Testosterone Lowers Male Heart Disease Risk

In the last couple of years, studies looking at the correlation between testosterone levels and heart disease in men have yielded mixed results.  However, if you look more closely at the data, most of the reports showing negative associations with testosterone failed to factor in other independent risk factors that can lead to heart disease.  The negative studies also used inaccurate laboratory methods and reference ranges to reach their conclusions, inflating the risks of testosterone.

A late 2011 study published in the Journal of the American College of Cardiology (JACC) demonstrated that men who had the highest levels of testosterone had a 30% lower risk of cardiovascular events.  Men with increasing levels of testosterone also had a decreased prevalence of diabetes, hypertension, and body fat mass.  One of the main reasons for testosterone’s beneficial effect on heart disease is it’s ability to boost HDL levels, and allow the liver to metabolize excess cholesterol more efficiently.  Testosterone also helps to dilate blood vessels and strengthen the muscles of the heart, further lowering the risk of hypertension, heart attacks, and heart failure.

So, with the link between testosterone and cardiovascular risk becoming more clear, why isn’t testosterone being tested routinely in men over the age of 50?  One of the main arguments has been the concern about inducing prostate cancer in men who are using supplemental testosterone.  However, contrary to popular belief, this fear has no basis.  In fact, in his book Testosterone For Life, Dr. Abraham Morgentaler demonstrated that men with low testosterone levels have an increased percentage of prostate cancer-positive biopsies.

Another factor interfering with more routine testing of testosterone levels is the belief that statin drugs are a cure-all for heart disease.  By only lowering cholesterol and ignoring the benefits of testosterone, as well as ignoring the effects of estrogen, insulin, and other hormones, it’s no wonder that heart attacks and strokes continue to be the leading causes of death in this country!  The fact is, if you’re a male over the age of 50, or you already have a history of heart disease, your doctor is doing you a gross disservice by not including testosterone as part of a routine screening for cardiovascular disease risk.

If you have low testosterone levels, this doesn’t necessarily mean you will need to supplement with testosterone injections or cream.  Your doctor should also look at other hormone levels to determine whether low testosterone levels are related to weight gain, insulin resistance, or lack of exercise, vs. a true deficiency.  Then, the appropriate underlying cause can be addressed, rather than just assuming that supplemental testosterone will correct everything.  Just as cholesterol is an important underlying clue when it comes to heart disease, looking at testosterone can be just as valuable, but we should never assume that one treatment is the answer for everything!

Are Annual Exams Really Necessary?

I hear it at least every week, if not more.  “My doctor gave me a clean bill of health.”  OK.  So maybe the annual battery of tests and exams didn’t reveal any serious underlying diseases, but that hardly equates to being healthy.  Unfortunately, we’ve become so accustomed to physical exams, even the insurance companies consider them “preventive care.”  The chief cited rationale is that the annual offers a regular opportunity to address risk factors and health or life concerns.  There may be some truth to this, but both insurance companies and doctors could be doing so much more to provide preventive care for patients.

“There’s little evidence that a routine physical exam and a standard 20-30 item chemical panel improve outcomes,” said Allan Goroll, MACP, a professor of medicine at Harvard Medical School and practicing general internist.  In 1979, a Canadian government task force officially recommended giving up the standard head-to-toe annual physical based on studies showing it to be “nonspecific,” “inefficient” and “potentially harmful,” replacing it instead with a small number of periodic screening tests, which depend in part on a patient’s risk factors for illness.  Yet, doctors and patients both continue to be dependent on “screening tests” that are thought to rack up an unnecessary cost of $325 million annually.

Instead of strictly focusing on “disease prevention”, our model of healthcare needs to move in the direction of teaching people how to be healthy.  It’s great if your test results are “normal”, but what changes can you be making to truly improve your health?  As doctors, we need to make it a point to not give people a false sense of security by sticking to the current standards of the annual physical exam.  This only reinforces bad habits, and most likely makes people more prone to chronic disease in the long-run.  As more and more doctors begin to move away from testing and towards individualized lifestyle counseling, patients will come to expect this with their annual exams, hopefully changing the standards altogether.

But that’s not what happens in many primary care practices, Dr. Prochazka and fellow researchers found in a 2005 survey published in Archives of Internal Medicine. Nearly half of the physician respondents, despite evidence to the contrary, still believed in annual mammography, lipid panels, blood glucose levels, CBCs and urinalysis.

“In general, there’s a bit of a disconnect,” he said. “Many patients wish for tests and think that’s what a physical actually means. And many physicians think that the traditional annual is necessary and of proven value.”

Ateev Mehrotra, an assistant professor at the University of Pittsburgh School of Medicine, has estimated that unneeded blood tests during physical exams alone cost $325 million annually.  And the over-screening for some occurs in a country where 50 million people are uninsured and receive little medical attention. More than half of uninsured adults in the United States did not see a doctor in 2010. Fifty percent of Americans are not up to date with the few screening tests that are recommended — like a colonoscopy once every 10 years for those over 50 — because of high costs, said Karen Davis, president of the Commonwealth Fund.

Intensive screening can prove useless for a number of reasons, experts say: Tests can have high rates of “false positives,” signaling that there may be disease, when further tests and procedures reveal none. Likewise, they can screen for conditions where early detection does not alter the course of the disease, either because the body might heal itself or because there are no effective remedies. In either case they can lead to aggressive procedures to clarify the diagnosis or provide treatment, which themselves can be harmful.

Ultimately, I think broader policy changes will need to be made to allow doctors the freedom to spend more time with their patients, especially since most insurance companies determine the definition of “preventive” services.  But if doctors can start emphasizing that “healthy” involves far more than just normal blood results, I expect that great progress will be made in our health care system.

Acid-Blocking Medications Aren’t Meant For Long-Term Use!

While I may have written about this more than once in the past, I feel like it’s a topic that continues to need revisiting.  A recent New York Times article (http://well.blogs.nytimes.com/2012/06/25/combating-acid-reflux-may-bring-host-of-ills/) highlights the many reasons why proton pump inhibitors (PPI’s), such as Prilosec, Nexium, and Prevacid, can cause more harm than good when used beyond the recommended window of 8 to 12 weeks.  While it seems to come as a surprise to the doctors who are handing out these medications like candy, our stomachs are supposed to make hydrochloric acid!  This is essential for initiating the digestive cascade that leads to the proper assimilation of nutrients.  As the article points out, blocking stomach acid production for an extended period of time can lead to a host of nutritional deficiencies, including iron, vitamin B12, and magnesium.  A decrease in stomach acid also takes away the protective barrier meant to protect us from harmful bacteria, setting up an environment that’s more prone to infection with Clostridium and other pathogenic bacteria.

I personally have seen countless patients in my practice who have been taking one PPI or another for years, and don’t even know why!  In many cases, I’ve seen young women who have persistent iron deficiency anemias, only to find out they have been on acid blocking medication for several years.  However, getting these patients to discontinue the offending medications proves to be extremely challenging, as the body increases the amount of acid-producing cells while on the meds.  Thus, the rebound production of acid is overwhelming, leading to more heartburn than the patient may have ever experienced before even starting the medication!

Fortunately, there are herbs and nutrients that can help to minimize the irritation that can occur when trying to wean off PPI medications.  Once you make the decision with your doctor to discontinue these medications, seek out a qualified naturopathic physician who can help to ease the transition.  Even if you were having legitimate symptoms before these medications were prescribed, it’s likely that diet and lifestyle changes will make a huge difference, without having to depend on a medication that is likely to be more risky than beneficial.

Is It Really IBS?

Irritable bowel syndrome (IBS) affects one in five adult Americans, and is responsible for up to 40% of referrals to gastroenterologists. While there are legitimate criteria used to diagnose IBS (alternating constipation and diarrhea, bloating, abdominal pain), the term is generally used to label patients who don’t have Crohn’s disease, ulcerative colitis, or other underlying “organic” diseases. Once patients have been labeled with having IBS, they are often given one or more medications to treat the symptoms, usually with little to no relief.

Fortunately for IBS sufferers, a multitude of underlying factors may be the real cause of digestive symptoms, making the likelihood of recovery much more promising. One condition in particular that’s often overlooked is small intestinal bacterial overgrowth (SIBO). This is an abnormal colonization of bacteria within the small intestine by bacteria that are normally found in the colon, mouth, or pharynx. When left untreated, SIBO is not only mistaken with IBS, but has been linked to fibromyalgia and chronic fatigue syndrome as well. The cause of SIBO isn’t always clear, but patients who are at higher risk include those with chronic constipation, achlorhydria, diabetes, scleroderma, diverticulosis, and adhesions from prior surgeries.

Up to 78% of patients who are diagnosed with IBS may in fact be experiencing SIBO. Testing for this condition is performed by blowing into a tube that measures gases given off by the excessive amount of bacteria that are present in the small intestine. While these tests are typically offered by gastroenterologists, there are several commercial laboratories that offer test kits for home use, which are then mailed back to the laboratory for analysis. If diagnosed, SIBO can be treated initially with specialized antibiotics. Once the offending bacteria are successfully eradicated, measures should then be taken to improve the intestinal environment (probiotics, digestive enzymes, etc.), which should help to prevent recurrence.

A diagnosis of IBS does not mean all hope is lost. Explore the possibility of SIBO, and seek out a naturopath or other alternative practitioner who can focus on how the digestive tract functions, rather than just looking for a disease.