Are You Ready for Thanksgiving?

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Paula and I would like to wish you all a very happy Thanksgiving (or if you’re not in the U.S., happy Thursday!) It’s been our pleasure to serve you this year, and we’re thankful for your support.

One of the questions that comes up year after year is how to deal with eating during the holidays. I’ve got you covered with Memo Classics from 2019. Just click on the links for a refresher on strategies to use this holiday season to keep your weight under control:

            Should You Have a Strict Holiday Eating Strategy?

            Is a Relaxed Holiday Eating Plan Better?

            Holiday Eating: The Best Solution So Far

A longer, more detailed look at holiday eating begins with this Memo:

            Holiday Eating: Abstain

Paula and I have finally lost a few pounds by changing what we eat, and we don’t want to discover them again this weekend. I believe these ideas will help you do the same.

We’re taking the rest of the week off to enjoy time with family; see you next Tuesday.

What are you prepared to do today?

        Dr. Chet

PSA: Sharing the Decision

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PSA screening is controversial because it may or may not indicate prostate cancer without additional testing and it may or may not indicate mortality from prostate cancer. As I said, many elderly men will die with prostate cancer but not of it. How do you know what to do? A recent study may provide some guidance.

Regular PSA Testing and Mortality

The Veterans Administration can be a challenging bureaucracy, but it’s one entity that can provide medical information on millions of subjects. Researchers wanted the answer to a simple question: Do higher rates of PSA testing yield a reduction in metastatic cases of prostate cancer?

The survey population included male patients getting a PSA test at 128 U.S. Veterans Health Administration facilities across the system from 2005 to 2019. The reason those years were chosen is that the U.S. Preventive Services Task Force (USPTF) had modified guidelines for PSA screening to recommend less frequent use of the test for men over 70. Over those years, there was a decrease in annual testing by 10% to 15% in non-VA healthcare facilities, and that was matched in the VA system. The USPTF recommended against screening all men, and PSA testing again fell in all age groups.

The data showed that as PSA testing decreased, the rates of metastatic prostate cancer increased. Drilling down into the data, those VHA facilities with higher rates of PSA screening had lower rates of metastatic prostate cancer.

Shared Decision-Making

The researchers were diplomatic in their conclusions. They simply presented the findings and suggested that the physician and patient should jointly decide on the course of action. Should we test? When do we proceed with a biopsy? What do we do if it’s benign? If it’s malignant? And a whole bunch more.

The Bottom Line

The researchers easily could have recommended that everyone gets tested and everyone gets a biopsy if the PSA is too high, but PSA testing is not precise enough. Some men have prostate cancer with PSA less than 4.0 and some do not have it with PSA over 10. The best course is having a discussion with your urologist and coming to a joint decision that satisfies you both. It’s also not a bad idea to get a second opinion, of whether you agree with the plan or not.

One thing for sure: always do the screening test again, regardless of whether it’s PSA, cholesterol, or HbA1c. For the most part, tests are accurate and reliable, but there’s always the possibility of a mistake; one test does not a diagnosis make. Retest, discuss, and plan a course of action with your healthcare professional.

What are you prepared to do today?

        Dr. Chet

Reference: JAMA Oncol. doi:10.1001/jamaoncol.2022.4319

Controversy: PSA Testing

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Medical testing is a blessing at times, a curse at others, and a source of controversy in the medical profession itself. I recently wrote about colonoscopies and why they provide information other colon health tests do not. The PSA (protein specific antigen) screening for prostate cancer has also been controversial. Here’s why.

If the PSA exceeds a specific number (another point of controversy), especially if a digital rectal exam reveals an enlarged prostate, more tests follow. The prostate biopsy takes samples of the prostate to see if cancer is present. If not present, the PSA was a false positive that resulted in a much more expensive test that probably increased the anxiety of the individual.

But wait—there’s more. Even if cancer is diagnosed, it may or may not indicate treatment. That’s because many prostate cancers are very slow growing, especially in elderly men, and will not impact how long they live. They may die with prostate cancer but not of prostate cancer.

How do you decide whether testing PSA is necessary? A new study may provide some direction, and I’ll cover that Saturday.

The Insider conference call is tomorrow night, and the topic is important: a recent study and the medical press that followed have indicated your ability to purchase dietary supplements may be under attack. If you’re an Insider, you don’t want to miss this call. If you’re not, purchase your Insider membership by 8 p.m. ET Wednesday night to get the latest information as well as all the other benefits of membership.

What are you prepared to do today?

        Dr. Chet

Resolving Gas Problems

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Whatever the cause, the question is how you can control any issues you have with intestinal gas. Once you realize how probiotics do what they do, and by that I mean via fermentation with the resultant gas, there are several strategies you can use to deal with it.

Strategies for Gas

Digestive enzymes can often help if the culprit is a specific food. For many people, beans cause gas while for others, excess protein can do it. With so many people doing keto these days, gas can be a substantial problem for them.

The solution may be to use a multi-purpose digestive enzyme before eating food you know causes you issues. Beans are obvious, as is protein. But for those who are lactose intolerant, milk and cheese can cause issues. Cellulases, proteases, and a lactase can help digest those macronutrients. For carbohydrates such as grains, amylases can be helpful.

The next question is whether taking digestive enzymes help with gas caused by supplements or pharmaceuticals. I can’t answer that because there’s no evidence one way or the other. Because your body naturally releases digestive enzymes, it’s doubtful they’ll interfere with the processing of the medication or supplement. It could be that your body isn’t making enough digestive enzymes to fully break down the substance, so adding or changing a digestive enzyme supplement is worth a try.

The second approach would be to identify which foods cause you problems, and it may not be as obvious as beans or dairy. It could actually be a spice that reacts with the microbes in your microbiome, and that’s not always easy to identify. Some foods such as sugar alcohols that are often used as sweeteners in processed food can cause gas. Once you’ve discovered which foods cause problems, sometimes the best policy is to limit them or avoid them entirely.

The third approach goes hand in glove with the second and that’s to change your diet. Research continues to show that people who eat more plant-based foods have different and perhaps better functioning microbiomes than those who do not. That’s a tough sell in this keto world we live in, but the carbs a person eats should lean toward vegetables with some fruit rather than starchy vegetables and grains.

Finally, if you take a probiotic supplement, stop it for a couple of weeks and see what happens. Remember in Tuesday’s Memo, the excess gas stopped when the person stopped taking the probiotic. It may be that a different probiotic blend might work better. There are over 6,500 different microbes that have been identified, and it may take trial and error as well as newly developed probiotic blends before you get it right.

The Bottom Line

There are a couple of other things that can contribute to gas such as drinking carbonated beverages and simply swallowing too much air. For most people, it’s still an issue of fermentation in the microbiome. The best approach is trial and error until you get the diet, prebiotic, and probiotic in balance.

Unlike other health issues, excess gas can be uncomfortable and can result in embarrassing situations, but as long as you’re not standing next to a flame, shouldn’t be fatal.

What are you prepared to do today?

        Dr. Chet

What Causes Increased Gas?

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Over the years, I’ve learned this about people as it relates to their health: they notice every change in their digestive system. They have their own bathroom habits, and they don’t like anything that changes their pattern. If they make a change in their nutritional intake—whether it’s a food, a supplement, or a medication—and it impacts their pattern, they really don’t like it. What’s not as noticeable immediately is another digestive change, and that’s an increase in gas.

In one case, a person developed an increase in gas production—and not in a good way; she stopped taking a probiotic (after regular use for a couple of years) and the problem stopped. Another person noticed an increase in gas after adding an amino acid blend. Yet another noticed an increase in gas after starting a medication. What gives?

The microbiome consists of the bacteria and other microbes that reside in the digestive system. The primary way they do what they do is by fermentation; the result is the production of gas, and that’s perfectly normal. Any change that impacts the microbiome can change the production of gas. Other than stopping the food, supplement, or medication, what can we do about it? I’ll give you some ideas on Saturday.

What are you prepared to do today?

        Dr. Chet

RSV in Infants

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Our daughter-in-law, Kerri, is a pediatric respiratory therapist with 32 years of experience, so she was an obvious choice to talk to about RSV, especially in babies. You need to know more about RSV (respiratory syncytial virus), especially if you’re parents or grandparents of infants less than six months old. The CDC reference at the end has more information for all age groups.

RSV is very common, and most of the time it seems like a common cold; the CDC estimates virtually all children will have RSV by the time they’re two. But with higher infection rates this year, there will be more severe cases than normal. Treating the symptoms, especially the inflammation of the lungs and the potential for pneumonia, is critical if the infection progresses.

How Bad Is It?

How bad is RSV this year? This is the worst year my daughter-in-law has seen. In Charleston where Kerri works, they’ve got beds in the hallway of the NICU because of overflow cases. Her mentor in Virginia has been an RT for 40 years, and it’s the worst she’s ever seen. Cases are up in Grand Rapids, and we’re not even in the critical part of the season yet, which is winter and spring. So it’s serious.

What You Need to Know

Infants will have symptoms, but they can’t tell you directly. A decrease in energy level, decrease in appetite, irritability, runny nose, and coughing are common. The child may or may not have a fever.

This info from my daughter-in-law was surprising to me: infants are nose breathers. The most important thing adults can do is suction the mucus from the nose to keep their breathing pathway open. Yes, you’ll hear the wheezing in the lungs, but the pathway goes through the nose. Use saline drops to keep the tissues moist and a suction bulb to keep the nasal passages open.

More tips from Kerri:

  • Keep a humidifier going; that helps with maintaining the mucus’s fluidity.
  • If the infant has a fever, keep her cool. Don’t pile on a lot of blankets, although that’s seems counter-intuitive. The baby’s breathing rate is higher to dissipate heat, so keep her cool—not cold, just cool.
  • Finally, watch the baby. If he’s really struggling to breathe, especially though his mouth, seek medical attention immediately.

The Bottom Line

Let me repeat: for most people of all ages, RSV seems like a cold. A weakened immune response can cause serious illness, so we have to be cautious. That’s especially true for infants, but also applies to elderly people and anyone with a chronic health condition. As with a cold, you’ll want to manage fever and pain; keep the liquids coming to avoid dehydration.

If there was one good thing that came out of the COVID pandemic, it was that the general public is more knowledgeable about dealing with viruses: wash your hands, keep surfaces clean, don’t touch your face, and cover your coughs and sneezes. RSV is especially communicable, so wearing masks can be beneficial.

Remember, there’s no RSV vaccine yet so prevention is the best option. We want to keep those who can’t speak for themselves as safe as possible, so always pay attention.

What are you prepared to do today?

        Dr. Chet

Reference: https://www.cdc.gov/rsv/high-risk/infants-young-children.html

Virus Update: RSV

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We have a viral uptick going on right now, and it’s not COVID. My health news feed has been sending warnings about an unusually high number of cases of respiratory syncytial virus (RSV), a very common respiratory virus that’s usually not problematic. It generally causes mild, cold-like symptoms, and most people recover in a week or two. However, that isn’t true for everyone; RSV can be very serious for infants under six months and preemies as well as older adults.

Why is it so serious? RSV is the most common cause of bronchiolitis, an inflammation of the small airways in the lung called the bronchia, and pneumonia infection of the lungs in children younger than one in the U.S. If you’re a numbers person, each year in the U.S., an estimated 58,000 children younger than five are hospitalized with RSV infection resulting in 100 to 500 deaths per year.

The elderly are also at high risk, especially those with compromised immune systems. You want more numbers? It’s estimated that more than 177,000 older adults are hospitalized and 14,000 of them die in the U.S. due to RSV infection every year.

One more complication: there’s no vaccine for RSV. What can we do? I’ll cover that on Saturday.

What are you prepared to do today?

        Dr. Chet

Protect Your Colon Health: Do a Test

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Continuing with our examination of the study on invited colonoscopies versus usual care, what could the researchers have said to cause any controversy? Remember, the comparative rates of diagnosing colorectal cancer were slightly lower in the invited group. The controversy came when they stated that there was no difference in mortality over the course of 10 years. That suggests that it doesn’t matter whether you’re specifically asked to have a colonoscopy or get one as part of your usual care—your risk of dying from colorectal cancer, the second leading cause of cancer deaths in the U.S., is no different. As you might expect, nothing is quite as simple as it appears to be.

Invitations Don’t Mean You’ll Accept

The stunning part to me was that only 42% of the people in the invitation group accepted and had the colonoscopy. This is where going back to ask why the subjects did or did not have the colonoscopy is important. The people were not identified by name but by a randomly generated number. In order for the data to be meaningful, we need to know why the potential subjects chose not to participate.

What About Other Diagnostic Tests?

The most common test at this point is the fecal occult blood test (FOBT). This test looks at a sample of your stool to check for blood; the key is that it’s blood that’s not visible to the eye (that’s what occult means in this case). Blood in the stool can be a symptom of several conditions including anemia and colorectal cancer; the test can also be used to identify genetic risk factors for colorectal cancer.

What the test can’t do is identify those people who have adenomas, a precancerous growth. Not all adenomas become cancerous, but they can be removed during a colonoscopy and tested for cancer. The fecal occult blood test can’t detect adenomas that are not bleeding.

The Bottom Line

The thing to remember is that testing is important, whichever way you do it. Colonoscopies require the marvelous “colon cleansing preparation” that may be too hard on elderly people or those with poor health; it’s no walk in the park for anyone. The cost may also be prohibitive depending on the type of insurance coverage one has. Protecting your colon health calls for a serious discussion with your healthcare provider to find out what the best course of action is for you. Family and personal history both have a role to play and need to be considered.

The purpose of research such as this is to help you find what your path should be. But once you know it, follow it. Ignoring it may bring undesired outcomes—and the last time I checked, death is permanent.

What are you prepared to do today?

        Dr. Chet

Reference: New England Journal of Medicine. 2022. DOI: 10.1056/NEJMoa2208375

Research Update on Colon Health

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If I were to take a poll, I’d wager that most people would skip a colonoscopy if there were an alternative that provided the same information on the health of your colon. The key words are “same information”—not only that, but provided the same diagnostic outcomes. Will the alternative test tell you whether you have colorectal cancer? Will it give information on the health of your colon? A recent research paper called that into question. Let’s take a look at the study published in the New England Journal of Medicine.

Researchers from several European countries (Poland, Norway, Sweden, and the Netherlands) wanted to examine the difference in outcomes between two groups. The first were a group who were invited to have a colonoscopy. The second was a group that received usual care. Simply put, the second group relied on physicals and doctor discussions to decide whether to have a colonoscopy or not. They recruited over 28,000 people from 55 to 64 years old for the invited colonoscopy and compared them with over 56,000 people who received the usual care.

After following the subjects for 10 years, they found the risk of colorectal cancer diagnosis was 0.98% in the invited group versus 1.2% in the typical treatment group. That looked pretty good for colonoscopies. But it’s what the researchers suggested in the discussion portion of the article that raised questions. I’ll cover that on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: New England Journal of Medicine. 2022. DOI: 10.1056/NEJMoa2208375

Yes, Fiber Is Healthy

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Almost all Americans need to increase their fiber intake by eating foods containing fiber as well as using supplemental fiber if needed. I do and will continue to do so with one caveat, which I’ll talk about later. Let’s get into the research that caused the headline about fiber and cancer.

Genetic Defects Were the Underlying Problem

Based on observational studies, researchers examined the role of soluble fiber on metabolic syndrome (MetS) in mice—not just any mice but mice that had a specific defective gene called Toll-like receptor 5 (TLR5). These mice develop MetS when fed a modern diet. Researchers used several types of soluble fiber, including inulin and pectin. While the symptoms associated with MetS were decreased, they discovered that close to half the TLR5 mice developed liver cancer while the normal controls did not. Why? One thing they noted was that the TLR5 mice became jaundiced due to bile acids in their blood.

Based on prior research, researchers suspected that something was causing bile acids to enter the blood stream. There’s a strain of mice, C57BL/6 mice, that has a defect which causes portosystemic shunt (an abnormal vein connecting the blood supply returning from the intestines to the vein returning blood to the heart, bypassing the liver). That allows bile acids to build up in the blood stream, damaging the liver, and causing liver cancer. The use of high soluble-fiber diets speeds up that process because of the fermentation of the fiber by probiotics. Hence that’s why the results associated fiber with cancer. But is it an issue in humans?

Soluble Fiber and Liver Cancer in Humans

I think the risk to humans is negligible for two reasons. Based on the latest data, the risk for portosystemic shunt in humans is about one in 30,000. The researchers suggest it may be higher, but we don’t test for it. The caveat I mentioned? Bile acids can be detected by a simple blood test; if you want to be sure you don’t have an issue, just request that test to eliminate the shunt or any other cause of bile acids in your blood.

The second reason is that the researchers fed the mice 10% of their diet as fiber. In one trial the inulin content was 2.5% while in another it was 7.5% of the mice’s dietary intake. The Daily Value for humans eating 2,000 calories per day is 1.4% or 28 grams, and that’s mixed fibers. We currently average 0.7%. It doesn’t seem likely that even people who supplement their food with fiber supplements will reach a comparably high level of intake.

The Bottom Line

Don’t for a minute think that this research isn’t important because it is. We live in a society that believes if some is good, more must be better. What they’ve shown is that some soluble fiber is good for weight loss and the symptoms of MetS, as well as keeping your bowels moving smoothly. We don’t need to overdo anything; we just need to do the average. Try to get about 25 to 35 grams of fiber daily from foods and supplements, get the blood bile test to be extra cautious, and you’ll be fine.

What are you prepared to do today?

        Dr. Chet

References:
1. https://doi.org/10.1016/j.cell.2018.09.004
2. https://doi.org/10.1053/j.gastro.2022.08.033