Health for life

Testing for hidden early lung cancer

Remember this article on screening for lung cancer? 

More than 54,000 former and current tobacco users who looked like they were free of cancer were randomly assigned to a yearly cheapo chest x-ray vs. a yearly pricey low-radiation-dose CAT scan. Over 5 to 7 years of follow-up, the CAT scan was better at picking up early lung cancer (119 cases) which translated into a small but statistically significant survival advantage of 62 lives saved per 100,000 patient years.

Does this mean that Medicare, Medicaid and all commercial insurers should "cover" a baseline and yearly follow-up screening CAT scan for tobacco smokers at risk for lung cancer?  According to actuary Bruce Pyenson and colleagues writing in the latest issue of Health Affairs, the answer may be yes.

The Disease Management Care Blog thinks the answer may still be no. 

Is it being a heartless curmudgeon?  Read on and decide for yourself.......

In the Health Affairs article, the authors assumed current and former tobacco smokers comprise about 30% of persons aged 50-64 years.  They further assumed that about 50% of persons at risk would agree to the CAT screening exam.  Based on prior studies, they estimated that 21% of the baseline scans and 7% of the follow-up yearly scans would require additional testing and figured lung cancers would be present in 0.6% and 0.2% of the baseline and follow-up scans. They used a fee rate of $247 per screening for both the scan and included the cost of a counseling session on smoking cessation.  

Spread over a population, the cost of the screening would amount to 76 cents per member per month (PMPM). On a nationwide basis, there would be 130,000 additional lung cancer survivors.  The cost per life-year saved in 2012 dollars would range between $11,708 and $26,016.  To put things in perspective, it costs more per life-year saved to use current screening approaches to cervical cancer with pap smears (more than $50,000), colon cancer with colonoscopies ($18,000 to $29,000) and mammography ($31,000 to $51,000).

Much of the high costs of these other cancer screening procedures are the result of more persons being eligible for the testing.  In the Health Affairs study, the only persons getting the scan are smokers who are at high risk.

What did the DMCB learn?

One important lesson in this study is that cancer screening is not free.  Its too easy to assume that the early detection provided by mammography, colonoscopies and pap smears pays for itself.  Thats simply not true.  What is true is that cancer screening is good value, but itll still cost you for each life saved.

The second lesson is that good value still represents incremental cost.  As a result, the 76 cents PMPM is in addition to the money already being spent by health insurers.  While the extra pennies doesnt seem like a lot of money, the health insurance dollar is comprised of coverage of similarly priced goods and services, and all those pennies are continuing to add up.  The DMCB thinks were getting to the point where the U.S. would need to ask what coverage of which service should be cut to pay for lung cancer screening.

Both of these issues make it unlikely that insurers will willingly include coverage of screening CAT scans in their health insurer benefit.  They can also argue that it would be highly unusual to decide to cover a new screening procedure based on a single study that hasnt even been reviewed yet by the U.S. Preventive Health Services Task Force.

Last but not least, the DMCB is willing to bet that there wont be much consumer demand for coverage by insurers because of bias against the victims of tobacco-associated illnesses as well as the argument that smokers should self-pay based on the comparative cost of a years worth of cigarettes.

It remains to be seen if, under their ability to define a minimum insurance benefit as part of the Affordable Care Act, the Feds will require lung cancer screening.

Stay tuned!

Image from Wikipedia

Perhaps you bent the wrong way while lifting something heavy. Or youre dealing with a degenerative condition like arthritis. Whatever the cause, once you have low back pain, it can be hard to shake. About one in four Americans say theyve had a recent bout of low back pain. And almost everyone can expect to experience back pain at some point in their lives.

Chill it. Ice is best in the first 24 to 48 hours after an injury because it reduces inflammation, says E. Anne Reicherter, PT, DPT, PhD, associate professor of Physical Therapy at the University of Maryland School of Medicine. "Even though the warmth feels good because it helps cover up the pain and it does help relax the muscles, the heat actually inflames the inflammatory processes," she says. After 48 hours, you can switch to heat if you per. Whether you use heat or ice -- take it off after about 20 minutes to give your skin a rest.
Keep moving. "Our spines are like the rest of our body -- theyre meant to move," says Reicherter. Keep doing your daily activities. Make the beds, go to work, walk the dog. Once youre feeling better, regular aerobic exercises like swimming, bicycling, and walking can keep you -- and your back -- more mobile. Just dont overdo it. Theres no need to run a marathon when your back is sore.
Stay strong. Once your low back pain has receded, you can help avert future episodes of back pain by working the muscles that support your lower back, including the back extensor muscles. "They help you maintain the proper posture and alignment of your spine," Reicherter says. Having strong hip, pelvic, and abdominal muscles also gives you more back support. Avoid abdominal crunches, because they can actually put more strain on your back.
Stretch. Dont sit slumped in your desk chair all day. Get up every 20 minutes or so and stretch the other way. "Because most of us spend a lot of time bending forward in our jobs, its important to stand up and stretch backward throughout the day," Reicherter says. Dont forget to also stretch your legs. Some people find relief from their back pain by doing a regular stretching routine, like yoga.
Think ergonomically. Design your workspace so you dont have to hunch forward to see your computer monitor or reach way out for your mouse. Use a desk chair that supports your lower back and allows you to keep your feet planted firmly on the floor.
Watch your posture. Slumping makes it harder for your back to support your weight. Be especially caul of your posture when lifting heavy objects. Never bend over from the waist. Instead, bend and straighten from the knees.
Kick the habit. Smoking can increase your risk for osteoporosis of the spine and other bone problems. Osteoporosis can lead to compression fractures of the spine. One study found that smokers are about a third more likely to have low back pain compared with nonsmokers.
Watch your weight. Use diet and exercise to keep your weight within a healthy range for your height. Being overweight puts excess stress on your spine.
Try an over-the-counter pain reliever. Anti-inflammatory drugs such as ibuprofen (Advil, Motrin), naproxen (Aleve, Naproxyn), and aspirin can help reduce back pain and swelling. Acetaminophen (Tylenol) is another over-the-counter option for pain management. Be sure to check with your doctor or pharmacist about any interactions over-the-counter pain relievers may have with other medications you are taking. People with a history of certain medical conditions (such as ulcers, kidney disease, and liver disease) should avoid some medicines

Older men who have low levels of vitamin B12 have a higher risk of having fractures. These are the findings of researchers at the Sahlgrenska Academy as a part of an international study of a total of 1000 older men.

Osteoporosis is one of the worlds most widespread diseases, and intensive research is under way worldwide to identify its causes and to be able to prevent fractures.

In an extensive study, researchers at the Sahlgrenska Academy at the University of Gothenburg can now show that low levels of vitamin B12 in the blood increases the risk of fractures in older men.

International research project
This study is a part of an international research project initiated by the National Institutes of Health (NIH) in the US and comprises 11,000 men in total. In their part of the study, the Gothenburg researchers studied 1,000 Swedish men, MrOS Sweden, with an average age of 75, and used various methods to analyze the blood concentrations of the B vitamins B12 and folate, which are found in our food naturally.

Higher fracture risk
The results show that the risk of suffering a fracture six years later was higher among men who had low B12 levels at the beginning of the study than men with normal B12 levels. In the quartile with the lowest B12 content, the risk was elevated by approximately 70 percent compared with the others. The risk increase pertained primarily to fractures in the lumbar region, where the risk increase was up to 120 percent.

"The higher risk also remains when we take other risk factors for fractures into consideration, such as age, smoking, BMI, BMD (bone mineral density), previous fractures, physical activity, the D-vitamin content in the blood and calcium intake," says Catharina Lewerin, researcher at the Sahlgrenska Academy.

Does this mean that older men can prevent fractures by eating more vitamin B12?

"It has not been scientifically established, but such studies are under way, including one large Dutch study where older individuals over the age of 65 are treated with both vitamin B12, folic acid and vitamin D to investigate the occurrence of fractures.

"Right now, there is no reason to eat more vitamin B12, but rather treatment shall only be applied in confirmed cases of deficiencies and in some cases to prevent deficiencies. For anyone who wants to strengthen their bones and prevent fractures, physical activity 30 minutes a day and quitting smoking is good self care," says Catharina Lewerin.

New method

In this study, the researchers used a relatively new method called holotranscobalamin, which measures the amount of vitamin that is taken up in the cells, which is considered to be a more sensitive test for B12 deficiency.

The article was published online in Osteoporosis International.

I hate to say I told you so.  But I did.  Like a million times.  Yet, the fear of cholesterol continues.  What is it?  Is it the Lipitor ads?  Is it your cholesterol-phobic doctor, determined to get your cholesterol under 200 mg/dl at all cost?  Whatever it is, its about time we stopped worrying so damn much about high cholesterol.  This new study, entitled "Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid?  Ten years prospective data from the Norwegian HUNT 2 study.", shows us why.  Did anybody hear anything about this one in the media??  I didnt think so, not with a catchy title like that.  At least now the 3 people that read my blog will be aware of it.  The researchers followed 52,087 Norwegians aged 20-74 who were free of cardiovascular disease (CVD) for 10 years, then assessed the relationship of total cholesterol with total mortality, CVD mortality, and ischemic heart disease mortality (IHD).  (Just to be clear, CVD mortality signifies deaths from any disease of the cardiovascular system, while ischemic heart disease ers only to diseases involving restricted blood flow to the heart.)  Lets jump straight into the data then, shall we?  And another note:  since this study comes from Europe, the units for blood cholesterol are shown in mmol/L, rather than the mg/dL that we are used to.  The researchers classified the participants into four groups, based on their blood cholesterol.  Here are the converted unit values in mg/dL for the four groups...  <193, 193-229, 230-269, and >270


First, the least shocking data.  This graph compares the association between cholesterol levels and death from ischemic heart disease.  For the men, it looks like theres not much variation.  Deaths from heart disease rose slightly along with cholesterol levels, but nothing dramatic.  Women, on the other hand, yielded a much more interesting result.  Clearly, by a LARGE margin, cholesterol below 193 mg/dL was most predictive of death from heart disease.  All other groups, including the group with cholesterol over 270 mg/dL, showed significantly lower risk.  Yes, seriously.  On to the next graph!




This one here shows the association between cholesterol and cardiovascular disease, or CVD, which includes heart disease with stroke and any other disease of the cardiovascular system.  Again, lets begin with the men.  The lowest risk appears to lie in those with total cholesterol between 193 and 229 mg/dL, but a close second is the next range up, from 230 to 269.  If you know your erence ranges, you know that anything over 200 is considered dangerous.  Does anybody ever bother to check why this is considered dangerous, or do we just accept it without question??  Clearly, the data from this study suggests that a cholesterol level in men between 193 and 269 is optimal for CVD prevention.  As for women... oops, looks like they screwed up the data there!  They must have it backwards!  Except they dont... yes, the data shows that if youre a woman, the higher your cholesterol is, the lower your risk of death from CVD.  Id repeat it, but Ill be doing that again shortly.  Read on to all-cause mortality!


Here we are, all-cause mortality... the only statistics that really matter.  Deaths from IHD or CVD are cool, but not nearly as cool as all-cause mortality.  This one cuts through the bullshit.  Its not your risk of dying from one disease that really matters, its your risk of dying overall.  So, for men... the group with the HIGHEST risk of dying overall had the LOWEST cholesterol (below 193 mg/dL).  Even those with a cholesterol level over 270 fared better.  The sweet-spot, protective level here was shown to be 193-229, a level that, based on the current erence ranges, will likely get you prescribed a statin drug for being too high!  Its just not right I tell ya.  And for the women, we see another complete inverse relationship between blood cholesterol and all-cause mortality.  High cholesterol appears to be protective for the ladies!  Maybe I could incorporate that into a pickup line somehow... but I digress.

So, does this prove anything?  No.  Not really.  Although it happens to be in accordance with what I believe, its all just observation.  But this isnt the only study to show this kind of trend, just the most recent; there are at least 20 others like it if you just follow that link.  And it certainly makes a strong case for women... having low cholesterol, in the healthy erence range, mind you, just appears to be straight up deadly!  Despite the studys inability to conclusively prove anything, that didnt stop the researchers from letting loose a little on the drug industry.  And I quote from the conclusion of the paper... "Many individuals who could otherwise call themselves healthy struggle conscientiously to push their cholesterol under the presumed danger limit, coached by health personnel, personal trainers, and caring family members.  Massive commercial interests are linked to drugs and other remedies marketed for this purpose."  That may not seem so harsh, but for a group of researchers to say this and imply that massive commercial interests are wrongly influencing the clinical guidelines... thats a pretty strong statement.  And I agree wholeheartedly.  The guidelines need to be reassessed.

What does this mean, though, if having high cholesterol isnt a bad thing?  What are the implications?  Well, for one, maybe it will get people off these ridiculous statin drugs.  But even more significant, to me, are the implications for saturated fat consumption.  These days, everyone just "knows" saturated fat is bad.  But if I asked you, could you tell me why?  The standard answer is, because saturated fat raises your blood cholesterol.  Well... um... so what?  If you step outside of this cholesterol=bad paradigm for a while, things start to look a bit different.  What else is known about saturated fat?  Well, if you eat more of it, it makes up more of your cell membranes, and its highly resistant to oxidative damage.  So thats good, it protects your cells.  And... short-chain saturated fats like butyric acid, found in butter, are burned perentially as fuel and promote proper immune function.  And... saturated fats enhance calcium absorption, along with all the fat-soluble vitamins (A, D, E, K).  And dont forget, if youre a woman, having high cholesterol appears to be beneficial.  Wait a minute... could saturated fat be... healthy!?  So much for a French paradox...

New research shows that a Mediterranean-style diet and diets low in available carbohydrates can offer protection against type 2 diabetes. The study is published in Diabetologia, the journal of the European Association for the Study of Diabetes (EASD), and is by Dr Carlo La Vecchia, Mario Negri Institute of Pharmacological Research, Milan, Italy, and colleagues.

The authors studied patients from Greece who are part of the ongoing European Prospective Investigation into Cancer and nutrition (EPIC), led by Dr. Antonia Trichopoulou, from the University of Athens. From a total of 22,295 participants, actively followed up for just over 11 years, 2,330 cases of type 2 diabetes were recorded. To assess dietary habits, all participants completed a questionnaire, and the researchers constructed a 10-point Mediterranean diet score (MDS) and a similar scale to measure the available carbohydrate (or glycaemic load [GL]) of the diet.

People with an MDS of over 6 were 12% less likely to develop diabetes than those with the lowest MDS of 3 or under. Patients with the highest available carbohydrate in their diet were 21% more likely to develop diabetes than those with the lowest. A high MDS combined with low available carbohydrate reduced the chances of developing diabetes by 20% as compared with a diet low in MDS and high in GL.

The authors say: "The role of the Mediterranean diet in weight control is still controversial, and in most studies from Mediterranean countries the adherence to the Mediterranean diet was unrelated to overweight. This suggests that the protection of the Mediterranean diet against diabetes is not through weight control, but through several dietary characteristics of the Mediterranean diet. However, this issue is difficult to address in cohort studies because of the lack of information on weight changes during follow-up that are rarely recorded."

They point out that a particular feature of the Mediterranean diet is the use of extra virgin olive oil which leads to a high ratio of monounsaturated to saturated fatty acids. But again research here has been conflicting. One review of dietary fat and diabetes suggests that replacing saturated and trans fats with unsaturated fats has beneficial effects on insulin sensitivity and is likely to reduce the risk of type 2 diabetes. However, in a randomised trial of high-cardiovascular-risk individuals who were assigned to the Mediterranean diet supplemented with either free extra virgin olive oil or nuts and were compared with individuals on a low-fat diet (comparison group), there was no difference in diabetes occurrence between the two variants of the Mediterranean diet when compared with the comparison group.

Regarding GL, the authors say: "High GL diet leads to rapid rises in blood glucose and insulin levels. The chronically increased insulin demand may eventually result in pancreatic β cell failure and, as a consequence, impaired glucose tolerance and increased insulin resistance, which is a predictor of diabetes. A high dietary GL has also been unfavourably related to glycaemic control in individuals with diabetes."

They conclude: "A low GL diet that also adequately adheres to the principles of the traditional Mediterranean diet may reduce the incidence of type 2 diabetes.

Maternal nutrition is important to a developing embryo and to the health of the child later in life. Supplementing the diet with specific vitamins is known to increase health of the fetus for example folic acid (vitamin B9) reduces the risk of spina bifida. However not everything an adult might consume is beneficial to a developing baby. New research published in BioMed Centrals open access journal BMC Medicine shows that caffeine is linked to low birth weight babies and that caffeine from coffee in linked to increasing length of pregnancy.

Along with nutrients and oxygen, caffeine freely passes the placental barrier, but the developing embryo does not express the enzymes required to inactivate it efficiently. The WHO currently suggests a limit of 300mg per day during pregnancy but some countries recommend a limit of 200mg, which can be less than a single cup of coffee from some high street cafes.

To investigate the impact of maternal caffeine during pregnancy on babies, a research team from the Norwegian Institute for Public Health used information about mothers diet and birth details collected over ten years. After excluding women with medical and pregnancy-related conditions almost 60,000 pregnancies were included in the study. All sources of caffeine were monitored in the study: coffee, tea, fizzy drinks, as well as food including cocoa-containing cakes and deserts and chocolate.

Explaining their results, Dr Verena Sengpiel, from Sahlgrenska University Hospital, Sweden, who led the project said, "Although caffeine consumption is strongly correlated with smoking which is known to increase the risk for both preterm delivery and the baby being small for gestational age at birth (SGA). In this study we found no association between either total caffeine or coffee caffeine and preterm delivery but we did find an association between caffeine and SGA. This association remained even when we looked only at non-smoking mothers which implies that the caffeine itself is also having an effect on birth weight."

In fact they found that caffeine from all sources reduced birth weight. For a child of expected average weight (3.6kg) this equates to 21-28g lost per 100mg caffeine per day. But it was not just caffeine, but the source of caffeine, which affected pregnancy outcomes. Caffeine from all sources increased the length of the pregnancy by 5hr per 100mg caffeine per day, but caffeine intake from coffee was associated with an even longer gestational length -- 8hr extra for every 100mg caffeine per day.

This association means that it is not just the caffeine in coffee which increases gestational length but either there must be a substance in coffee which is responsible for the extra time or there is a behaviour associated with coffee drinking not present in women who drink only tea (for example). SGA babies are at higher risk of both short term and lifelong health problems and it seems from these results that since even 200-300mg caffeine per day can increase the risk of SGA by almost a third these recommendations need to be re-evaluated.

Whats the one issue that drives the most doctors crazy?  The Disease Management Care Blog suspects its persons who use basic vaccinations.  Thats because physicians are inculcated from the first day of their education with triumphant stories of how basic science and public health joined forces to banish many common and fatal infectious diseases. 

Not getting your shots is crazy.

DMCB readers are probably aware of how childhood U.S. vaccination rates are dropping.  While we continue to wonder just how any parent or guardian could let that happen, heres a handy summary on the story behind the story: the New England Journal has an article on Improving Childhood Vaccination Rates:

Total U.S. rates of vaccination remain greater than 90%, but there are some pockets of the country with rates just over 50%. Thats where there have been outbreaks of disease leading to some pointless deaths.

Parents (or guardians) opposed to vaccination are unlikely to change their minds.  Thats why high vaccination rates among the remainder of children are important to create herd immunity.

There are four approaches to achieving high vaccination rates:

1. Make shots free and think about paying parents to have their children immunized.

The DMCB likes the idea but wishes the authors had pointed out that in the context of value-based insurance, this is hardly a radical idea. 

2. Make it really difficult to attend school without proof of vaccination.  Getting an exemption should demonstrate that the parents are serious and not shuffling by on lax enforcement.

The DMCB grew up in New York City and recalls being immunized against polio in the schools cafeteria.  Is it time to bring this back as a first-line strategy?

3. Confront the anti-vaccine community with counter-education campaigns that rely on more than facts and figures.  Anecdotes and trusted public figures should also be used.

Whither social media?  And, at a traditional marketing level, the DMCB thinks that maybe its time to partner with the pharma companies that do such a good job of convincing TV viewers to take lipid-lowering agents and anti-depressants.  Nothing against the colleagues in public health, but theyre not known for their marketing savvy.

4. Physicians need to step up one patient at a time and, while theyre at it, make sure theyre up to date with their shots.

The DMCB did a literature search on "shared decision making" and "vaccination" and found no useful information.  Given the success of aids and engagement strategies that enable truly informed decision-making, the DMCB thinks its time for the population health management community to step up and offer their services.

(One last thought: Newts been lampooned for his moon-base wackiness, but as the DMCB understands it, his recommendation is really based on an X-Prize approach, which he contrasts with the discontinued Shuttle program.  The DMCB wonders if such an approach couldnt work in those areas of the country with critically low childhood vaccination rates: a 5 figure prize to any outfit that can move it to 90%.  Why not?)

Image from Wikipedia

Recent research from the American Journal of Clinical Nutrition supplies more evidence that a low-fat vegan diet is better than a conventional diabetes diet for managing blood glucose and cholesterol.¹

People with type 2 diabetes were assigned to either a low-fat, vegan diet (49 participants) or a diet adhering to the 2003 American Diabetes Association (ADA) guidelines (50 participants).

After about a year and a half (74 weeks), members in both groups lost weight, but the difference between them wasnt significant: 4.4 kg (9.7 lbs) wt. loss in the vegan group, 3.0 kg (6.6 lbs) weight loss in the ADA group.

However, there was a significant difference between the groups in the following measures:

• Hb A1c:
  -0.40 for the vegan diet
  -0.01 for the ADA diet
  
  
• Total cholesterol (mg/dL):
  -20.4 for the vegan diet
  -6.8 for the ADA diet
  
  
• LDL cholesterol (mg/dL):
  -13.5 for the vegan diet
  -3.4 for the ADA diet

The authors concluded:

"Both diets were associated with sustained reductions in weight and plasma lipid concentrations. In an analysis controlling for medication changes, a low-fat vegan diet appeared to improve glycemia and plasma lipids more than did conventional diabetes diet recommendations."

________
¹ A Low-Fat Vegan Diet And A Conventional Diabetes Diet In The Treatment Of Type 2 Diabetes: A Randomized, Controlled, 74-Wk Clinical Trial, AJCN, May 2009

Photo of vegan pyramid: Nutrispeak.com, the home page of Vesanto Melina, MS RD.

Men with prostate cancer who ate a low-fat diet and took fish oil supplements had lower levels of pro-inflammatory substances in their blood and a lower cell cycle progression score, a measure used to predict cancer recurrence, than men who ate a typical Western diet, UCLA researchers found.

The findings are important because lowering the cell cycle progression (CCP) score may help prevent prostate cancers from becoming more aggressive, said study lead author William Aronson, a clinical professor of urology at UCLA and chief of urologic oncology at the West Los Angeles Veterans Affairs Medical Center.

"We found that CCP scores were significantly lower in the prostate cancer in men who consumed the low-fat fish oil diet as compare to men who followed a higher fat Western diet," Aronson said. "We also found that men on the low-fat fish oil diet had reduced blood levels of pro-inflammatory substances that have been associated with cancer."

This study appears in the early online edition of Cancer Prevention Research, a peer-reviewed journal of the American Association for Cancer Research.

This study is a follow-up to a 2011 study by Aronson and his team that found a low-fat diet with fish oil supplements eaten for four to six weeks prior to prostate removal slowed the growth of cancer cells in human prostate cancer tissue compared to a traditional, high-fat Western diet.

That short-term study also found that the men on the low-fat fish oil diet were able to change the composition of their cell membranes in both the healthy cells and the cancer cells in the prostate. They had increased levels of omega-3 fatty acids from fish oil and decreased levels of the more pro-inflammatory omega-6 fatty acids from corn oil in the cell membranes, which may directly affect the biology of the cells, Aronson said.

"These studies are showing that, in men with prostate cancer, you really are what you eat," Aronson said. "The studies suggest that by altering the diet, we may favorably affect the biology of prostate cancer."

The men in the previous study were placed into one of two groups, the low-fat fish oil diet or the Western diet. The Western diet consisted of 40 percent of calories from fat, generally equivalent to what many Americans consume today. The fat sources also were typical of the American diet and included high levels of omega-6 fatty acids from corn oil and low levels of fish oil that provide omega-3 fatty acids.

The low-fat diet consisted of 15 percent of calories from fat. Additionally, the men on this diet took five grams of fish oil per day in five capsules, three with breakfast and two with dinner, to provide omega-3 fatty acids. Omega-3 fatty acids have been found to reduce inflammation, and may be protective for other malignancies.

For this study, Aronson wanted to look at the potential biological mechanisms at work in the low-fat fish oil diet that may be providing protection against cancer growth and spread. They measured levels of the pro-inflammatory substances in the blood and examined the prostate cancer tissue to determine the CCP score.

"This is of great interest, as the CCP score in prostate cancer is known to be associated with more aggressive disease and can help predict which patients will recur and potentially die from their cancer," Aronson said.

Further, Aronson and his team analyzed one pro-inflammatory substance called leukotriene B4 (LTB4) and found that men with lower blood levels of LTB4 after the diet also had lower CCP scores.

"Given this finding, we went on to explore how the LTB4 might potentially affect prostate cancer cells and discovered a completely novel finding that one of the receptors for LTB4 is found on the surface of prostate cancer cells," Aronson said.

Further studies are planned to determine the importance of this novel receptor in prostate cancer progression, Aronson said.

Based on the results of his research, Aronson has been funded to start a prospective, randomized trial at UCLA next year studying 100 men who have elected to join the active surveillance program, which monitors slow-growing prostate cancer using imaging and biopsy instead of treating the disease. Study volunteers will receive a prostate biopsy at the beginning of the trial and again at one year. The men will be randomized into a group that eats their usual diet or to a low-fat fish oil diet group. Aronson will measure markers in the prostate biopsy tissue to check for cell growth and CCP score.

Prostate cancer is a leading cause of death among men in the United States. Its estimated that more than 230,000 American men will be diagnosed with prostate cancer this year alone, with more than 29,000 dying from their disease.

Low vitamin D blood levels are linked to greater risk of heart disease in whites and Chinese, but not in blacks and Hispanics, according to a study appearing this week in JAMA, a journal published by the American Medical Association.

Growing evidence has suggested that low blood levels of 25-hydroxyvitamin are associated with higher risk of developing coronary heart disease among whites. Few of these studies included substantial numbers of people from other races.

Vitamin D levels tend to be lower among people from other racial and ethnic minority groups, and some of these populations have higher rates of heart disease. However, after correcting for other risk factors for heart disease in their large, multi-ethnic study group, the researchers reporting in the JAMA paper did not find an association between low vitamin D and cardiovascular events in their black and Hispanic study participants.

"Our study suggests that the results of ongoing vitamin D clinical trials conducted in white populations should be applied cautiously to people of other racial and ethnic backgrounds," said Cassianne Robinson-Cohen, the lead author for the JAMA paper. The senior author is Ian deBoer, University of Washington assistant professor of medicine, Division of Nephrology.

Robinson-Cohen is an affiliate instructor in epidemiology at the UW School of Public Health and a researcher at the Kidney Research Institute, where her team explores the genetic, metabolic and epidemiological factors related to heart and kidney disease.

She noted that the findings in their recent JAMA paper came from an observational study, not a randomized clinical trial, and could not guarantee cause and effect.

"Our future studies will examine the genetics affecting the levels and use of Vitamin D in the body to try to figure out why the link between low vitamin D blood levels and heart disease varies by race and ethnicity," she said. "We dont know for sure, but perhaps genes affecting the need for and use of vitamin D could have evolved to adapt to different levels of sun exposure in places where various ethnic subgroups of people originated."





IMAGE: Researchers will be studying genetic variations to try to understand why there are racial and ethnic differences in the need and use of vitamin D.
Click here for more information.



Her team plans to look for variations in genes known to mediate Vitamin D activation and metabolism. She said these genes have been identified, but at present scientists havent determined how gene variation influences susceptibility to the adverse effects of low vitamin D.

The report published this week was from one of the projects within the Multi-Ethnic Study of Atherosclerosis. MESA is a major, long-term medical research effort sponsored by the National Heart Lung and Blood Institute of the National Institutes of Health. More than 6,800 men and women from six regions across the United States are participating in MESA. They were a diverse study group that was 38 percent white, 28 percent black, 22 percent Hispanic, and 12 percent Chinese. Robinson-Cohen and her team studied 6,436 MESA participants who enrolled between July 2000 and September 2002.

All participants were free of any known cardiovascular diseases at the time they enrolled, and had their blood levels of V25-hydroxyvitamin D measured. The mean age of participants at the start of the study was 62 (range 45 to 84 years) and slightly more than half were women.

The mean blood concentrations for whites was 30.1 ng/ml, Chinese 26.7, Hispanic 24.6, and blacks 19.2, The researchers tested the association of Vitamin D levels with the first incidence of coronary heart disease events – myocardial infarction, angina, cardiac arrest, or death from coronary heart disease — occurring from the start of the study until May 2012. During the eight-and-a-half year study, 361 participants had such an event. The researchers used several statistical risk analyses to check to see if links between blood vitamin D levels and coronary heart disease differed among white, black, Chinese and Hispanic populations.

"The differences in associations across race-ethnicity groups were consistent for both a broad and restricted definition of coronary heart disease and persisted after adjustment for known risk factors for coronary heart disease," the researchers noted in their paper.

Robinson-Cohen believes the strengths of the study are its size, duration, the use of several statistical analyses, the rigorous definition of heart disease events, and the efforts made to control for many confounding risk factors, such as age, gender, smoking, diabetes, blood pressure, cholesterol levels, physical activity, kidney disease,C-reactive protein concentrations, educational attainment, income and so on. A main weakness of the study, she said, is that it is observational, and theore cant be ascertain cause and effect.

"To determine cause and effect, a large, multiethnic, randomized control clinical trial would need to be conducted," she said.

Robinson-Cohen pointed out, that beyond these specific results, the nature of the findings show the importance of designing medical research that includes a diverse ethnic and racial makeup of participants. Such multi-ethnic studies would help prevent cases where findings from one group are incorrectly applied to other groups.

"We need to make a bigger effort to design and fund medical studies with large enough representation of various racial and ethnic backgrounds that we dont draw ungrounded conclusions based on one group," Robinson-Cohen said.

Low levels of the "sunshine" vitamin D appear to increase a childs risk of anemia, according to new research led by investigators at the Johns Hopkins Childrens Center. The study, published online Oct. 10 in the Journal of Pediatrics, is believed to be the first one to extensively explore the link between the two conditions in children.

The researchers caution that their results are not proof of cause and effect, but rather evidence of a complex interplay between low vitamin D levels and hemoglobin, the oxygen-binding protein in red blood cells. The investigators say several mechanisms could account for the link between vitamin D and anemia, including vitamin Ds effects on red blood cell production in the bone marrow, as well as its ability to regulate immune inflammation, a known catalyst of anemia.

To capture the interaction between the two conditions, researchers studied blood samples from more than 10,400 children, tracking levels of vitamin D and hemoglobin. Vitamin D levels were consistently lower in children with low hemoglobin levels compared with their non-anemic counterparts, the researchers found. The sharpest spike in anemia risk occurred with mild vitamin D deficiency, defined as vitamin D levels below 30 nanograms per milliliter (ng/ml). Children with levels below 30 ng/ml had nearly twice the anemia risk of those with normal vitamin D levels. Severe vitamin D deficiency is defined as vitamin D levels at or below 20 ng/ml. Both mild and severe deficiency requires treatment with supplements.

When investigators looked at anemia and vitamin D by race, an interesting difference emerged. Black children had higher rates of anemia compared with white children (14 percent vs. 2 percent) and considerably lower vitamin D levels overall, but their anemia risk didnt rise until their vitamin D levels dropped far lower than those of white children. The racial difference in vitamin D levels and anemia suggests that current therapeutic targets for preventing or treating these conditions may warrant a further look, the researchers say.

"The clear racial variance we saw in our study should serve as a reminder that what we may consider a pathologically low level in some may be perfectly adequate in others, which raises some interesting questions about our current one-size-fits-all approach to treatment and supplementation," says lead investigator Meredith Atkinson, M.D., M.H.S., a pediatric kidney specialist at the Johns Hopkins Childrens Center.

Untreated, chronic anemia and vitamin D deficiency can have wide-ranging health consequences, including organ damage, skeletal deformities and frequent fractures, and lead to premature osteoporosis in later life.

Long known for its role in bone development, vitamin D has recently been implicated in a wide range of disorders. Emerging evidence suggests that low vitamin D levels may play a role in the development of certain cancers and heart disease and lead to suppressed immunity, the researchers note.

Anemia, which occurs when the body doesnt have enough oxygen-carrying red blood cells, is believed to affect one in five children at some point in their lives, experts say. Several large-scale studies have found severe vitamin D deficiency in about a tenth of U.S. children, while nearly 70 percent have suboptimal levels.

Low levels of vitamin D may be associated with longevity, according to a study involving middle-aged children of people in their 90s published in CMAJ (Canadian Medical Association Journal).

"We found that familial longevity was associated with lower levels of vitamin D and a lower frequency of allelic variation in the CYP2R1 gene, which was associated with higher levels of vitamin D," writes Dr. Diana van Heemst, Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands, with coauthors.

Previous studies have shown that low levels of vitamin D are associated with increased rates of death, heart disease, diabetes, cancer, allergies, mental illness and other afflictions. However, it is not known whether low levels are the cause of these diseases or if they are a consequence.

To determine whether there was an association between vitamin D levels and longevity, Dutch researchers looked at data from 380 white families with at least 2 siblings over age 90 (89 years or older for men and 91 year or older for women) in the Leiden Longevity Study. The study involved the siblings, their offspring and their offsprings partners for a total of 1038 offspring and 461 controls. The children of the nonagenarians were included because it is difficult to include controls for the older age group. The partners were included because they were of a similar age and shared similar environmental factors that might influence vitamin D levels.

The researchers measured levels of 25(OH) vitamin D and categorized levels by month as they varied according to season. Tanning bed use, which can affect vitamin D levels, was categorized as never, 1 times per year and 6 times per year. The researchers controlled for age, sex, BMI (body mass index), time of year, vitamin supplementation and kidney function, all factors that can influence vitamin D levels. They also looked at the influence of genetic variation in 3 genes associated with vitamin D levels.

"We found that the offspring of nonagenarians who had at least 1 nonagenarian sibling had lower levels of vitamin D than controls, independent of possible confounding factors and SNPs [single nucleotide polymorphisms] associated with vitamin D levels," write the authors. "We also found that the offspring had a lower frequency of common genetic variants in the CYP2R1 gene; a common genetic variant of this gene predisposes people to high vitamin D levels.

These findings support an association between low vitamin D levels and familial longevity." They postulate that offspring of nonagenarians might have more of a protein that is hypothesized to be an "aging suppressor" protein. More research is needed to understand the link between lower vitamin D levels, genetic variants and familial longevity.

A prospective study led by researchers from the University of California, San Diego School of Medicine has found that low serum vitamin D levels in the months preceding diagnosis may predict a high risk of premenopausal breast cancer.

The study of blood levels of 1,200 healthy women found that women whose serum vitamin D level was low during the three-month period just before diagnosis had approximately three times the risk of breast cancer as women in the highest vitamin D group. The study is currently published online in advance of the print edition of the journal Cancer Causes and Control.

Several previous studies have shown that low serum levels of vitamin D are associated with a higher risk of premenopausal breast cancer. "While the mechanisms by which vitamin D could prevent breast cancer are not fully understood, this study suggests that the association with low vitamin D in the blood is strongest late in the development of the cancer, "said principal investigator Cedric Garland, DrPH, FACE, professor in the Department of Family and Preventive Medicine at UC San Diego.

Analyses of vitamin D levels measured more than 90 days before diagnosis have not conclusively established a relationship between serum levels and risk of premenopausal breast cancer in the present cohort. However, this new study points to the possibility of a relevant window of time for cancer prevention in the last three months preceding tumor diagnosis –a time physiologically critical to the growth of the tumor.

According to Garland, this is likely to be the point at which the tumor may be most actively recruiting blood vessels required for tumor growth. "Based on these data, further investigation of the role of vitamin D in reducing incidence of premenopausal breast cancer, particularly during the late phases of its development, is warranted," he said.

The new study drew upon 9 million blood serum specimens frozen by the Department of Defense Serum Repository for routine disease surveillance. The researchers thawed and analyzed pre-diagnostic samples of serum from 1,200 women whose blood was drawn in the same time frame – samples from 600 women who later developed breast cancer, and from 600 women who remained healthy.

A 2011 meta-analysis by Garland and colleagues estimated that a serum level of 50 ng/ml is associated with 50 percent lower risk of breast cancer. While there are some variations in absorption, those who consume 4000 IU per day of vitamin D from food or a supplement normally would reach a serum level of 50 ng/ml.

Garland added that a consensus of all available data has shown no known risk associated with this concentration of vitamin D, which is measured as serum 25-hydroxyvitamin D. But he urges patients to ask their health care provider to measure their serum 25(OH)D before substantially increasing vitamin D intake.

"Reliance should not be placed on different forms of vitamin D, such as vitamin D2, and megadoses should be avoided except those ordered by a doctor for short-term use," Garland added.

This autumn, why not get out of the gym and try something new? Exploring the beauty of life around your city. Or try a class that youve always considered but never dared participate in. You can do a variety of excellent low-impact workouts, and yet still get in great shape. Now that bikini season is over, youll be under less pressure to get in "prime condition." Its time to have some fun with your workouts, and take it easy on your joints too!


1. Fusion Classes

Have you ever tried to do dance and Yoga at the same time? Or cardio Pilates? Fusion classes are all the rage, and theyre a fun way to get in shape in a new and unique way. This workout involves two or more different styles of exercise, and combines them in a way that youd never have dreamed of before. Youd be amazed at the crazy combinations people can dream up when theyre trying to come up with new exercise programs--which may be surprisingly fun!

2. Paddleboarding

This is somewhat of a cross between surfing and kayaking, and youll find that its a great workout for your upper body. Stand-up paddleboarding is done using a paddle to propel your board out onto the water. Those on the West Coast will no doubt have heard of this style of boarding, and youll find that theres even crazy combinations like Paddleboard Yoga. What a fun way to get in shape before it gets too cold to swim!

3. Aqua Aerobics

Most people think of Aqua Aerobics as being for senior citizens only, but there are many hardcore water aerobics classes for the younger generation. Imagine trying to run in place while knee deep in water, or trying to do inverted push-ups while half submerged. Its a pretty intense form of exercise/cardio, and yet the water makes it very easy for your joints. These classes tend to be low-impact workouts that get you breathing hard!

4. Swimming

Theres nothing quite like a good swim to take the edge off the late summer/early autumn heat--particularly in the south of the country (Arizona, New Mexico, Texas, Florida, etc.). Swimming is very low impact--easy on the joints--but its amazing for both your cardio endurance and for your upper body muscles. As long as youre actually swimming and not just splashing around, you can get in amazing shape. The best part: you can swim in a heated indoor pool even throughout the chilly winter.

5. Canoeing or Kayaking

Kayaking and canoeing both involve very little stress placed on your knee and ankle joints, and its pretty easy on your arm and shoulder joints as well. It will work those upper body muscles like nothing else can, and youll find that youre in much better shape after just a few weeks of hard rowing.

6. Inline Skating

Inline skating is a bit hard on your feet and ankles, but its actually quite good for those with tender knees and arms. Youll be amazed by how quickly you can tire out, and youll love the feeling of speeding down the street on those slick inline wheels. Whether you train on the streets or at a track, its a good way to take the pressure off your upper body.

7. Walking/Hiking

If you want the ultimate low impact workout, let Mother Nature be your trainer! Taking a walk/hike out into the forest or mountains near your home will allow you to see the beauty of the autumn wilderness, while easily walking away those calories. A daily walk in the park can help you to prepare for those weekend-long hiking and camping trips youll plan with your family. Its a low-impact exercise that involves a whole lot of fresh air--it doesnt get better than this.
_http://www.fitday.com/fitness-articles/fitness/7-fun-low-impact-workouts-you-should-try-this-autumn.html

Its estimated that between 10 and 20% of people over the age of 65 suffer from mild cognitive impairment or have been diagnosed with Alzheimer`s disease. By the age of 80 more than half have some loss of memory or functional decline and the trend continues to escalate as the number of baby boomers turned senior citizens explodes.