Transcript Leading Causes of Death (all ages)

Theodore C. Friedman, M.D., Ph.D.
Professor of Medicine-UCLA
Chief, Division of Endocrinology, Molecular
Medicine and Metabolism
Charles R. Drew University
www.goodhormonehealth.com
How to Live to 100!*
Magic Convention
Chicago
June 13, 2010
*In spite of what the brochure says, do not sell your
life insurance policy!
Why Live to 100!*
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Enjoy a full live
Not just years, but quality years
Be a productive member of society
Impart wisdom to your offspring
Many issues I discuss are controversial,
discuss with your doctor!
• *In memory of John Wooden 1910-2010
Why Live to 100!
• Slightly based on the book “The Long Life
Equation” by Trisha McNair and Dr. Olga
Calof
Why is it realistic to live to 100
in 2010?
• Better screening
• Better treatment
• More knowledge on diseases
What can you do?
• Informed consumer
• Days of blindly following your doc are long gone
• Be your own advocate-docs are busy/overwhelmedyou need to lobby/push
• Keep your own records
• Be organized
• Get a good doctor that will listen to and work with you
• Make it easy for your doc
• Go to good docs-if something seems illogical, get a
2nd opinion.
How to Live to 100-my
approach
• Identify and screen for major causes of death
(heart disease, cancer, diabetes)
• Know when to screen
• Learn to do the right test
• Improve modifiable risk factors
• Can’t pick your parents (but know your family history)
• Healthy lifestyle
• Medications as needed
• Risk/benefit ratio for each person-I do not believe that
each test has to be “cost-effective” for population
• Start now, set a time to get everything done by (next
birthday)
How to Live to 100-my
approach
• Screening has risks (identifies an abnormality that is
not a clinically important problem)
• Interventions have risks.
• Always think about risk/benefit ratios.
• Medicines have side effects and interact, only take
what you need.
What diseases can you
prevent?
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90%
Exceptions:
Some cancers
Some types of heart disease
– Heart failure
– Rare incidents of heart attacks strokes
Leading Causes of Death (all
ages)
Leading Causes of Death by
Age
Heart disease
• Also called atherosclerosis or coronary artery
disease.
• Cholesterol plaques build up in the blood vessels in
the heart supplying blood to the heart muscle.
• Plaques become calcified
• As plaques get larger, not enough blood goes
through the arteries to the heart muscle-angina-chest
pain (pressure)
• Angina almost always starts at exertion as heart
needs more blood to keep up with demand
Plaques
Heart disease
• As plaques increase in size, angina gets worse-may
occur at rest.
• If artery is blocked-heart attack (myocardial
infarction)-crushing chest pain
• Leads to damage of heart muscle-heart failure
• Associated with arrhythmias
• Want to avoid heart attacks and its damage
• If having a heart attack-call 911 and take an aspirin
• In emergency rooms, can dissolve clot or open up
clot with angioplasty
Heart disease-detection
• EKG-can detect angina (impaired blood flow to
muscles), current or prior heart attack, or arrhythmias
can not detect early blockage
• Stress test-can detect angina on exertion-major
blockage of heart vessels
• Echocardiogram-can detect heart failure, structural
problems and prior damage to the heart
• Angiography-can accurately detect varies degrees of
blockage in heart vessels, but very invasive
• High-resolution CT scans and MRIs- new, somewhat
experimental, but likely to have a role
EBCT-Priceless
• Electron beam CAT scan- (EBCT)
• This is often part of what is called a “body scan,” which also looks for
lung cancer and other types of cancer.
• The electron beam CT scan of the heart detects early calcification in
the heart vessels.
• Radiation exposure is very low.
• Early calcification is a sign of atherosclerosis.
• The electron beam CT scan of the heart is done at most major medical
centers and costs between $350 and $500 (may or may not be covered
with insurance).
EBCT-Priceless (2)
• Patients get a calcium score, which indicates how much calcium
plaque the patient has in their heart’s vessels.
• It tells you the number of plaques and how big they are, to come up
with a calcium score, and also usually tells which coronary artery
contains the plaque.
• In some circumstances, if the calcium plaques are in a dangerous
region, such as in the main coronary artery called the left anterior
descending, it may be more dangerous than having them in a more
minor heart vessel.
• A person can get a zero score, which is ideal; and the lower the score,
the better.
• Generally, a score above 300 is considered dangerous
Who should get a EBCT
• Men > 40 years, women > 45 years
• Patients that are being considered for treatment of elevated cholesterol.
• Cholesterol is only a marker for heart disease, and it is much better to
look for actual heart disease.
• If you have no calcifications in your heart vessels, it does not really
matter what your cholesterol is, as you are not going to die from or
develop atherosclerosis.*
• If you do have significant coronary calcification, you should be on
drugs designed to lower your cholesterol, such as statin drugs, take an
aspirin and undergo other dietary and exercise modification to decrease
your chances of having heart disease.
• *A low percentage on patients have light, fluffy LDL particles that do
not give calcification, yet can lead to heart disease.
• ** Patients can also have a good cholesterol profile and still get heart
disease.
EBCT Sample results
EBCT Sample results
EBCT Priceless
• As the MasterCard commercial says:
• Price of an EBCT: $350-$500
• Knowing that you have clean coronary
arteries: Priceless.
• www.goodhormonehealth.com
Medical treatment to prevent/treat
heart disease-Aspirin
• Aspirin (baby aspirin-81 mg/day)
• It used to be said that taking an aspirin was the most important
prevention for cardiovascular disease that you could do
– Evidence is shifting and aspirin is less strongly recommended
• Aspirin leads to increase gastro-intestinal bleeds and maybe more
cerebro-vascular hemorrhages
• Aspirin is effective in men in preventing heart disease and in women in
preventing strokes
• Likely to benefit more those that have risk factors for heart disease:
elevated cholesterol, high blood pressure, diabetes
• Most beneficial study at reducing heart attacks was the Physicians
Health Study which studied men and gave them aspirin at a dose of
325 mg every other day. Other studies using smaller doses were less
effective.
Aspirin (2)
• US preventive service task force recommendations
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Encourage men age 45 to 79 years to use aspirin when the potential benefit of
a reduction in myocardial infarctions outweighs the potential harm of an
increase in gastrointestinal hemorrhage.
Encourage women age 55 to 79 years to use aspirin when the potential benefit
of a reduction in ischemic strokes outweighs the potential harm of an increase
in gastrointestinal hemorrhage.
Do not encourage aspirin use for cardiovascular disease prevention in women
younger than 55 years and in men younger than 45 years.
Evidence is insufficient to assess the balance of benefits and harms of aspirin
for cardiovascular disease prevention in men and women 80 years or older.
Aspirin (my recommendations)
• Anyone with a positive score on heart scan.
• Anyone with history of heart disease
• Men greater than 45 with elevated cholesterol or
diabetes
• Men greater than 45 and women greater than 55
with high blood pressure
Medical treatment to
prevent/treat heart disease
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Blood pressure control
Target blood pressure should be 130/80.
Diet first-exercise, low salt, less stress.
Make sure BP monitor is accurate and no white coat syndrome.
Most drugs work well, combinations often have to be given.
– Diuretics (HCTZ) are cheap and effective, but raise cholesterol slightly.
– ACE inhibitors (Benzapril, Lisinopril) and ARBs (Cozaar, Diovan) are
good choices.
– Beta blockers (Metoprolol, Atenolol, Propanalol) may give fatigue, hair
loss, and erectile dysfunction and are less recommended.
Cholesterol Lowering Agents
• LDL Cholesterol-bad cholesterol- high levels strongly
linked to heart disease
• HDL Cholesterol-good cholesterol- low levels linked to
heart disease
• Triglycerides- fat in blood, very high levels related to
pancreatitis, slight relation to heart disease
• Non-HDL cholesterol= total cholesterol -HDL cholesterolalso linked to heart disease.
• Apolipoproteins- Proteins that bind to cholesterol-related
to heart disease.
• CRP-marker of inflammation-linked to heart disease.
Statins
• Blocks cholesterol synthesis
• Lipitor, Zocor (generic, simvastatin), Crestor, Prevachol (any that
work is ok)
• Lowers LDL cholesterol
• Reduces inflammation (CRP)
• Most widely prescribed class of medications
• Heavily pushed by industry
• Definitely reduces heart disease and deaths
• Side effects include muscle pain, cramps, elevated liver tests
Who should get a statin?
• Anyone with plaques on EBCT!
• LDL Cholesterol > 160 mg/dL
• One risk factor (age > 50, family history, smoker): LDL
Cholesterol > 130 mg/dL
• Diabetes, kidney disease: LDL Cholesterol > 100 mg/dL
• Known heart disease, history of MI : LDL Cholesterol >
70 mg/dL
Zetia/Vytorin
• Zetia-prevents cholesterol absorption-lowers cholesterol,
less side effects
• Not shown to reduce heart disease
• Vytorin-combination of simvastatin (Zocor; statin) and
Zetia
• Recent study says it was no better than simvastatin alone
at reducing a marker of plaques at 100 times the cost.
Niacin
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Vitamin B3 (deficiency is called pellagra)
One of the oldest cholesterol-reducing agents around with a long-standing
track record of effectiveness and safety
Available as a prescription drug as well as a variety of "nutritional
supplements”
Niacin lowers the amount of small low density particles, the most damaging
variety.
It can cause rashes and aggravate gout, diabetes, or peptic ulcers. Early in
therapy, it can cause facial flushing for several minutes soon after a dose,
although this response often stops after about two weeks of therapy and can be
reduced by taking aspirin or ibuprofen half an hour before taking the niacin. A
sustained-release preparation of niacin (Niaspan) appears to have fewer side
effects.
Increase high-density lipoprotein (HDL), the "good" cholesterol.
Brand names include niaspan and niacor.
Niacin is found in many foods, including:Dairy products, Lean meats, Poultry,
Fish, Nuts, Eggs, Enriched breads and cereals
Fish oils
• Ratio of linoleic acid (omega-6 fat) and linolenic acid
(omega-3 fat) important
• Too much omega-6 fat = inflammation and damage
to organs
• Omega-6 fat in fried foods, snacks and other foods
with corn oil
• Omega-3 fat in fish (ocean caught, not farmed),
walnuts, fruits and vegetables
• Can supplement Omega-3 fat
• Omega-3 fat fortified ice cream and margarine have
lots of fat and calories
• Better to eat foods high in Omega-3 fat
Cancers
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Genetic and environmental causes
Avoid toxic chemicals (oil refinery in Los Angeles)
Solvents and other chemicals
Obesity/poor diet is related to cancers
Do not smoke!
Both males/females
Cancers-Males
• Colon cancer
• Prostate cancer
• Lung cancer
Cancers-Females
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Breast cancer
Colon cancer
Ovarian cancer
Uterine/Cervical cancer
Lung cancer
Other Cancers
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Brain cancer
Lymphoma/Leukemia
Pancreas cancer
Kidney cancer
Stomach cancer
Colon Cancer
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Colonoscopy!
Starts as polyps
Prep is not pleasant, but otherwise easy and very recommended.
Males > 40, females >45 (earlier than often recommended).
If negative, every 5 to 10 years
All males with anemia, old females with anemia should get it
Do not recommend sigmoidoscopy or stool occult blood.
Virtual colonoscopy in the future, but not as good as colonoscopy
Lung Cancer
• Do not smoke!
• If do smoke-Body scan that includes high resolution CT
scan of chest.
• Nonsmokers-Men > 50, women > 55: high resolution CT
scan of chest.
• Problem is it may pick up non-cancer lesions that require
biopsy.
Prostate Cancer (men)
• Prostate specific antigen (PSA; blood test) every 5 years starting at age
50.
• Digital rectal exam -not sure its worthwhile.
• If either are suspicious-ultrasound or MRI
• Problem is many men have slow growing prostate cancer that doesn’t
effect their life and is better if its not known.
• Basic tests can not tell the difference between slow growing and
aggressive cancers (will change in the near future).
• Intervention may be worse than the disease (erectile dysfunction,
osteoporosis).
• Rate of increase of PSA may be more accurate than the actual levels
Breast Cancer (women)
• Mammograms yearly starting at age 40
• Problem is picking up benign lesions that lead to
unnecessary surgery
• Ultrasounds or MRIs can be done as well, if strong family
history or on suspicious lesions.
• BRCA screening (common in Ashkenazi Jews) if family
history of early breast or ovarian cancers
• Self exam doesn’t hurt, but does not substitute for
mammogram
Ovarian Cancer (women)
• Pelvic ultrasounds every 3 years starting at age 40
• BRCA screening if family history of early breast
or ovarian cancers
• CA125-blood test that picks up ovarian cancer
every 3 years starting at age 40
• Pelvic exam-yearly at age 40
Cervical Cancer (women)
• Liquid based PAP test-every 2 years
• Beginning at age 30, women who have had 3
normal Pap test results in a row may get screened
every 2 to 3 years.
• Get vaccinated against human papilloma virus
Endometrial Cancer (women)
• See if a gynecologist if you have post-menopausal vaginal
bleeding
Other Cancers
• Whole body scan every 5 years starting at the age 50.
• CBC (blood counts) to look for leukemias yearly starting
at age 50.
• New onset depression should be a possible flag for cancers
(brain, pancreas, colon)
• Unexplained weight loss is also a flag for cancer
Stroke
• Same risk factors and markers as heart disease
• Good blood pressure control < 130/80
• EBCT-shows calcification in aorta-similar to that of
carotid (neck) arteries.
• Daily baby aspirin
• Carotid ultrasound-(plaques in the neck arteries)-every 5
years starting at age 45
Diabetes
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Very linked to being overweight/inactivity
Fasting glucose should be < 100 mg/dL (get screened yearly)
Diabetes is fasting glucose is > 126 mg/dL
Prediabetes is fasting glucose is 101-125 mg/dL
Best way to prevent progression form pre-diabetes to diabetes is
exercise and weight loss
• Fasting insulin level > 15 iU/mL -insulin resistance
• Prediabetes or insulin resistance-can take the medicine metformin
(glucophage)
Diabetes (2)
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HgbA1C-measures average blood glucose levels
Includes glucose after meals
Does not require fasting.
Diabetes >7.0%
Prediabetes 5.8% to 7.0%
Test yearly
Avoid getting diabetes and if you get it, get it under control.
See a specialist
HgbA1C < 7.0%, LDL cholesterol < 100, BP < 130/80
Osteoporosis
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Thin bones
Predisposes to fractures, especially hip fractures
Hip fractures are a major cause of mortality
Bone density (DXA scan) in women starting at age 50, men starting at
age 65.
• Mostly a disease of thin women
• Treat if osteoporosis, watch with repeat DXA scans if osteopenia
• Look for underlying cause-vitamin D deficiency or high parathyroid
hormone
Accidents
• Car accidents-safest car possible-electronic stability
control, air bags
• Avoid cell phone (may also lead to cancers)
• Avoid texting
• New tires, keep car maintained
• Wear seat belts
• Drive defensively, don’t take risks
• Avoid road rage/inciting road rage
• Avoid bad neighborhoods
• Do not confront thieves rogues
• Avoid firearms
• Avoid risky sports (skydiving, scuba diving, diving, rapid
river rafting, hiking alone, motor sports, skiing)
Home safety
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Smoke alarms
Fire extinguishers
Safety glass
Make sure no lose wiring
Careful about house work-ladders
Avoid pesticides
Infections
• Wash hands!
• Avoid antibiotics for viruses as that will lead to drug
resistance when you get bacterial infections
• Avoid non-domesticated animals (turtles and reptilessalmonella, wild birds)
• Get vaccinated-influenza, H1N1, pneumovax
• Get early treatment for pneumonia-high fever chills, pain
on breathing
Dental Hygiene
• Poor dental hygiene linked to heart disease, respiratory
disease and diabetes.
• Gingivitis allows bacteria to enter blood stream-leads to
inflammation
• See your dentist regularly
• Brush and floss regularly
Diet
• Maintain desired body weight
• Eat healthy-lots of fruits and vegetables, fish,
chicken, lean meat and dairy products
• Avoid overly processed foods, foods with too
many preservatives and additives (ingredients that
you can’t pronounce)
• Avoid sugar, corn syrup, most sweets, simple
carbs
• Avoid fried foods
Diet
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Avoid saturated and trans fat
Mindful eating-do not do anything else while eating.
Take small portions, do not have food in front of you.
Healthy food around the house
Weigh yourself weekly (maybe daily) so that you are mindful of your
weight
• But healthy eating and good physical activity are more important than
the actual weight
• Figure out your weaknesses
• Exceptions are the downfall
Exercise
• Ability to perform cardiovascular exercise is probably more important
than actual weight.
• Daily exercise is the best-make it part of your day, like brushing your
teeth.
• Sneak exercise in, even for short periods of time (ride your bike or
walk to errands, take the stairs, power walk)
• Aerobic and non-aerobic exercise including stretching
• Yoga/pilates (Studio 613 is highly recommended)
• Prevents cancer (breast cancer!), dementia, stroke, heart disease,
diabetes
• Slow and steady increase
• Set up a scorecard
• Have a partner
• No excuses
Sleep
• Sleep deprivation linked to heart disease, obesity and
diabetes, high cholesterol, blood pressure
• 7-8 hrs per night, those who sleep < 5 hrs or > 9 hrs-higher
mortality
• Avoid night time stimulants such as caffeine and exercise
Sleep
• Growth hormone deficient patients
have disturbed sleep
• May be improved with GH treatment
• Go to sleep at about the same time
each night
• Wind down before going to bed
• Fall asleep too late?
– Get morning light, avoid afternoon light
• Fall asleep too early?
– Avoid morning light, get afternoon light
• Melatonin (0.5 mg is probably best dose) is safe and usually effective
Nutritional Supplements
• Multi-million dollar enterprise
• Not regulated by the FDA
• Do not have to be shown to be beneficial
(unlike medicines)
• Only rules
– Cannot be dangerous
– Cannot make false claims (lots of it “may help
decrease X”)
• Lots of health care providers know more
than me about supplements and use them
a lot
• Little published articles on benefits
Nutritional Supplements (2)
• Some health care providers order less than
scientific tests (urine for neurotransmitters)
and then sell you a supplement package
based on these results.
• Many of my patients have pocketbooks full
of supplements costing thousands of
dollars/month.
• If each one worked so well, we do you
need to take so many
• I’m fairly skeptical, but will not take
someone off them, if patient feels they are
working (unless they are harmful).
My General Approach
• Look carefully for early signs of
hormonal/vitamin deficiency via
blood testing
• Replace deficiencies until
achieving mid-normal range
• Don’t treat if not deficient
• Look at risks/benefits of treating
Vitamins
• Eat foods with natural vitamins better than supplements
• Eat a wide variety of foods, especially fruits and
vegetables
• A multivitamin is reasonable
• Calcium supplementation has shown only marginal effects
on bone density, no effects on reducing fractures and can
not be recommended.
Foods with Vitamins
• Eat foods with nutrients/anti-oxidants/vitamins,
not isolated nutrients/anti-oxidants/vitamins
• Healthy foods have other not yet isolated nutrients
• Most studies using anti-oxidants (Vit A, C and E, betacarotene) have been disappointing
• Vegetables
– Orange veggies are good (beta-carotene)
• Sweet potatoes, carrots
– Green leafy vegetables
• Careful! Goitrogens if eaten in excess
in primary thyroid disorders
– Tomatoes
• Lycopenes
Summary of The Effects of Antioxidants
as Antiaging Interventions
Vitamin E
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No decrease in total cardiovascular mortality
No reduction in risk of stroke
Inconsistent data on the effect on lipids
Inconsistent data on the effect on cognition
Insufficient evidence in the treatment of Alzheimer’s
disease
Inconsistent data on all-cause mortality
Vitamin C
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No decrease in total cardiovascular mortality
No reduction in risk of stroke
Inconsistent data on lipid profile
Carotenoids
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Inconsistent data on risk of stroke
Increase in all-cause mortality
Increase in cardiovascular mortality
Vitamin D
• Important hormone obtained by either being in the sun or
drinking milk, also genetic component
• Deficiency very common
• Low levels associated with osteoporosis, diabetes, cancer,
high blood pressure, heart disease
• Suggestive evidence that giving vitamin D reduces the
progression of pre-diabetes to diabetes, development of
heart disease and development of cancers.
• Treatment has been shown to decrease mortality!
• May help with infections and tuberculosis.
• Have doctor measure 25-OH vitamin D in blood
• If < 30 ng/mL, should be replaced.
• Target level 30-40 ng/mL, maybe around 50 if history of
breast cancer.
• See goodhormonehealth.com
Lifestyle
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Avoid stress
Be optimistic
Avoid confrontations
Pets
Happy marriage
Good balance between work and leisure
Take your meds and be active in your health care
Be part of the community
Church goers live longer
Most important aspect
• Attending MAGIC conventions can add years to
your life
• Thanks to Dianne and all the MAGIC foundation
workers!
For more information or to schedule
an appointment
• goodhormonehealth.com
• [email protected]
• 310-335-0327