Leading Causes of Death (all ages)

1
Theodore C. Friedman, M.D., Ph.D.Professor of
Medicine-UCLAChief, Division of Endocrinology,
Molecular Medicine and MetabolismCharles R.
Drew University www.goodhormonehealth.comHow to
Live to 100!Magic Convention Chicago June 13,
2010 In spite of what the brochure says, do not
sell your life insurance policy!
2
Why Live to 100!

• 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

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Why Live to 100!

• Slightly based on the book The Long Life
  Equation by Trisha McNair and Dr. Olga Calof

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Why is it realistic to live to 100 in 2010?

• Better screening
• Better treatment
• More knowledge on diseases

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What can you do?

• Informed consumer
• Days of blindly following your doc are long gone
• Be your own advocate-docs are busy/overwhelmed-you
  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.

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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
• Cant 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)

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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.

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What diseases can you prevent?

• 90
• Exceptions
• Some cancers
• Some types of heart disease
• Heart failure
• Rare incidents of heart attacks strokes

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Leading Causes of Death (all ages)
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Leading Causes of Death by Age
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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

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Plaques
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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

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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

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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).

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EBCT-Priceless (2)

• Patients get a calcium score, which indicates how
  much calcium plaque the patient has in their
  hearts 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

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Who should get a EBCT

• Men gt 40 years, women gt 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.

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EBCT Sample results
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EBCT Sample results
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EBCT Priceless

• As the MasterCard commercial says
• Price of an EBCT 350-500
• Knowing that you have clean coronary arteries
  Priceless.
• www.goodhormonehealth.com

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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.

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Aspirin (2)

• US preventive service task force recommendations
• 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.

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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

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Medical treatment to prevent/treat heart disease

• 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.

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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
  cholesterol-also linked to heart disease.
• Apolipoproteins- Proteins that bind to
  cholesterol-related to heart disease.
• CRP-marker of inflammation-linked to heart
  disease.

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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

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Who should get a statin?

• Anyone with plaques on EBCT!
• LDL Cholesterol gt 160 mg/dL
• One risk factor (age gt 50, family history,
  smoker) LDL Cholesterol gt 130 mg/dL
• Diabetes, kidney disease LDL Cholesterol gt 100
  mg/dL
• Known heart disease, history of MI LDL
  Cholesterol gt 70 mg/dL

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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.

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Niacin

• 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, includingDairy
  products, Lean meats, Poultry, Fish, Nuts, Eggs,
  Enriched breads and cereals

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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

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Cancers

• 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

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Cancers-Males

• Colon cancer
• Prostate cancer
• Lung cancer

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Cancers-Females

• Breast cancer
• Colon cancer
• Ovarian cancer
• Uterine/Cervical cancer
• Lung cancer

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Other Cancers

• Brain cancer
• Lymphoma/Leukemia
• Pancreas cancer
• Kidney cancer
• Stomach cancer

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Colon Cancer

• Colonoscopy!
• Starts as polyps
• Prep is not pleasant, but otherwise easy and very
  recommended.
• Males gt 40, females gt45 (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

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Lung Cancer

• Do not smoke!
• If do smoke-Body scan that includes high
  resolution CT scan of chest.
• Nonsmokers-Men gt 50, women gt 55 high resolution
  CT scan of chest.
• Problem is it may pick up non-cancer lesions that
  require biopsy.

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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 doesnt 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

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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 doesnt hurt, but does not substitute
  for mammogram

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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

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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

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Endometrial Cancer (women)

• See if a gynecologist if you have post-menopausal
  vaginal bleeding

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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

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Stroke

• Same risk factors and markers as heart disease
• Good blood pressure control lt 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

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Diabetes

• Very linked to being overweight/inactivity
• Fasting glucose should be lt 100 mg/dL (get
  screened yearly)
• Diabetes is fasting glucose is gt 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 gt 15 iU/mL -insulin
  resistance
• Prediabetes or insulin resistance-can take the
  medicine metformin (glucophage)

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Diabetes (2)

• HgbA1C-measures average blood glucose levels
• Includes glucose after meals
• Does not require fasting.
• Diabetes gt7.0
• Prediabetes 5.8 to 7.0
• Test yearly
• Avoid getting diabetes and if you get it, get it
  under control.
• See a specialist
• HgbA1C lt 7.0, LDL cholesterol lt 100, BP lt 130/80

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Osteoporosis

• 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

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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, dont 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)

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Home safety

• Smoke alarms
• Fire extinguishers
• Safety glass
• Make sure no lose wiring
• Careful about house work-ladders
• Avoid pesticides

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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
  reptiles-salmonella, wild birds)
• Get vaccinated-influenza, H1N1, pneumovax
• Get early treatment for pneumonia-high fever
  chills, pain on breathing

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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

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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
  cant pronounce)
• Avoid sugar, corn syrup, most sweets, simple
  carbs
• Avoid fried foods

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Diet

• 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

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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

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Sleep

• Sleep deprivation linked to heart disease,
  obesity and diabetes, high cholesterol, blood
  pressure
• 7-8 hrs per night, those who sleep lt 5 hrs or gt 9
  hrs-higher mortality
• Avoid night time stimulants such as caffeine and
  exercise

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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

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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

57
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
• Im fairly skeptical, but will not take someone
  off them, if patient feels they are working
  (unless they are harmful).

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My General Approach

• Look carefully for early signs of
  hormonal/vitamin deficiency via blood testing
• Replace deficiencies until achieving mid-normal
  range
• Dont treat if not deficient
• Look at risks/benefits of treating

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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.

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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, beta-carotene) 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

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Summary of The Effects of Antioxidantsas
Antiaging Interventions

• Vitamin E
• 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
  Alzheimers
• disease
• Inconsistent data on all-cause mortality
• Vitamin C
• No decrease in total cardiovascular mortality
• No reduction in risk of stroke
• Inconsistent data on lipid profile
• Carotenoids
• Inconsistent data on risk of stroke
• Increase in all-cause mortality
• Increase in cardiovascular mortality

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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 lt 30 ng/mL, should be replaced.
• Target level 30-40 ng/mL, maybe around 50 if
  history of breast cancer.
• See goodhormonehealth.com

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Lifestyle

• 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

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Most important aspect

• Attending MAGIC conventions can add years to your
  life
• Thanks to Dianne and all the MAGIC foundation
  workers!

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For more information or to schedule an appointment

• goodhormonehealth.com
• Mail_at_goodhormonehealth.com
• 310-335-0327