What the Heck Has Been Going on in My World?
By Mark A. Moyad, MD, MPH, University of Michigan
article #68 – Spring 2015
Note: A total of 68 times in a row (and for 15+ years!) I have written and volunteered for this newsletter, and I have yet to receive any personal financial compensation or personalized classic time less gifts such as: a PAACT invisible dog fence, free tickets to see a Broadway Show, Coach Jim Harbaugh T-shirt and Khaki pants or even a meet and greet Tom Brady Super Bowl package extravaganza that would allow Tom and I to hang out and toss a football around and give us the opportunity to be best friends forever!
306) What’s happening to the quality control of dietary supplements? How do we fix this problem?
(Reference: Moyad M. The Supplement Handbook)
Recently the NY attorney general accused several large store chains that sell herbal dietary supplements that most of the products they are selling are bogus and don’t contain what they advertise. However, they may actually have misjudged the situation and performed the wrong tests. Regardless, if you take your time and investigate things, with some guidance, this whole mess shouldn’t be a big problem.
WHAT ELSE DO I NEED TO KNOW?
The past few months have not been good for dietary supplements and quality control (understatement of the year Moyad). The New York State Attorney General accused four national retailers (GNC, Target, Walgreens and Walmart) of selling dietary supplements that were fraudulent and, in numerous cases, “contaminated with unlisted ingredients. A total of 4 out of the 5 products tested contained none of the herbs advertised on the label! However, in a wonderful twist GNC and others fought back and stated that the NY State Attorney General’s office commissioned a group that actually performed the wrong test! And, they have proof that exactly what is advertised in their products is actually what’s in their products! The NY investigation and accusation was based on testing of herbal products using “DNA barcoding.” It’s a very reliable method, but here’s the key – it needs to be performed on the appropriate material. In other words, herbal extracts found in many supplements contain DNA but it is often of a low quality and broken down or degraded to a level that could make it really difficult to prove what is in the bottle based on this testing method. In other words, there is a chance that the supplement companies were in compliance and were right and the NY office was wrong, but at the time of this writing no one knows the exact truth (similar to when your local politician gives a campaign speech). Wow! This has all the makings of a reality TV show! Yikes! Is this a surprise? Not really. Recently, research out of Canada showed similar findings. Regardless of who’s right or who’s wrong or semi-wrong there is little doubt that many supplements still have issues or at least the public seems to be growing more skeptical about quality control of dietary supplements. So, what the heck or HE DOUBLE TOOTH PICKS (could have used a bad word there) can you do about it? I’m glad I asked myself this question. Here are a few steps that have helped me along the way when making a recommendation or finding the right product.
A. Always Revaluate your situation and do not be afraid to be a guinea pig.
Only take the supplements that you and the doctor you trust (and a pharmacist) think you need. Revisit your list every single year. Now, this sounds simplistic but I meet people daily that don’t know why they are taking many of their supplements and they have no idea if they are experiencing any benefit. In other words, I hear words like it has “anti-aging” effects or “prevents free radicals” but this means nada (aka “nothing”- I took one year of Spanish and I also learned that “rojo” means “red”) unless you feel or see some benefit. Would you follow this same approach with a drug? No way! Unless you really need it then why take more pills. Most supplement pills have very low levels of heavy metals or other pollutants that aren’t a concern daily, but when taken over years this amounts to a great deal of exposure and no one knows the implications. And, then there are all these pills that folks take with hopes of a benefit, but in many instances the research is nonexistent if you’re otherwise perfectly healthy. For example, fish oil or ginseng or other supplements some people ingest and often remark that they don’t know if it is doing anything for them and I tell them to stop the product for 4-6 weeks and see if they feel any different or if anything on their blood tests get better, worse or stay the same. The other day I talked to a friend that says he takes fish oil for prostate health and I told him there was no evidence (good or bad) that fish oil helps with prostate health. Next, he claimed it made his skin feel and look better and I told him he needed to not take it for 4-6 weeks and see if his skin actually got worse (guess what happened – sorry Charley). On the other hand, I knew a friend with bad dry eye syndrome and she hated spending money on expensive pharmaceuticals in this area of medicine and tried fish oil (which actually has some positive research in this area) and guess what happened (worked like a charm).
B. Look for a seal of approval that is legitimate (NSF, USP, NPA…).
There are several seals on supplement bottles that increase the chance that what is reported on the label is actually in the bottle. For example, the NSF label (used by many professional athletes and teams to ensure quality) is one of the best, along with USP or NPA seals. There are times these seals of approval appear on the web site or educational material or even on the bottles themselves. These are seals of approval that are usually reliable that you have purchased a product that contains exactly what is advertised on the label.
C. Pharmaceutical brand supplements have a lot to lose if they are wrong (Note: this does not mean I endorse any of these brands or want you to take one, it is a simple tip for guidance).
When a pharmaceutical company begins to market and sell supplements such as Pfizer (Centrum®) or Bayer (One-A-Day®) or Abbott Labs… they generally have very good quality control and overall their prices are competitive (aka low cost or cheap like me). Another reason I like them is that personally, I believe they have a lot to lose if they are wrong. In other words, bad products on the supplement side could be a disaster in terms of public relations and profit on the drug side. So, in general I find that these companies fly straight because they cannot afford to fly any other way. Now here’s the catch! I wrote this exact same tip on a popular web site recently and about 10% of those that read it lost their freaking minds! They thought I was endorsing big pharma and suggesting that the only products you should buy when it comes to supplements are pharmaceutical supplements! This is not what I was saying, instead I wanted readers to know that they could rely on these brands in terms of the accuracy of what is on their label is almost always in the bottle (for example this is exactly what consumerlab.com, please see below – Step G, has found since 2007). In addition, I was upset that individuals somehow think that pharmaceuticals are all bad! This is absolutely ridiculous! It is never my intention to have anyone perceive that I am personally endorsing or advertising a specific brand whether it is from a pharmaceutical or nutraceutical company. My only goal is to provide an audience with many things to consider when choosing any pill. One of the most critical factors has to be the human or clinical evidence that a product or procedure currently has compared to others. Right now the supplement that has the longest and most rigorous multivitamin clinical trial compared to a placebo is Centrum Silver®. This clinical trial included over 14,000 completely healthy individuals over an average of 11 years and compared this multivitamin to a placebo, and I believe the results were noteworthy (side effects overall were similar to the placebo by the way). The moderate reduction in cancer diagnosis and cataracts (two large and devastating conditions to our health care system and families) were impressive and even surprised me (and my track record for predictions in nutrition and supplements is pretty good folks). There is simply no other multivitamin that has this amount of human evidence. Let me play devil’s advocate here – if the Centrum trial would have failed then their product and business would not have survived. This was an incredibly risky venture as is the case with any supplement or drug that decides to actually test their product in a human research setting. This is also the reason some supplement companies never really want to test or invest in research. My goal is to never engage in an “us” versus “them” scenario or mentality because in my opinion it’s so toxic and unhealthy in so many areas from politics to television news to pharmaceutical versus nutraceutical companies. I am grateful for many pharmaceutical companies and the researchers behind them that have changed the course of AIDS, Breast Cancer, Hepatitis C, advanced prostate cancer… for many of my friends and family and of course for patients. In fact, there are also some friends and family members that weren’t able to live a long life simply because a game changing drug for their disease (including breast cancer and Hepatitis C in the case of my family) was invented just a few years after they died. However, I have also been very vocal about other pharmaceutical companies that have provided no purpose to the overall health and well-being of individuals and I will continue to be critical of them. Supplements are no different, I have found over 25 years of experience – that we have very good and very bad supplement companies. We have some that simply gauge the public and are dangerous and others that provide benefits. It is messy out there at times (especially now) and it takes a lot of information (evidence, cost, quality control, safety…) for someone to personally decide what they need to take (or not). I mention in my recent book, in my articles and all my lectures all the different factors someone should consider as if I am advising my own wife and kids. If you decide not to purchase Centrum or any other brand, I think it’s fabulous! Do what you are comfortable with after all the evidence is in. I will continue to push to extract the most information on these pills to help provide some guidance. Of course I would like to see all companies become more transparent with their consumers including Centrum or any other company. I also would like to see more supplement clinical trials that include women and minorities, which is a major past and current problem. I would like to see companies think twice before giving or offering kids supplements with no research such as many gummi or chewable brands (many of these are loaded with sugar). I would like to see more companies utilize less toxic ingredients, but at the same time others need to quit hiding behind a “natural is better” label and really invest and test their specific product in a clinical research setting. Natural is better when proven to be better especially when it comes to taking a pill. Arsenic and tobacco are natural but I do not recommend them. I cannot objectively educate future health care professionals on the positives of lifestyle and supplements without research. My list is endless for what I want to see change ASAP (more on that at a later time). In the meantime, I can promise you that I will never take a side in a discussion simply because I have to pick a side and ignore the other important qualities offered in the argument (okay Moyad that was a serious statement and you need to lighten up a bit – where is my therapist when I need her? By the way my therapist is my wife).
D. Herbal supplements are a whole new and old wild animal, so make sure you treat them that way!
I usually have little to worry about when it comes to basic vitamins and minerals in supplements like vitamin D, A, C or magnesium. The amount listed on the label is usually accurate. However, the real concern over quality control lately has been herbal products, so if you think you might be purchasing one soon demand some level of quality control testing. In other words, look for a seal of approval as mentioned earlier and look on the web site for some other types of quality control testing. Also, understand that every herbal product that has ever showed a benefit, from American ginseng reducing cancer fatigue to ginger reducing chemotherapy nausea, all have an active ingredient that should be standardized. So, look for the active ingredient on the web site and label. For example, in many of the cancer fatigue reducing studies of American ginseng the active ingredients were standardized to 3-5% ginsenosides (the active ingredients). Study or purchase a research based guidebook so you know exactly what to look for when it comes to herbal ingredients. For example, “The Supplement Handbook” by Dr. Moyad (Shameless plug alert but it is the book many doctors and other health care professionals are now using) will identify exactly what herbal products have been used in many of the best studies and what to look for on the supplement label or which company to look for when buying a specific product.
E. Multivitamin with some herbal ingredients? No thanks!
The largest and best objective multivitamin clinical trials like the Physicians Health Study II (PHSII) never used any herbal products in their multivitamin and they have the longest and best clinical study ever conducted in this area and they still showed a benefit (slight reduction in risk of cancer and cataracts)! In other words, I see no reason to purchase a multivitamin with any herbal ingredients on the label because you might as well mimic what worked best in the largest clinical trial of a multivitamin (they used Centrum Silver®).
F. Only purchase a single ingredient supplement except in rare situations (like a multivitamin). Dilution=Pollution?
Most well done clinical studies of supplements to help almost any condition usually used a single standardized ingredient. For example, melatonin use for jet lag or insomnia (single ingredient) or even SAM-e supplements for mental health improvement or osteoarthritis. Where consumers get in trouble is when they start to buy products with multiple ingredients in them that were never used in the largest and best studies. This process not only dilutes the active ingredient rendering it less effective but also pollutes the product and can make it tougher on your liver to metabolize. Think about this for a second, you would never buy a bottle of aspirin that also contained multiple herbs and vitamins and compounds in the aspirin because it would not only make the aspirin itself less effective, but would increase the risk of further toxicity because now you are a clinical trial of one! Aspirin was only studied in most major clinical trials as a single ingredient and not combined with multiple other products. There are exceptions such as macular degeneration where several ingredients were used together (500 mg vitamin C, 400 IU vitamin E, 10 mg lutein, 2 mg zeaxanthin, 25-80 mg zinc, and 2 mg copper) but in those situations it is clear what was used in the clinical trial (called AREDS2 for macular degeneration) and you should only use those ingredients. Another example is glucosamine sulfate (1500 mg daily) and chondroitin sulfate (800 mg daily) used together in notable clinical trials such as LEGS study. So, do your research and again, only buy what was used in the most impressive clinical trial and copycat that.
G. Consumerlab.com is a decent web-site but you may have to pay a fee.
This is a web-site that commissions independent testing on all kinds of dietary supplement brands so you know exactly what you are or are not getting in them. It was this site that informed me about many multivitamins and which ones passed their test. Check it out!
H. Center for Science in the Public Interest (CSPI) is another decent web site and newsletter, but again, you probably have to pay a fee.
Another group that helps to keep the nutrition and supplement industry in line is CSPI and you should google them. They generally do a good job letting you know what is working and what is worthless.
I. Next steps – demand more and better for yourself and the supplement company you financially support.
When it comes to supplements feel free to write your Congress person and ask for more strict penalties for companies that do not comply with quality control standards. I think Congress currently is under pressure to come up with some kind of solution to this mess. Also, do your research on the amount and diversity on ingredients in your supplements. Do they have heavy metals or other pollutants and what about the amount of silicon dioxide (aka “sand”) in the product(s)? When you begin to realize what’s in your product from the label and testing by the manufacturer then it will make you more objective on whether or not you even want to use that product or that company at all. If I see silicon dioxide as one of the principal ingredients or the company will not release their report of heavy metals or pollutants in their pills then I get nervous. Additionally, and here comes a clear conflict of interest I admit, but I would demand that the company subscribe to some type of software policing service. I own stock in the Park City Group (PCYG) because food and supplement companies that use their service are forced to comply with standards and transparency from dirt to store shelf. In other words, it forces all the folks up and down the supply chain to follow the rules (via software monitoring batch by batch)! I wish I was a consultant for this company, but instead I have stock in them. There are companies looking at better bar coding, so that in the future you can scan the product and see where all the parts of your supplement came from and what’s in it (this is the future my friends, kind of like thought texting where you will be able to think about something and then it will generate an automatic text – just kidding). Regardless, until all supplement companies subscribe to some kind of transparency service or another similar future service part of the supplement industry will be as messy as a new puppy on an expensive rug without newspaper on it (that is pretty messy folks).
307) You cannot trust health TV shows like Dr. Oz and The Doctors? Say it isn’t so!
(Reference: Korownyk C, et al. BMJ 2015).
A recent study of the Dr. Oz show and The Doctors television shows found that often their advice isn’t accurate and conflict of interest is revealed less than 1% of the time! The conclusion of this large research study was the following: “Recommendations made on medical talk shows often lack adequate information on specific benefits or the magnitude of the effects of these benefits. Approximately half of the recommendations have either no evidence or are contradicted by the best available evidence. Potential conflicts of interest are rarely addressed. The public should be skeptical about recommendations made on medical talk shows.” YIKES! OUCH! ZOWIE (I added those last 3 words for pure drama by the way).
WHAT ELSE DO I NEED TO KNOW?
Look I was on Dr. Oz and it was a lifestyle piece and I was really good – just ask me and no one else. In general TV health shows have provided some valuable advice (politically correct statement). However, apparently these shows have also had some very bad moments and this new research may be one of those really bad moments. A fabulous group of Canadian researchers got together not to drink beer, fight, or play hockey (actually fighting and playing hockey are redundant) but rather to evaluate the accuracy of the Dr. Oz show and The Doctors and what they found was scary (kind of like the first time you find a hair growing out of your ear or an eyebrow hair that won’t stop growing in a North or South direction)! They randomly selected 40 episodes and reviewed 80 recommendations total from both shows. Less than half the time there was evidence to support a claim and over 50% of the time there was no evidence or contradictory evidence – this was for the Dr. Oz show and The Doctors show only did a little better than this. And, if that was not enough, less than 1% of the recommendations from these shows included information on conflicts of interest. The researchers concluded their study by suggesting that consumers need to be skeptical about recommendations on these shows! Ouch! Bam! Yikes! Scary! Zowie! Yikes (already said that Moyad)! Exclamation points rule! Regardless, there are many lifestyle tips on these shows that I believe help a lot of folks! However, when these shows begin to recommend dietary supplements or some drugs and medical procedures they have some inaccurate information. I think all of this can be cleaned up but will it keep their audience? In other words, I believe there are many people that want to believe in magic potions and miracle weight loss products and quick fix it situations. So, when a health show no longer promotes a quick fix product or idea I do believe they will lose a large chunk of their audience. Also, part of what is driving this criticism is that I believe there are a lot of jealous doctors that would like to have their own show (not me – I want to replace Pat Sajak on Wheel of Fortune and my wife would be the new Vanna White). Still, these TV shows need to do a better job of referring to well-done research and if you think about it for a second, when it comes to surgery or taking pills how can you decide what is right for you in a several minute segment? That is wacky! I like Doctor Oz and The Doctors, just like I like some reality TV shows, but I‘m not about to get prostate or other specialized advice from these folks without doing a heck of a lot of my own research. Health shows are part entertainment and part information so if you take them too seriously (like a reality TV show) you’re going to be disappointed. I will let you know how that Wheel of Fortune thing turns out for me but needless to say the folks at PAACT are real nervous that I might get the job and forget about them. I would never do that – if they ever call me I will have my butler inform my maid who will then inform my manager and then my assistant, who will take a note and send them an autographed photo of me and my wife along with free tickets to a future show).
308) Carrots have anti-prostate cancer properties!?! Have you ever seen a rabbit with glasses or with prostate cancer or with constipation or high blood pressure?!
(Reference: Xu X, et al. Eur J Nutr 2015)
Carrots are low in calories, high in fiber and potassium and contain natural salicylates (aspirin-like compounds), which is why they may have anti-prostate cancer properties.
WHAT ELSE DO I NEED TO KNOW?
Numerous fruits and vegetables have and continue to receive plenty of attention because of their ability to potentially reduce prostate cancer risk. However, despite 10 completed studies no summarized conclusion over carrot intake has been completed. So, a meta-analysis was conducted utilizing data from 8 casecontrol and 2 cohort studies. The quality of each study was determined by 2 investigators who rated every study using a standardized scoring system. A significant 18% reduction in the risk of prostate cancer was associated with an increased intake of carrots. The dose-response analysis showed that for each serving per week (10 gram increment) of carrot consumption the risk of prostate cancer was reduced by 5%. No evidence of a publication bias existed for overall past studies on carrots. Thus, there was not only a hint of carrots to prevent prostate cancer, but I also believe this data suggests they may reduce the risk of prostate cancer recurrence after treatment. Remember all the folks that got excited about tomatoes and lycopene only to realize the benefit was not that great. Next came cruciferous veggies (aka broccoli and others that kids love to eat daily – sarcasm alert…although have you ever had steamed broccoli with a lot of butter – yummy!). Recently, it was all about the pomegranate and I bet that will also get humbled in some way. When are we going to learn that eating healthy, being healthy and whatever eating patterns help someone reach that point will be associated with a reduction in the risk of prostate cancer. Carrots are awesome but simply do not have the publicity dollars of pomegranate nor the money to throw at researchers around the world to make them look good. Arguably, carrots are as healthy as any other healthy food. They are loaded with fiber, low in calories, contain one of the highest concentration of natural salicylates (aka aspirin) versus any food/beverage and they are one of the biggest friends of the urologist because they contain one of the highest concentrations of potassium and very little sodium. How cool is that! Of course they are known primarily for their beta-carotene and vitamin A and maintaining good eye health (ever seen a rabbit with poor eyesight – nope!). In this publication the researchers focused on the beta-carotene and vitamin A as a potential mechanism of disease reduction but I disagree. It’s time to move away from the cliché or jaded nutrition profile of carrots and talk about the other stuff (fiber, salicylates, calories, potassium…). Still, the carrot has a few other problems to deal with besides the vitamin A permanent tag. They were ridiculed during the low carbohydrate movement as being high in glycemic load (aka causing a large insulin response) but that turned out to be false when looking at a normal or moderate carrot intake. And, carrots are boring because they have been around a long time and they aren’t “sexy” like the newer more expensive and exotic fruits and vegetables. Regardless, what research has taught us through the years is that it is precisely the boring and nonsexy advice (lower blood pressure, cholesterol, exercise, no tobacco…) that has stood the test of time and has the greatest impact on reducing disease risk and improving life expectancy – not the latest and greatest anti-aging food or high antioxidant juice that comes and goes with time like the latest celebrity gossip. So, at my house and when talking to patients, boring is the new cool and carrots (not stripped of their outside fiber) will always take up more space in the refrigerator compared to pomegranate, lycopene, resveratrol, fish oil, krill pills or any other product du jour will ever hope to occupy! Oh and by the way I put in a call to Bugs Bunny the other day and asked him a few questions and he told me he is now approximately 75 years old (debut was in a film in 1940 called “A Wild Hare”) and he has never needed glasses, Metamucil, prostate cancer treatment or hypertensive medications. What’s up with that doc!
309). Selenium supplements are in trouble again! This is getting ridiculous!
(Reference: Kenfield SA, et al. JNCI 2015)
Selenium supplements may increase the risk of prostate cancer mortality (aka death). Patients with prostate cancer should not take an individual selenium supplement (the amount in multivitamins is usually fine if low or below the RDA).
WHAT ELSE DO I NEED TO KNOW?
It is well-known now since the SELECT trial that vitamin E dietary supplements can increase the risk of prostate cancer but the impact of selenium supplements are controversial. Recent evidence also suggests an increased risk of prostate cancer with selenium but more human research was needed in this area. So, a recent study looked at this impact. A total of 965 deaths were documented, 23% (226) due to prostate cancer, and 28% because of cardiovascular disease (CVD) during a median follow-up of 8.9 years. Multivariate analysis found a significant (P trend=0.001) association with increasing selenium intake and prostate cancer mortality (1 to 24 ug/day=HR of 1.18 times the risk; 25-139 ug/day=1.33 times the risk; and 140 or more micrograms/day=2.60 times the risk). There was no statistically significant relationship between selenium supplement use and other endpoints including CVD or overall mortality. It was only a decade or more ago that everyone and their neighbor jumped on the selenium bandwagon. Decades ago almost no patients were taking these supplements and then after the year 2000 almost 25% of men were taking them from clinical studies. Now there is increasing evidence that men taking a selenium supplement that are already replete in selenium from dietary sources might be increasing their risk of being diagnosed with high-grade prostate cancer, or increase the progression of existing disease and now prostate cancer mortality. This is some scary stuff but is it such a shock. Selenium recommended daily allowance is 55 micrograms per day! Think about this because many folks confuse micrograms (ug) with milligrams (mg) and they are as different as the size of the state of Rhode Island and Texas. A microgram is a millionth of a gram (or one thousandth of a milligram) and a milligram is a thousandth of a gram (1000 times the difference)! So, what this means is that the human body requires “trace” amounts of selenium and it is for this reason it is often called a “trace mineral” or “trace element.” Another synonym for the word “trace” is “barely detectable.” The U.S. has numerous documented recalled selenium supplements that actually carried milligrams in the bottle (instead of micrograms) and patients experienced everything from permanent hair and nail loss to hospitalization. So, when it comes to selenium more is not better for most individuals and it appears that it already increases the risk of skin cancer recurrence, type 2 diabetes and now prostate problems. Selenium is a critical nutrient and there are some people that might actually benefit from supplementation, for example those that are deficient and it’s also being studied for the treatment of some thyroid diseases. However, the vast majority of men and women out there should avoid individual selenium supplements as much as they would avoid strolling outside during a massive lightning storm in Rhode Island or in Texas with a 9-iron golf club raised above their heads while sitting on top of a large tree or power line (I think you get the point).
310) Obesity/Belly fat myth number 323: Bone loss is reduced with weight gain? Not really and remember what happened to hot flashes?!
(References: Zhang P, et al. Am J Clin Nutr 2015;101:337-343).
Weight gain was thought to increase estrogen levels in men and women and reduce the risk of osteoporosis, but new research suggests it may actually weaken bones and accelerate bone loss and muscle weakness in some individuals.
WHAT ELSE DO I NEED TO KNOW?
Here’s the problem, when a person gains body fat it not only can surround the organs but it also begins to release all kinds of inflammatory compounds and hormones that are not healthy. So, researchers at the University of Michigan (Hey that is a groovy place but to be honest I don’t know this research team but they did a heck of a job – the only folks I know at Michigan can get me football tickets or red velvet cake) decided to look at 8833 CT scans in patients aged 18 to 65 years old. What they greater weight is associated with better bone mineral density they found worse muscle and bone quality with increased weight. This suggests that fat actually infiltrates or moves right into the muscle and bones. This is a scary thought! Is it possible that weight gain at an early or older age is associated with poor bone quality and less bone formation? This also supports the notion that obesity may be associated with an increased risk of bone fracture! Muscles also surrounded by fat tissue appears to also lower muscle quality so I think future research will continue to support this initial finding in men and women! Perhaps one of the best pieces of advice is to lose weight to improve your bones and muscle! Basically, this is just another myth buster of belly fat. What this means is that what we used to think as an upside of weight gain is no longer an upside. Another example of this was a past article I wrote on belly fat and hot flashes. Research used to suggest that greater belly fat was associated with fewer hot flashes because again belly fact produces estrogen. However, recent research has suggested that obesity or a lot of fat tissue increases the severity of hot flashes by acting as an area of insulation to not allow the heat from the hot flash to dissipate or leave the body. So, we are starting to see more intense and severe hot flashes in men and women that gain weight. Again, all these suggest that the weight gain and its negative effects far outweigh (no pun intended) the small benefits of getting a little estrogen to enter the blood from fat tissue. So, what myth about obesity will be broken next? Who knows, but when it comes to hot flashes and bone loss more weight or belly fat is not better.
311) Dr. Moyad you have never written about food cravings in 15 years?! Why? And, can you comment on them please or else I will not donate to PAACT or buy you beer (now those are fighting words you lily-livered _____! No one takes my beer away or stops donating to PAACT!)
(Reference: Moyad MA.; and Rodriguez-Martin BC, et al. Front Psychol 2015)
I have received many a letter about food cravings and their impact on health, but I didn’t think there was a lot of good research on them, but now some research exists in this area. So, feel free to read about them below because they are fascinating and dangerous and in some cases beneficial.
WHAT ELSE DO I NEED TO KNOW?
Okay, it’s now 3 PM, you’re at work and you start craving chocolate or candy. What is your body telling you? It tends to be a commonly held belief that food cravings are simply your body’s way of informing you of its needs. However this is only a theory, and it’s being challenged because cravings may be more complex (read on please) than we ever imagined. Food cravings are so common especially at younger ages that they shouldn’t be considered unique events but commonplace. Surveys completed in the U.S., Canada, and Great Britain show that almost 100% of young adult females and 70% of young men have experienced one or more food cravings at some time in the past 12 months (why less cravings in men – were they just lying about them because I believe men lie more than women especially when it comes to whether or not they know directions to a certain location). However, the elderly tend to experience slightly less food cravings with age, approximately 60% experienced them regularly. Cravings are associated with likes and rarely associated with dislikes. For example, some of the most-commonly-craved foods, for example chocolate, are some of the most highly palatable foods. Still, the word “Cravings” is quite polarizing today! Why? It’s no accident that this one word describes not only the intense desires for different foods, but it is also the same name for a diversity of drugs that can be abused. Wow! In fact, there is some preliminary evidence for common brain pathways shared for food and drug reward centers in humans. For example, increased activity in one part of the brain (orbitofrontal cortex) is found with alcohol and cocaine cravings. And, this same area is also associated with obsessive-compulsive disorder. Whether or not food cravings are also found in this area needs more research, but the preliminary results suggest this is the case. So, what specifically is a food craving? It’s usually considered an intense desire to consume a specific food (gee tell me something I don’t know Dr. Moyad). Yet, there are two aspects of this definition that should be remembered. First that the desire is intense in nature so it’s something that someone goes out of their way to get, which makes it different from a plain old ordinary food choice. The other important aspect of this definition is selectivity, which separates the craving from hunger. A variety of food selections or choices can fulfill hunger, but a more specific selection or need equates to a real, food craving. So, how can food cravings have a similar pathway and power to drugs of abuse? The body produces and releases something known as “opioid peptides,” which give you a euphoric or feel good feeling when a craving is temporarily satisfied. Infants when given a heel stick for blood collection cry less when given sugar water than infants who are just given plain water. All of these findings are consistent with a human body that produces opiate compounds that reduce pain and is triggered a stimulus from the taste buds in humans. And, if you have ever experienced the so-called “runners high,” this is also the result of body opioids being released and enjoyed. So, think of a food or drink that can give you those same feelings as runners high! In fact, recent research suggests that an intense exercise high not only releases opioid-like compounds but also impact endo-cannabinoid receptors in the brain, so exercising is one of the only legal ways to get high and feel morphine-like effects simultaneously (no kidding). Research also suggests that some individuals feel this same impact when a food craving is satisfied. Now say hello to some serious food cravings! Imagine experiencing some of those same feelings with food or a drug! Scary stuff my friends! Food cravings can also be negative in other more subtle ways such as disrupting or derailing a diet or compliance with a health program and even being the cause of binge eating. This is what I like to call “self-medication” where individuals seek out certain foods like sugary products or unhealthy eating patterns to soothe the mental and/or physical pain they are dealing with on a regular basis. It could be from stress, depression, anxiety, fear, abuse… One of the biggest problems I see is the ability of some individuals to use alcohol or unhealthy fast food as self-medication. There are times I think we have become a “self-medication” generation using unhealthy behaviors to distract or sooth us temporarily from our cravings or needs. Another problem that occurs when relying on these factors or cravings for comfort is that the brain develops what we call in the medical world “tachyphylaxis,” which essentially means your body gets used to these foods or drugs and then begins to require even higher doses or intakes for satisfaction. One of the best things to do after recognizing a negative food craving that is unhealthy, for example greater alcohol, sugar or salt or fast food intake or late night snacking, is to try and begin to redirect it into a more productive and positive pattern. I have watched many individuals that were addicted to these bad things become addicted to exercise, meditation, more self-education, increased family time, reading, gardening, volunteering, …almost anything that brought a more balanced mental and physical health and perspective. Let’s look at the recent research on sugar for a second! We used to think that increasing our intake of sugar increased weight gain and dental problems. However, it used to be thought that it was primarily a marker for an overall unhealthy diet and obesity, but now it seems it may be an independent risk factor for cardiovascular disease and other conditions like diabetes, dementia and liver problems. So, too much sugar not only can increase your weight, but can make you real sick. Although sodium and trans-fat have limits, the U.S. government does not have a dietary limit for additional sugar in food. In fact, sugar is “generally regarded as safe” (GRAS) by the FDA. This allows manufacturers to add large amounts to the food supply. Yikes! Still, the recommendations are all over the place, for example the Institute of Medicine (IOM) suggests no more than 25% of calories from sugar and the American Heart Association (AHA) suggests not more than 25 grams of sugar for women daily and 38 grams per day for men (5 to 7.5% of 2000-calorie daily diet), and the WHO (World Health Organization – a group that has a great deal of support from Owls around the globe) suggests less than 10% of calories from sugar. And, yet new research suggests it is best to consume less than 15% of daily calories as added sugar. COME ON! This is as confusing as an alarm clock in a new hotel (you would find that funny if you traveled a lot), and who really knows the total intake of sugar you are getting daily and even if you knew, how long would you continue to count these calories (1 week, 1 month, 1 year – COME ON!). The bottom line is almost 3 out of every 4 Americans consumes more than 10% of calories from added sugars, and based on recent research drinking one 12-ounce sugar filled soda a day increases the risk of death by almost 33% (Yang Q, et al. JAMA Intern Med 2014). WOW! And, what does that mean for folks that also consume a lot of fruit juice filled with as much sugar as a Coca-Cola?! And, what does all this have to do with food cravings!!!??? Well, sugar cravings are one of the most commonly reported cravings or foods with a lot of sugar in them (same thing folks)! Laboratory studies suggest that increased sugar intake not only creates more tolerance but drug-like withdrawal occurs when sugar intake is reduced. Again, as mentioned earlier these changes in dopamine and opioid systems are similar to when animals use substances like nicotine and alcohol. In other words, sugar is one of the greatest food addictions that can lead to health problems. And, research is ongoing as to what types of foods could discourage sugar addiction. It is also important to realize that cravings in some cases can also be very positive by promoting greater dietary diversity. For example, research with adults continue to demonstrate when a diet is monotonous or narrowly focused it could result in a variety of nutritional limitations and deficiencies and less self-satisfaction and more cravings! In fact, there are countless studies being conducted with once forbidden foods that are attempting to quench unhealthy cravings. For example, studies of adding more fats and/or proteins in patients that were strictly low-fat or no-fat have been able to show healthy weight and cholesterol changes and less food cravings in some participants of this studies (more on this in a future column -sorry but how else can I get you to pay attention to my constant need or craving for attention). I am reminded of a famous excerpt from the The Teaching of Buddha to describe my approach to lifestyle changes and food diversity and it is known as The Middle Way. “To those that choose the path that leads to enlightenment, there are two extremes that should be carefully avoided. First, there is the extreme of indulgence in the desires of the body. Second, there is the opposite extreme of ascetic discipline, torturing one’s body and mind unreasonably. The noble path that transcends these two extremes & leads to enlightenment & wisdom & peace of mind may be called the middle way.” So, basically the path that transcends these two extremes leads to greater peace of mind, which is The Middle Way, but I realize it is easier said than done.
312) A new potential method of treating tough cases of CRPC (castrate resistant prostate cancer) by giving some testosterone and chemotherapy is known as “bipolar androgen therapy” or “BAT.” What does this have to do with diet and supplements? Nothing.
(Reference: Schweizer MT, et al. Sci Transl Med 2015)
Small studies of bipolar androgen therapy (BAT) including a recent one from Johns Hopkins suggest this may be an interesting treatment option for a small number of patients.
WHAT ELSE DO I NEED TO KNOW?
I realize this has nothing to do with diet and supplements, but many of you already know that when some interesting treatment option arrives I like to review it. There is basic science research to suggest that large doses of testosterone in some patients for a short time could actually cause death of some prostate cancer cells. So, a recent study of 16 CRPC patients without symptoms and minimal to moderate metastatic disease were treated with testosterone cypionate (400 mg intramuscular; day 1 of 28) and the oral drug “etoposide” (100 mg daily; days 1 to 14 of 28). After 3 cycles, those patients with a declining PSA continued on intermittent testosterone therapy – monotherapy. Researchers allowed for rapid cycling from high levels of testosterone drug treatment to then near-zero serum testosterone levels (hence “bipolar androgen therapy” or BAT). Interestingly, of 14 evaluable patients 7 had a PSA response and 5 of 10 had responses on their imaging tests. Despite all of the men eventually having PSA disease progression, 4 men remained on BAT for one year or more. A total of 10 out of 10 patient’s demonstrated PSA reduction when receiving androgen reduction therapies AFTER BAT, which suggested that BAT could also reestablish some sensitivity to androgen deprivation therapy. Wow! So, this may be hard to grasp, but again the term BAT or “bipolar” is used to show that when using this potential treatment there is a very rapid cycling between two polar extremes: from very high blood testosterone levels from a single testosterone injection and then back to near zero levels of testosterone over a 4-week cycle. CRPC cells with higher levels of androgen receptors could be sensitive to cell death when exposed to lots of testosterone and cancer cells with low levels of receptors might die when quickly exposed to low levels of testosterone over this treatment cycle. Testosterone can go to over 1500 ng/ dl within the first few days after injection and then reduce to high-normal testosterone after 2 weeks, and then a return to near zero by day 28 or the final day of the cycle. Interestingly, no patient developed worsening pain from prostate cancer, and no skeletal related events or worsening urinary issues. So, this suggests that BAT may be an option to potentially reverse resistance to some drugs in patients. The researchers go on to say that “Although this pilot study enrolled only a small number of patients, it provides compelling preliminary evidence that challenges the current treatment paradigm for CRPC, which is focused primarily on inhibiting ligand binding to AR (androgen receptor).” COOL STUFF RIGHT?
313) 13 is an unlucky number so I will not put anything here!
(References: No one)
I have nothing to say.
WHAT ELSE DO I NEED TO KNOW?
NADA. THATS ALL FOLKS…I’m now 50 years old but it feels more like half a century I have been around and so I am tired and need to take a nap and then go out to dinner at 4:30 PM and I seem to forget to zip the zipper on my pants more these days and I turn to my wife a lot more and say “do I take that” when someone asks me a question. See you in the SUMMER, when I will write about many other serious issues and give timeless advice in the next newsletter, such as why it is never good to feel slightly heavier in the buttocks area and a “tick, tick” sound deep within your body a day after your rectal exam and then for your doctor who performed the rectal exam call you that same day you are feeling funny and say “have you seen my wrist watch?”