Breaking News: Fish Oil Supplements "Out"?

Today the Journal of the American Medical Association (JAMA) published a study about the Association Between Omega-3 Fatty Acid Supplementation and the Risk of Major Cardiovascular Disease Events. The popular media has picked this up and many headlines are focusing on removing these fish oil supplements from your medicine cabinet- is that the take-home message? Maybe not...

There are a few separate issues to discuss. First of all, note that the reason there was a study to begin with is that it has long been established that populations with primarily fatty fish-based diets have lower rates of heart disease. Being Americans looking for a quick fix, we'd rather pop a pill than change our behavior, so rather than add fish to our diets, we look to taking a capsule filled with fish oil. Supplement studies, however, have not been as robust in demonstrating the same heart benefits as simply changing your diet. This study was a meta-analysis that examined over 3600 previous studies, ultimately including 20 of them that met criteria to eliminate bias and make them truly "evidence based". This included nearly 70,000 patients and their rates of heart attack, stroke, and death. Ultimately, fish oil supplements by themselves were NOT shown to lower the risk of death, heart attack or stroke. Do omega-3 supplements lower triglycerides? Yes- but if you are focusing on patient outcomes and not simply lab numbers, the benefits are not there.

Are there other reasons to consider taking fish oil supplements? Probably so, although I will continue to argue that you are better off adding salmon, tuna, trout or sardines to your diet several times per week. Beyond lowering triglycerides, Omega 3 Fatty Acids have been been recommended for potential benefit against numerous cancers, inflammatory bowel disease, dry eyes, rheumatoid arthritis and even dementia. If you are NOT willing to add fish to your routine diet, then taking fish oil supplements for any of these reasons may be beneficial, and there appear to be no serious negative effects (except for a shrinking wallet.)

BOTTOM LINE: If you are taking fish oil supplements to improve your cardiovascular health, you may be improving your lab values but not decreasing your risk of heart attack or stroke- go for a jog or go fishing (and eat your catch) instead. 

Worried about your STATIN?

The FDA has updated the labelled recommendations on statins, the class of drugs most commonly used to lower cholesterol. Like many things medical, there was "good news & bad news". On the plus side, doctors are no longer obligated to check routine blood tests to see if the liver is behaving properly on the statin. We know that there is the potential for a rare, severe liver complication, but it turns out that the routine screening of the liver enzyme levels are ineffective in detecting or preventing it. On the negative side, the FDA now warns against the possibility that statins may raise blood sugar levels, because in several large trials there has been a marked increase in diabetes in patients taking statins (compared to those receiving placebo.) Additionally, the FDA has noted that statins might cause some "minor and reversible cognitive side effects". What does that mean? Basically, there is a subset of people who notice significant short-term memory loss or difficulty concentrating when they take statins. The good news is that those mental changes seem to revert back to normal (or at least, pre-statin levels) once you stop the drug. AND that this side effect occurs in less than 1% of patients.

What does this mean? Should we pull statins from the market? Why take a drug to help your heart when it hurts your liver, muscles, and brain, and could cause diabetes? Well, obviously we feel that in most cases, the benefits far outweigh the risks for this class of medication. Statins have been shown to decrease the risk of DEATH from cardiovascular disease by up to 25% in certain populations- this is a good thing! But- here's the rub-statins are not a substitute for a healthy diet and daily exercise, and not everyone with elevated cholesterol needs to take them. My own father used to chase down his cholesterol pill with chocolate and butter (though in fairness, he exercised every day of his life until his Parkinson's disease robbed him of balance and flexibility in his early 80's). But I digress...

How should we decide if a patient needs a statin? Number one, everyone initially diagnosed with high cholesterol should have dietary counseling on a high fiber, low cholesterol diet and see if they can improve their numbers through the behavioral modification of diet and exercise. Two, there is a wonderfully useful tool called the Framingham risk scorethat will help predict your risk of a cardiovascular event in the next ten years. Plug in your cholesterol, blood pressure & smoking status, and see if adding a statin will significantly lower your risk.

BOTTOM LINE: As with EVERY medication you take, be sure you understand the true anticipated benefits as well as possible risks of statins, and stay tuned...what we rave about today (in medicine), we shake our heads about next year.

Heart Disease in Women- New AHA Guidelines

The American Heart Association has recently published an update to their Guidelines for the Prevention of Cardiovascular Disease in Women, so I thought I would highlight a few issues that may surprise you. Did you know that women are more likely to have a stroke than a heart attack? My patients with risk factors such as high blood pressure or high cholesterol worry far more about having a heart attack than having a stroke, yet at every age, women truly are more likely to suffer a stroke. (The opposite is true for men.) Sadly, in the United States, one woman dies every minute from cardiovascular disease.

The numbers of young women (aged 35-54) dying from cardiovascular disease is rising, paralleling the rise in obesity in our country. Now 2 of 3 women over the age of 20 are overweight or obese. This is why I spend so much time counseling patients and blogging and talking about weight loss and healthy lifestyle changes!

Women who had any pregnancy related complications such as premature birth, pre-eclampsia or gestional diabetes are now known to have higher risk of future cardiovascular events- possibly doubling their risk- despite blood pressures and sugars returning to normal after childbirth. We need to treat these women more aggressively to reduce their risk factors both with behavior modification and with medications.

BOTTOM LINE: Women, recognize that YOU are at risk for strokes and heart attacks as much, if not more than the men you are worrying about! Schedule a check up with your family doctor today.

B Vitamins and Omega 3 Fatty Acids vs. Heart Disease

We are always looking for ways to prevent heart disease, the number one killer in the United States. As we gain technology, we are able to look at more and more components in our blood that lead to clot formation and heart attacks. You'd have to be hiding under a rock to not have heard about cholesterol levels, right?

Well, the trick in medicine today is to make sure that we are focusing on PATIENT OUTCOMES more than LAB VALUES. This is the premise behind evidence-based medicine, where we try to look at specific outcomes (did he have a heart attack or stroke) versus did we lower his cholesterol numbers. My patients hear me whine that so many people are willing to spend money on vitamins, supplements and prescription medicines to "lower their numbers" but are NOT willing to change their behavior to eat more fruits and vegetables and to exercise daily. Why do I complain? Because we DO have evidence-based medical data that shows convincingly more exercise and healthier diets not only lower weight, blood sugars and cholesterol numbers, but they decrease the number of heart attacks, strokes and deaths- and isn't that what we're looking for?

Along those lines, a study was published last month in the British Medical Journal that looked at whether or not giving B Vitamins and Omega 3's to patients who had already had a cardiovascular event (heart attack, stroke, or unstable chest pains) would reduce their subsequent numbers of additional cardiovascular events. What they found was that although the supplements worked better than placebo to change some blood tests, there was no difference in actual heart attacks and strokes.

What is the take home message here? Am I saying B Vitamins and omega 3 fatty acids are useless? NO, I am not. It does appear that they don't have great benefit when started AFTER you've already had a heart attack or stroke. Might they help prevent disease in a healthy person? Maybe.

BOTTOM LINE: Let's focus on the common sense changes that we KNOW benefit our health (MORE fruits and vegetables and exercise) and spend less time, money and energy chasing down lab values.

Avandia Latest News

Last week, the FDA issued more restrictions regarding the diabetes medication Avandia (rosiglitazone). You can read the full notice at FDA.gov, but I will try and hit the highlights for you.

Avandia is a "TZD" which is a class of medications that helps to increase the body's sensitivity to insulin in diabetics. We have seen that it is very effective at lowering blood sugars. Unfortunately, it was discovered that this class should NOT be used in diabetics who also have congestive heart failure. Now, additional studies have shown that there is also an increased risk of heart attack and stroke in patients who took Avandia. At this time, the other drug in the same TZD class, Actos (pioglitazone) is not proven to have the same risks, though many experts are concerned this will be a class effect. Europe has completely withdrawn Avandia from the market, but in the United States, patients doing well on Avandia may discuss the risks with their physicians before making a decision whether or not to continue this drug.

What should YOU do if you take Avandia? There is no need to panic, but schedule an appointment with your doctor to discuss what is best for you. My advice is to take this news as a wakeup call that it is time to STOP LOOKING TO PILLS for an answer for your diabetes, and get serious about the behavior modifications in your diet and exercise that are necessary to reverse your disease! Yes, there are patients with adult onset diabetes who are thin and fit (I have three such patients in my practice) but the vast majority are significantly overweight. The GREAT news is that I have seen time and time again that when patients really embrace healthy eating and daily exercise ("MORE") the high blood sugars, high blood pressures, and high lipids (cholesterol) not only improve, but often disappear!

In Western medicine, we are conditioned to find the quick fix for disease states by prescribing the "right" pill. We have invented wonderful medications that improve the quality and quantity of life. However, the longer people take them, the more long term side effects we identify. What is safe and the "best" practice today is often the next great lawsuit tomorrow. I am NOT anti-medication, but I am most definitely PRO-behavior modification when that choice exists to treat the same problem.

BOTTOM LINE: If you take AVANDIA, please schedule an appointment with your physician and ask for concrete suggestions for a healthier lifestyle!
PS. For a jump start towards "MORE" health, check out my January 2010 blogs: More, More Exercise Buddies, More Fun, When is a pound really gone, etc.

What's in YOUR Medicine Cabinet?

Ever wonder what doctors keep inside their medicine cabinets for their families? Well, my friends (and patients) have definitely asked me, so I thought this week I would share with you my answer. Before I launch into the first ingredient, however, let me encourage you to head directly to YOUR cabinet and THROW AWAY EVERYTHING THAT IS EXPIRED! Just like you should check your smoke detectors a couple times per year, you should also take a look in your stash of medical supplies and toss everything that is expired. Yes, I realize that tiny bottles of prescription medications (especially eye drops, for example) can cost a small fortune, but the only thing worse than "wasting" them by not finishing them is depending on them to work later, when their potency is gone. Don't wait till someone is having a bad allergic reaction to discover your benadryl is long expired!

So, what's the first medication on my list? ASPIRIN- yep, good old-fashioned aspirin. Actually, I keep the enteric coated aspirin, because it's easier on the stomach, but you get the picture. Why do we have aspirin in our cabinet? Not for headaches, though it certainly could be used for that malady. We keep it for several reasons:

1. Heaven forbid a grownup in our home (or neighbors') appears to be having a heart attack- the FIRST response is to have them swallow an aspirin.
2. Studies show that an adult aspirin a couple times per week reduces the incidence of colon polyps (and therefore, hopefully colon cancer, which runs in our family.)
3. Before sitting on a plane or going for a long car ride, a single aspirin can help prevent blood clots from forming in your legs (DVTs- deep vein thromboses.)

BOTTOM LINE: Throw away ALL expired medications, and start your family's medicine cabinet supply list with ASPIRIN.

When Does High Cholesterol Start "Counting"?

Calcium and heart disease are staying together in the news. Yesterday, I talked about calcium supplements. Today, I want to tell you about another study- the "CARDIA" study (Coronary Artery Risk Development in Young Adults). Basically, this study looked at young people who began the trial at age 18-30 in the early 1980's. Their blood cholesterol levels were measured at baseline, and then followed periodically for twenty years. At the endpoint, coronary calcium scores were evaluated. (These scores are from a CT scan that looks at calcium deposits in the coronary arteries- the ones that if clogged, cause a heart attack.) The question was whether or not high lipid (cholesterol) levels in your youth led to these deposits in your middle age. The answer: a resounding YES.

As always, there is a catch. This time, the tricky part is that although high calcium deposit scores are definitely associated with heart disease, it is not the same objective evidence as whether or not people with early high cholesterol levels will actually have more heart attacks. I believe, however, that the take-home message is this: we do indeed pay for "the sins of our youth"- high cholesterol levels that are UNTREATED in young people are going to lead to problems down the road.

What should we do? The jury is still out on whether or not we should be starting younger patients on lipid-lowering medications, despite numerous studies trying to evaluate this issue. We DO know that improving diets and increasing aerobic activity reduces heart disease, with NO negative side effects.

BOTTOM LINE: Don't wait till you are 40 to check your cholesterol levels- find out EARLY and make lifestyle and dietary changes to improve your numbers NOW so you can decrease your heart disease risk LATER!

Now CALCIUM is Dangerous??

Have you heard about the latest study that showed CALCIUM supplements may increase your risk of heart attacks? What's next, finding out Vitamin C makes you sick? Okay, I'm being facetious here, but let's talk about this news from a couple different angles.
First of all, here is what the study from the BMJ (British Medical Journal) says. They looked at a bunch of studies with a total of roughly 12,000 patients and assessed whether those people who took calcium supplements of 500mg or more (without Vitamin D) had more or less heart attacks compared with those who took placebo pills. There were a total of 296 people who suffered heart attacks- 166 on calcium supplements, and 130 on placebo pills. Does this mean placebos CAUSED 140 heart attacks? NO. Does it mean that calcium supplementation by itself CAUSED heart attacks? No- but it does show "an association" with heart attacks, one that may or may not be present if you add Vitamin D, which plays a role in calcium absorption, bone health, and cardiac protection.
There is NO association of heart attacks with increased purely dietary calcium intake (meaning high calcium intake through eating dairy and other calcium-containing foods). What does this tell me? Once again, we are spending a zillion dollars to PROVE THAT GETTING OUR NUTRITION FROM WHOLE FOODS, RATHER THAN SUPPLEMENTAL PILLS, IS BETTER FOR OUR HEALTH.
We've got to stop looking for a quick fix, and start improving our diets (MORE fruits and veggies, less of everything else) and increasing our exercise. Common sense AND scientific studies have proven this over and over.
In the meanwhile, realize that medicine is constantly evolving. What we preach as doctrine today may be heresy tomorrow. Look at what we have recommended for positioning of newborn babies in the last couple decades as an example- first we said on their stomachs (so they don't choke if they spit up), then their sides, and now their backs. Each time, we are SURE we have the answer. Remember that doctors used to recommend smoking to relax- how crazy is THAT?
BOTTOM LINE: Calcium supplements are unlikely to be your greatest risk factor for heart disease- talk with your doctor about your total health picture before you decide whether or not to take ANY supplement!

Hearts a-flutter

Have you ever had the sensation that your heart was jumping around, skipping beats or "fluttering"? Doctors use the word "palpitations" to describe this feeling. Patients experiencing palpitations are often very worried that they are going to have a heart attack. The good news is that the vast majority of the time, early or skipped heart beats cause nothing more than the simple sensation of a heart "hiccup". They are not dangerous, and do NOT lead to additional problems. (Of course, you need to check with your doctor about your symptoms to be sure you are not in the percentage that has a truly concerning arrhythmia, but be reassured this is uncommon.) Now, if your "heart hiccups" are also associated with increasing shortness of breath or trouble exercising- that's a different ball game, so head to your doctor now to be checked out.
Heart attack symptoms, on the other hand, rarely involve any type of flipping sensations- instead, think more about escalating pressure and squeezing chest discomfort, as well as nausea, sweating, and shortness of breath. Palpitations, on the other hand, most often occur without any other types of discomfort, and may occur in healthy young people as well as those medically challenged.
There are numerous triggers for palpitations. The most common ones I see in my practice are decongestants and caffeine. Alcohol overindulgence is another frequent cause. Once we identify the trigger, avoidance is the simple treatment. For patients who develop persistent palpitations, there are medications available to reduce the symptoms (and therefore the patient's anxiety from the symptoms) but they are not typically necessary.
BOTTOM LINE: If your heart is flip-flopping, reduce stimulants such as caffeine and decongestants, and head to your doctor to get checked out- but don't worry that this is leading up to a heart attack.