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Intelligent Questions to Ask Your Doctor Summer 2015

Intelligent health and fitness questions answered by the experts...


New research has found that taking muscle-building supplements may increase the risk of developing testicular cancer up to 177 percent. 

Q: I took protein and creatine supplements as a teenager. What can I do now to counter this rather alarming connection?

A: There is really nothing to do to counteract the effect, but to be honest, this proposed link is still considered controversial. One suggestion is to perform monthly testicular self-examinations and see a doctor if you note any changes or the development of a mass.

—Christopher G. Wood, MD, FACS, professor of urology at the University of Texas MD Anderson Cancer Center

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A new study found that in women ages 70 to 80, those who exercised and took vitamin D sustained fewer injuries in falls.


Q: How much vitamin D is protective against injuries, and what kinds of exercise help most?

A: Most of the evidence for vitamin D’s helpfulness has been in supplementation in women with low levels. Prior medical literature indicates that as little as 800 IUs daily could help confer this benefit, but more recent data show mixed results. That being said, there is little to no harm associated with vitamin D supplementation at this level. It is thought that vitamin D is important for proper skeletal muscle function and that low levels could be linked to muscle weakness, hence the value of supplementation. There has been no benefit noted in clinical trials of vitamin D in reducing fracture risk, although vitamin D supplementation is critical when taking medications to treat osteoporosis that do reduce risk of fracture (but not falls). 

Exercise has been shown to reduce risk of falls, particularly when a physical therapist conducts an assessment and assigns specific exercises tailored for the individual. The medical evidence suggests that a patient must do two different types of exercise—any combination of balance training, strength or resistance training, gait training, or flexibility—to derive this benefit. Other exercises such as tai chi, yoga, and more recently Pilates have also been shown to reduce falls risk. The key is that the individual must do these exercises consistently to see results.

—Ronan Factora, MD, Center for Geriatric Medicine at Cleveland Clinic 

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A 30-minute bout of moderate-intensity exercise increased concentration and reasoning ability in the subjects of a new study.

Q: Does that effect last throughout the day, or does it happen only immediately after the exercise?

A: Some studies have looked at regular sustained exercise—when people walk for a half-hour three days a week, or walk 15 minutes per day, or do something to get cardiovascular exercise—and if one does that over a period of time, one does see sustained benefits. How long a single exercise session may provide benefits depends on the intensity and duration of the particular exercise. Of course, the effects wear off over time; however, continued cardiovascular conditioning has a definite impact. A University of Illinois study found that regular aerobic conditioning actually led to growth of the hippocampus, a key memory center of the brain. And there is a correlation between the growth of the hippocampus and a better-functioning brain.

There is an immediate mental boost with cardiovascular and strength training that we experience subjectively: mental clarity, alertness, and improved mood. We know from other studies that physical conditioning will increase endorphins, which are natural antidepressants. Some individuals experience a reduction in pain as a result of exercise, and it also promotes an increased anti-inflammatory effect. (One of the challenges with brain aging in general is that we have too much inflammation, which can damage healthy brain cells.)

The short answer is that exercise confers an immediate effect that is positive, and if one continues to exercise on a regular basis, there will be sustained effects.

—Gary W. Small, MD, Parlow-Solomon Professor on Aging, David Geffen School of Medicine at UCLA, and director of the UCLA Longevity Center

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A British Medical Journal study reports that acetaminophen is ineffective in treating low back pain and provides minimal short-term benefit in treating osteoarthritis.

Q: What are my choices for analgesics if I have adverse reactions to ibuprofen?

A: My take on the article is that the data for spinal pain were based on only three studies, and as with almost all studies for lower back pain, the researchers did not try to identify the specific cause. As such, there may be a very small effect for acetaminophen in well-selected patients.

Still, nonsteroidal anti-inflammatory drugs (NSAIDs) absolutely are more effective (when tolerated) than acetaminophen. Identifying someone as a poor candidate for NSAIDs would depend on the specific adverse effect experienced; if it is gastrointestinal, then COX-2 inhibitors (like celecoxib) or an NSAID combined with a protein pump inhibitor drug has been shown to reduce gastrointestinal adverse effects such as ulceration or gastritis. 

In addition, acute back pain always responds better to treatment than chronic back pain. For acute back pain, muscle relaxants have been shown in well-designed clinical studies to be helpful. For chronic low back pain, antidepressants (duloxetine and tricyclic antidepressants) have been shown to reduce pain and improve function in some people.  

It would also be helpful to try to identify the specific cause of pain. For example, for a type of arthritis called facet joint arthropathy, several placebo-controlled studies show that radiofrequency ablation—a safe, minimally invasive procedure that involves burning the nerves that transmit pain from the joints—can provide considerable pain relief and improvement of function lasting six months to one year. For pain that comes from the intervertebral discs, the treatments tend to be more invasive and less effective (for example, spinal fusion, disc replacement, or burning the disc, called biacuplasty).  

—Steven P. Cohen, MD, professor of anesthesiology, professor of physical medicine and rehabilitation, and director, Blaustein Pain Treatment Center, Johns Hopkins School of Medicine

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The brains of poor sleepers and those with sleep apnea are more likely to contain abnormalities that are associated with the development of dementia, according to a recent study.

Q: I have had sleep apnea for years. If I learn to better manage it now, will that help to repair any damaged tissue?

A: If there is brain atrophy or damaged brain tissue already present, there is nothing currently available to repair the affected areas. Treating sleep apnea with CPAP may prevent further brain tissue from being damaged by decreasing inflammation in the brain. There may also be an improvement in mood and cognitive functioning.

—Charles Bae, MD, staff physician, Sleep Disorders Center of the Neurological Institute, Cleveland Clinic 

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Johns Hopkins Medicine researchers discovered a new biomarker—the amount of mitochondrial DNA in blood that may predict frailty and mortality.

Q: How can I get my mitochondrial DNA measured?

A: I want to be clear that this is not a clinical test yet. There is a lot of work to be done—standards, references, and the like—before this could become a clinical test. But in theory it could be possible to identify people who are at risk for becoming frail and for having negative outcomes. In our study, we have also seen an association with overall mortality. Yet the question remains, once patients are identified as frail, what are the interventions? That might mean more careful screening of these individuals, or something like fall prevention exercises for people who are at risk for being frail and are therefore more at risk for falling, or changes to the diet, or drugs that are known to increase the number of mitochondria. The idea is that one could identify people 10 to 15 years before they become frail and prescribe interventions that would improve their outcomes, hopefully before something happens. 

There is a very specific definition of frailty, comprised of five components: slowness (or walking speed), exhaustion, shrinking (unintended weight loss), grip strength, and whether one has high or low levels of physical activity. Combining these five metrics provides an estimate of whether someone is frail. And the reason that is important is because frail individuals are more likely to have bad outcomes such as hip fractures or higher mortality. Taking this measure of older individuals is actually predictive of future health consequences.  

There is also this underlying hypothesis that energy reserves are a critical component of overall health and of frailty in particular. When exposed to illness, most people have these reserves that allow them to recover and resume their normal state of health. A frail person has reduced energy reserves, so he or she does not readily recover from illness. With regard to energy, mitochondria are the powerhouse of the cell and provide energy to the cellular system, so mitochondrial function is a natural place to look if one is examining energy reserves. In our research we looked at the number of mitochondrial genomes that an individual has and can show that this seems to decrease over time: The older you are, the fewer mitochondrial genomes you have, and having fewer is not a good thing. 

As for the next step, we are looking at larger studies to validate some of our findings. The other thing is refining the findings that we are interested in; so overall mortality is a broad outcome, but does this have more of an impact on specific outcomes, such as diabetes or heart disease? And we have some preliminary work showing a pretty strong association with heart disease. Lastly, this is only one particular measure of mitochondrial function. There are plenty of other metrics that we can explore that potentially may directly measure mitochondrial function rather than just the number of mitochondria. We can measure the downstream effects on what we think the mitochondria may be doing and try to understand the biology a little better and exactly why these people are having a worse outcome.

—Dan Arking, PhD, associate professor of medicine and codirector, DNA Diagnostic Lab, Johns Hopkins University


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