Tuesday, April 19, 2022

Avocados, coffee and wine

Two articles in the press caught my eye last month. One reported that eating avocados twice a week lowered your risk of heart disease by 20% and the other that drinking 2-3 cups of coffee daily lowered your risk of death and heart disease by 10-15%. Since I need my two cups of coffee to get going in the morning but have never eaten avocados, I had to dig a bit deeper.

Both these studies, it turned out, were observational studies.

The gold standard for testing the value of a new treatment is the controlled trial. You take two groups of people who are similar in all respects and randomly give one half of the group treatment A and the other half treatment B. You then compare the results and if the results are substantially different, you can assume this is because A or B is better.

When the treatment is something people cannot do by themselves, this type of trial is straight-forward to design and conduct. When you are looking at diet, exercise, smoking or other habits, things get a lot harder. To compare the effects of eating avocados twice a week or not, you would have to control the subjects’ diets 24/7, clearly impractical. For this type of comparison, people are recruited and asked to do or not do things, but the researcher cannot control their actual behavior, or their usual behaviors are ascertained by questioning them.

Many large groups have been studied over the years in observational trials, and much useful information has been learned by following their health outcomes, but findings from such studies are almost never proof that the behaviors caused the outcomes.

The classic example of this misunderstanding about observational trials is the effect of post-menopausal estrogen use. For decades, almost every doctor believed that taking estrogens after menopause prevented heart disease. Why? Because women who took estrogen had much less heart disease. Only after the Women’s Health Initiative trial seemed to refute this did doctors pause to think that women who took estrogen were different in many other ways from women who did not. They smoked less, exercised more, saw doctors more often and were generally more health conscious. It seemed they were healthier to begin with.

More recently, the “fact” that light to moderate alcohol consumption benefits heart health has also been questioned. Researchers looked at over 371,000 people in the United Kingdom Biobank. They found, as expected, that light to moderate drinkers had the lowest heart disease risk. They also found that this group tended to have healthier lifestyles than abstainers: they smoked less, ate more vegetables and were more physically active. Taking the lifestyle factors into account eliminated any beneficial effect that could be attributed to their drinking habits.

Bottom line: observational studies may suggest harms or benefits but rarely if ever can they prove such effects. If you enjoy avocados or your morning coffee, go on consuming them, but I would not depend on either to keep you forever young.

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Monday, March 28, 2022

Reigning: Cats and Dogs

Pet owners know that dogs and cats are like family members and get joy (as well as the occasional pain) from their animal companions. It is well known that pet ownership went up during the Covid pandemic: the “pandemic puppy” phenomenon.

What you may not know is the health benefits that accrue to pet owners, particularly dog owners.

A recent study from the University of Michigan followed 1369 adults 65 and older, who had normal cognitive skills at entry, over six years. They found that there was less cognitive decline among pet owners. The effect was most pronounced among those who had owned a pet for five years or more. Using a 27-point test score, pet owners had an average score that was 1.2 points higher at 6 years than non-pet owners. For comparison, this is a great difference than bestowed by the controversial drug aduhelm!

Another study looked at 11,233 Japanese adults 65 and older who had no pet or who owned a cat or a dog and followed them over 3.5 years. The dog owners had half the rate of disability develop over the study period compared to non-pet owners. There was no major benefit seen in cat owners. The researchers suggested that the benefit was due to the increased exercise forced on dog owners: dogs must be walked regularly, unlike cats.

Another interesting study was done in the emergency department of a large teaching hospital in Saskatchewan, Canada. Patients coming to the emergency department with painful conditions were randomly assigned to either receive a 10-minute visit from a “therapy dog” or not. Those who had the canine visits had significantly lower pain scores after the visit, as well as less anxiety and depression.

So, when your pet chews the furniture, cut them some slack: they are doing you a lot of good!

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Thursday, March 10, 2022

Long Covid - it is not "all in your head."

If you follow the news, you are aware that some people who recover from a COVID-19 infection have persistent complaints for months after their apparent recovery. These can occur in almost every body system, but the most prominent tend to be fatigue, shortness of breath and “brain fog:” difficulty concentrating.

While an enormous amount has been written about post-acute Covid syndrome, popularly known as Long Covid, the medical profession still has more questions than answers. There are many challenges to understanding what is happening. For those who were sick enough to be hospitalized, the medium and long-term symptoms seen in Covid survivors are not that different than those seen in many patients who spent time in the ICU for any reason. In these people, “long Covid” may be a form of “post-ICU syndrome,” which has only recently been studied.

Another problem is that to date, we have no good measures to evaluate the long haulers’ complaints. There are no blood tests or X-rays that we can point and say that these explain the symptoms or that they “prove” you are truly sick. Just as with the chronic fatigue syndrome, when all the usual blood makers are normal, many doctors dismiss the complaints as being imagined.

Several recent studies have shed some light. Comparing people who have recovered from Covid with those who have recovered from other illnesses, there are more complaints of shortness of breath and of a variety of neurologic and psychologic symptoms. A large study of Chinese Covid survivors found them to have more decline in mental acuity, particularly among those who had severe acute Covid. Strengthening the idea that this was not psychological, a small study in Britain found both cognitive decline and shrinkage of the brain on MRI among people who had recovered from mostly mild cases of Covid but had persisting symptoms.

A very large study done by the VA showed that compared to people hospitalized for other reasons, Covid survivors had more blood clots, atrial fibrillation, strokes and heart failure. Most recently, a study of 10 patients who complained of shortness of breath but whose routine tests were all normal found, with more sophisticated tests, that their tissues did not take up oxygen normally, thus explaining why they had trouble exercising.

On the bright side, a British study found that only 9.5% of vaccinated individuals who had break though infection had Long Covid symptoms compared to 14.6% of unvaccinated individuals. Since vaccination also clearly reduces your chances of any symptomatic Covid, the value is even greater.

Finally, a very preliminary study in the U.S. found that enhanced external counterpulsation, a harmless but tedious treatment shown to improve circulation to the heart and brain, improved symptoms in most of the 50 patients studied.

Bottom line: 1. Get vaccinated. 2. If you have symptoms months after recovery from Covid, don’t let your doctor tell you “it is all in your head,” but ask to be referred to one of the specialized centers bringing a multi-disciplinary approach to treating Long Covid.

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Sunday, February 27, 2022

To mask or not to mask... that is the question

As you have probably read, the CDC has relaxed its mask guidance in response to the falling numbers of Covid cases and hospitalizations. What should you do?

There are several key points to consider.

The first is that being fully vaccinated is the most important thing you can do to protect yourself from serious illness. While the vaccines’ ability to prevent infection wanes, their protection against hospitalization and death has remained strong.

The second is that masks, while not a panacea, clearly reduce risk. If you are in close contact with an infected person and both of you are wearing masks, your likelihood of catching the virus is reduced by 50%.

Finally, life is inherently risky, and you can balance your tolerance for risk against other things that are important to you, as you do every time you get in a car.

There is little need for most people to wear masks outdoors unless packed together as in a stadium.

If you are healthy and fully vaccinated, and so are your family, it is reasonable to stop using a mask in most settings. I would still use one when you are indoors in crowded environments such as theatres and public transportation.

If you or a family member or close friend are immune compromised, masks are still a useful barrier to infection and should still be used in most indoor settings.

When gathering indoors with friends, if you are all vaccinated and have no symptoms, you can skip the masks. If someone in the group is immune compromised, you can add an extra layer of safety by all doing a self-test before the gathering.

One of the things that mask-wearing has done is markedly cut down both influenza and colds, which are spread the same way as Covid – the respiratory route. I may just keep wearing one in stores and such for a while longer!

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Thursday, February 17, 2022

Move it!

Just as with clothing, medicine has its fads. Coffee is good for you, then it is bad, Chocolate is harmful or perhaps it is helpful. Red wine prevents heart attacks, then it does not. Through all these ups and downs, the one thing that remains true is the value of exercise.

Regular aerobic exercise helps the joints, is one of the few activities shown to reduce the risk of dementia and can help elevate your mood. How much is necessary is unclear, and there does seem to be a point beyond which no extra benefit is seen.

Another feature that has been uncertain is whether the heart benefits of exercise require you to start young. A recent study from Italy tells us that exercise at older ages is very protective. The study looked at 3100 men and women 65 and older (60% female). Their baseline physical activity level was assessed when the study began and again 4 and 7 years later. “Active” seniors were those who engaged in at least 20 minutes of moderate or vigorous physical activity daily.

Those who exercised at 70-75 and kept it up had 50% fewer cardiovascular events than those who were sedentary throughout the study period. The benefit was greatest at preventing coronary disease, somewhat less at preventing congestive heart failure and least helpful at preventing strokes.

The benefits began at 20 minutes/day of exercise and seemed to plateau at 60 minutes. This agrees with other observations: you do not have to run marathons to gain the greatest reduction in heart disease. 40-60 minutes a day seems to get you “the most bang for the buck.”

It is also true that you do not have to push yourself beyond your safe limits. The study defined vigorous physical activity to include gardening, gym attendance, bicycling, dancing and swimming.

The take-home: it is never too late to start. If you find an activity (or several activities) you enjoy, get out there and do them every day. Your heart will thank you.

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Saturday, January 29, 2022

I want to live forever - or do I?

Do you remember resveratrol? This was the “magic” antioxidant that supposedly made red wine so healthy, and on which pharmaceutical companies spent a fortune. I always believed that the reason the French smoked more and yet had fewer heart attacks than Americans had little to do with red wine and more to do with their relaxed lifestyle: 2-hour lunch breaks at home with family and the month of August off. In any case, Glaxo Smith Kline spent $720 million on a start-up that was working on a resveratrol-like compound only to shut it down for failure to produce useful results in increasing health and longevity.

Two products that are currently being studied as anti-aging compounds are an old drug used to treat diabetes, metformin, and a newer agent, rapamycin, that is used to prevent transplanted organs being rejected. Both have shown promise in increasing longevity in animal studies.

The average human lifespan has certainly increased dramatically over the past few centuries. World-wide, human life expectancy at birth has risen from about 30 years in the mid-19th century to 73 years in 2020. The reasons for this are the dramatic reduction in infectious disease deaths through immunization and, to a lesser degree, antibiotics, safer food and water, safer work environments and better maternal care. These mean fewer people die young.

What has not changed much is the maximum human lifespan. The oldest old live to be 110 to 120 years, and this has not changed, though we are certainly seeing more centenarians. Most species have an upper limit to their lifespan in the absence of disease or trauma, and for humans, this would appear to be about 120 years.

One impediment to “anti-aging” drug development is that the FDA does not recognize “aging” as a disease to be treated and would thus probably not approve a drug targeted at extending lifespan rather than treating a specific disease. Another is the very high safety threshold such a drug would face if it were to be targeted at everyone.

The other big question is whether many of us would want to live longer if this meant living with a growing array of medical problems and frailties. The ideal drug would not necessarily make us all live to 120 but would let us get into our 80’s, 90’s and beyond with intact joints, brain, and muscle.

Both metformin and low-dose rapamycin are currently in human trials, and other products are in animal studies. No promises, but stay tuned.

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Friday, January 7, 2022

Quo vadis, Omicron?

What a difference a day makes. In my December 1 post, I said “While there have been no cases identified yet in the U.S., I would be shocked if there are not already a handful here.” Of course, now 5 weeks later, a local testing center said that 93% of Covid isolates in Massachusetts were Omicron.

Much of the early information about this variant has proved true. The Omicron variant is dramatically more easily transmitted than earlier variants; no disease but measles seems to spread as easily. Fortunately, it also remains true that Omicron is much less lethal than earlier variants. While the daily case counts in the state have increased 20-fold – from 1200 positive samples/day over last summer to 25,000/day this week, hospitalizations have “only” gone up five-fold – from 500 at the summer low to the current 2500 and daily Covid-related deaths have increased 4-fold, from 10/day to 40.

The fact that it is less deadly does not mean it is harmless. A virus that spreads 10 times as easily but kills half as many of those infects will kill 5 times as many people!

The good news for those who have followed the science is that the current serious cases are almost all among the unvaccinated. Hospitalization due to Omicron is 9-10 times greater among the unvaccinated than those who have had the full series (including booster).

A recent study found that prior Covid infection gave good SHORT-TERM (3-4 month) protection against the original virus and the Delta variant, but much less protection against Omicron.

There is also the very real concern that as hospitals are over-run with Covid cases, other treatments, including elective surgeries, have had to be delayed.

What should you be doing? If you are fully vaccinated, I would go about my life using just simple common-sense precautions. Avoid crowded venues when you cannot be sure that other people there are vaccinated and wearing masks. At theatres with good protocols for enforcing mask use and checking vaccination status, I am comfortable attending performances. Wear a mask when you are inside stores, museums, etc. Do what you enjoy outside. Gather with friends and family if you know all are vaccinated.

Nothing is risk-free. Getting in a car involves risk. Without being cavalier, I think those of us who are vaccinated and careful can enjoy getting back to living.

If you have been delaying, PLEASE get vaccinated.

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