Winter 2015, Article 71

What the Heck Has Been Going on in My World?
By Mark A. Moyad, MD, MPH, University of Michigan

article #71 – Winter 2015

Note: A total of 71 (YES THAT IS 71…that’s a lot…even higher than the number of times my kids said “I am sorry and I will not do that again” and then they did that again!) times in a row (and for 16+ years!) I have written and volunteered for this newsletter. I have yet to receive any personal financial compensation or personalized classic timeless gifts such as PAACT complimentary lifelong mental health therapy for Dr. Moyad after Michigan lost to Michigan State in football on the last play of the game when we were all set to beat those evil guys and their “I am always serious and in a cranky mood” coach (although the guy is really a genius and needs to go coach another team far away, for example some team at the North Pole or Russia, because he is making me crazy) so I can quit seeing him finally semi-smile when he beats Michigan!!! At least it took a miracle to beat Michigan this year and that will be true in the future. Also, by the time you read this newsletter the Mighty Michigan versus the Overrated Ohio State Football game will be over and if we don’t beat those dudes, I’m going to need twice as much mental health therapy so PAACT should get ready to pay for my medical needs ASAP! However, if Michigan can beat Ohio State this year, then I’m going to be in a VERY HAPPY PLACE!!! In fact, if Michigan beats/upsets Ohio State this year, please send me beer and money, because I will have deserved it and if they lose please send me beer and money because I will deserve it and need it!

I WANT TO THANK YOU AGAIN FOR CONTINUING TO MAKE “THE SUPPLEMENT HANDBOOK” – my semi-new book a best seller. YEAH!! THANK YOU!!! Second, if you have not picked up a copy please get one on Amazon.com (the very cheapest place to procure a copy) to support my “Just for Men” fund because my hair is turning even more gray and thin with every issue of PAACT (because I’m getting older, not because I’m experiencing more stress – except when Rick Profit from PAACT sends me an email every 2.5 months stating “your column is due this Friday.” Then I experience stress and I place a small picture of him on my office wall and throw darts at it – especially trying

to hit his mid-section, but then after I turn the column in I feel bad that I did this and take his picture down, but I never tell him that I have this nefarious regular habit and I am sure there is no way he will ever find out that I temporarily throw darts at his picture – I mean how could he find out that I do this on a quarterly basis???)! And, for about 19 bucks (the cost of only 10 two dollar candy bars or a few boxes of Girl Scout cookies – I like the mint ones by the way) you get 512 pages of material on over 100 medical conditions and when not using this amazingly big book it also functions as a football or a Discus.

BREAKING NEWS!!!

325) HILLARY CLINTON EMAILS & President Bill Clinton and Monica Lewinsky! (Actually have nothing to do with this article I just wanted to get your attention).

MY TRIP TO ITALY AND WHAT IT MEANS FOR YOU = COFFEE HAS ANTI-CANCER EFFECTS (Maybe) AND POMEGRANATE DOES NOT???! HEY, THIS IS 3 ARTICLES IN ONE! A TRIFECTA! WHAT A DEAL!!!

(Reference: Moyad and Delta Airlines; Guercio BJ, et al. J Clin Oncol 2015, released early on-line; Liu H et al. Nutr Cancer 2015;67:392-400. & Discacciati A, et al. Ann Oncol 2014;25:584-591).

BOTTOM LINE

Italians drink a lot of coffee and now caffeinated, low or no calorie coffee has some preliminary evidence that it could

Cups of coffee with smoke and coffee beans on old wooden background

reduce the risk of colon and prostate cancer returning after treatment OR this positive evidence only exists because some men that drink a lot of coffee harbor a lot of other healthy behaviors. Regardless this is pretty cool stuff! And, pomegranate juice/extract? Let’s just say it’s not been a good year for pomegranate and prostate cancer evidence, especially when compared to placebo.  OUCH!!!

WHAT ELSE DO I NEED TO KNOW?

I just returned from a brief working trip that took me throughout Southern Italy – I know…life is really tough at times, but someone has to be Mark Moyad. Now I am semi- or actually fully addicted to coffee because in Italy it is ubiquitous, you can’t escape from it, which is kind of like those lawyer ads on TV that promise you big money if you just take someone to court, and they/lawyers do not get paid unless you get paid (wow!). That’s so kind! Expresso, cappuccino, café Americano …yummy for my tummy. I learned about all of them by trying them over and over again! Man, I had more energy than a 16-year old kid getting his driver’s license and a new car on the same day! However, wha t was really incredible is that I saw no one – not a single person in Italy use a “to go” cup or simply walk down the street drinking coffee – not a single person in any of the many cities I visited?! What the heck is going on? These well-dressed Italians (Man they look good even in the early morning…I mean who looks that good in the United States so early in the morning…apart from my wife of course – BOOM! Man, I am as smooth as a baby’s bottom) stand or sit in a café and drink and talk and then move on with big smiles on their faces.

Now it appears that coffee is healthy for you? Perhaps it’s not the coffee but the underlying comprehensive healthy behavior of the coffee drinker in some of these countries. They appear to regularly socialize, relax, remain strong spiritually, walk constantly, and eat very healthy diets, but only in small to moderate portions. For example, I ordered a crab-stuffed ravioli in Rome, a pizza in Naples, Caprese salad in Sorrento, and anchovies in Amalfi that I swear in every case were considered a main course, but were so small that in America they would not even qualify as an appetizer! In other words, the portion sizes were so tiny! I mean even their soda drinks were tiny! This must be the secret of the Mediterranean diet or perhaps it’s the fact that I dumped gallons of olive oil on everything because right now the oil is so fresh and yummy with bread and veggies and meat and fish and _______ (insert your favorite food)! You could almost drink the olive oil straight because it was so fresh in Italy! And, olives themselves were so fresh that I ate a plate of them at every meal! Just call me “Mayor of Olive City” because I LOVE to EAT OLIVES (get it…olive is like saying “I love” – in fact it you mouth the words “olive juice” from a distance to a friend or relative they actually think you are saying “I love you.” Try it sometime, it’s funny!).

Back to my story! Multiple new human (not mouse or rat) studies are also suggesting that coffee (especially the low or no calorie caffeinated type) itself has some anti-cancer/anti-inflammatory properties and could reduce insulin over-exposure, which means not only as a preventive, but also as a way to reduce cancer recurrence. Wow! Is this possible? I mean coffee actually does have some interesting compounds like “chlorogenic acid” that could be healthy! And, in a recent American colon cancer study of patients that had been treated for colon cancer the results were pretty good and got my attention (even though I never drank coffee before except one time in high school before I had to stay up all night for an exam that I think I ended up failing – thanks a lot coffee). In a recent study a total of 953 patients with stage III colon cancer during and 6 months after adjuvant chemotherapy who were prospectively followed over time and the dietary intake of a variety of foods and beverages were self-reported and recorded. Patients ingesting 4 cups/day or more of caffeinated coffee experienced a significant (p=0.002) 52% reduction of colon cancer recurrence or mortality (HR=0.48) versus never drinkers. Non-herbal tea and decaffeinated coffee were not associated with a clinical benefit. Greater coffee intake could be correlated with a significant reduction in colon cancer recurrence and mortality in patients with stage III colon cancer. I wanted to ignore past data that had been primarily retrospective and observational through the years but the accumulating data in cancer has become difficult to ignore.

Yet, is it really the coffee or the average healthy behavior of the coffee drinker that is the secret? It doesn’t even matter because the message of eating a healthy diet but in small portions and moving more and staying skinny is just part of the theme of the coffee drinker. If many Italians would just quit smoking they would live even better and longer, this is what they can learn from us in America (not smoking). Although, many Italians would then start struggling with massive weight gain, which has begun to occur. My trip to Italy was a beautiful educational experience that reinforced some of the similar cultural secrets to a better and/or longer life that I have witnessed from traveling throughout the world from Singapore to South Africa to South America over the past 30 years. However, the smoking part is devastating because although smoking DEFINITELY helps you stay skinnier it also increases the chances of making your life worse while you are living it and ending your life earlier and exposing all those arounds you to this carcinogen. DISGUSTING! In fact, a few times my wife and I walked into a store and were going to spend an obscene amount of money (aka 20-30 dollars) and the store employee or store itself smelled so much like tobacco we had to turn around and leave the store!

Interestingly, at the time I was writing this column, suffering from massive acid reflux and sleepless in Ann Arbor, moments from drinking coffee, there was another research study from the National Cancer Institute (aka NCI) that was published (Loftfield E, et al. Cancer Epidemiol Biomarkers Prev 2015;24:1052-1060.), which suggested that coffee is potentially associated with lower death rates from colon, endometrium, liver and prostate cancer and that improving insulin sensitivity and decreasing inflammation may be the reasons for this potential benefit. So, NCI researchers decided to measure blood levels of 77 immune system and inflammatory markers in over 1700 individuals. Coffee drinkers appeared to have lower blood levels of several inflammatory blood tests! Man, this is getting weird and awesome (kind of like watching your parents trying to operate an I-phone)! And now the bad news that has to do with another highly touted anti-cancer beverage (please read the next paragraph)!

Despite over 10+ years of excitement in the area of pomegranate extract or juice there were few long-term placebo comparative trials and this is what always worried me. It was also worrisome that when someone ingested pomegranate supplements (juice, pills…) there were no significant beneficial changes in weight/waist size, blood sugar, blood pressure, or LDL or “bad” cholesterol. HEART HEALTHY = PROSTATE HEALTHY = Moyad circa 1999 and beyond. It was for these and other reasons I have for years commented that pomegranate could be getting WAY, WAY too much hype and might not do well overall in more rigorous clinical trials and I predicted in my SUPPLEMENT HANDBOOK (available now on Amazon.com = shameless plug #345) that it would fail to work in bigger and better studies. Many people/experts that will remain nameless (until I see them and remind them that they were wrong), pushed the pomegranate agenda aggressively and I do not believe this was helpful. Regardless, here are the issues – after 3 high quality trials it seems that pomegranate is not working much better than a placebo for most individuals. One study was for advanced prostate cancer patients (Stenner-Liewen F, et al. Journal of Cancer 2013;4:597-605.), another was for patients having surgery for prostate cancer (Freedland SJ, et al. Cancer Prev Res 2013;6:1120-1127.), and the third and more recent major trial was for men with rising PSA after primary therapy (Pantuck AJ, et al. Prostate Caner and Prostatic Disease 2015;18:242-248). This is not good news for pomegranate juice or other products derived from the pomegranate, but I have always believed that eating a real and NATURAL (can I use that dirty word) POMEGRANATE will always be healthier than drinking the juice or taking the supplements. Now, that’s a clinical trial I would like to see….pomegranate juice versus supplements versus a pomegranate itself in a CAGE MATCH for a FIGHT WHERE WINNER TAKES ALL!!! My money is on the ignored low cost pomegranate fruit to win in a knockout in the second round!! Regardless, let me remind you what a “natural” pomegranate gives you and why it’s always a healthier choice (in my opinion) versus the pills or juice. It’s because there is approximately 3.5 GRAMS OF FIBER in a serving of pomegranate seeds, which is very high compared to many fruits and helps control the amount of sugar absorbed from the juice. And, if you remove the fiber and just keep the juice then what do you have apart from a lot of liquid sugar? I’m not sure what you have, this is why I put a question mark at the end of the last sentence.

Now, let me ask you 5 questions that are more important than any pomegranate or supplement product or almost any product on the market. PLEASE INSERT YOUR NUMBERS BELOW AND THEN BRING THEM TO ME WHEN YOU SEE ME AT A LECTURE, MEETING, BAR, OR A MCDONALD’S NEAR YOU!

1. Do you know exactly your weight/waist size?

2. Do you know exactly your last LDL cholesterol (aka “bad cholesterol”) value?

3. Do you know your blood sugar value?

4. Do you know your blood pressure numbers?

5. Do you know why Coach Jim Harbaugh at Michigan will win the national title in college football in 2017 and 2018 (rhetorical question…of course the answer is “because he is Jim Harbaugh the most brilliant coach in the history of college football” and because he went to grade school with another fabulous person named Mark Moyad…no kidding “St Francis of Assisi” in the 1970s, I think…it was while ago)?

Anyhow, let’s conclude this section on coffee by reminding you that the next time you go to Starbucks just order a tall medium or light coffee with no extras and that’s only 5 CALORIES!! If you don’t like coffee just order their OATMEAL (only 160 calories and 4 grams of fiber and virtually no sugar and 5 grams of protein) with a dash of milk and no extras – you will like it and your colon and prostate and heart and your sexual organs (I was going to use that “p” word for example, but PAACT is a family newsletter so using the word “penis” would have been inappropriate, so whenever you see the letter “p” by itself it means “penis” or it could also mean “PAACT” I guess…you decide) will say thank you very much for consuming such a healthy product!

326) What I ordered at McDonald’s the other day!

(Reference: McDonalds in Ann Arbor, MI or Detroit Airport or Denver, Colorado or coming to a McDonalds near you)

BOTTOM LINE

Fast food restaurants get a lot of criticism, as they should, because many items are as unhealthy as a swift kick in the groin area that just keeps on hurting, but once in a while they come up with a delicious low calorie option that should be given credit! So, let’s give them credit for inventing the EGG WHITE DELIGHT McMUFFIN! Hip, Hip, Hooray, it may actually be good for your waist and hip bones!

WHAT ELSE DO I NEED TO KNOW?

What tastes amazing, costs very little money, and only has 250 calories but also has 18 grams of PROTEIN (that’s a lot) and 7 grams of fat, zero trans-fat, only 30 milligrams of cholesterol, 1 gram of dietary fiber, 3 grams of sugar and 230 milligrams of calcium (that’s a lot) and again did I mention it tastes VERY YUMMY AND AMAZING AND IT MAKES ME FEEL FULL!!! IT IS THE EGG WHITE DELIGHT McMUFFIN!!! HIP, HIP, HOORAY!!! HIP, HIP, HOORAY!!! HIP, HIP, AND IT’S GOOD FOR YOUR HIP(s)!

Wait, Dr Moyad you are actually pushing fast food and McDonalds, which has arguably kept most cardiologists in business over the past few decades?! So, what’s the catch with this newer food or breakfast item besides the fact that McDonalds invented it? There is a catch – it contains 760 mg or 31% of your daily intake of SODIUM – YIKES!!! So, of course there’s a catch, but if this is all that you eat for breakfast and you regularly watch your sodium intake or in reality increase your potassium intake then WHO THE HECK CARES!!! I LOVE THIS NEW BREAKFAST ITEM!!! TRY IT AND AFTER YOU LOVE IT SEND ME A GIFT CERTIFICATE TO MCDONALD’S FOR CHRISTMAS or HANUKKAH or whatever you celebrate! Anytime is a good time to buy Mark Moyad a gift!!!

327) Why calcium supplements are not needed anymore for most people (exceptions include those on osteoporosis prescription drugs and steroids long-term like prednisone and those that rarely consume foods and beverages with calcium, which is hard to do by the way…did you see the amount of calcium in the McDonalds item from the previous news story Moyad discussed?)!   (Reference: Moyad MA. The Supplement Handbook-best book in world)

BOTTOM LINE

Calcium supplements (with or without vitamin D) have many risks including: increasing the risk of kidney stones, constipation (Hey, wait slow things down – get the joke…constipation? Really?), inflammation of the throat, swallowing problems, and even heart disease (controversial, but concerning). Additionally, there’s so much calcium in food and beverages today that people are being over exposed to it. The goal is to normalize your intake of calcium and vitamin D to prevent falls but there’s no reason to get excess amounts of calcium and vitamin D. I have written about this many times but there’s new information on the subject so let’s discuss it.

WHAT ELSE DO I NEED TO KNOW?

If you want to learn about the highest sources of calcium in foods and beverages go ahead and GOOGLE IT (or in reality I say “MICHIGAN IT” because one of the founders of google went to the University of Michigan and he loved it as much as Tom Brady loved it, because it’s the greatest school in the world.

I’m not biased at all….oh and did I mention it’s the greatest school in the world and Tom Brady went there and loves it!).

Calcium is so replete in multivitamins (heck I saw one the other day with 500 mg of it per multivitamin pill), food and fortified beverages today it has become easier than ever before to attain the recommended 1000-1200 mg per day (1000 mg in 19-50 year old males and females, 1000 mg in 51-70 year old males, 1200 mg in females 51 years and older and males 71+ years). The table on this page is a representation of how much easier it is to reach the RDA goal of calcium without having to take separate calcium supplements.

In fact, in the largest dietary supplement trial ever conducted on calcium supplements (WHI) the baseline intake of calcium from foods, beverages and supplements was already approximately 1150 mg/day of calcium before randomization to the calcium or placebo groups! In other words, many of us are already getting too much calcium or enough calcium.

The Women’s Health Initiative (WHI) was a double-blind, placebo-controlled clinical trial and the largest U.S. clinical trial to address the issue of calcium and vitamin D supplementation. This trial included 36,282 postmenopausal U.S. women who were to ingest 1000 mg elemental calcium carbonate plus 400 IU of vitamin D3 (OsCal® brand of calcium supplements, GSK Company) or placebo for 7 years. The average BMI was 29 (almost obese) and there were a greater number of obese versus overweight women in the trial, which interestingly appears to reflect the current U.S. population. The primary endpoint was the reduction in hip fractures, and secondarily total fractures and colorectal cancer. Calcium and vitamin D supplementation significantly increased hip and total bone mineral density (BMD) versus placebo (p<0.01), but there was no overall evidence to suggest a reduction in hip or total fracture risk. There was an increase in kidney stone risk and there were no impacts on cardiovascular events or colorectal cancer risk. This study, the largest of its kind, continues to suggest that normalization or increased calcium and vitamin D supplementation could improve bone mineral density and may have an impact on hip fracture risk but arguably only in those individuals that are not getting enough calcium and vitamin D. But, keep reading because you might be surprised as to how calcium and/or vitamin D might be reducing the risk of bone fractures, if they do at all.

A recent extensive analysis of the calcium and vitamin D supplementation data from the U.S. Preventive Services Task Force or USPSTF (the same group that now discourages PSA screening…love them or hate them) found treatment of vitamin D deficiency in some asymptomatic person might prevent falls (not fractures). They concluded their findings the following way: “Treatment with vitamin D, with or without calcium, may be associated with decreased risk for mortality and falls in older or institutionalized adults. Vitamin D treatment did not reduce fracture risk…” This is a critical initial finding from the research, which in my opinion also suggests cancer patients should normalize their calcium and vitamin D intakes to maximize the benefits of bone loss prevention and especially FALLS, which could lead to an increased risk of fractures. And, there is enough evidence from these past reviews of the data that calcium and vitamin D are also important for muscle health and coordination.

Additionally, most major trials of drug interventions to prevent bone loss and fractures in cancer patients, including denosumab (Xgeva®) and zoledronic acid (Zometa®), utilized some form of calcium (1000 mg per day) and vitamin D supplementation (400 or more IU per day) or normalization of intake to ensure adequate responses to these bone medications.

Thus, when these drugs received FDA approval in breast and prostate cancer it was due to phase-3 trial evidence of the drug with the use of calcium and vitamin D in combination (not by itself) to normalize daily intakes. So, how much vitamin D is enough? Well, the Institute of Medicine (IOM) has done a good job of simplifying the requirements. Age 18 to 70=600 IU of vitamin D a day and from the age of 71+ then 800 IU per day! That’s it!!!

Now, without going through all the side effects of taking calcium dietary supplements, which I have covered adequately in past PAACT issues (along with which calcium supplements are better or worse or pose less of a risk of kidney stones…) there is now a new issue “PILL ESOPHAGITIS” (inflammation of your food pipe). Pills come with unique side effects and although life-saving in many cases another reason not to ingest a pill unless needed is due to “pill esophagitis.” This is well-known in the pharmaceutical industry, for example, and often it is due to patients not drinking enough water or standing up when ingesting a pill (for example this is why all osteoporosis pills come with these instructions and warnings). The symptoms of pill esophagitis include difficulty swallowing, pain on swallowing and retrosternal pain. Yet, dietary supplements can also cause pill esophagitis and esophageal ulcers, so the concern or at least recognition over this side effect in the supplement industry should immediately match that of the pharmaceutical industry. Increasing awareness of dietary supplement side effects allows for the identification of pill side effects unique to the industry itself, especially when compounds such as “silicon dioxide” (aka “sand”) are utilized in some products to a large extent. Recently, recognition of an increased risk of 100% silicate based kidney stones can occur in products that contain ample amounts of this compound. And, this is just one of many compounds uniquely utilized in pills, especially supplements that were believed to be inert in humans.

However, back to the famous/infamous calcium supplements for a second because some are as large as the front door of your house (THAT IS A BIG FRONT DOOR Dr. Moyad). Recently there was a report that suggested over 23,000 emergency room visits occur PER YEAR because of dietary supplements (Geller AJ, et al. N Engl J Med 2015;373:1531-1540)! YIKES!!!! I actually think this number is a lot higher for many reasons that would be boring to you and would just take up a lot more space and I am getting tired typing (I have fingeritis, I wonder if I should call one of those lawyers on TV and hold PAACT responsible for this clear cut disease caused by PAACT)! Anyway what got missed in the publicity around this paper that mostly focused on weight loss supplements or energy products was the finding that “AMONG ADULTS 65 YEARS OF AGE OR OLDER, CHOKING OR PILL-INDUCED DYSPHAGIA” (problems with swallowing) was responsible for 38% of all those emergency department visits in this age group!!! And, more than half of the swallowing problems (54%) with pills from this study from emergency room departments around the U.S. were due to “CALCIUM PRODUCTS/SUPPLEMENTS!!!” This is another big problem with calcium supplements today because like multivitamins they are becoming too big or are too big! In the pharmaceutical world the FDA recommends that a pill should not be greater than 22 millimeters, but with supplements there is no recommendation or rule! GEESH!!

328) Fiber Primer and why getting more dietary (not supplemental fiber) is one of the keys to internal anti-aging! So, it’s a form of BOTOX®? YES!!! But, wait you have talked about this before in the PAACT newsletter and readers are sick of hearing about it! Nope! There is breaking news and new information on it and it has to do with PSA screening?! And, how about some of my favorite BOTOX jokes you have never heard and why exercise keeps things flowing and lets you sleep at night if your prostate is large and in charge?

(Reference: Moyad MA, 2015)

BOTTOM LINE

Consume more (soluble and insoluble) dietary fiber (20-30 grams/day or 14 grams per 1000 calories consumed), especially from food sources. “Fiber is nature’s internal Botox for the human body” (Moyad Circa 2014) and both soluble and insoluble fiber have unique and synergistic benefits when found together (as in most healthy dietary sources). OH BOY HERE GOES MOYAD AGAIN TALKING ABOUT FIBER!!! That’s correct! I have mentioned much of these benefits before, but let’s review again and add some new information! So, let’s get things moving (get it?) and talk fiber!

WHAT ELSE DO I NEED TO KNOW?

General and numerous health benefits are derived from consuming dietary fiber that have been well documented and include reductions in the following:

• Coronary heart disease (CHD) risk

• Stroke

• High blood pressure

• Diabetes

• Obesity

• All-cause mortality=death from all•causes (which is a good thing)

For example, a pooled analysis of past cohort studies of dietary fiber for the reduction of CHD (coronary heart disease) included research from 10 international studies and included the U.S. Over a period of 6-10 years of follow-up, and after multivariate adjustment it was revealed that each 10 gram/day increase of calorie-adjusted total dietary fiber was correlated with a 14% reduction in the risk of total coronary events and a 27% reduction in risk of coronary death. These findings were similar for both genders, and the inverse associations occurred for both soluble (also known as “viscous”) and insoluble fiber (both are found in most healthy food sources of fiber compared to commercial pills and powders that normally just or primarily contain “soluble” fiber).

Past studies have not observed a consistent benefit with one class of fiber over the other (soluble or insoluble). Recent large U.S. and other international studies have even found more striking overall potential benefits for consuming more dietary fiber. For example, the NIH-AARP U.S. prospective cohort found not only a lower risk of dying from cardiovascular, respiratory and infectious disease with greater intakes of fiber but a significantly lower risk of dying younger (“total death”) in men and women. This study may represent a major shift into the research behind fiber intake because now the potential health impact may be so much larger than first realized since reductions in the death rates of some of the largest causes of mortality may occur with greater fiber intakes.

Even minor additions of some commercial fiber sources (to your overall large dietary fiber intake) can positively impact medication dosages. A total of 15 grams of psyllium (Metamucil for example) husk supplementation daily with a 10 mg statin (simvastatin) was demonstrated to be as effective as 20 mg of this statin by itself in reducing cholesterol in a preliminary placebo-controlled study of 68 patients over 12-weeks. Although adding soluble fiber from commercial products appears to be safe and synergistic with cholesterol lowering medications, the first choice of increasing fiber intake should be FOOD SOURCES based on cost-effectiveness and simplicity. I’m not a big fan of Metamucil in large amounts, but if you need a little help getting to your daily fiber total, then Metamucil is an option.

More benefits should be emphasized so let’s do this – a meta-analysis of 24 randomized placebo-controlled trials of fiber supplementation found a consistent impact on blood pressure reduction. Supplementation with a mean dose of only 11.5 g/d of fiber reduced systolic blood pressure by –1.13 mm Hg and diastolic pressure by –1.26 mm Hg. The reductions were actually greater in older and more hypertensive individuals compared to younger and normotensive participants. Recent international studies continue to support the modest reduction or control in blood pressure with greater intakes of dietary fiber.

How much fiber should patients be consuming daily? Daily intakes of total fiber in the U.S. and many other Western countries is approximately 10-15 g/d, which is approximately only half or even less than half of the total amount consistently recommended by the American Heart Association (AHA) and American Dietetic Association (20-30 g/d) for adequate overall health. Another perspective on recommended fiber intake for children and adults is that for every 1000 calories of food and beverage consumed there should be at least 14 grams of fiber consumed.

Dietary fiber from food is easily achieved by low cost sources of soluble and insoluble fiber. For example, I often tell patients to consume a third of a cup of a bran cereal such as All-Bran Buds several times a week, which is approximately only the size of 1-2 liquor shot glasses, with flaxseed and some fruit, and before they leave the door in the morning approximately 20 grams of fiber will have already been ingested toward the 25-30 gram goal! Low cost fiber sources such as flaxseed can provide potentially numerous heart healthy and overall health benefits. Perhaps the low-cost and non-commercialization of this product on a large-scale has led to the lack of adequate education that I’ve observed on this product. Flaxseed is one of the highest plant sources of heart healthy omega-3 fatty acids, and chia seed is arguably the largest plant source of fiber and omega-3, and both of these additions to the overall diet would be ideal. Also, the
original Fiber One® cereal contains 14 GRAMS of fiber in just a half a cup! WHAMMMO! This definitely keeps the train moving!

Interestingly, the preliminary clinical trial data on ground flaxseed (average of 30 grams or 3 rounded tablespoons per day) in other hormone mediated cancers such as breast cancer has been as or more impressive (reduced proliferation rates or Ki-67, which is a marker of potential cell or abnormal cell growth). Thus, it shouldn’t be a surprise that preliminary data of flaxseed in prostate cancer is also impressive and similar to some of the breast cancer observations. Flaxseed oil also has preliminary data against cancer, but this and other oils are a large source of calories (120-130 calories/tablespoon) and contain no fiber so rarely have I recommended them over low cost flaxseed powder (similar to the real whole non-processed fruit versus the fruit juice debate mentioned earlier).

Overall dietary fiber intake (again not pills or powders) continues to garner evidence as a method of cancer prevention. Multiple mechanisms are potentially involved with this fiber benefit including:

• reduction in by-products of male and female hormones that could stimulate cancer growth

• reduction in insulin and growth factors/mitogens,

• reduction in inflammatory compounds potentially via production of short-chain fatty acids when fibers are fermented in the colon by flora and products of fermentation such as butyrate and propionate enter the circulation.

• plethora of heart healthy changes altering cancer risk/recurrence (lower weight/waist, reduced cholesterol and blood sugar…)

Still, fiber itself appears to have become overtly commercialized, and in my experience some patients are turning primarily toward powders and pills to solve their fiber deficit, and this is not only costly, but also provides primarily small amounts of soluble fiber that make it difficult to reach total fiber goals utilizing only these sources. For example, I often ask audiences and students how many fiber capsules/pills are needed to be consumed daily to obtain just 20-30 grams of fiber, and the answer always seems to provide adequate shock value (the answer is 30-50 pills a day or more depending on the commercial source)! A bolus of only soluble fiber without insoluble fiber can also create excessive bloating and other gastrointestinal issues because soluble fiber is utilized by gut bacteria and then subsequently converted to gaseous compounds (aka “passing gas”).

Processed soluble fibers abound today in protein bars and cookies and these items need to be avoided not only for a lack of evidence but again gastrointestinal discomfort with moderate to high intakes. Research continues to support the overall and heart healthy health benefits of fiber, especially when it’s primarily derived from food sources, because these sources also provide a unique and optimal balance of soluble and insoluble fiber. Another comprehensive list of dietary fiber benefits are found in the table on this page (see table) and this is why I often tell patients that “nature’s greatest internal Botox” has to be dietary fiber! The plethora of internal anti-aging effects it provides is noteworthy, from preventing cholesterol and glucose changes to preventing hemorrhoids, and it’s easy to forget that humans don’t just age externally but internally with time. Botox for cosmetic anti-aging is attention grabbing but why isn’t fiber just as notable for preventing internal aging?

I find it interesting that most fruits, veggies, beans, bran, oatmeal and other dietary sources of fiber are primarily an equal mix of soluble and insoluble fiber or insoluble fiber actually predominates over soluble in these products, while again most commercial products are basically almost all soluble fiber. They are both needed to improve overall health (Yin and Yang). The reason one can consume 2 medium apples (about 10 grams of fiber total) without experiencing significant bloating, gas or discomfort is the majority of the fiber is insoluble (about 30% soluble). Again, the reason one cannot consume a large bolus of processed or commercialized fiber supplements or powders is that the vast majority is soluble fiber.

Now, you think all of this information would be enough to make you run out and start gobbling (Is that even a word???)

It is on Halloween….bad joke…like most of my jokes) up a ton of fiber! Still, there is another reason to do this and this is the most surprising of all! You may remember the U.S. study called “PLCO” that demonstrated no benefit to general PSA screening and the USPSTF used this information to no longer recommend PSA screening. After that point all heck broke loose and people started arguing back and forth on whether or not PSA screening should be recommended or not. It was kind of like Republicans and Democrats arguing back and forth and not getting anywhere, which is what happens only 365 days a year (they get things done on the other days of the year). Yet, the USA PSA screening study known as “PLCO” was a well done study not just in terms of asking the screening question, but perhaps more importantly answering other important questions on diet and exercise and this is what gets missed or no one knows about! So, what other findings occurred in this famous study that hardly received any media attention. Here is one conclusion of a finding that was also uncovered in the PLCO study and I quote: “This large, prospective study within a population-based screening trial suggests that individuals consuming the highest intakes of dietary fiber have reduced risks of incident colorectal adenoma and distal colon cancer and this effect of dietary fiber, particularly from cereal and fruit, may begin early in colorectal carcinogenesis.” (Reference is Kunzmann AT, et al. Am J Clin Nutr 2015;102:881-890). THAT IS INCREDIBLE!!! So, while all these folks run around and argue whether or not an otherwise healthy man should be screened for prostate cancer, the same study that helped generate this controversy found that DIETARY FIBER (not fiber from pills) found a potential large reduction in colon cancer or precursors to colon cancer-premalignant lesions with fiber! Amazing! Okay, tell me more Dr. Moyad! Tell me more! Okay I will and quit yelling at me with exclamation marks!

In the same PLCO clinical study that generated so much controversy with PSA screening and found a potential great benefit with fiber, also found another potentially incredible benefit with physical activity or exercise that few people know about and again why these researchers did such an incredible job! Here is what they found: “we did find strong and significant associations between physically active lifestyle and nocturia….Combined with other management strategies, physical activity may provide a strategy for the management of BPH-related outcomes, particularly nocturia.” (Reference is Wolin KY, et al. Med Sci Sports Exerc 2015;47:581-592). SEE IF YOU UNDERSTAND THIS INCREDIBLE FINDING! The same study that generated the PSA controversy and found that dietary fiber could be colon healthy also found that exercise could reduce the risk of getting up at night to urinate (NOCTURIA) when a man has prostate enlargement or BPH! This is amazing!!!

In the meantime, it you are not convinced that you should be more physically active and consume more fiber you could instead pay a ton of money for the real BOTOX. Ahhh, yes the real BOTOX, which is really expensive and comes with many jokes such as:

• “People tell me that Botox is way too expensive but I just met 10 people who paid for the treatment and they didn’t look surprised!”

• “There was some major recent controversy over Botox injections but these stories never seem to make the headlines!”

Okay, that’s it! I actually don’t have any good Botox jokes, but I don’t know how to use an iron so I did inject my favorite shirt with Botox before my last talk so that there would be no wrinkles in it – Ouch! That was bad!

329) Over the next 2 years there is a good chance there will be a new Shingles vaccine and it could be one of the best preventive vaccines ever invented! Keep asking your doctor about it!

(Reference: Himal L, et al. N Engl J Med 2015;372;2087-2096)

BOTTOM LINE

The company GSK has a new shingles vaccine and you should ask your doctor about it over the next year or two. Cross your fingers! If this gets approved it could be incredible because it would be over 97% effective for all age groups from 50 and older! The current shingles vaccine is not that great especially as you get older it gets weaker and weaker. However, this is not the case with the GSK vaccine!

WHAT ELSE DO I NEED TO KNOW?

The current shingle vaccine (Zostavax®) isn’t that great as you get older, but it’s all we have right now! For example, it’s 64% effective for those in their 60s but when you are age 70 and older it’s only 38% effective compared to 70% effective for those ages 50-59 years! So, we can do better and better may be right around the corner! A new vaccine that may hit the market in 2017 is currently MORE THAN 97% EFFECTIVE REGARDLESS OF AGE!!! THAT WOULD BE INCREDIBLE! Notice how I like the word “incredible” because it is incredible. GSK completed a study in 2015 with more than 15,000 patients age 50 and older (some 80 years and older). Currently only about 1 out of 4 individuals age 60 and older get the currently available Zostavax vaccine, but if this new one becomes available, I hope we get close to 100% of the people that need it get vaccinated. What’s the catch with the new GSK vaccine if it becomes available? Well, the study was over about 3 years, so long-term, researchers are not sure if the results will continue to be this amazing. Also, you will need 2 shots separated by 2 months when or if you get it. Still, if these results stand then I wouldn’t hesitate to get this vaccine when it comes out, also because side effects are not greatly different compared to a placebo vaccine.

And, now another new study from Sweden or as I like to say “Svvvvvveeeden” (because it sounds so much cooler) continues to demonstrate an increased risk for stroke and other unpublicized problems when getting Shingles! So, yes I do think the Shingles vaccine will eventually demonstrate that it can prevent cardiovascular disease including shingles! The risk of stroke and sepsis (serious infections) were significantly higher in the 12 months after getting shingles from this population study of over 13,000 cases of shingles! Yikes! Some researchers theorize that the shingles virus can actually infect arteries in the brain and others suggest that it creates a full body long-term inflammatory response that increases the risk of a number of cardiovascular problems. It’s interesting that in this recent study it was found that even younger individuals had a much larger risk of stroke if they had shingles. This is scary stuff and another reason why I am a BIG, BIG FAN of the current and future shingles vaccines. Finally, I think the potential for another benefit could occur with shingles and that is a reduction in the risk of COLD SORES! What? Moyad has lost it (but he never had “it”) and thinks the future shingles vaccine could prevent cold sores?! Yes, because cold sores are in the herpes virus family, which is a large family of viruses that also includes shingles. In fact, there are several studies now showing that there is an increased risk of being infected or bothered by one condition if you already have the other and vice versa. HOW MUCH FUN IS THIS STUFF (not shingles or cold sores but just this information is fun right?)!!!

I just love to talk about cold sores and shingles especially at the family dinner right after the family begins to take their first bite! It’s really great watching everyone get sick or look horrified at the table (reminds me of the holidays). You should try this some time, it will definitely get the attention of everyone and it’s also educational!

THAT’S ALL FOLKS…. See you in the SPRING, when I will write about many other serious issues and give timeless advice in the next newsletter, such as: why it’s never good to carry a heavy, hard to manage chainsaw in a crowded male nudist camp, it’s never good to talk about shingles and cold sores at the dinner table, it’s never a good thing to hear a surgeon say “I can’t find my glasses” right before you receive anesthesia as a patient, it’s never a good thing to take a laxative, a sleeping pill and a Viagra at the same time, and why it’s never good to tell someone you love them and then burp loudly.