Sunday, June 9, 2013

How to Age Faster by Increasing Glycation

You hear a lot about oxidation and the importance of anti-oxidants.  I want to introduce you to a concept at least as important - glycation.  New studies reveal that all of us suffer to some degree by the damage caused by glycation.  What is glycation?  It is sugar binding to a protein or fat.   Glycated fats and proteins are described by scientists as Advanced Glycation End-products, appropriately abbreviated as A-G-Es.  A-G-Es damage our bodies by causing cross-linking that leads to intracellular damage and cell death.  Think of glycation as caramelization of your body.  Essentially, glycation speeds up aging by turning your tissue into CRÈME BRÛLÉE. 

Recent research indicates that these damaging end products play a role in skin wrinkles, hypertension, impotence, heart disease, cancer, neurodegeneration (dementia), cataracts, kidney failure and in general - aging itself.   

How does one increase glycation and age faster?  Eat like most Americans.  If you didn’t know better, you might think we are trying to age faster by the way we are eating.  

Measuring Glycation
The hemoglobin A1c test is also known as glycosylated hemoglobin.  The hemoglobin A1c test is best known as a common test for tracking long-term glucose control in people with diabetes.   However, we know realize that the hemoglobin A1c is quite useful for those without diabetes too: The Hemoglobin A1c or glycosylated hemoglobin correlates with age-accelerating glycation reactions in the body.  In other words, by monitoring the hemoglobin A1c level, we can identify age accelerating excessive glycation in our bodies and take measures to reduce it. 

By the way, another dark side of high A1c levels is their association with higher insulin levels.  Higher insulin levels cause increases in blood pressure, appetite, weight, heart disease, cancer and chronic inflammation.  In men, impotence and prostate enlargement is also associated with hyperinsulinemia.

An Optimal Level of the Hemoglobin A1c is less than 5%
Research suggests that a hemoglobin A1c level of less than 5% is ideal.  It can also be challenging to achieve.

What raises our hemoglobin A1c? Many physicians only consider foods which raise the blood glucose levels as causing the A1c to increase. Surprisingly, blood sugar levels are only part of what increase the A1c.  Eating advanced glycosylated end products increase glycation in our body too. 

So, Glycation and the hemoglobin A1c rise when:

1.     We eat foods that raise our glucose.  Sugary, starchy foods cause our glucose to increase and this causes glycation of our proteins.

2.     We eat A-G-E rich foods.  These glycotoxins cause both direct damage and the expression of genes which accelerate aging.

5 Ways to lower your hemoglobin A1c. reduce glycation and slow aging

1.     Eat low sugar foods – those with a lower glycemic load.  

This includes vegetables, lower sugar fruits like berries, nuts and some animal products.  Avoid processed foods, artificial sweeteners, sugar, fructose and grains – especially wheat (even whole grain).  Animal-derived foods that are high in fat and protein are prone to A-G-E formation during cooking.  This can be reduced by smart cooking methods - see point 2 below. In contrast vegetables and fruits contain relatively few A-G-Es, even after cooking.  Read “Wheat Belly” by William Davis and “Eat to Live” by Joel Fuhrman for more details.

2.     Cook Smart: Steam, Stew, Boil or Raw.

You get A-G-Es with dry heat.  A-G-Es/glycation are significantly reduced by cooking with moist heat, using shorter cooking times, cooking at lower temperatures and by use of acidic ingredients such as lemon juice or vinegarLow-AGE– generating cooking methods include boiling, poaching, steaming and stewing.  The high AGE content of broiled chicken (5,828 kU/100 g) and broiled beef (5,963 kU/100 g) can be significantly reduced (1,124 kU/100 g and 2,230 kU/100 g, respectively) when the same piece of meat is either boiled or stewed. 

Eating raw foods can often rapidly improve health.  Why are raw foods so good for us?  Raw foods are rich in nutrients and live enzymes plus they have virtually no A-G-Es.  Many have found to be helpful.

Unfortunately, A-G-Es taste good and many foods are cooked in such a way as to increase their A-G-E content.  For optimal health and to slow the aging process you should largely avoid foods which are:

·       Barbecued
·       Blackened
·       Broiled
·       Browned
·       Carmalized
·       Charred
·       Fried
·       Grilled
·       Microwaved
·       Roasted
·       Toasted

A-G-Es are also found in roasted coffee, cereals, biscuits and chocolate.

The use of acidic marinades such as lemon juice and vinegar before cooking can limit A-G-E generation.  Reducing glycation does not require eating cardboard; A-G-E reducing culinary techniques have long been used in Mediterranean, Asian and other cuisines throughout the world to create delicious easily prepared dishes. 

3.     Exercise regularly.  Exercise reduces insulin resistance and lowers blood glucose.

4.     Hormonal balance: Thyroid, DHEA, testosterone in men, progesterone in women reduce glycation and help the body repair itself.

5.     Supplements to lower glycation include: Cinnamon, garlic, psyllium, chromium, alpha lipoic acid, fish oil, Vitamin C, Vitamin B6 and L-taurine.   Carnosine and benfotiamine help too.  Resveratrol helps protect against AGE damage.  The enzyme transglucosidase has also shown promise in reducing the release of sugar from starch and converting it to fiber.

How to get a Hemoglobin A1c test

Testing your hemoglobin A1c can help you refine your lifestyle so you feel better and enjoy a longer, healthier life.  Getting an A1c level is easy.  You can ask your doctor (Hotze Health & Wellness guests will have this test run routinely as of this summer).  You can also have many labs run this test without a doctor’s order– i.e. ZRT labs Hemoglobin A1c Blood Spot Test Kit or Life Extension Foundation.  Since the Hemoglobin A1c test reflects what you have been doing the past 3 months, you would not want to repeat this test more often than every 3 months. 

 To your health!  

Don Ellsworth, M.D. 

Wednesday, February 20, 2013

Are Screening Mammograms Safe and Effective?

In 2009, I reviewed the issue of screening mammograms and supported the US Preventative Services Task Force (USPSTF) recommendation that women of average risk should start mammograms at age 50 and continue mammography every 2 years until age 75.  I have recommended mammograms with the caveat that as new information is available, I would reassess the best strategy.  New information casts further doubt as to the safety and effectiveness of mammography as a screen for breast cancer.

Let me start off by saying the obvious, we all want to reduce the rate of breast cancer.  If cancer cannot be avoided, we want to improve the outcome through earlier detection. 

Objectively thinking through the issue of breast cancer screening with mammograms is no easy task.  Screening mammograms have been promoted far more than any other diagnostic test.  Particularly in the United States, breast cancer screening is an emotionally, politically and economically charged issue.  Powerful forces are in place which put pressure on physicians and women to promote mammography but are we helping women?

The findings and conclusions of numerous studies are not at all intuitive or obvious. To digest this information, you will want to set aside what seems to be “obviously” correct and consider the facts carefully. 

What Makes For a Good Screening Test?
To understand the issue of screening mammograms, it is helpful to back up and look at what makes for a good screening test.  Screening should meet several criteria:

·       The procedure should allow early detection of cancers destined to cause death.  By diagnosing the cancers earlier - screening should be associated with better outcomes.

·       The procedure should have a high safety profile.

An effective screening approach should show early disease rates go up in an amount equal to the decline in late disease.  Effective screening tools such as Pap smears for cervical cancer and colonoscopies for colon cancer demonstrate the expected increase in early disease with a corresponding drop in late disease.  We will see this is not the case with screening mammograms.

Landmark Study
The November 22, 2012 New England Journal of Medicine landmark article “Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence” by Archie Bleyer, M.D., and H. Gilbert Welch, M.D., M.P.H. looked at an enormous amount of federal data on screening mammography compiled from the mid-1970s through 2008. 

Key Study Findings
·       The rate of diagnosing breast cancer in early stages increased by 200% with screening mammography.
·       However, the rate of late stage cancer did not drop significantly in the screened group.  Metastatic disease was completely unchanged – screening did not prevent this.

This thorough review confirmed what numerous other studies have pointed to: screening mammograms do not make much of a difference in preventing late stage cancer.  They are not achieving their main goal which is to prevent cancer deaths.

Overdiagnosis of “harmless” cancer cells
You may be thinking that any chance of improvement would justify doing a mammogram.  This would be true if there were no downside to screening. While the breast cancer “overdiagnosis” problem has been discussed in the medical articles for over a decade, this issue is rarely understood and discussed even among physicians. 

While it seems obvious that it is a good thing to find cancer cells and get rid of them, the studies show this is not always so.  Our bodies often contain cancer cells that would have never effected out lives.  When we go looking for the early cancers, we often find what I am going to call harmless cancers – cancer which would never have caused disease.  We also find some of the bad cancers - destined to cause disease and potential death. 

The problem is that mammograms appear much better at diagnosing harmless cancers than early bad cancers.  Furthermore, at this time, once cancer is diagnosed there is no way to tell whether it is likely to cause disease or not.  As a result of screening mammograms, the overdiagnosis of cancer cells were found and treated in more than 1.3 million women over the past 3 decades.   In 2008, 70,000 women were overdiagnosed with breast cancer. This amounts to almost 1/3 of breast cancers diagnosed in women 40 years of age and older.  

Overdiagnosis is not benign:  These women overdiagnosed with breast cancer gained nothing by their treatment.  They would have enjoyed living their lives never being affected by breast cancer. The cancer would have never materialized as a diagnosis or health concern. 

Overdiagnosis causes overtreatment with the attendant emotional stress of the cancer diagnosis, unnecessary treatment such as surgery, radiation & chemotherapy and all the potential complications.   While treatment of early stage cancer is safer than treatment of late stage cancer, this overtreatment can sometimes cause serious complications and even death. 

The data shows 2 important problems with screening mammography:
·       Screening mammograms fail the most important criteria for screening: they fail to substantially reduce late stage disease. In fact, from 1975 to 2008 the rate of metastatic breast cancer was unchanged.

·       Screening mammography causes many women to become cancer patients who would not have been had they not been screened.

**I would want to make sure all readers recognize that all breast masses should be carefully evaluated.  The above negative findings are for screening mammograms– not diagnostic mammograms used to evaluate lumps/masses. If a woman has a breast lump/mass – it definitely should be evaluated with mammograms, ultrasound and when indicated, biopsy**

The NEJM article prompted a discussion over which of the following strategies doctors should recommend:
Option 1: Recommend Screening Mammography Starting at the Age of 40
Option 2: Recommend Screening Mammography Starting at the Age of 50
Option 3: Do Not Recommend Screening Mammography

The fact that option 3 is on the table speaks volumes.  The pressure to do screening mammograms is very intense.  For a prestigious journal to discuss this as a reasonable option reflects a large body of evidence that screening mammography has very limited benefit and significant problems.
The preponderance of the evidence we have gathered in many different countries and by many different groups show disappointing results with screening mammograms.  While the exact findings vary, women need to be aware that screening breast mammography is poor at picking up important cancers and clearly results in a great deal of overdiagnosis and overtreatment. As much as we all want a good tool to reduce breast cancer death, screening mammograms do not fill this role well. 
Should I have screening mammograms?
Since screening mammograms are not very effective or accurate, missing most important cancers and diagnosing many unimportant ones, I lean toward option 3 of not recommending mammography.  I encourage you to consider the best statistics we have and make a decision based on your assessment of the benefit versus risk:

·       We are weighing a low benefit of 0-10% in the reduction in late stage cancers

·       A significant risk of overdiagnosis.  The harm of overdiagnosis includes:
·            emotional stress
·            pain and potential complications from testing
·            complications of the cancer treatments (surgery, chemotherapy, hormonal blockers,  radiation) ranging from mild issues to severe impairment and death
·       The pain involved with screening mammograms
·       The stress of screening mammograms, waiting for the results, needing additional studies and biopsies.
·       Possible x-ray induced cancer.  X-rays involved in mammograms have a small but definite risk of causing cancers – especially when you start early and have yearly studies

This is a personal decision but the case for the often stated “screening breast mammography save lives” is much weaker than most realize.  You may choose to get screening mammograms but please do so knowing there is clear evidence that screening is associated with significant harm coming from the many cases which involve finding cancerous cells that would have never affected your life.
The Cochrane Review as a tool to make your decision
When I did medical missions overseas in Central Asia, I worked in the area of medical development with consultants with the World Health Organization (WHO) to make recommendations.  We were trying to focus on what really mattered, what really made a difference.  It was not uncommon to discuss the findings of the Cochrane Reviews. The Cochrane Review is internationally recognized as a leading source of quality evidence-based health assessments.  Because the Cochrane Review is international, it is not easily influenced by political and local economic factors.  I would urge you to consider the Cochrane Reviews’ stance on screening mammograms:
Cochrane Review 2008
·       Initially in 2008, their summary was that since mammography had both benefits and harms, either way – having it done or not having it done was reasonable.
·       At the time they estimated that if 2000 women were screened regularly for 10 years, one will benefit from the screening by avoiding dying from breast cancer.
·       At the same time, 10 healthy women would unnecessarily become cancer patients and will be treated unnecessarily. These women will have either a part of their breast or the whole breast removed and often receive radiation therapy and sometimes chemotherapy.
·       Furthermore, about 200 healthy women will experience a false alarm. The psychological strain women experience from false alarms can be severe.

Cochrane Review Revised Position
·       Since the trials used to accumulate the above statistic were performed, treatment of breast cancer has improved considerably.  When improved treatment of breast cancer is factored in, it indicates mammography screening may no longer be effective in reducing the risk of dying from breast cancer.
·       Screening produces patients with breast cancer from among healthy women who would never have developed symptoms of breast cancer. Treatment of these healthy women increases their risk of dying, e.g. from heart disease and cancer.
·       It no longer seems reasonable to recommend mammograms for breast cancer screening. In fact, by avoiding going to screening, a woman will lower her risk of getting a breast cancer diagnosis.
·       However, despite this, some women might still wish to go to screening. But women should know that screening produces patients with breast cancer from among healthy women who would never have developed symptoms of breast cancer. Treatment of these healthy women increases their risk of dying, e.g. from heart disease and cancer.

Source: Cochrane review: Screening for breast cancer with mammography   

Better Approaches
To continue to do the same thing over and over again, expecting different results, is one definition of insanity.  Moving forward, we need better tools.  Deadly cancers are routinely missed with mammograms and mammograms pick up too many unimportant cancers. 
Although clear benefit is lacking – it seems prudent to do self-breast exams as well as have your doctor perform regular breast exams.  Also, I repeat, you should definitely have a breast mass evaluated with all appropriate tools including mammograms (when done to evaluate a lump, this is called a diagnostic mammogram rather than a screening mammogram).
What might work instead of screening mammograms? Screening with ultrasound and breast thermography are promising.  However, we will only know if they really help when long term rigorous studies done on them.  Read more about breast thermography in my previous posts in the January & November 2009 blog posts. 

To your health!  
Don Ellsworth, M.D.  

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Disclaimer:  The information provided should not be construed as personal medical advice or instruction.  No action should be taken based solely on the contents of this site. Readers should consult appropriate health professionals on any matter relating to their health and well-being. The information and opinions provided here are believed to be accurate and sound, based on my best judgment and research.  I cannot assume responsibility for any possible errors or omissions.

References and further reading
Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence
Archie Bleyer, M.D., and H. Gilbert Welch, M.D., M.P.H.
N Engl J Med 2012; 367:1998-2005 November 22, 2012

Cochrane Review:

Overdiagnosed: Making People Sick in the Pursuit of Health by H. Gilbert Welch, Lisa Schwartz and Steve Woloshin