction in recurrent events by around 25%.

Evidence over the last decade has also suggested up to a 30% reduction in a variety of common cancers in people who take daily aspirin. But, the primary prevention trials (people who do not have established disease) have produced quite variable results with some studies suggesting a possible benefit and others showing none at all.

The New England Journal of Medicine recently published the ASPREE trial. This was a trial of 19,000 people over the age of 70 with a follow up period on average just under five years, performed in Australia. All people were free of cardiovascular disease, dementia and considered healthy at the start of the trial and at the end of follow up there was no benefit in terms of reduction of cardiovascular disease and dementia from taking aspirin 100 mg daily compared with the placebo group.

This trial demonstrated an increase in significant bleeding and thus the conclusion of the trial is that aspirin should not be given as preventative therapy for people over the age of 70. This message is consistent with the other trials in younger people, which again did not show any dramatic benefit.

So, who should be taking aspirin? I believe the evidence to date support the use of low-dose aspirin in all people with established cardiovascular disease such as heart disease and stroke or people with very strong risk factors for heart disease, along with a high coronary calcium score. This is, of course, excluding people who are allergic to aspirin or have had a past history of significant gastrointestinal or cerebral bleeds. Aspirin (even the low-dose variety with a protective coating) is also associated with a significant increased risk for gastrointestinal reflux.

Thus, it is important to realise that aspirin is not a magic bullet although has been proven to be highly effective as a blood thinning agent for people with established disease. But, as with all aspects of medicine, one size does not fit all and if anyone reading this article does have established cardiovascular disease and has had no problems from the use of chronic aspirin therapy, it is important that you do not misinterpret this evidence thinking that there is no benefit for you. The message is purely for people without a history of cardiovascular disease or not at a particularly strong risk for this condition. As far as taking aspirin as a prevention for common cancers, although there is weak evidence, I do not believe the medical profession should be encouraging patients to use this for all the reasons I have said above.

As with all aspects of medicine, it is much more important to focus on key lifestyle principles than to believe that pharmaceutical therapy is the panacea that will keep you living for many years without disease.

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The rise of the super bug

Monday, September 17, 2018

Every year in the United States alone there are around 23,000 deaths related to drug resistant bacteria. Two million people are infected on a yearly basis in America with some form of drug resistant bacteria.

Most of us have heard of golden staph, better known as methicillin resistant staphylococcus aureus but there are, in fact, more scary bacteria that hardly make news in the public arena, despite the fact that medical and nursing staff in hospitals throughout the world are battling these infections on a daily basis.

The bacteria that causes typhoid fever, salmonella typhi, which affects 21 million people across the globe on a yearly basis, is becoming increasingly resistant to standard antibiotics.

It may shock you that the world’s leading infectious disease is Tuberculosis, killing 1.7 million people per year and often requiring a combination of four antibiotics for six months to eradicate the bacteria. It Is estimated that now 13% of cases are multiresistant to antibiotics.

Multi resistant Klebsiella pneumoniae has a 50% death rate once the infection becomes blood-borne. The bacteria pseudomonas aeruginosa is resistant to the vast majority of commonly used antibiotics.

The mostly forgotten (by the public) sexually transmitted disease, gonorrhoea, has now developed a super resistant strain to all but one antibiotic.

A common skin organism, staphylococcus epidermidis, has become an increasing problem for the elderly or those people with immune disorders, especially if there have any prosthetic materials such as joints, catheters or heart valves.

All forms of super bugs are spreading like wildfire especially in places such as intensive care units where strong antibiotics are often used as a routine in very ill patients.

Many infectious diseases researchers are working furiously to find new ways to attack these deadly bacteria including the development of new, stronger antibiotics; changing older antibiotics to become more powerful; the use of bacteriophages-which are viruses that only attack bacteria. These are some techniques that are being trialled at present.

A recent study combined 4-5 existing antibiotics in one treatment (similar to how Tuberculosis is treated currently) found using over 18,000 different combinations of these antibiotics were highly effective in treating a multi resistant form of E.Coli.

Regardless, the large variety of drug resistant bacteria are increasing and becoming more virulent with many experts in the field predicting at some stage over the next 10 to 15 years we will enter the post antibiotic era where we purely have no treatments to combat these issues.

Hopefully, Science will find the right answers because if not, we will be living in a vastly different world to the one we know today.

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Is booze a poison or a tonic?

Thursday, September 13, 2018

With so many of the contradictory health messages over the years, you’d be forgiven for being sceptical and somewhat confused. The latest study published in the Lancet adds more to this confusion, suggesting the only safe intake of alcohol is none whatsoever. The introduction to the study suggests that alcohol is responsible for 3 million deaths around the planet on a yearly basis and is the leading cause of death for people in the 15 to 50 age group, causing around 12% of deaths especially in males.

This study analysed 592 separate reports analysing 28 million people. Understandably, intake of alcohol varies between countries with a rather healthy place like Denmark having over 95% of the adult population consuming alcohol on a regular basis, whereas Muslim countries, such as Bangladesh and Pakistan, have an expected less than 1% of people who consume alcohol regularly.

The study took people who were non-drinkers, compared to those who consumed only one alcoholic drink per day over a 12-month period. The analysis suggested that for every daily alcoholic beverage consumed there was a 0.5% increase in the health problems related to alcohol consumption. In real terms, over the course of a year, the 23 separate health problems related to alcohol consumption were increased from 914/100,000 for the abstainers from alcohol to 918/100,000 for those who drink one alcoholic beverage daily (hardly earth shattering statistics to strike fear in the hearts and other organs of light drinkers).

The variety of health problems included cardiovascular disease and diabetes, a variety of cancers, liver & pancreatic disease, neurological disorders, a variety of infections, along with accidents and violence.

I’d like to take a somewhat different view of these statistics and the entire issue of alcohol consumption. Firstly and most importantly, no one benefits from the excessive consumption of alcohol, apart from people who own hotels or liquor stores. There is no doubt that the regular consumption of four or more standard drinks per day for a male and half that for a female is associated with increasing health problems, such as those mentioned above. Therefore, we should not see the evidence that consuming low dose alcohol may have some benefit as an excuse for heavy or binge drinking.

Secondly, it is my opinion that it isn’t just the alcohol but “who the alcohol is hanging around with” that contributes to the health disorders. What I am inferring here is that you can’t consume an unhealthy diet and expect two glasses of alcohol will afford you some health benefit. For example, if you look at the data from areas of America where a poor diet is consumed, there is no benefit from consuming alcohol and a possible detriment. But, for example, in a more affluent area such as Boston, The Male Physician’s trial demonstrated around an 80% reduction in sudden cardiac death associated with the consumption of one glass of red wine on a daily basis. The Copenhagen Heart study, clearly performed in Denmark where there is a very high proportion of drinkers, demonstrated a 50% reduction in heart disease and cancer when two glasses of red wine were consumed with a healthy Danish diet. The Lyon Heart study, of 36,000 Frenchmen over 12 years showed exactly the same result.

Again, staying with the Harvard data from the Boston area from the Nurses Health study, again suggested that even one glass of alcohol daily can increase the risk for breast cancer. This risk, however, was negated by taking a daily multivitamin on a regular basis for 15 years and beyond.

Finally, it is also important to ask why people consume alcohol? Many people use alcohol as an antidepressant or sedative to numb the pain of a difficult life. Could it be that the alcohol in these people is purely a marker for a mental health disorder and not the actual cause of the problem, thus also increasing the risk for physical disease-a well known association?

Food and alcohol are at the centre of many of our celebrations in life. With around 70% of Australian males and around 50% of females overweight or obese, could it be more that the obesity interacts poorly with the alcohol contributing to all the health problems mentioned above?

I was recently asked the question as to whether grape juice had the same benefits as red wine? The reality is that the polyphenols (strong plant chemicals) in grape juice are in a very complex, polymeric form and therefore are more difficult to absorb. When wine is fermented, these polyphenols are converted to a more monomeric form and are more easily absorbed. I therefore believe the combination of the reduced absorption of polyphenols and the sugar content of grape juice makes it less healthy than the low dose consumption of wine. Red wine, especially, has very concentrated polyphenols, that is, in my view, the evidence for the health benefits in low doses in people who also consume a healthy diet and take a daily multivitamin.

There will always be people with a vested interest either way who will condemn any alcohol consumption on the one hand and those who for other reasons will want to promote the health benefits of alcohol consumption, often playing down the social and health problems created by overuse. As with most issues in life, I believe the answer lies somewhere in the middle and am yet to be convinced that the low-dose, responsible intake of alcohol causes harm and in my view this low dose consumption does have a weak health benefit when combined with all the other aspects of a healthy lifestyle.

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Is coffee going to kill you?

Thursday, September 06, 2018

The most commonly used addictive drug in the world is coffee. A few decades ago, coffee was maligned as a substance that should be taken in low doses, if at all, because of the potential for deleterious effects, especially on the heart. But, over the past decade there is increasing evidence for a variety of health benefits when the ingestion of coffee is studied in populations.

But, with the advent of nutrigenetics, which looks at the science of the variety of genetic variations on dietary responses and nutrigenomics, which is the role of nutrients in gene expression, the position on coffee has clearly changed and is very much in the one size does not fit all category.

The human genome contains around 25,000 genes that code for around 150,000 proteins in the body. Logically, you would think that one gene codes for one protein but because of subtle movements in the DNA machinery, different proteins can be created depending on the position of DNA at the time. There are around 60 genes that dictate cardiac risk and in regard to the interaction between coffee and the cardiovascular system, there are four major genes that determine an individual’s response to coffee.

These genes include

1) CYP1A2

2) ADRA2B

3) ADORA2A

4) COMT

The actual designation of the genes is not really important unless you are a geneticist but it is important to realise firstly with CYP1A2 that there are two possibilities. One variation of this gene indicates that you are a fast metaboliser of caffeine and this is associated with reduced cardiovascular risk. The second variation of the gene indicates you are a slow metaboliser of caffeine, which is associated with a higher cardiovascular risk.

The second and third, AD genes, if the rather common mutations are present, then having a double espresso coffee will markedly increase your blood pressure. If however, you do not have these gene mutations, then coffee will have minimal effect on your BP.

Finally, COMT, which affects circulating and locally released adrenaline like hormones, if you have the genetic variation that gives you low activity in this enzyme system, then you will metabolise caffeine slowly and thus there is an increase in acute coronary events.

The bottom line with this discussion is that when genetic testing becomes more widespread, it is important that you have an understanding of your own personal mutations and if you are a coffee drinker with one of the riskier gene mutations, I would strongly suggest you switch to decaffeinated coffee. A standard cup of coffee purchased in a café as around 100 mg of caffeine. Decaffeinated coffee has only 8 mg and therefore the risk of any interactions with these abnormal genes is markedly reduced by drinking decaffeinated coffee.

With our increasing understanding of genetics, in the not too distant future (and, in fact there many good high quality genetic services already offering these tests), we will be able to gain a much better understanding of which nutrients are suited to a particular genetic make up and also which nutrients may affect your own particular gene expression. The same will be true for pharmaceutical drugs where there are already some basic tests available to gauge response to commonly used medications.

Until recently, the only way to determine your response to a particular food or medication is to trial the pill, test the benefits and assess the potential side effects. Fortunately, with these increasing advances in genetic screening, we are much closer to the vitally important field of personalised medicine.

Dr Walker is on the board of Imagene, a company that provides genetic screening services.
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Flying cattle class

Thursday, August 30, 2018

Around a decade ago, there was significant publicity around the Economy syndrome. A handful of people travelling on long haul flights when they arrived at their destination (or soon after) developed painful, swollen legs and were found to have clots related to many hours of sitting cramped in the economy section of the plane.

These people wanted to sue Qantas but, in reality, should be suing their parents for giving them the genes that led to excessive blood thickening. Around 1% of the population carry one of the variety of genes that predispose to clotting, typically during periods of immobilisation. The immobilisation is the precipitant but not the cause.

The same can be said for the occasional young woman who takes the pill and within a month has suffered a stroke. Hormone therapies can increase blood thickness but typically this is only clinically relevant in people with a genetic predisposition to clotting. Therefore, again, instead of suing the pharmaceutical company that makes the contraceptive pill, the affected person should be suing their relatives for exactly the same reason I have given above.

These genetic abnormalities range from the most common Factor V Leiden to the rather uncommon Anti-thrombin 3 deficiency. If you have a strong family history of any form of clotting, such as deep venous thromboses, pulmonary emboli (clots travelling into the lungs) that affect the venous side of the circulation, or even a very strong family history of arterial clotting, such as recurrent heart attacks or stroke, then there could be a familial predisposition to clotting. There are specific blood tests that can be performed to determine these conditions.

Blood thinners have been available for a number of years, mainly in the form of warfarin or the much weaker aspirin. Aspirin is inappropriate for venous clotting or clots in the lower pressure chambers in the heart i.e. the atriae but typically covers most forms of arterial clotting, although over the past 10 years the evidence has grown to support often using two forms of antiplatelet agents that include aspirin.

Over the past decade, new stronger anticoagulant agents have replaced warfarin in many cases, apart from long-term use with mechanical heart valves.

Research by the superb Baker Heart and Diabetes Institute in Melbourne, in conjunction with Harvard University recently published in the Journal of Clinical Investigation Insight, has discovered a new antibody that purely targets fresh clots. This only works on activated platelets, which are the sticky cells that form part of a clot along with the protein clotting factors but leaves normal components of clotting alone and thus markedly reduces any risk of bleeding that can occur with all of our existing clotting agents, including aspirin up to the newer stronger oral anticoagulants.

Thus, people with a strong predisposition to clotting or a prior history of thromboses could have an injection of this antibody prior to travel, or an operation as pure prevention. This may also have a place in the management of heart attack and stroke, dissolving fresh clots that occur in this situation.

To date, the antibody has proven enormously successful in laboratory animals and human blood but it needs to be trialled for clinical safety in humans. It will probably not be available for clinical use for at least five to 10 years but, if proven safe in humans, which is highly likely, this will be a major breakthrough in the prevention and treatment of blood clotting.

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Is salt good or bad for you?

Thursday, August 23, 2018

There has long been a debate about the potential benefits or detriments of using salt. There is no doubt that human beings have acquired a significant taste for salt and in fact is one of the key ingredients in most of our foods to make it palatable.

But there has been increasing scientific work, especially over the past two decades to suggest that modern society is using far too much salt and there is a clear link with all forms of cardiovascular disease, in particular hypertension.

The World Health Organisation has published a statement suggesting we should have no more than 5g of salt per day, which is the equivalent of 1 teaspoon. The American Heart Association says approximately the same thing but also states that ideal salt intake is no more than 2½g per day or in other words, ½ a teaspoon.

But there are some researchers around the world who have disputed this and in fact have stated that salt is good for us and helps prevent heart attack. A recent study published in the Lancet may have found the answer to this dilemma.

This study followed 94,000 people, aged between 35 to 70 for eight years from 18 different countries. It found that the vast majority of people ingested up to 5g of sodium, which is just over 12g of salt per day and those with the highest salt intake up to this point had the lowest rate of cardiovascular disease including stroke, in the entire cohort. But, in China where typically they have a salt intake above this level, that’s when the risk for cardiovascular disease and in particular stroke starts to kick in.

So, it does appear that there is a J-shaped curve for salt intake as there is for alcohol i.e. moderate amount are probably good for you but too much then starts to cause problems.

Probably the most important message from the study was that those people who benefit from a moderate salt intake are also those who had a diet high in potassium and low in processed foods. Natural foods, such as fruit and vegetables, are high in potassium, whereas processed foods have little potassium and thus high unopposed salt without an adequate potassium intake may have adverse effects on BP and all forms of cardiovascular disease.

Fruits and vegetables that are particularly high in potassium include bananas, oranges, tomato and spinach, kidney beans and avocado. Almonds are very high potassium as well.

One word of caution is that some BP drugs lead to higher potassium levels in the bloodstream and when combined with foods very high in potassium may lead to a dangerous rise in your blood potassium levels. If you have long-standing high blood pressure and, in particular, are an elderly diabetic, it is important to have your potassium checked on a relatively regular basis and not to go overboard with the foods containing potassium.

As with most aspects of life, this is more evidence where moderation in all things is good for your health. Unfortunately, 80% of the salt we ingest comes from processed, packaged foods and not from the salt shaker on the table. Because of this, it is still unnecessary to add salt to anything. Also, don’t be deluded into thinking that Rock salt, sea salt or Himalayan salt is any different. It’s still all salt.

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Sleep - who needs it?

Thursday, August 16, 2018

Over the past decade, the vital importance of good sleep for health has been emphasised by many people in the medical profession. A recent study has suggested that 7-8 hours of high quality sleep every night is as good for your body as not smoking. Although this timeframe is said to be the “sweet spot” for good quality sleep, many people will sleep for this time and still feel unrefreshed when they wake.

Sleep patterns

However it’s actually the quality of deep sleep that determines how rejuvenated and refreshed you are the next day. There are many factors that contribute to good quality sleep which includes following your genetic sleep pattern i.e. 70% of people are larks – go to bed early and wake up early, whilst the remaining 30% are night owls i.e. go to bed late and wake up late. It’s also important to go to bed at approximately the same time and wake up at approximately the same time every day, regardless of whether you’re working or it’s the weekend. Sleeping in a cool dark room, devoid of electronics also improves the quality of sleep.

Health affects

A recent study of pooled data of 3 million people showed that sleeping outside the 7-8 hour per night window increases the risk of death and cardiovascular disease. This was a UK study published in the Journal of the American Heart Association which showed a J-shaped relationship between hours of sleep. Sleeping less than 6 hours per night has been linked to a much greater incidence of cardiovascular disease, cancer, obesity and diabetes.

Poor quality sleep is linked to a 44% increased risk for coronary heart disease. Poor quality sleep is defined as non-restorative sleep or waking unrefreshed. It’s suggested that the ideal sleeping time for people between 25-65 is somewhere between 7-9 hours and for those above 65 in the 7-8 hour range. For people who slept for 9 hours or beyond, there was a 14% increased death risk and for those who slept for 10 hours and beyond a 30% increased death risk.

There is a clear link between insufficient sleep (less than 6 hours) and hormonal changes which are associated with poor energy and increased appetite leading to obesity and impaired blood sugar levels. Insufficient sleep is also linked to inflammation which is a key factor in the generation of cardiovascular disease and cancer.

Too much sleep?

The big question is – why is there a link between increased sleep time and disease? It may actually be that increased sleep is a marker of other health problems such as sleep apnoea or an underlying disease state e.g. inflammation, anaemia etc. In other words, it is the disease leading to increased sleep rather than the increased sleep time leading to disease. There is a known link to increasing sleeping times and depression, unemployment and lower socio-economic status – all features of increased risk for disease.

As with most situations, it is having balance in your life that is important. Too much or too little of most things can cause problems. There is an interesting similar relationship with alcohol consumption. It is suggested that teetotaller’s have more disease than people who are light to moderate drinkers as opposed to heavy drinkers who always come unstuck with some health issue.

The most important message here is that high quality sleep is vital but make sure it is the right dose.

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Is there a cure for Alzheimer’s in sight?

Friday, August 10, 2018

There is an estimated 426,000 people living with some form of dementia in Australia alone. With the rising and ageing population, it’s no surprise that this figure is predicted to rise to astronomical proportions over the next few decades. At present, it is the second leading cause of death in Australia affecting 5.4% of males and 10.6% of females.

It is estimated that three in 10 people over the age of 85 experience some form of dementia, whilst one in 10 over the age of 65. It is said to be the single greatest disability for people over the age of 65. It is also estimated that well over 1 million people in Australia are either directly or indirectly involved in the care of a person with dementia.

The commonest cause of dementia is Alzheimer’s disease but there are other causes such as vascular dementia and less common genetic variants that can also present with similar symptoms.

The cure

So, is there any end in sight for this horrible scourge that affects so many people? The answer is clearly yes! In fact, a few years back a small pilot trial of only 11 patients with varying degrees of Alzheimer’s disease was published titled the MEND trial. This program involves the combination of lifestyle changes, specific vitamin supplementation based on each individual’s assessment, brain training and trans cutaneous cranial stimulation. In 10 out of the 11 patients, the disease was reversed and this did not involve any pharmaceutical therapy.

Recently at a Dementia conference in Chicago, two new experimental therapies were presented showing great promise for the management of Alzheimer’s disease. The first trial involved in a monoclonal antibody, BAN2401. You always know a therapy is not available clinically because it doesn’t even have a proper name. This treatment reduces the amyloid plaques in the brain of people with Alzheimer’s, which are accumulation of junk proteins destroying normal nerve tissue.

Therapy on trial

Eight hundred and fifty six patients with early Alzheimer’s disease were given this therapy in a placebo controlled trial and in varying doses. After 18 months there was a 26% reduction in the clinical decline towards Alzheimer’s disease, compared with placebo, and 50% in those given the high-dose. Previously, the same company had released the results of a small part trial of a similar drug Aducanumab which again showed very similar results.

The second trial, albeit small, was an Australian trial of 32 patients with mild-to-moderate Alzheimer’s disease. This demonstrated that a new experimental treatment, Anavex which is a sigma-1 receptor agonist, appeared to slow, and in some cases, even reverse the disease. The study also looked at a variety of genetic abnormalities and found that 20% of patients had two variants of specific genes that reduced the effect of Anavex. This trial was to continue for just over 12 months.

Vitamin-B the answer?

Interestingly, a few years ago the results of the Optima trial, performed in Oxford University were released. This was a placebo-controlled study of high dose B-group vitamins in 271 people with mild cognitive impairment (a precursor to Alzheimer’s disease). This two-year study, using MRI and neurocognitive testing, demonstrated a 30% reduction in progression to Alzheimer’s disease in the people given the high dose vitamins.

There has also been some promising work using the antidepressant Cipramil and some early data for chronic non-steroidal anti-inflammatory drugs.

It is my opinion that with an integrative approach combining lifestyle modification, brain training and brain stimulation, complementary therapy and evidence based pharmaceutical drugs we are at the cusp of a new era in the management of Alzheimer’s disease. Hopefully, in the very near future, this scourge will become a thing of the past.

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Metabolism - it’s what keeps us alive!

Friday, August 03, 2018

Metabolism is defined as the chemical processes that occur within a living organism in order to maintain life. Basically, it’s the combination of all the actions of all the chemicals in your body that keep us functioning on a day-to-day basis.

We have heard concepts for many years such as fast or slow metabolism but most people really don’t know what this actually means.

Our metabolism is driven by the combination of genetic & environmental factors, with a variety of essential chemicals within the body determining efficiency.

The thyroid

Thyroxine is the key hormone produced by the thyroid gland which basically regulates our metabolism.

To give an example, imagine three groups, each containing five people, asked to dig a large hole. The first five are somewhat lazy and slow, the next five work normally and the last five are superefficient and work very quickly.

This is a good analogy to how the thyroid works. If your thyroid is underactive your body is basically lazy and slow because your metabolism is working at a much slower pace.

Thus, in the example given above, it takes longer to dig the hole. If your thyroid is working normally, your metabolism works at the expected rate and the job is done at the expected time.

But, if your thyroid is overactive and therefore hyper efficient, the job is done quicker but doing things too quickly can lead to burnout because your metabolism (to use the same analogy) is working too fast.

But, this is far too simplistic to just focus on the thyroid gland as the only key to healthy metabolism. There are many complex metabolic pathways that work together to ensure our metabolism keeps our bodies functioning normally.

Five key rules

Genetics aside, how we manage our life it is vitally important to a healthy metabolism. Practising the five keys to being healthy to ensuring a healthy metabolic function

These five keys include:

1)    Quitting all addictions

2)    Generating a healthy sleep pattern

3)    High quality nutrition-which is basically eating less and eating more naturally

4)    3 to 5 hours weekly of moderate exercise

5)    Cultivating peace and happiness in your life

Meal time

Focusing on two of these key points, a recent trial demonstrated that eating your evening meal earlier leads to a lower cancer risk.

This trial looked at just over 620 men with prostate cancer and just over 1200 women with breast cancer and compared these with 870 men and 1320 women who did not have these diseases.

The study reviewed the mealtimes, sleeping habits and whether the participants were larks or night owls (a lark is someone who goes to bed early and wakes up early whereas a night owl is someone who goes to be late and wakes up late).

It is also important to note that the body works on a 24-hour cycle, otherwise known as circadian rhythm. Any genetic abnormality or environmental aberration that affects this 24-hour cycle has the propensity to induce disease.

This study demonstrated that those people who consume the evening meal before 9 PM or at least two hours before bed had 20% reduction in breast cancer and prostate cancer compared with those who consumed food after 10 PM or went to bed soon after eating.

This is a very good example of how maintaining an healthy circadian rhythm or in other words the body’s 24-hour cycle is an important aspect of ensuring healthy metabolism and thus less risk for disease.

The best treatment of any modern killer such as cardiovascular disease or cancer is surely prevention and clearly following healthy preventative lifestyle principles and maintaining an healthy 24 hour cycle is a vital step to staying healthy and free of disease.

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Supplements - Are we really wasting our money?

Thursday, July 26, 2018

Well over 50% of Australians take some form of supplementation on a daily basis. Two of the most commonly used supplements are multivitamins or some type of omega 3 fatty acid, typically fish or krill oil.

But, two recent very extensive reviews published in well-respected medical journals have suggested no harm or benefit from regularly taking multivitamins. The first published in one of the Circulation journals, “Cardiovascular quality and Outcomes” pooled data from 18 randomised controlled trials and cohort studies including around 2 million people, showing no major benefits from the regular ingestion of Multivitamins. These people were followed for an average of 12 years but the longer studies were not randomised controlled trials.

The second review published by Dr Lee Hooper and her group was a large Cochrane review of 79 randomised controlled trials involving 112,059 patients, again showing no benefits from the regular use of some form of omega 3 fatty acids, especially supplementation but also included foods that have a high level of omega 3.

Both reviews focused on cardiovascular outcomes such as heart attack, stroke and cardiac associated death.

So, is this the end of the story? Are supplements purely a waste of money with no evidence to support such widespread use?

Both these reviews included an enormous amount of people and were based firstly on the gold standard of medical science, the randomised controlled trial where one group was given the active therapy and the other half, placebo controlled. There was, however, a large contribution from cohort studies. This is where one group take the active component compared with people who choose not to take the active component who have similar demographics.

Many human beings are seeking a magic pill that will allow them to continue their many poor lifestyle choices but still offer some protection against many of our common killers, in particular cardiovascular disease and cancer.

That’s the first problem.

No one can take any form of pill or potion-either pharmaceutical or complementary and expect it will protect them from the consequences of poor lifestyle choices.

Before you put any pill in your mouth, you derive the greatest benefit from lifestyle modification. A recent trial from Holland, the MORGEN trial demonstrated those people who follow the five keys to ultimate health i.e. no addictions, good sleep, healthy nutrition, 3 to 5 hours of exercise per week and achieving happiness, peace & contentment have an 83% reduction in cardiovascular disease compared with those who are in the poorest categories for lifestyle behaviours.

Now, here’s the key to the entire argument. Drugs are like a high-performance motor vehicle, taking you from A to B very quickly but with potential of crashing and killing or harming yourself, thus the need for strong road rules, high level safety equipment in the car and seat belts.

Supplements, however, are like bicycles which take you from A to B at a much slower pace, but with less risk of harm and the added benefits of exercise. Randomised controlled trials are relevant and important for any trials involving drugs because of the strong effects and possible strong side effects of pharmaceutical preparations. Vioxx (as one example) was seen as the new miracle drug for arthritis but after it had been on the market for 10 years it was shown to double risk of heart attack & thus was withdrawn.

A safe option

No evidence of any death or major harm from the long-term use of supplements has ever been reported, but that’s the key, long-term. The best epidemiology study in the world, in my opinion, has been the combined Nurses Health Study and Male Physicians Trial performed by Harvard university.

One component of these trials showed no benefit from multi vitamins taken up to 10 years. But in the Male Physicians Trial at 10 years, there was an 8% reduction in common cancers and cataracts. When the observational data from the Nurses Health Study was analysed at 15 years, there was a 75% reduction in bowel cancer, a 25% reduction in breast cancer and a 23% reduction in cardiovascular disease in the nurses who took a multivitamin daily for 15 years compared with those who didn’t.

The 20 year data from the Male Physicians trial was recently released demonstrating a 44% reduction in cardiovascular disease. Firstly, it is a huge commitment to your health, to take a multivitamin daily for 20 years, considering that for the general population, 50% have stopped taking any form of therapy whether it be pharmaceutical or complementary, 12 months after it was prescribed or recommended.

The second review showed no cardiovascular benefit from omega 3 therapy such as fish or krill oil in the reviewed 79 randomised controlled clinical trials of just over 112,000 people, but again it’s the same principle. The studies ran for somewhere between one to six years, the vast majority being less than five years showing no cardiovascular benefits. A recent review published in Mayo Clinic Proceedings (Jan 2017) again showed that trials of Omega 3 lasting for less than 5 years showed no benefit but the trials longer than five years showed an 18% reduction in cardiovascular disease.

There are clear messages from both of these reviews:

1)  There is no cardiovascular benefit from taking multivitamins or Omega 3 oils in the short-term i.e. less than five years

2)  Most of the studies were done in high risk patients i.e. those with established cardiovascular disease or multiple risk factors for heart disease.

3)  It is unlikely there will ever be any major, long-term randomised controlled clinical trial of supplementation in any population (i.e. longer than 10 years), because of the lack of short-term data (therefore the belief by researchers that these therapies don’t work, so why bother), the enormous expense of the trial for the group performing the study and the lack of patents on the supplements. Thus if benefits were shown it would be open slather for any company to sell the supplements without contributing to the initial research.

So, in reality, there is a large body of evidence showing an enormous benefit on cardiovascular risk markers from the regular ingestion of multivitamins and omega 3 fatty acids, but the studies to date show the benefits only start to manifest after long term (at least five years or longer) and only in people who follow healthy lifestyle principles.

I have had a number of patients in my practice who have told me, “I took vitamins for a few months and didn’t feel any different, so I stopped!”

With our current level of evidence, I will continue to take supplements long-term but just like addressing healthy lifestyle principles, it must be a long-term commitment to achieve any benefit. All I believe these two major reviews of multivitamins and Omega 3s prove is that taking supplements for a short period of time in high-risk people is too little, too late. Surely the best treatment of any condition is prevention and the earlier you start preventative health strategies, the better chance you have of preventing major illnesses.

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