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METABOLIC SYNDROME: THE DISEASE OF THE NEW MILLENIUM

We now have a medical term in common usage for the cluster of problems caused by poor diet and obesity: metabolic syndrome. The term has actually been in use in medical research since the mid-1960s, but wasn’t widely recognized or accepted by the medical community until a few years ago.

Metabolic syndrome describes an obese person with central or abdominal obesity (a fat stomach) who also tends to have a poor cholesterol profile, high blood sugar and insulin and the attendant insulin resistance, high blood pressure, and clogged arteries. In other words, diabetes and/or heart disease waiting to happen.

Hormonally, a woman with metabolic syndrome tends to have high androgen (male hormone) levels, high estrogen levels (the fat cells are making estrogen from androgens), high cortisol and low thyroid. In other words, breast cancer waiting to happen.

Men with metabolic syndrome tend to have low testosterone and high estrogen. In other words, prostate problems waiting to happen.

Both men and women with metabolic syndrome are more prone to inflammation, which predisposes one to heart disease, arthritis and headaches.

The Mediterranean Diet

A group of European countries participated in a 12-year study of the effects of a Mediterranean diet and healthy lifestyle on metabolic syndrome symptoms. Associated with that study, a group from Italy recruited people who actually had metabolic syndrome and instructed them to adhere to a Mediterranean diet for about two years. The results of both were published in JAMA in September.

Not surprisingly, the two-year diet researchers concluded that, “A Mediterranean-style diet might be effective in reducing the prevalence of the metabolic syndrome and its cardiovascular disease,” which is a roundabout way of saying that most of the participants were healthier at the end of the study.

The large 12-year study concluded that, “Among individuals aged 70 to 90 years, adherence to a Mediterranean diet and healthful lifestyle is associated with a more than 50% lower rate of all-causes and cause-specific mortality.” In other words those who didn’t smoke, got some exercise, used alcohol in moderation, and ate plenty of whole grains, vegetables, fruits, legumes and olive oil had half the chance of dying as those who didn’t lead a healthy lifestyle. More specifically, those who maintained all four low risk factors had a 65 percent lower death rate.

Insulin, Androgens and Women’s Health

And speaking of metabolic syndrome, one of the key issues addressed in the “…Breast Cancer” book is the role of excess sugar and carbohydrates in setting the stage for breast cancer. A study published in September 2004 in Cancer Epidemiology Biomarkers & Prevention showed that women who ate the most carbohydrates had more than double the risk of breast cancer compared to women who ate the least carbohydrates.

Excess glucose (from sugar and carbohydrates) in the bloodstream, raises insulin levels which increases androgen (male hormone) levels in women. In plain English this means that if you eat excess sugar and carbs you’ll make excess male hormones. This was underscored in a Johns Hopkins study published in the American Journal of Epidemiology in September 2004 which showed that women with metabolic syndrome have high androgen levels.

An aside: This study is particularly interesting because it showed that only excess “free” or bioavailable androgens were strongly associated with metabolic syndrome, which means that conventional blood tests didn’t show this effect. “Free” hormones are what is measured by saliva hormone testing. In the few years before his death, Dr. Lee lobbied hard to get across the point that conventional blood tests of hormone levels are almost meaningless in assessing hormone status because they don’t measure bioavailable hormones.

High insulin and the resulting high androgens are the underlying cause of polycystic ovary syndrome (PCOS) which can cause terrible ovarian pain, PMS and excess hair growth. The typical doctor will give women with PCOS potent diabetes drugs to help control insulin levels, but a much simpler, healthier and more direct solution is to eat differently and get some exercise.

GREEN TEA IS A HEALTHY HABIT TO GET INTO

The more it’s subjected to scientific scrutiny, the better green tea looks as a health tonic. The Chinese and Japanese consume it as much or more as Americans drink coffee—it’s a staple of both cultures. Here’s a list of its beneficial effects, just based on recent research published in major journals:

• Prevention and treatment of cancer
• Reduction of blood pressure
• Protects the brain and nervous system from oxidation and excitotoxins
• Anti-inflammatory
• Anti-bacterial
• Reduces cavities
• Improves cholesterol profiles
• Helps clear arteries

Getting your green tea in one of those awful corn-syrupy bottled drinks will probably negate its benefits. Try it plain, hot or cold—it’s a very benign-tasting beverage not likely to offend even picky palettes.

THE BEST OF JOHN R. LEE, M.D.

Intended letter to the editor of the New England Journal of Medicine

Re: “Dietary fiber and the risk of colorectal cancer and adenoma in women,” C.S. Fuchs et al. NEJM 1999; 340: 169-176.

Dear Editor,

Like many others, I have long admired Dr. Burkitt and his “suggestion” that a high fiber diet is a protective factor against colorectal cancer. The findings of your study appear not to support that thesis. Dr. Potter, in his editorial, refers to this discrepancy as a paradox and wonders about the determination of fiber intake.

This morning at breakfast I was reminded how difficult it must be to eat over 24 grams of fiber a day, as Dr. Burkitt’s Africans did, and as was reported by the fifth quintile of the women in this study. My wife chose a cereal made of wheat supposedly of ancient Egyptian origin while I chose good old oatmeal. My serving of oatmeal provides 2 gms of fiber while my wife’s “wheat” cereal lists its fiber content as zero. Assuming 4-5 gms of fiber from vegetables I eat during the day, I would have to eat oatmeal 10 times a day to reach 24 grams/day. And, no matter how many servings of the Egyptian wheat cereal my wife ate, the fiber intake is still zero.

I have tried, in the past, to eat a diet providing 24 grams a day and have never been able to do it without fiber supplements. I don’t know of any person who routinely eats a diet providing 24 grams of fiber a day except one very skinny colleague who eats nothing but unprocessed, uncooked vegetables of all kinds. I doubt very much that 17,662 nurses eat a diet providing 24 grams of fiber a day. In fact, I doubt that any of them do.

In my 35 years of practice I have seen many patients’ food questionnaire reports and find, after talking with the patients, their written reports to be of questionable validity. That should not be surprising. For example, I would be hard put to recall with any specificity what I ate three days ago. Even more valid than face-to-face histories is the house call. A brief tour of the patient’s kitchen and pantry will most often provide valuable clues to the patient’s food intake, much different than they reported. Sending a food questionnaire to people every two years asking them to estimate their usual intake over two years of 136 items seems to me to be the least reliable method of all, regardless of its reproducibility.

Dr. Potter states that in understanding the nutritional factors in human health, “We have barely begun.” I agree with that sentiment. In the Fuchs, et al., study, the weak link is the dietary data. If that is invalid, the study’s conclusions are invalid. All this gives a new meaning to the phrase, “Garbage in, garbage out.”

John R. Lee, MD

OLD AND NEW BREAST CANCER RESEARCH OF INTEREST

There are thousands of good published studies on the relationship between hormones and breast cancer, but it’s not easy to sift through the tens of thousands out there to find them. Since What Your Doctor May Not Tell You About Breast Cancer was published in 2002, readers and researchers have sent us dozens of studies they’ve found that lend weight to the material in the book.

Here are some examples of old and new studies on the subject of progesterone and breast cancer.

A study published way back in 1984 in the journal Cancer Research found a “strong association” between decreased levels of progesterone and increased breast cancer risk. The same study also found that high testosterone and androgen levels were associated with increased breast cancer risk.

In a 1980 study published in Cancer Research, it was found that “The presence of progesterone receptors was found to be associated with a favorable prognosis in 98 patients with primary breast cancer. The occurrence of metastases was 3.6 times less probable in patients with progesterone receptor-positive tumors than in patients with progesterone receptor-negative tumors.”

Twenty years later, researchers working on tumors and hormone receptors in mice concluded that, “These results suggest that progesterone may provide effective treatment for estrogen receptor- and PR receptor [progesterone] –negative breast cancer….” (Lin et al, 2001)

In more recent news, a study published in August 2004 in Cancer Research on the topic of BRCA breast cancer stated, “We conclude that deregulation of progesterone receptor expression… may represent an early event in BRCA1-linked breast tumorigenesis [the start of tumor growth].”

Drs. Lee and Zava maintain in the “…Breast Cancer” book that having a progesterone-positive breast cancer tumor is a good thing because it means that the progesterone can get in there and help stop the growth of the cancer. The above research suggests that even in progesterone-negative tumors, adding progesterone (e.g. using progesterone cream) may help.

THREE TIPS FOR SAFER USE OF PRESCRIPTION DRUGS

The recent removal of Vioxx (rofecoxib) from the market due to an increased risk of heart attack and stroke as a side effect was about six years too late (the drug was approved about six years ago). Both the FDA and the drug maker have known about this potential side effect all along. Apparently they just weren’t sure exactly what the risk/benefit ratio was, meaning how much risk (i.e. death) is acceptable in order to provide larger benefit. Considering the variety of other drugs available to treat pain, any larger benefit is questionable when compared to death. Worldwide sales of Vioxx in 2003 amounted to $2.5 billion so there was clearly a financial benefit.

In April of 2001, about two years after the drug came onto the market, the Public Citizen/Health Research Group warned of these side effects and recommended that, “ A second box warning (the first box recommended was for gastrointestinal damage) about cardiovascular toxicity needs to be added. It should warn of the lack of platelet aggregation inhibition of the drugs which protects those at risk from an increased occurrence of heart attacks. In addition, the evidence which is rapidly accumulating about the heart damage caused by these drugs must be mentioned in this cardiovascular box warning.”

Three Tips

Some 200,000 people a year are killed by inappropriate drug prescriptions. That’s about 160,000 more than are killed by breast cancer. The best way to avoid becoming part of that statistic is to simply avoid prescription drugs. Otherwise, here are some guidelines you can use to stay safer when taking prescription drugs:

• 1. The Public Citizen/Health Research Group has long advocated waiting at least seven years after a new drug comes on the market to see if it’s really “safe and effective” as promised by the FDA. Vioxx is a perfect example.
• 2. If you have serious side effects from a drug, don’t take it. Examples of “serious” include insomnia, weight gain, dizziness, nausea and irregular heartbeat. Among the most common side effects of Vioxx are variations on the theme of irregular heartbeat: atrial fibrillation, tachycardia, palpitation, bradycardia. I wonder how many tens of thousands of people complained of these symptoms to their doctor and instead of being taken off the drug were given more drugs to treat the side effects—which brings me to the next point.
• 3. Once you mix more than two prescription drugs all bets are off as to side effects and their severity—it’s a form of medical Russian roulette that is further complicated by other health problems, diet, lifestyle and genetics. It’s a common practice to prescribe a third, fourth or fifth drug to treat the side effects of the first two. Easy for the doctor, potentially deadly for you. At the very least, that many drugs will put a heavy burden on your liver and kidneys and you’ll feel tired and cranky.

You can find more tips on the safer use of prescription drugs as well as a very thorough list of drug side effects, drug interactions and drug alternatives in a book I co-authored with Dr. Earl Mindell, Prescription Alternatives.