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Intelligent Questions to Ask Your Doctor Winter 2015

Intelligent Questions Answered by the experts...

<< Back to Robb Report, Robb Report Health and Wellness January 2015

Research has recently linked male pattern baldness at age 45 to an increased risk of aggressive prostate cancer.

Q: My hairline is definitely receding. Should I begin prostate screenings earlier and schedule them more often than is typically recommended?

A: The established factors for a higher risk of prostate cancer are African-American ethnicity and a close male relative with prostate cancer (such as a father, uncle, or brother). In addition, some guidelines for prostate screening would advocate a baseline prostate-specific antigen (PSA) test and digital rectal exam at age 45. If the exam is normal and the PSA is less than 1.0, then a patient’s risk is low and he can be screened again two to five years later. If the PSA is greater than 1.0, consider screening yearly for high risk; a common threshold for a prostate biopsy would be 2.5 or so. Any abnormal prostate exam should trigger biopsy consideration, even with a low PSA.

The baldness association paper was published in a very highly cited journal and will likely encourage more definitive research on the topic. The source of patients for this study, however, is very controversial: These men were heavily prescreened before entry into the study and the baldness categories were completed by memory of the patient. Thus, it is not a definitive study that would change clinical practice; men with and without baldness should think about prostate cancer screening at age 45, and discuss the pros and cons with their primary physicians.

Regarding prevention, the best advice is to incorporate a low-fat diet (similar to cardiac diet recommendations) and regular exercise. It is often quoted that men are most likely to die of cardiac disease, and that includes men with prostate cancer. It is fortunate and convenient that virtually all cardiac disease prevention methods also help mitigate prostate cancer risk.

—John W. Davis, MD, associate professor in urology, The University of Texas MD Anderson Cancer Center

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Scientists have learned that artificial sweeteners may alter the microbiome of the digestive system and increase glucose intolerance, which can lead to diabetes.

Q: Should I stop using sugar substitutes such as Splenda or Sweet’N Low in my coffee?

A: Nutrition has a profound effect on microbiota systems. Artificial sweeteners could alter the biome by stimulating different bacteria, but we cannot yet say whether sugar is better than sugar substitutes in its effect on intestinal flora. This is an intriguing study, but with such a small group of patients, strong recommendations cannot be made until more information is available.

Increasing evidence exists, however, that suggests intestinal biota is almost like a different biological system in the body. Science has shown that taking the microbiota from an overweight animal, for instance, and putting it in a normal animal will likely cause that normal animal to gain weight. But we are not yet sure if this result is a cause or an effect.

—W. Allan Walker, MD, Conrad Taff Professor of Nutrition and Pediatrics at Harvard Medical School, director and chairman of the division of nutrition at Harvard School of Public Health, and founder of the mucosal immunology lab and division of pediatric gastroenterology and nutrition at Mass General Hospital for Children

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A group of investigators in the United Kingdom have found that daily singing exercises can help curb snoring, even in people with sleep apnea.

Q: My husband’s snoring is disruptive for both of us. Should I get him singing lessons?

A: In this study, a number of patients who complained of snoring or mild sleep apnea found that singing lessons improved their symptoms and gave them a greater perceived level of alertness. These findings are intriguing because snoring and sleep apnea are such common conditions, and the available treatments are not always palatable.

A singing protocol does hold some promise, with the theory being that the exercise of singing improves the muscle tone in the throat. Snoring and sleep apnea are caused by the relaxation of those same muscles: When they are relaxed and loose during sleep, they vibrate. It is likely that those muscles lose their tone as we age, yet anatomical issues like nasal blockages can also aggravate snoring, as can the consumption of alcohol or muscle-relaxing medications.

It is not only the person who snores who suffers from disruptive sleep; the spouses of loud snorers get an hour less sleep per night [than spouses of non-snorers]. Men are known to snore worse than women, so we suspect there is a hormone factor at work; either testosterone brings it out or estrogen suppresses it. Women are more likely to develop such symptoms after menopause. However, the biggest factor here is obesity. When people gain weight, fat that accumulates in the neck can affect the anatomy of the airway, and the tongue can also increase in size.

The caveat to all this is that this study is a preliminary report. Eight or nine years ago, there was research into whether playing the didgeridoo would curb sleep apnea, but some reports since then have indicated that playing a wind instrument won’t necessarily help. Those who suffer from moderate to severe sleep apnea should not forgo standard, proven treatments such as CPAP (continuous positive airway pressure) therapy or dental appliances—mandibular advancement devices—that hold the jaw forward slightly to keep the throat open.

—Mark R. Hansen, MD, assistant professor of psychiatry at the Mayo Clinic College of Medicine and a consultant at Mayo Clinic’s Center for Sleep Medicine

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Making a concrete plan to get a flu shot—writing down a date and time—led to improved rates of follow-through, according to a study in Proceedings of the National Academy of Sciences.

Q: Does this carry over to New Year’s resolutions? If I write down my goals, will I be more likely to achieve them?

A: Writing them down is certainly helpful: It is a form of commitment to ourselves that we are more likely to follow. Yet scheduling specific steps—say, working out at a certain time on certain days—is even more likely to help. And if you schedule the task in the morning, you will have more chances to fulfill it. We are generally more resourceful and have more energy at that time of day, and we are less likely to get sidetracked with other activities.

You are also more apt to follow through if you add the task to something else you do every day. If your goal is to start practicing meditation or mindfulness, for instance, there is a greater chance that it will happen if it becomes an extension of a daily activity, like after you brush your teeth. This method works for me. If the task is something that you do not want to do, try to involve someone else to encourage you. After about six to eight weeks, the resolution will become self-reinforcing as you experience the reward (of feeling less stress, looking slimmer, etc.) and the habit has been formed. Those initial few weeks are the hardest.

—Emanuel Maidenberg, PhD, clinical professor of psychiatry and director of cognitive behavioral therapy at the Semel Institute at UCLA

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Probiotic consumption may lower blood pressure, according to an analysis published in Hypertension.

Q: How much yogurt, cheese, or fermented soy products (like miso) do I need to consume to get this effect?

A: There is a misconception that all probiotics are the same. Probiotics are very different from one organism to another; just taking probiotics per se doesn’t really solve the issue. Yogurt has certain ones, and it is a beneficial food that might have some beneficial effects. There are a huge number of bacteria in the intestines that are metabolically active, and we haven’t yet scratched the surface of what these microorganisms can do.

If the analysis about probiotics lowering blood pressure is true, it is likely that the microbes are producing molecules that move across from the intestine, reducing hypertension and the factors that make blood pressure go up. Bacteria produce anti-bacteria that can have an effect on infection by secreting modulating factors. The same thing could pertain to other diseases, as the bacteria are perhaps modified by diet or probiotics.

This is just a single study, however, and there are unresolved questions. With such limited data, it is not yet possible to make specific recommendations on what particular pro–biotics should be taken and when to have a positive effect on lowering blood pressure. Much more research is needed in this context, as there is no one-size-fits-all pro-or prebiotic. Responses are dependent on the different species and strains of the cultures.

—W. Allan Walker, MD, Conrad Taff Professor of Nutrition and Pediatrics at Harvard Medical School, director and chairman of the division of nutrition at Harvard School of Public Health, and founder of the mucosal immunology lab and division of pediatric gastroenterology and nutrition at Mass General Hospital for Children

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Some scientists have claimed that triclosan, a chemical compound found in a few toothpastes and antibacterial soaps, is a dangerous

endocrine disruptor.

Q: Is there a cumulative danger of using products that contain it?

A: Triclosan is added to a number of materials to reduce the chance of bacterial and algal growth, and it has been shown to be effective in reducing gingivitis when used in toothpaste. The chemical structure, which contains two benzene rings, makes it possible for triclosan to bind to estrogen and androgen (testosterone) receptors, and therefore it can have a biological effect. Studies show that it takes a high concentration of the molecule to have any influence on the receptors and that effects in animals were found only when very high doses were used.

Since adult humans of both sexes have high levels of both androgens and estrogens, there is virtually no chance that triclosan would have an impact on them through that mechanism. Children of both sexes have much lower hormone levels, but I don’t know of any evidence of an adverse effect, although the studies are not definitive. There are particular aqueous species that are very sensitive to chemicals with any estrogenic properties, but the available data show no well-demonstrated adverse effect.

In the presence of gingivitis, the risk/benefit analysis of triclosan in toothpaste favors its use. In the absence of gingivitis, I believe the agent is not needed because gingivitis is not inevitable. The ecological damage does not seem to be much, as far as we know, and is certainly less than other substances in the environment. But if there is no benefit to its use, why bother?

—Stanley Korenman, MD, professor of medicine in endocrinology and associate dean for ethics at the David Geffen School of Medicine at UCLA

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According to statistics from the Centers for Disease Control and Prevention, patients with the Ebola virus have about a 37 percent risk of death in the West African countries where it is most virulent: Guinea, Liberia, and Sierra Leone.

Q: I travel internationally quite often. How can I stay safe while I am flying?

A: Ebola is spread through bodily secretions or fluids from individuals who are infected and showing symptoms. The possibility of contracting Ebola on a plane is very low. Ebola requires certain conditions to survive outside the body. On dry surfaces it can survive several hours; in a body fluid it can survive several days. That said, to avoid pathogens overall when traveling, wash your hands and avoid unnecessary touching of the face and eyes, which can increase your chance of getting a virus. On planes, I carry a small bottle of alcohol-based hand sanitizer, and I use a packet of wipes to clean the tray table, armrests, and seatbelt buckle. There is not much science to support lining your nostrils with an antibiotic gel or wearing a surgical mask for prevention, and either of those things can create physiologic stress by blocking the flow of air getting into the body.

—Matthew Levy, DO, Assistant professor in the department of emergency medicine at Johns Hopkins Medicine

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