The incidence of BRCA1 and BRCA2 mutations is higher in the Ashkenazi Jewish population and hence studies on population screening have initially been done in Israel. This week we celebrate the Jewish New Year…and the latest JAMA article on population based screening for these mutations was most timely.

The article published in the September 17 JAMA is based on the 2014 Lasker Award. This award in medical science was presented to Dr. Mary-Clair King to recognize and honor her “for bold and imaginative contributions to medical science and society – exemplified by her discovery of a single gene BRCA1 that causes a… form of hereditary breast cancer…” The article both describes the application of this discovery and suggests that population-based screening of women for BRCA1 and BRCA2 should become a routine part of clinical practice.

Just to remind you: BRCA1 mutation carriers have a combined risk of developing either breast or ovarian cancer of 60% by age 60 and 83% by age 80. For BRCA2 mutation carriers, risk is 33% by age 60 and 76% by age 80.

A recent study in Israel recruited more than 8000 healthy Ashkenazi Jewish men. The men were tested as a gateway to families for breast and ovarian cancer. (The men were unaffected by breast-cancer themselves but if they were positive, it would enable researchers to identify female mutation carriers, not based on their personal or family history of cancer.) 175 men were identified as carriers of the mutation and genetic testing was offered to all of their female relatives. Surprisingly, 50% of families found to harbor BRCA1 or BRCA2 mutation had no history of breast or or ovarian cancer that would have triggered clinical attention. However, female mutation carriers from these theoretically low-cancer- incidence families had similar cancer risks to female carriers from families with high cancer incidence. Low-cancer-incidence families were simply smaller with fewer females and hence were less likely to exhibit a significant breast or ovarian cancer history.

The authors of the article point out that without population-wide screening, women with BRCA1 or BRCA2 mutation from such families would not have been identified until they developed cancer; a failure of cancer prevention. This study has significant implications for preventive care in Israel which has a large population of Ashkenazi Jews. But in another study, it was found that only 35% of families with high incidence of breast or ovarian cancer had even previously been referred for genetic counseling, despite common knowledge of the increased risk due to BRCA1 and BRCA2 in the Ashkenazi Jewish population and the availability in that country of free testing and counseling.

In the United States, the number of carriers of mutations in the BRCA1 and BRCA2 genes is estimated to be between 1 in 300 and 500 women or between 250,000 and 450,000 adult women for whom breast and ovarian cancer is both highly likely and potentially preventable. Wide scale population genetic counseling and screening should go on our medical wish list. But at present, the US Preventive Services Task Force (USPSTF) supports BRCA1 and BRCA2 testing based on family history and ancestry, but not for the entire female population. Unfortunately only 19% of US primary care physicians accurately assess family history for BRCA1/BRCA2 testing. This is clearly unacceptable.

The author states at the end of the article that “population wide screening will require significant efforts to educate the public and to develop new counseling strategies, but this investment will both save women’s lives and provide a model for other public health programs in genomic medicine…. Women should have the choice to learn if they carry an actionable mutation in BRCA1 or BRCA2.” We have much to learn and do…

Since I tend to report on aspects of my personal life, I want to announce some personally exciting news: My daughter and her two small children moved to LA for a year. Not only are they living three minutes away…the children are in my temple school. I am delighted!

I have also become involved with a terrific organization, the National Breast Cancer Coalition (NBCC) which sponsors and supports the research that will help us prevent, diagnosis and effectively treat breast cancer. They are holding their annual event in LA on October 6. It will be a phenomenal French style review of dancing and singing titled “Les Girls” with performances by many of your favorite TV and theater stars and will be hosted by Allison Janney (who, I might add just won two Tonys). I am somewhat embarrassed to add that the NBCC board decided to present me with an award that evening and I am truly honored.

So if you think you would like to come to a fun evening and contribute to an important cause you can download details HERE.

Now onto the medical subject of this week’s website….Weight Loss

The September 3 issue of JAMA was dedicated to this weighty subject. As you know, one third of Americans are overweight or obese. It truly is an American epidemic. (And by the way, risk for a majority of cancers is significantly increased or just plain caused by obesity.) Multi billions of dollars are spent on branded weight loss programs, foods, diets, lifestyle recommendations and “come-on books” that suggest a secret way to lose pounds quickly, now and forever… A meta-analysis of 48 unique, randomized trials was published in that issue of JAMA and after many tables and graphs concluded that both low-carbohydrate and low-fat diets were associated with more weight loss than no dietary intervention over a 12-month period and that behavior support and exercise enhanced weight loss. (So far, I think we all knew this.) What made this article unique and caused it to create a stir was the fact that the statisticians found that weight loss differences between individual diets were small and likely of little importance. Their suggestion: if you want to lose weight adhere to any diet that you can stay on be it low-carb or low-fat.

The last article in the JAMA issue discussed two drugs, now on the market, that may aid and albeit weight loss: lorcaserin (Belviq) and Qsymia (Vivus). These new products are FDA approved for use in obese patients with body mass index (BMI) equal to or greater than 30 or overweight patients (BMI over 27) who also have at least one weight- related risk factor such as hypertension, abnormal lipids or type 2 diabetes.

In short: Belviq activates a serotonin receptor (type 2C to be exact) and is thought to suppress appetite. It can, however, cause headache, nausea and dizziness and in trials was discontinued 36 to 50% of the time. In the first year of one major trial, patients lost somewhat more that 5 % of their body weight but regained a quarter of it back during the second year of therapy. Qsymia combines phentermine and Topamax, a drug used for epilepsy. ( In the past phentermine was combined with fenfluramine (“phe-fen”) and caused heart valve problems…hence it was discontinued and now a new combination has been formulated, and felt to be heart valve safe.) Weight loss of 5% or more in the first year occurred in 45 to 70 % of patients depending on the dose and those who continued the medication for two years had an average weight loss of 10% compared to 1.8% in those on placebo. Side effects that occurred in more than 5% of patients included dry mouth, constipation, numbness and in the higher doses, insomnia. There were also reports of difficulties in concentration and memory.

In conclusion, the article states that either drug, taken as an addition to diet and exercise “may be affective in increasing weight loss in the first year of use, but much less so in the second year. Qsymia appears to be more effective than lovaserin, but may cause more troublesome adverse effects.”

A lot of information…I (or your other physicians) will be happy to discuss all of this in your next visit.

And I hope to see some of you (not in the office) October 6….

The media has been recently focused on this (at least when not reporting on ISIS). It’s likely that many of you have heard about the report that came out comparing mortality rates for three types of surgery for breast cancer: bilateral mastectomy (both breasts), unilateral mastectomy (single) or lumpectomy with radiation. The article that the media has been quoting was published in the September 3 issue of JAMA.

The reported study included 189,734 California women who were diagnosed with breast cancer in stages 0 to 3 between January 1998 and December 2011. The researchers reviewed the types of treatments they received, their follow up and the death certificates of those who died during the follow up. They excluded those women who were diagnosed after 2010 because of incomplete mortality data. If appropriate records were not available they also eliminated some of the patients, so basically, the final analysis included 174, 917 women whose medium follow up time was 89.9 months. (I am not sure you wanted all these numbers but I thought I would try to be as exact as possible,at least at the beginning of this website article.)

What they found was that the rate of bilateral mastectomy increased from 2% in 1998 to 12.3% in 2011 and this represented an annual increase of 14.3%. Women younger than 40 were most likely to have an increased rate of bilateral mastectomy which went from 3.6% in 1998 to 33% in 2011. This procedure was more often used by non-Hispanic white women, those with private insurance and those who received care at a National Cancer Institute (NCI) designated cancer center (8.6% among NCI cancer center patients versus 6% among non-NCI cancer patients). Unilateral mastectomy (obviously on the side diagnosed with breast cancer) was more often used by racial/ethnic minorities and those with public/Medicaid insurance (up to 52%). Breast conserving surgery with radiation was done in about 55% of all patients but again varied according to age, insurance and tumor size.

The important conclusions of the study was that compared with breast conserving surgery (lumpectomy) with radiation that had an overall ten-year mortality of 16.8%, unilateral mastectomy was associated with a higher all-cause mortality and a ten-year mortality rate of 20.1%. There was no significant mortality difference between lumpectomy and radiation and bilateral mastectomy (in which the ten-year mortality rate was 18.8%).

I know these mortality rates seem high. But there was a huge variability in cancer stage between zero and stage III, so the rates included the higher stage cancers. The study was not randomized and treatment was dependent on a lot of other factors including size of the tumor, tumor features that suggested a poor prognosis as well as lymph node metastases, receptor status and genetic changes which could worsen the prognosis. And as new reconstruction procedures were developed (which look better and allow symmetry), it was likely that some women would choose to have bilateral rather than unilateral mastectomy. Finally, younger women who have a longer period of time for risk of recurrent or new cancer or have a higher probability of carrying genetic mutations were more likely to chose to have surgery on both breasts.

The conclusion of the authors was that although the use of bilateral mastectomy increased throughout California through 2011, overall it was not associated with lower mortality than that achieved with breast conservativeness surgery and radiation. Unilateral mastectomy was actually associated with higher mortality than the other two surgical options.

I want to add my own take on this… it is an important study, but the fact that so many stages of breast cancer were lumped together and prognostic features were varied, there are significant drawbacks. Today with MRI, genetic tumor analysis and profiling, the prognosis of a woman’s breast cancer is more defined, allowing therapy to be targeted and of course improved. When deciding on the course of surgery, considerations of family history, ability to follow up with therapy and surveillance as well as complications of radiation and/or extensive surgery warrant careful consideration. Insurance status is an issue and is unfortunate; hopefully in the future no woman will be denied appropriate care. Every woman who has a diagnosis of breast cancer should carefully consider all choices of therapy with her physicians. Taking a few weeks to consider these will not make a difference in the outcome. This study should be part of the discussion.

There is a precancerous condition that can lead to esophageal cancer called Barrett’s esophagus. When we complain of the heartburn symptoms that can be due to GERD (gastroesophageal reflux disease) most physicians (and those ubiquitous TV ads) suggest an antacid or a PPI (protein pump inhibitor such as Nexium and Prevacid). There is a concern however, that if reflux symptoms continue, long term use of the PPI’s or antacid may cause us to ignore the warning sign that Barrett’s esophagitis or even esophageal cancer has developed. (Note PPI’s have patient instructions that they should be used for just 14 days and if longer use is needed a physician should be consulted.) Over the last few weeks my reflux has returned and indeed I started a PPI… so my interest was piqued when I read the review article in the New England Journal of Medicine on Barrett’s esophagus. Here are some of the highlights:

It is estimated that 5.6% of adults in the United States have Barrett’s esophagus. This is a condition in which the cells lining the esophagus undergo injury or metaplasia due to damage from reflux of gastric acid produced in the stomach. The metaplastic cells are then more likely than normal cells to undergo malignant changes. This can result in development of esophageal adenocarcinoma which is considered a deadly tumor. Unfortunately, the incidence of this cancer has increased seven fold in the US during the past four decades The diagnosis of Barrett’s esophagus requires a biopsy of the abnormal mucosa cells via endoscopy, a procedure done under anesthesia.

There are both risk factors and protective factors for Barrett’s esophagus and esophageal adenoma carcinoma and I thought it would be interesting to list them.

Risk factors include:

  • Older age
  • White race
  • Male sex
  • Chronic heartburn
  • Age under 30 at onset of GERD symptoms
  • Hiatal hernia
  • Obesity with abdominal fat distribution
  • Metabolic syndrome (obesity, hypertension, prediabetes, high triglycerides etc.)
  • Smoking
  • Family history of GERD, Barrett’s esophagus or esophageal adenocarcinoma
  • Obstructive sleep apnea
  • Low birth weight
  • Consumption of red meat or processed meat
  • HPV infection
  • Protective factors:
  • Use of statins
  • H. pylori infection
  • A diet high in fruits and vegetables
  • Breast feeding (for the mother)
  • Tall height

So look at this list and calculate if you are at risk. If you have ongoing GERD symptoms and especially if you also have significant risk factors, you should consider an endoscopy. There are new therapies for Barrett’s in which the abnormal cells are ablated or destroyed. This has been shown to diminish the risk of esophageal cancer. So talk to your doctor or ask for a referral to a gastroenterologist. Barrett’s is not an esophageal friendly disease.

And if my symptoms don’t go away in the near future I may have to do this… Just so you know, I do follow most of the medical advice I give. I had an endoscopy a number of years ago; thank goodness it was clear.

Most of us watched with amazement (at least I did) during the World Cup as the soccer players used their heads and feet to make goals. (I will not discuss the Brazil team.). We have also been bombarded with information about concussions, especially in male football players. I suppose that butting the ball with one’s head in soccer is not brain protective. An article in the clinical review of JAMA at the end of August caught my attention. It was titled “Concussion and Female Middle School Athletes”. There were definitions of concussion, a list of health implications of concussion and statistics that I thought were highly informative for many of us as we watch our daughters and the daughters of our friends and family engage in this “getting more popular” sport.

A concussion in sport is defined as a process that affects the brain as a result of traumatic forces. (Well that part is clear.)

There are five features that characterize a concussion:
1. A direct blow to the head a blow to the body that transmits and “impulsive” force to the head.
2. This results in a rapid onset of short lived neurologic impairment that resolves spontaneously.
3. The clinical symptoms may or may not include loss of consciousness.
4. No abnormalities are seen on imaging studies.
5. The symptoms may be prolonged in a small percentage of cases.

Among high school athletes, concussion rates are highest in boys football and girls soccer. And in similar sports girls have higher rates of concussions then boys. Apparently female sex is a risk factor, so is prior concussion, young age and a history of migraine headaches. Symptoms include headache, dizziness, mental fogginess, difficulty concentrating and remembering and fatigue. Loss of consciousness occurs in less than 10% of concussions and the typical recovery time for an adolescent athlete is 7 to 10 days. (But the article noted that for some individuals, recovery may take weeks or months.)

In a report that was published in JAMA Pediatric a study, was done between 2008 and 2012 for soccer clubs in Washington state that involved 351 elite female soccer players from 33 youth soccer teams age 11 to 14. Among these girls 59 concussions occurred within over 43,000 athletic exposure hours. This meant that the cumulative concussion incident was 13% per season and the incidence was 1.2 per 1000 athletic exposure hours. “Heading” the ball counted for 30.5% of the concussions and most players continued to play with symptoms!

Perhaps the most concerning part of the report pertained to potential long-term effects of concussion. These include persistent deficits in memory and visual processing, decline in academic performance, depression, dementia and postconcussion syndrome (the symptoms last longer than three months) as well as second impact syndrome. That means that if another concussion occurs it can cause rapid brain swelling and this can be fatal!

The good news is that there is now legislation in all 50 states requiring schools to have protocols in place for concussions. They are supposed to have educational materials and guidelines for athletes, coaches and parents and the parents and athletes have to sign informed consent acknowledging the dangers of concussion before participation in sports. Any student who shows signs of concussion must be evaluated and cleared by a healthcare professional before being allowed to return to practice. However, unlike many high schools where athletic trainers are trained (we hope) to evaluate and manage injuries, youth sports leagues rarely have any type of medical coverage on site.

Since I knew so little of this information, I thought it was worthy of being shared…my conclusion is that parents need to be aware of concussion risk and engage in discussions with their daughters’ coaches. And just perhaps, encouragement to play tennis, swim, dance or go out for track is in order…

This week passed quickly and before I knew it my Friday website was due. As I scanned the various medical journals, I found an interesting article in the Journal of the North American Menopause Society. The long but very comprehensive title of the article is “Calcium/vitamin D supplementation, serum 25-hydroxy vitamin D concentrations, and cholesterol profiles in the Women’s Health Initiative calcium/vitamin D randomized trial.”

The authors (17 of them in multiple centers in the US) wanted to evaluate whether increased levels of active vitamin D concentrations in the blood, the 25 hydroxy form (25OHD3), became elevated after calcium/Vitamin D supplementation and were associated with improved cholesterol levels in postmenopausal women.

The randomized, placebo-controlled trial included women already in the Women’s Health Initiative Study (WHI) and who had been enrolled in 1993 and 1998. The group they specifically studied included 300 white women, 200 African-American and 100 Hispanic women that were randomly selected from the larger WHI trial. They measured their serum (blood) vitamin D levels before starting the study as well as their lipid levels which included fasting triglycerides (TG), high density lipoprotein cholesterol (HDL- C) and calculated low density lipoprotein cholesterol (LDL- C) levels before and after calcium vitamin/D supplement.

After two years, they compared these blood tests for the women who took 1000 mg of elemental calcium and 400 units of vitamin D (CaD) and those who took a placebo. They found that those who took supplemental CaD significantly increased their vitamin D levels and decreased their LDL- C levels. The women with the higher vitamin D concentrations had more favorable lipid profiles including an increase in their HDL-C (the good cholesterol), lower LDL- C and lower TG.

If you want the numbers… In the study the women on CaD increased their vitamin D levels by 38% compared with those on placebo and those randomized to CaD decreased their LDL- C by 4.46 mg/DL. And if the serum concentrations of vitamin D increased significantly then all three parameters of the lipids improved.

They did add one thing… That many of the women were on hormone therapy and there is the possibility that there is a synergistic relationship between vitamin D and estrogen therapy which could have improved the impact of Vitamin D on lipid levels.

Bottom line: According to this study as well as many others, your vitamin D level is important to your health and improving it with supplements may have a positive impact on your lipid profile and ultimately (and I have to interject “a perhaps” here, since this has not been sufficiently studied) on coronary heart disease. I usually suggest that my patients follow “the one and one” rule. Make sure you get 1000 to 1200 mg of calcium through diet or supplements and take 1000 units of vitamin D.

I’ve been back from vacation this week and have diligently looked at the articles in most of the usual journals. Initially, I didn’t find one that I wanted to report.(Note one article, in the New England Journal of Medicine, dealt with a mutation in a gene in 154 families in Europe and their risk for breast cancer… but I think it was a bit too esoteric to cover in the website.)

I did download an article that appeared in Contemporary OB/GYN which I get online. Under the heading “expert advice” they reviewed an article published in the Journal Radiology (which I don’t read) and that I thought was interesting. This was a study of 1162 women who had primary breast cancer and were 75 or older. Information in their charts from the time of diagnosis was reviewed and accessed for stage, treatment, outcomes, and whether the disease was detected by the patient, her physician or with mammography. The women’s survival rates were then compared. During the study (between 1990 and 2011) mammography detection of cancer over time increased from 49% to 70% and was most common for early stage 1. Detection by a patient or her physician was more common when the disease was more advanced at stage II or stage III. The investigators found that lumpectomy and radiation were common and mastectomy and chemotherapy less common in women who had mammography-detected disease than those with cancers found by the patient or her physician. Additionally, five-year disease specific survival was better in women with invasive breast cancer detected by mammogram (97% versus 87%). The investigators concluded that women who have mammogram-detected cancer were diagnosed at earlier stages, required less overall treatment and had better survival rates than women with cancer detected by themselves or physicians.

Bottom line: Women older than 75 may still derive benefits from mammography screening. I will keep ordering them…

I have to admit that I’m writing this in the midst of feeling wide-awake, rested and in fabulous mountain air while vacationing with my family at Mammoth Lake. Amidst the hiking and biking, I relaxed by checking out recent medical articles on my iPad. (Yes, I know this is not a sign of great mental health.) And what I found were the new clinical guidelines from the American College of Physicians based on their review of the medical literature on obstructive sleep apnea (OSA). No, this did not cause a diminution of family worries, but I thought the guidelines were worth sharing…

A quick review of the subject: In individuals with obstructive sleep apnea, breathing slows or briefly stops because the airway becomes blocked during sleep. This is usually accompanied by snoring (which annoys or disrupts the sleep of anyone within 20 feet and certainly a bedmate). The clinical symptoms of sleep apnea include unintentionally falling asleep, daytime sleepiness, waking from sleep without feeling refreshed, fatigue, and cognitive impairment. OSA affects 10 to 17% of the US population! It’s not just an annoyance; it is a serious health condition and is associated with cardiovascular disease, hypertension, difficulty with cognition and type two diabetes. It is not gender specific and the most common risk factor is obesity. As women get older, go through the menopause transition and often gain weight they begin to equal men in their incidence of obstructive sleep apnea.

Clearly there are are other causes for day time sleepiness and fatigue. Too few hours devoted to sleep and chronic insomnia are, unfortunately, extremely common…. The National Sleep Foundation states that as many as 40% of the population may be sleep deprived! Other disorders that can cause these symptoms include thyroid disease, GERD (reflux), and respiratory conditions. Until they are ruled out, the ACP states that it’s important to diagnose excessive daytime sleepiness with a sleep study, preferably done overnight in a sleep lab. A special monitor called a polysomnograph is used to monitor breathing, airflow, brain activity, oxygen levels and certain muscle movements during sleep. The study is fairly expensive and not always available…the alternative is to have a physician prescribe testing with a portable sleep monitor that can be used at home or in the hospital.

The most common form of treatment for obstructive sleep apnea is with a CPAP or continuous airway pressure device which keeps the airway open while asleep. It consists of a mask or other device that fits over the nose or the mouth and nose. This is connected to a motor that blows air into a tube connected to the mask. Most CPAP machines are small, lightweight and fairly quiet. The noise they make is soft and rhythmic (sort of white noise) and often does not impede relaxation and sleep. According to the NIH most people who use a CPAP report feeling better almost immediately once they begin treatment; they feel more attentive and better able to work during the day. So do their partners. There are surgical therapies, but they’re usually not used unless the CPAP has failed. And because obesity is the most weighty factor for obstructive sleep apnea, weight loss is vitally important. Every expert will tell patients that the first thing they should do is to lose weight. That alone may suffice to treat OSA.

So instead of using the expression “good night, sleep tight” when we send loved ones off to bed, we should probably say “sleep silently and continuously”. Those eight hours (the ideal) mean as much to our health and well-being as our daytime behavior.

I was considering omitting a website article this week. It’s been a tough week… A very good friend died from virulent leukemia. But I am back in the office and seeing patients and yes, I did look at some of the articles. The one that I thought might be of interest was a report by the FDA and the Environmental Protection Agency encouraging pregnant women as well as women who may become pregnant or breast-feeding as well as young children to eat more fish.

In their draft guidance, the agencies are calling for women to consume 8 to 12 ounces of a variety of fish that are lower in mercury; that amounts to an average of 2 to 3 servings per week. The fish that have lower mercury levels include salmon, shrimp, pollock, tuna (light canned), tilapia, catfish and cod. The US Department of Agriculture suggests an amount of 3 to 5 ounces per week for children under the age of six and 4 to 6 ounces per week for children age 6 to 8. The agencies feel that there is “long standing evidence of nutritional value of fish in the diet. Fish contain high-quality protein, many vitamins and minerals, omega-3 fatty acid and are mostly low in saturated fat, and some fish even contain vitamin D. The nutritional value of fish is especially important during growth and development before birth, in early infancy for breast-fed infants, and in childhood.”

There have been long standing concerns about the mercury content of fish and as a result the FDA found that 21% of pregnant women consume no fish and 50% are eating fewer than 2 ounces per week. There are some types of fish that the FDA still suggest that women and children avoid: these include tilefish from the Gulf of Mexico, shark, swordfish, and king mackerel. They also recommend limiting white (albacore) tuna to 6 ounces per week for adults and even less for children.

So there you have it…as usual recommendations can be changed. And now those issued by the FDA/EPA in March 2004 have been replaced with a recommendation of simply consuming up to 12 ounces of a variety of fish per week (two average meals) avoiding the four types of fish I listed above because that have a high mercury content.

Hooray for salmon! Now I just have to figure out what gefilte fish is made of…

By now you have heard about the side effects of this commonly used both over-the-counter and prescription medication to raise HDL and lower LDL. But I finally got the article in the July 17 New England Journal of Medicine and wanted to give you a little more scientific information.

I almost didn’t write this segment because I’ve been overwhelmed with what’s happening in Israel. The good news is that my daughter and her young children came to Los Angeles two days ago. They literally got out on the last flight before the 24-hour closure of the Ben-Gurion airport. I think it’s open now to flights on all airlines and hopefully some of this conflict will be resolved. I can’t stop watching the news and despair over the fighting in Gaza that has destroyed the homes and lives of civilian population that could not or would not find refuge and the hourly bombardments of missiles sent by Hamas to Israel, intended to cause widespread killing of anyone in range. (Thankfully, the iron dome works.) I like everyone, hope that a valid cease fire will be negotiated. But how does one negotiate with a terrorist organization whose goals are to hold on to power and eliminate the country of Israel and it’s citizens from the face of the earth? They show no regard for their civilian population (other than to allow them to shield weapon stores) and take every opportunity to run with cameras to record their suffering, and mourning…and yes, we all have to be appalled. As many of you know, I am on the board of Save the Children. We have programs in Gaza and have tried over the years to improve the health care, education and hope for a better future for the children there. Children are never to blame for conflict and are always the ones who suffer. Unfortunately, it would seem that much of the millions of dollars sent there by so many NGO’s has been used to building tunnels and purchasing weapons rather than for infrastructure and care of the population.

I”ll stop now…I know I am not supposed to wax political, but it’s hard to always be the evidenced based doc.)

So on to niacin… Ever since I went to medical school we’ve been taught that high density lipoprotein or HDL particles help decrease coronary heart disease. The higher the HDL the lower the disease in the general population. Likewise LDL or low density lipoprotein cholesterol increases plaque formation and enhances heart disease. The question is, are these two types of cholesterol risk factors or signs of heart disease or do they indeed have an impact in causing heart disease? The articles published in the July 17 New England Journal of Medicine may have changed our assumption of causation. In the heart protection study two- treatment of HDL to reduce the incidence of vascular events (HPS 2-THRIVE), 25,673 adults ages 50 to 80 with underlying cardiovascular disease were given either an extended release niacin combined with laropiprant (an agent that helps prevent flushing) or placebo and were followed for four years. Prior to the randomization, they had been put on statin based therapy. During the trial, the participants who received niacin raised their HDL 6 mg/dL and lowered the LDL cholesterol 10 mg/dL as well as their trygliceride level 33 mg/dL compared to those receiving placebo. Despite these favorable responses there was no significant reduction in major vascular events. Moreover, there were significant side effects which included an increase in gastrointestinal complications, infections, muscular skeletal pain, development of diabetes and a 9% increase in the risk of death. The American Heart Association now gives a very limited and cautious recommendation regarding the use of niacin…They state that niacin may still have a role in patients with very high risk for cardiovascular events who truly have contraindications for taking statins and who have a high LDL-cholesterol level. They also suggest that there may also be a use for those who have very high triglycerides and for whom it could be used to prevent pancreatitis. In an editorial in the same journal the author suggests that “it is time to face the fact that increasing the HDL cholesterol level in isolation seems unlikely to offer cardiovascular benefit”.

So before you take niacin as a so-called easier way to deal with cholesterol problems, please consult your physician. Next week, I hope I can write an article that doesn’t also deal with the middle east conflict.