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ADT, Apalutamide and Exercise in the Treatment of Prostate Cancer

Hormone Deprivation therapy, also known as Androgen Deprivation Therapy (ADT) is a common long-term treatment for men with more serious prostate cancer or short-term therapy before undergoing radiation therapy. Either way, when a man’s testosterone levels go down to nearly zero, life is experienced differently.

My partner, David at XY Wellness recalls when he was on short-term ADT  before radiation nearly fifteen years ago;

“ ADT materially alters how you interpret and engage with the world around you. It taught me that there is far more than a mind-body connection by suggesting that they are one in the same.”

He continues;

“While undergoing ADT, it is not so much that the man is disinterested in sex but that it simply does not cross his mind.”

Recently, Apalutamide, trade name Erleada was approved for treating men with rising PSA (recurrence) after treatment for prostate cancer without metastasis. Currently, this is the first standard treatment for a scenario for a rapidly rising PSA without metastasis after a study was published in the New England Journal of Medicine.

Study Details

  • A total of 1207 patients underwent randomization: 806 were assigned to the Apalutamide group(240 mg per day) and 401 to the placebo group in the phase 3 SPARTAN (Selective Prostate Androgen Receptor Targeting with ARN-509) trial

NOTE: It is common for there to be funky names to large trials like this and other ADT studies, i.e, LATITUDE, CHAARTED, etc. It helps physicians (especially when lecturing) and lay people alike mention the studies with ease. Of course, SPARTAN has a warrior kind of implication… as in, are you ready to fight? Clever.

  • Follow up was for close to two years.

 

  • Study participants had confirmed prostate cancer that was castration-resistant and was at high risk for the development of metastasis, which was defined as a PSA doubling time of 10 months or less during continuous androgen-deprivation therapy.

 

  • Patients with evident bone metastasis were excluded from the study.

 

  • RESULTS: Time to metastasis, progression-free survival, and time to symptomatic progression were significantly longer (70% better) with Apalutamide than with placebo

 

  • Apalutamide was associated with higher rates of rash, fatigue, joint pain, weight loss, falls, and fracture than placebo.

(Study Link)

 

My Take on the Use of Apalutamide (Erleada is the trade name) non-metastatic Castrate Resistant Prostate Cancer

Apalutamide is an anti-androgen agent, meaning it lowers testosterone and Dihydrotestosterone (DHT) to almost zero, similar to other forms of Androgen Deprivation Therapy (ADT) except this new drug blocks the genetic formation of androgen receptors.

The study was paid for by Janssen Pharmaceutical, the developer of the drug. I say this because when studies funded by the company that makes the drug questioned, the results are often favorable to the company sponsoring the product. Thus, there seems to be some bias playing a role in such scenario.

That said, the design of the study was good, and it was published on one of the most respectable journals, New England Journal of Medicine (NEJM), so I will proceed with a small air of caution.

Seventy percent improvement from cancer worsening in two years compared to placebo is darn good. Of course, no drug that works well comes without downside (excuse the pun).

Men on Apalutamide showed higher rates of rash, fatigue, joint pain, weight loss, falls, and fracture than placebo.

Long-term treatment of ADT is associated with side effects, such as fatigue, reduced bone mineral density, increased fracture risk, decrease in skeletal muscle mass (muscle wasting), associated with the development of metabolic syndrome/insulin resistance, increase in adverse cardiovascular events effects and increases the risk of anemia, hot flashes, gastrointestinal tract disturbances, loss of libido, impotence, osteoporosis, gynecomastia, deep vein thrombosis, congestive heart failure, myocardial infarction, pulmonary edema, cognitive decline and psychological changes.

As I continue to monitor the well being of many prostate cancer patients on ADT, I can say with very little doubt that men can live long and strong while undergoing hormone therapy.

With one caveat…

You must follow a lifestyle and exercise regimen that supports your body.

Many of my patients on ADT are “crushing it” by practicing a prescribed exercise and nutritional regimen gathered from the science I’ve researched.

Not only is prostate cancer successfully managed when combining ADT with lifestyle, but the quality of life is also exceptional. I am not exaggerating.

Should I be on ADT? What would you do if you were me?

I’m often asked by patients, “What would you do if you were in me? Would you go on ADT?”

Such question reminds me of a line in one of the few books I read from cover to cover in high school (I wasn’t a big reader then), To Kill a Mockingbird by Harper Lee…

“You never really understand a person until you consider things from his point of view, until you climb inside of his skin and walk around in it.”

In other words, I am not you. And I have not been diagnosed with PSA recurrence after initial treatment for prostate cancer with curative intent.

That said, I do read many scientific papers on prostate cancer, have extensive clinical experience with patients battling this disease, and have opinions about prostate cancer treatments and quality of life.

Here’s what I’d say…

I am a sucker for a good quality of life. I’d choose the quality of life over longevity in most cases. Much would depend on the severity and length of time of adverse effects from ADT.

Thus, every case is different.

If God forbid, I am diagnosed with aggressive, stage 4 lung cancer; it is likely that I will choose no medical treatments as experience and data show not a significant survival rate and poor quality of life with the available treatments for such disease and numerous others alike.

But I digress. We are talking about prostate cancer.

Men on ADT in my clinical experience are doing exceptionally well, likely because they are following my nutritional and exercise advice – at least, that’s what I’d like to think. Getting on ADT for the right patient and based on the scientific data supporting its use in improving survival is a good option.

Exercise Prescription for men on Hormone Deprivation Therapy or Androgen Deprivation Therapy (ADT) to treat Prostate Cancer

The goal for men on ADT and applying lifestyle and exercise program are:

  1. Minimize adverse and unwanted side effects from ADT treatment
  2. Create a hostile biological environment for cancer in the body to support medical treatment
  3. Optimize quality of life despite ADT.

Wow! That’s a lot. Can we accomplish all that?

Yes, it is. And yes you can.

The right lifestyle and exercise program like the CaPLESS method can minimize about 80% of those side effects. I am not kidding.

Low libido, impotence (or let’s call it sexual dysfunction. Impotence sounds a bit harsh) and hot flashes are non-life threatening and more difficult to overcome.

Most other life-threatening side effects  are greatly reduced.

Studies on Exercise while on Hormone Deprivation Therapy or ADT.

In one study of 2,700 male health care professionals (average age 70 years) with non-metastatic prostate cancer and found that those participating in vigorous physical activity for a duration ≥3 hours/week demonstrated a 49% lower risk of all-cause mortality and a 61% lower risk of death specifically from prostate cancer, compared with men who did 1 1 hour/week of vigorous activity. (Kenfield et al. 2011)

A systematic review of ten studies (five randomized and five uncontrolled clinical trials) examined the effects of exercise on patients receiving ADT. This paper demonstrated that physical performance was improved by exercise. Randomized controlled trials found exercise to be consistently beneficial for muscular performance: reported as increases in muscular strength and increases in upper and lower limb strength, compared with the control population. (Gardner et al. 2014)

Body composition (the amount of fat compared to muscle in the body) is a component of many studies investigating exercise effects on prostate cancer patients on ADT and resistance training has been shown to either increase lean body mass or not decline. Loss of muscle mass is a common scenario amongst ADT patients. (Galvão et al. 2010)

An observational study reported in 2006 looking at over 70,000 men observed 11% increase in myocardial infarction risk and a 16% increased risk of coronary heart disease and death from cardiac arrest in the study of prostate cancer patients receiving ADT, versus those not on hormone therapy. (Keating et al. 2006)

We would want to avoid those cardiovascular problems while on ADT, right?

Although there are no studies I can find specifically to evaluate the effect of exercise on ADT-induced cardiovascular events, there is a large body of evidence supporting the role of physical activity in the prevention and management of cardiovascular disease in the general population. (Thompson et. Al 2003)

Osteoporosis ( bone fragility), is a major side effect of ADT can lead to bone fractures, and bone fractures lead to 37% of deaths in older men. (Ebeling; 2008)

A study of 8,833 men aged 18–64.9 years used computed tomography to show an inverse relationship between adiposity (BMI and visceral and subcutaneous adiposity) and bone quality (Zhang et al. 2015)

Studies show that resistance training in older men and women, where only high-intensity, and not moderate-intensity, strength training resulted in increased bone mineral density. (Vincent et al. 2002)

METABOLIC SYNDROME WHILE ON ADT

Metabolic syndrome defined by weight gain, especially waist gain; fasting glucose 100 mg/dL or higher, peripheral insulin resistance; and increased diabetes risk increase the risk of heart disease and stroke, in addition to diabetes as is a common side effect when ADT.

Results from a randomized pilot study assessed the impact of over six months of combined metformin, a low-glycemic-index diet, and exercise in 20 prostate cancer patients at ADT initiation and compared this with 20 men who were on ADT alone. The metformin and exercise group had decreased abdominal girth, weight, BMI, and systolic blood pressure, compared with the group on ADT treatment alone, although insulin-resistant biochemical markers were not significantly different. In this small study, however, it was not possible to separate the metformin and dietary effects from the exercise components. (Nobles et al. 2012)

63 prostate cancer patients were randomized to receive either a 3-month aerobic and resistance exercise program or usual care, concomitant to initiation of ADT. Patients receiving the exercise-based intervention demonstrated significant reductions in ADT-associated metabolic effects, including decreased whole body fat mass, abdominal fat, and percentage fat, compared with the usual care control group. (Cormie et al. 2015)

C-reactive protein, an inflammation marker commonly elevated in metabolic syndrome, showed a clinically meaningful reduction in a randomized controlled trial of exercise in 57 men on ADT (Galvão et al. 2010)

Exercise Prescription while on ADT

Exercise four hours a week in moderate to high intensity. Anyone on ADT must include weight resistant exercise, two to three times a week, where you push and pull weight against gravity.

Types of exercises used in some studies include:

Leg presses 

Leg extensions

Leg curls 

Lat pull downs

Biceps curls (with dumbbell)

Triceps extension

These are the main strength training exercises performed on many of the studies listed above showing benefit.

Strength training movements I strongly recommend include:

Kettlebell training – Pavel on this video sounds like a military agent. He is the best at kettlebells and one of the most knowledgeable on physical strength. 

(Me and a friend after Kettlebell training)

Squats

Deadlifts

Benchpress

The Press

Pushups

Pull-ups

 

If the above movements and exercises sound foreign then consider hiring a physical trainer if able to. Not only can a trainer help you with the movements but also help prevent injuries.

If an injury occurs during any movements mentioned above, all bets are off, you will not or cannot get the benefit of the exercise.

Listen…

Fear should not stop you from trying and consistently training with the exercises mentioned.

Prostate cancer has to be fought with courage.

The most important point in doing any of the above exercises is to first master the technique of that movement. That is one of two ways you prevent injuries from doing those exercises. The other is avoiding doing too much weight too soon. Yes, you should challenge yourself and increase the weight you push or pull, but it must be done incrementally.

Again, hiring a personal trainer can be priceless if your pockets allow.

Last 3 Blog Posts:

Traditional Chinese Medicine treatment for Erectile Dysfunction

Why I’m Into Intermittent Fasting

Does Eating Chicken Cause Prostate Cancer

 

Resource:

Much of the research for this blog post is from Moyad et al; 2016

Nutrition while on ADT – Advanced ADT Support

 

References:

Kenfield SA, Stampfer MJ, Giovannucci E, Chan JM. Physical activity and survival after prostate cancer diagnosis in the health professionals follow-up study. J Clin Oncol. 2011;29(6):726–732.

Gardner JR, Livingston PM, Fraser SF. Effects of exercise on treatment-related adverse effects for patients with prostate cancer receiving androgen-deprivation therapy: a systematic review. J Clin Oncol. 2014;32(4):335–346

Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) Circulation. 2003;107(24):3109–3116.

Keating NL, O’Malley AJ, Smith MR. Diabetes and cardiovascular disease during androgen deprivation therapy for prostate cancer. J Clin Oncol. 2006;24(27):4448–4456.

Ebeling PR. Clinical practice. Osteoporosis in men. N Engl J Med. 2008;358(14):1474–1482

Galvão DA, Taaffe DR, Spry N, Joseph D, Newton RU. Combined resistance and aerobic exercise program reverses muscle loss in men undergoing androgen suppression therapy for prostate cancer without bone metastases: a randomized controlled trial. J Clin Oncol. 2010;28(2):340–347.

Zhang P, Peterson M, Su GL, Wang SC. Visceral adiposity is negatively associated with bone density and muscle attenuation. Am J Clin Nutr. 2015;101(2):337–343.

Vincent KR, Braith RW. Resistance exercise and bone turnover in elderly men and women. Med Sci Sports Exerc. 2002;34(1):17–23.

Nobes JP, Langley SE, Klopper T, Russell-Jones D, Laing RW. A prospective, randomized pilot study evaluating the effects of metformin and lifestyle intervention on patients with prostate cancer receiving androgen deprivation therapy. BJU Int. 2012;109(10):1495–1502.

Cormie P, Galvao DA, Spry N, et al. Can supervise exercise prevent treatment toxicity in patients with prostate cancer initiating androgen-deprivation therapy: a randomized controlled trial. BJU Int. 2015;115(2):256–266

DA, Taaffe DR, Spry N, Joseph D, Newton RU. Combined resistance and aerobic exercise program reverses muscle loss in men undergoing androgen suppression therapy for prostate cancer without bone metastases: a randomized controlled trial. J Clin Oncol. 2010;28(2):340–347.

Exercise Lowers Prostate Cancer Death & Improves Mental Health – Study

[ My garage gym. Serves as a meditation area for me too]

 

This recent study of over one million people demonstrates that those who exercise experience 43% more mental health than those who don’t.

Let me say that again, 43% better mental health.

Folks, imagine a drug that improves depression by 43%?

By far that would be the most successful pharmaceutical drug for depression to date. The news would be all over the news – headlines everywhere, the top story on CNN and Fox, the front cover of the New York Times (NYT).

But you likely don’t know about this strong association between exercise and mental health until now.

Crazy!

While all exercise in this study decreased what authors called “mental burden,” the most significant associations were seen for popular team sports like soccer and basketball, cycling and aerobic and gym activities.

Activities like yoga and tai chi had a nearly a 23% reduction in poor mental-health days.

For maximal benefit exercise duration was about 45 minutes a day, three to five times per week, according to the study.

Mental health is generally defined as depression, anxiety, post-traumatic stress and general stress.

This recent study was published on one of my favorite and most prestigious journals, the Lancet Psychiatry.

By the way, the association between exercise and mental health is not new. Actually, the science is ridiculously old.

A few months ago in another prestigious journal, JAMA, they looked at close to eighteen thousand middle-age people noticed a significant decrease in depression, death from heart disease and death from heart disease specifically associated with depression.

In addition to mental health, exercise is also linked with lower risk of dying from prostate cancer.

A study that tracked tens of thousands of midlife and older men for more than 20 years has found that vigorous exercise and other healthy lifestyle habits may cut their chances of developing a lethal type of prostate cancer by up to 68 percent. While numerous lifestyle factors such as eating tomatoes, not smoking, eating fewer process meats and exercise contributed to less prostate cancer-related deaths, the connection with exercise was most substantial.

Again, 68% less prostate cancer mortality! Lord!

In addition, I have talked about the benefits of exercise in men undergoing hormone therapy for prostate cancer – HERE is the link.

How to start an Exercise Regimen right for you.

The first thing is to quit making excuses for why you are not physically active.

HERE is a list of common excuses why you are not physically active, and I suggest you stop making them and get going. Seriously.

Physical activity is real medicine and one of the most powerful types to not only prevent many disease but also to treat it.

The other point here is that as one ages building strength becomes essential.

You see, the body wants to muscle waste as one age – a process called sarcopenia – and you need to fight that as your life depends on it because it does.

The best method to fight that is by practicing weight resistant exercises.

Research shows the stronger you are, the longer you live.

 

Two years ago, along with my regular strength training routine, I began Krav Maga (KM), an Israeli martial art.

The reason I began training in KM was because I was itching for something new and completely out of my comfort zone. Additionally, I always enjoyed combat sports so why not try it.

And I love it. There is a community element that is pretty cool. While my fighting partners and I don’t necessarily have drinks together, we do talk about life, fighting, and current events when we are at our KM school.

Interestingly, a recent NYT article demonstrates and aging researcher from Harvard, Dr. Kirk Daffner, trains in Greek Karate ( known as Pankration) with his teacher who is 90 years old. In martial arts, Dr. Daffner explains, not only is there mental stimulation and movement but also social engagement and connection, which is likely therapeutic.

The takeaway for today is to get out of your comfort zone, quit making excuses and start consistently moving your body. Join a group of whatever you like, yoga, cycling, running, martial arts, whatever.

The other thing is to exercise every day. That’s right. Every single day you should do 20 to 60 minutes of something physical. One day you can do stretching, the other day, say, yoga, third-day weight resistance, day four tennis, etc.

Even if its ten minutes a day, that’s good for now. Just go!

You get as much benefit from the volume of exercising (doing it often) as you do from the intensity.

 

Lastly, while I like lifting weights by myself – as it is a form of active meditation for me – my neighbor Scott (above pic) joins me on Sunday mornings for a session we call “lift and learn.”

We made this “lift and learn” thing up. Primarily, we do either barbell squats or deadlifts, with pull ups and push ups then talk about improving our lives as men. Anything from religion to philosophy to raising kids is on the table. I have to say this one of the most enjoyable events of my weeks, and I feel empowered after our Sunday morning sessions. I think Scott does too.

Here’s the bottom line; Implementing the science it what it’s all about. Team activities seem to be extremely beneficial for your health and longevity. But if for whatever reason joining a fitness group is not an option, just put on some sneakers and go for a 10-minute walk. Start somewhere, and you will see how beautifully you will progress and fee.

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Another Study on Exercise and Prostate Cancer

CaPLESS RETREAT (will close for registration tonight, August 26th at midnight)

The CaPLESS Retreat is coming in September 14 – 16, 2018 to help prostate cancer (CaP) thrivers live their best life by implementing science-based lifestyle practices. Prostate cancer is an opportunity to live healthier than before your diagnosis. Learn how. There is limited space.

 

L-Citrulline: The Heart and Penis Connection

The penis is a barometer of male health. Since erectile dysfunction (ED) is closely linked to various forms of heart disease, failure to keep an erection may be a sign of an incoming cardiac event.

STUDY DETAILS

According to the Massachusetts Male Aging Study, conducted in 1994, erectile dysfunction is a common problem for aging men. More than half of men over 50 and more than two-thirds of men over 70 have ED.

A recent review article in the European Heart Journal showed that ED has a strong connection to heart disease.

In patients who had ED;

• Cardiovascular events were 44% more common
• Cardiovascular mortality rose by 19%
• Heart attack was 62% more likely in patients
• Cerebrovascular events (such as stroke) were 39% more likely
• All-cause mortality (death, period) was 25% more likely.

What connects the Heart to the Penis?

Poor arterial health, and an important compound called Nitric Oxide.

Nitric Oxide (NO) links Erectile Dysfunction with Cardiovascular Disease

NO is mainly responsible for widening the arteries during physical activity, but it also plays a role in sexual activity. It opens the arteries in the penis so that blood can flow in and cause an erection. Without NO, the arteries don’t expand as they usually would.

Plaque ends up forming in the walls of the arteries, and this leads to a variety of heart problems including heart attack and stroke.

This plaque doesn’t just form on the walls of arteries in the heart and around the brain. It collects on all of the arteries in the body, and the penis is no exception.

Plaque formation in the pelvic area blocks blood flow and is one contributing factor to ED

What’s different about the penis, though, is that you can easily see whether or not the organ working (It’s harder to look inside the arteries of your heart). And since erections depend on healthy arteries, an erect penis a significant marker of a robust cardiovascular system.

 

In Chinese Medicine, the Heart and Penis are Connected

In Chinese medicine, the Heart channel is related to the Kidney channel within the Shao Yin channels. It is also indirectly related to the Kidneys through the Du Mai and Ren Mai, both of which flow through the Heart and originate from the space between the Kidneys. Both the Du and Ren Mai have a profound influence on sexuality and the sexual function including sexual desire, sexual arousal, erection, maintenance of erection and ejaculation. Furthermore, the Chong Mai also starts from the space between the Kidneys and goes to the Heart and, also, it controls the zong muscles in the abdomen which many interpret as being the penis. (Giovanni Maciocia, February 2013)

I know, now I am talking Chinese (haha)

My Take on Erectile Dysfunction Connection to the Heart

Erectile Dysfunction (ED), or impotence, is a common problem, but, for reasons I will explain, I would not say it’s normal. Because of the strong links between erectile dysfunction and cardiovascular issues, and then perhaps stronger links between cardiovascular health, diet, and exercise, I see the penis as a kind of barometer of male health. When the fluid transport systems in the body are working correctly, erections are a natural result. When arteries are clogged and hardened by an unhealthy lifestyle, the arteries in the penis take a hit just as much as the arteries in the heart and erections are blocked.

So, how many erections should you be getting? What’s a “day in the life” of a healthy penis? If you’re not sexually active, you should experience morning erections at least 3 to 4 times a week. During regular REM sleep each night, the average man has between three and five erections. (Yes, that many.)

And, of course, it should not be difficult to gain an erection leading up to sexual activity.

 

L-Citrulline for Erections and Heart Health

What do we learn from this? First, frequent and regular erections are a sign of good cardiovascular health.

Of course, this link does not apply to men who have undergone prostate cancer treatment like surgery or radiation as they would experience less to no erections normally.

Keep in mind, though, that ED is not necessarily a sign of a heart problem; it can be caused by anxiety as well, and a failure to rise could stem from fear, discomfort, or other stressors. But if these are not your problems, then I’d advise taking a look at your lifestyle.

The best thing you can do is to prevent or resolve metabolic syndrome by changing your lifestyle. Get out and exercise. Cut out processed foods from your diet. To make sure your body produces enough NO, get some extra L-Arginine from animal protein and nuts.

Better yet, consider L-Citrulline which is a nutrient that makes more L-Arginine in the body than L-Arginine itself and has shown to help with sexual function. Eating pomegranate and taking Resveratrol can help with endothelial dysfunction.

How L-Citrulline Works?

L-Citrulline is an amino acid not found in proteins but found mainly in watermelon. The health-related applications of l-citrulline supplementation due to the ability of l-citrulline to increase l-arginine availability for NO production.

l-citrulline increases NO biosynthesis indirectly by increasing l-arginine synthesis, which in turn may lead to improved endothelial vasodilator function. In other words, it helps open up arteries.

One small study showed L-Citrulline improved penile hardness.

When Not to Use L-Citrulline

I prescribe L-citrulline in the formula of XYVGGR to help men with sexual function.

However, after using XYVGGR successfully for over seven years, I have had to take about three patients off of it because of a lowering blood pressure effect. Due to the dilating arteries effect of L-Citrulline, a desirable response when needing a pelvic lift, it opens up the arteries of the whole body reducing blood pressure.

When a patient has normal low blood pressure, say 90/60 mmHg or less, they DO NOT get XYVGGR or anything with L-Citrulline. The typical complaint of unwanted lower blood pressure is dizziness. On the other hand, if there is a sexual problem in a man and he also has high blood pressure, using L-Citrulline in a formula like XYVGGR may have a duo effect.

 

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CaPLESS EVENTS

The CaPLESS Retreat is coming in September to help prostate cancer (CaP) thrivers live their best life by implementing science-based lifestyle practices. Prostate cancer is an opportunity to live healthier than before your diagnosis. Learn how. There is limited space.

Prostate Cancer: Late Night Eating Increases the Risk

I spend much of my clinical time talking to patients about nutrition and helping them choose what to eat.

As always, I challenge my knowledge to do better for my patients and my family.

As of late, the conversation on eating has shifted a bit not only on the what to eat but also on when to eat.

Here’s the deal; it turns out the earlier your meals, the less likely you will get prostate cancer or breast cancer based on this new study.

Study Details:

  1. Case-controlled based study conducted in 12 Spanish regions in 2008–2013
  2. 1,738 breast and 1,112 prostate incident cancer cases
  3. People working night-shift (which increases prostate and breast cancer risk) were excluded from the study to control for the possibility of night shift work being the cause of cancer and not nighttime eating

CONCLUSION: Those who ate their last meal of the day before 9 p.m. was found to have a 20 percent lower risk of breast and prostate cancers than compared to those who ate after 10 p.m. or went to bed right after dinner, those

Dr. Geo’s take on Late Night Eating for Cancer

This is not the first study suggesting against late night eating for disease prevention.

In a group of over four hundred overweight participants, late eaters had a more difficult time losing weight compared to early eaters despite having similar age, appetite, hormones values, food intake, sleep duration, etc.

Another study observed that those who ate late at night had 55% higher risk of heart disease compared to the early eater.

Interestingly, in Traditional Chinese Medicine (TCM), which I trained in as well, digestion is a yang activity, and nighttime is yin – doing a yang activity doing yin time contributes to disease in TCM.

The ill effects of eating late are not necessarily what I want to hear as nighttime eating can feel soooo gooood.

Here are some holistic but realistic tips:

  • Know that doing the right things, i.e., exercising, last meal early, taking good supplements it’s not supposed to be always fun, but its essential to do if the goal is to live longer and function optimally. Some pain, psychological or physical is OK.

 

  • Life happens. Sometimes is a toss-up between coming home late from work and not eating or having a meal with your family even though it’s 10 pm. I would opt with eating with my family, eat light and not eat again for 12 to 16 hours later (intermittent fasting). Implement this same advice with late-night dinner meetings and holidays.

 

  • Eat less protein at night and more carbs. Yeah, I know this is tough to do at a steakhouse and anti-paleo but here’s the story; protein gives you energy, carbs have a calming effect by secreting more serotonin, a precursor to the sleep hormone melatonin. Now, if you eat too many carbs, especially processed carbs (i.e. bread, pasta, etc.) you will have a carb hangover the next morning – that awful, dragging feeling as if you downed ten shots of tequila. Eat small portions of whole carbs like sweet potato, rice, etc.

 

  • Get to bed early. The longer you’re up, the more you will want to eat.

 

  • Take the dietary supplement, 5-hydroxytryptophan (5-HTP) if you crave food at night. Tryptophan is an amino acid precursor to serotonin, and it has been my experience it reduces cravings at night. There might be some sleep benefit there as well.

You only get one shot at living your best life. You don’t always have to like doing the right things – do them anyway. Don’t eat after 8 pm, most days of the week. Change is good. Purposeful, smart pain is good too. Enjoy the benefits. Trust the process. Also, often what is good for prostate (and breast cancer) prevention is also good after the diagnosis of these diseases as well.

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CaPLESS EVENTS

The CaPLESS Retreat is coming in September to help prostate cancer (CaP) thrivers live their best life by implementing science-based lifestyle practices. I to connect with you there. There is limited space.

BREAKING NEWS: USPTSF Position on Prostate Cancer Screening

The United States Preventive Service Task Force (USPSTF) on PSA screening

The United States Preventive Services Task Force (USPSTF)  is a government supported panel composed of national medical experts in primary care and researchers (no urologist or oncologist on the panel) who collectively review the evidence for what screening tools and treatments are most useful for patients.

The USPSTF has a grading system ranging from grade A, where the task force recommends for a service (screening or treatment) to grade D where the recommendation is against a service, and everything else in between. (see below chart).

In 2012 the United States Preventive Services Task Force (USPSTF) issued a report opposing the use of PSA in screening for prostate cancer and gave a grade “D” recommendation, discouraging physicians to screen for prostate cancer and that there is more harm than good with the use of the PSA test.

Then two years later after further data review, the USPSTF graded PSA screening to a “C,” suggesting that the decision on whether or not to screen for prostate cancer with PSA test should be shared between the physician and patient and it should be used selectively in a case by case basis.

Today, published in the Journal of American Medical Association (JAMA), the USPSTF concludes that there is a small overall benefit with the use of PSA in screening for prostate cancer, but continues to note that damages may occur during this screening process.

There is still a major age-related problem in this current recommendation because studies have predominantly included patients aged 55-70 years. Thus, the new USPSTF will not recommend PSA for men over 70 years nor for those under 55 years, which seems inadequate, given that it does not take into account clinical characteristics nor individual volition.

This new screening grade is important because the task force has an influence on how clinicians practice on what health insurance companies pay for.

Now Three Studies Driving Prostate Cancer Screening Controversy

Initially, the two main trials influencing the USPSTF’s grading on prostate cancer screening are The European Prostate Cancer Screening Trial (ERSPC) and The American Prostate Cancer Screening Trial (PLCO) study. Now there is a more recent study, the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP) that reinforces the task force position on screening.

The Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP)

This British study was conducted in the United Kingdom, where about five hundred primary care practices in the United Kingdom were offered to screen men aged 50 to 69 years an invitation to a single PSA test (271 practices) and a control group that did not offer PSA testing (302 practices).

In an average of ten years follow-up, there was no all-cause mortality difference between the screened and the non-screened group.

In other words, men who were screened for prostate cancer died from any cause, not just prostate cancer as much as men who were not screened at all. As one would expect, there was an increase in low-risk prostate cancer detection in the screening group in the CAP study.

The European Prostate Cancer Screening Trial (ERSPC)

The ERSPC randomized trial of about 160,000 men between 55 and 69 years for PSA screening or control without PSA where the PSA average to indicate a prostate biopsy is ≥ 3.0 ng/ml. The PSA test was taken, on average, only every four years. After monitoring for 11 years, screening reduced the risk of metastases by 41% and the chance of death from prostate cancer by 21%.

More recently, the European ERSPC study, now with almost 14 years of follow-up, confirmed that prostate cancer mortality in PSA screened patients decreased by 32% suggesting that as time goes on study subjects continued to be followed, there will be more benefit from PSA screening.

On the other hand, ERSPC trial continues to show a major problem with over diagnosing for prostate cancer screening with PSA of clinically insignificant tumors.

In fact, in the ERSPC study, the finding of low-risk tumors (PSA less than10 ng/mL and Gleason score less than 6) was almost three times higher in the screened group than the control group.

The American Lung, Colorectal, and Ovarian Cancer Screening Trial Trial (PLCO) study

Lastly in the American Lung, Colorectal, and Ovarian Cancer Screening Trial Trial (PLCO) study randomized over 76,000 men aged 55 to 74 years for annual screening with PSA and rectal exam or control group with the “usual urological care,” that is, at the discretion of the urologist.

The PSA value used to indicate biopsy was ≥ 4.0 ng/mL. This study initially showed no mortality benefit for men who received PSA screening in comparison with those who did not.

The problem in the PLCO trial was the control group. Since “usual care” in the USA includes PSA, in this case almost 90% of the patients in the “usual care” group did the test compared to the randomized group. Therefore, it is no surprise that the rates of prostate cancer death were similar to the screening arm.

When researchers combined all the major prostate cancer screening studies, they did not find a significant decrease in prostate cancer-specific mortality except in the ERSPC which screening did indeed lower prostate cancer mortality.

They concluded that “Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms.”

The Takeaway from the USPSTF on Prostate Cancer Screening

The task force grade recommendation for prostate cancer screening stays at a “C” which mostly means that you, the patient, can dictate whether or not you want to be screened for prostate cancer. If you do not want a PSA test taken, then you can decline, and in theory, your physician should be fine with it.

Essentially, there is no grand change in the USPSTF recommendation from 2014, other than they are doubling down on their “C” grade reinforced by the CAP study.

The Dr. Geo’s Guide to Prostate Cancer Screening & Protection

I am all for patient empowerment and for men partnering with physicians to improve his health. Furthermore, many of my patients, naturally, since I am a holistic practitioner, want to avoid biopsies.

I don’t blame them. I don’t know anyone who gets excited about having their prostate poked 12+ times and had blood come out their urine and semen for up to two weeks.

The evidence is clear that most men with high PSA scores who get biopsied, do not have prostate cancer (what we call a false positive). It is also obvious, based on volumes of research that there is overtreatment of prostate cancer, meaning, most men with prostate cancer will not die from it making prostate cancer treated with either surgery or radiation obsolete.

Why not screen for prostate cancer and not treat if the outcome is low-grade disease?

Because that diagnosis is daunting to your brain. It’s the “cancer” word. In other words, the problem in many cases is the diagnosis itself – it provokes anxiety and unease – so rather than letting those feeling linger “taking it out” is what many men opt for.

The problem is not the PSA test. And ignorance is not bliss. Before the late 1980’s most men diagnosed with prostate cancer had advanced disease, and those numbers went down drastically after the commercial use of PSA test.

The problem is how the PSA number is used (or abused). As the CAP study revealed, just one PSA number that is relatively high does not dictate you have prostate cancer or that a biopsy is needed.

When I partner with patients to determine if avoiding a prostate biopsy is the right for them, we look at:

  • Age of the patient
  • Family history
  • Race
  • PSA relative to age
  • PSA free percentage
  • PSA density
  • the blood test 4K score
  • the urine test Select MDx.

If most of the results from testing indicate suspicious prostate cells, then we look into getting a 3-Tesla MRI. Still, no biopsy needed up to this point.

If the MRI highly suggested suspicious cells, typically of Gleason 7 or higher, then I would recommend a biopsy, but not a random ultrasound guided one, a targeted MR fusion biopsy.

The bottom line is how a physician uses a PSA test matters most, as imperfect of a biomarker for prostate cancer screening as it is, it saves lives.

At a minimum, an elevated PSA can tell you if something wrong in the prostate, even if it’s not cancer, maybe inflammation or other benign development.

The ultimate goal of prostate cancer screening is this:

• Find a cost-efficient method of locating tumors that have the most life-threatening potential.

• Leave tumors that are not deadly alone, or better yet, not find them in the first place.

• Have a treatment that can remove the possibly deadly cancer without sacrificing quality of life.

The methods of the screening I highlight above provide the best chance of accomplishing the ultimate goal for prostate cancer screening.

Also, prevention is the best medicine.

When I say prevention, I also mean prostate cancer recurrence prevention or, if it returns, preventing spreading of cancer.

Nutrition and Lifestyle is real medicine.

My recommendations:

  • Eat protective foods. A plant-based, Mediterranean method of eating is protective, and it’s the cornerstone of the CaPLESS method of eating.
  • Exercise four hours a week with moderate intensity.
  • Consume selected, targeted supplements from companies that exceed governmental quality manufacturing practices. My favorite supplements for ultimate protection are what I call my one-two punch: ImmunoPCTN and GDtoxSel.

Part Three: PSA use for Prostate Cancer Screening

This is part three of a four-part series on the PSA test in an attempt to demystify the most feared blood marker in men.

 

Part one: What is PSA and what it does

Part two: Benign reason’s why PSA goes up

Part three: PSA use for Prostate Cancer Screening 

Part four: PSA after prostate cancer treatment

 

The Prostate Specific Antigen (PSA) test is the number one used biomarker for prostate cancer screening. In other words, the PSA blood test starts the unpleasant process of biopsies, prostate cancer treatment when malignant cells are found and side effect treatment from the cancer treatment. Many people think PSA is an expensive waste. One of those people is Dr. Richard Ablin, the discoverer of PSA who called this test in a New York Times article, The Great Prostate Mistake. He also wrote the book the Great Prostate Hoax condemning the PSA test for prostate cancer.

Should we stop PSA testing for prostate cancer screening?

No. I will explain. Stay with me.

How does PSA work?

As we learned in the previous article of this series, PSA breaks through the wall of the glandular portion of the tissue and seeps into the bloodstream for many malignant and mostly benign reasons. Ideally, the PSA molecule is only found in the semen. In fact, there are one million times more PSA in the semen than in the blood.

PSA in men before Prostate Cancer diagnosis

The “normal” range of 0.0ng/ml – 4.0ng/ml you see in lab reports is absurd.

Anything under 4ml/ng does not mean you don’t have prostate cancer. In fact, 15% of men with a PSA under 4 develop prostate cancer (Thompson et al. 2004)

Generally speaking, PSA is age-related. For example, a 40-year-old “should” have a PSA well under 1.0ml/ng (exception to the rule, this individual may have an infection of his prostate or other non-cancer causes to his PSA to be above 4).

A 60-year-old with a PSA of 2 may be fine.

A steady trend upward, even if the number is under 4, after three or four PSA tests may be more connected to prostate cancer once prostatitis or other benign conditions are ruled out.

On the previous article, we spoke about non-cancer reasons why PSA is elevated, but there are also numerous reasons why PSA is falsely low, meaning, one can have cancer while there PSA is “low.”

There are two things that cause a false lower PSA:

  1. The meds Finasteride (Proscar) and Dutasteride (Avodart) – falsely lowers PSA up to 50%.

2. Obesity: estrogen activity (which big men have more of) causes a decrease in PSA.

FYI: Obese men typically have worse cases of prostate cancer and higher changes of prostate cancer relapse after treatment. (Cao, 2011) Yet another motive for overweight men to get in shape.

The Good with PSA Screening for Prostate Cancer

Over the past 28 years, since the introduction of prostate-specific antigen (PSA), the incidence of metastatic prostate cancer and dying from this disease has significantly decreased. Although it is hard to connect the cause of prostate cancer decline to PSA, the five-year cancer-specific survival increased from 69% in the 1970s to now more than 95%, associating longer survival in diagnosed men to PSA examination.

 

The United States Preventive Service Task Force (USPSTF) on PSA screening

The United States Preventive Services Task Force (USPSTF) is a group of non-urologists or oncologists; mostly experts in primary care and researchers who collectively review the evidence for what screening tools and treatments are most effective for patients.

The USPSTF has a grading system ranging from grade A, where the task force recommends for a service (screening or treatment) to grade D where the recommendation is against a service, and everything else in between. I stand for insufficient evidence to recommend for or against a service.

In 2011 the United States Preventive Services Task Force (USPSTF) issued a report opposing the use of PSA in screening for prostate cancer and gave a “D” grade recommendation, meaning that existing scientific data demonstrate that there is more harm than good with the use of this test.

Then two years later after further data review, the USPSTF graded PSA screening to a “C,” suggesting that the decision on whether or not to screen for prostate cancer with PSA test should be shared between the physician and patient and it should be used selectively in a case by case basis.

The USPSTF concludes that there is a small overall benefit after a decade with the use of PSA, but continues to note that damages may occur during this screening period. However, there is still a major age-related problem in this current recommendation, because studies have predominantly included patients aged 55-70 years. Thus, the new USPSTF will not recommend PSA for men over 70 years nor for those under 55 years, which seems inadequate, given that it does not take into account clinical characteristics nor individual volition.

The Two Main Studies Driving PSA controversy

The two main humongous trials influencing the USPSTF where the PSA controversy is derived from is The European Prostate Cancer Screening Trial (ERSPC) and The American Prostate Cancer Screening Trial (PLCO) study.

The ERSPC randomized trial of about 160,000 men between 55 and 69 years for PSA screening or control without PSA where the PSA average to indicate a prostate biopsy is ≥ 3.0 ng/ml. The PSA test was taken, on average, only every four years. After monitoring for 11 years, screening reduced the risk of metastases by 41% and the chance of death from prostate cancer by 21%.

More recently, the European ERSPC study, now with almost 14 years of follow-up, confirmed that prostate cancer mortality in PSA screened patients decreased by 32% suggesting that as time goes on and study subjects continued to be followed, there’s benefit from PSA screening.

On the other hand, ERSPC trial continues to show major problem with over diagnosing for prostate cancer screening with PSA of clinically insignificant tumors.

In fact, in the ERSPC study the finding of low-risk tumors (PSA less than10 ng/mL and Gleason score less than 6) was almost three times higher in the screened group than the control group.

The other influential study on prostate cancer screening is the American Lung, Colorectal, and Ovarian Cancer Screening Trial Trial (PLCO) study randomized over 76,000 men aged 55 to 74 years for annual screening with PSA and rectal exam or control group with the “usual urological care,” that is, at the discretion of the urologist.

The PSA value used to indicate biopsy was ≥ 4.0 ng/mL. This study initially showed no mortality benefit for men who received PSA screening in comparison with those who did not.

There is a major problem in the PLCO trial, however.

The “usual care” subjects ( the control group) in the USA includes PSA, in this case almost 90% of the patients in the “usual care” group did the test compared to the randomized group. Therefore, it is no surprise that the rates of prostate cancer death were similar to the screening arm.

This is a multi-million dollar study with a major flaw in it that influence how physicians practice.

That’s freaking insane!

When another group of researchers combined all the major prostate cancer screening studies, they did not find a significant decrease in prostate cancer-specific mortality except in the ERSPC which screening did indeed lower prostate cancer mortality.

They concluded that “Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms.”

Other Big Studies on Prostate Screening to Note

Other studies on prostate cancer screening that I find valuable but do not get the attention of PLCO and ERSPC are these two Swedish trials:

In the Gothenburg, in Sweden, 20,000 men were randomized 1:1 for PSA screening every two years or control without PSA. Their average age of participants were 56. The PSA value used to indicate the biopsy was between 3.0 and 4.0 ng/mL. After a 14-year follow-up, there was a relative decrease in prostate cancer mortality of 44%. Prostate cancer was diagnosed in 12.7% of the patients in the screening group and 8.2% of those in the control group.

Again, there was a high rate of overdiagnosis and overtreatment in this trial as well.

Researchers concluded that 293 cases needed to be screened and 12 treated for prostate cancer to prevent one tumor-related death.

[These figures are similar to those for breast cancer screening by the way]

Lastly, this study from Malmo Sweden of over 21,000 patients demonstrated that PSA levels in patients around 45 years of age with no family risk factors could provide data on the chance of developing aggressive prostate cancer and risk of death from the tumor in the coming decades.

When the baseline PSA values were below the population median according to the different age ranges:

  • up to 42 years: ≤ 0.6 ng/mL the chance of death from prostate cancer in 25 years was estimated at 0.1%
  • up to 50 years: ≤ 0.7 ng/mL the chance of death from prostate cancer in 25 years was estimated at 0.5%
  • up to 55 years: ≤ 0.9 ng/mL the chance of death from prostate cancer in 25 years was estimated at 0.8%

These authors suggest that only three PSA measurements, the first performed at around 45 years, the second at the beginning of the fifth decade of life, and the third at 60 years may be sufficient for a safe risk assessment for half of the population.

My Take on the Science of PSA use on Prostate Cancer Screening

There’s no question that the majority of men screened for prostate cancer will not die from it. In other words, there is indeed over-diagnosis and over-treatment of prostate cancer from PSA screening. No one will argue that.

However, many lives have been saved from prostate cancer screening since the beginning of clinical use in the early 1990’s.

If I am the one in the unfavorable percentage of developing aggressive prostate cancer, I want to know as early as possible and do something about it.

The idea of beginning PSA testing at the age of forty as suggested by the Swedish trial is appealing as I have seen many men in their forties with aggressive prostate cancer.

Prostate cancer screening is a case-by-case process. Every case is different, and the approach has to be individualized to the one patient in the office, not only to what researchers conclude as there are design flaws in all studies.

The Dr. Geo’s Guide to Prostate Cancer Screening

Many of my patients, naturally, since I am a holistic practitioner, want to avoid biopsies.

I don’t blame them. I don’t know anyone who gets excited about having their prostate poked 12+ times and have blood come out in their urine and semen for up to two weeks.

When I partner with patients to determine if avoiding a prostate biopsy is the right for them, we look at:

If most of the results from testing indicate suspicious prostate cells, then we look into getting a 3-Tesla MRI.

If the MRI highly suggest aberrant cells, then I would recommend a biopsy, but not a random ultrasound guided one, a targeted MR fusion biopsy.

Additionally, I recommend men to get a PSA reading at forty years of age, regardless of family history and use that as their baseline. If there is no family history and PSA is normal relative to age, do a PSA every five years. If there is a family history (father, brother, etc) then PSA should be taken once a year.

The PSA number is not the problem. What you do with that number is what matters. 

Not all elevated PSA requires a biopsy.

The bottom line is that PSA is decent, though imperfect marker for prostate cancer screening and have saved lives.

At a minimum, an elevated PSA can tell you if something is going on in the prostate, even if it’s not cancer, maybe inflammation or other benign reasons.

The ultimate goal of prostate cancer screening is this:

Find a cost-efficient method of locating tumors that have the most potential to be deadly. Leave tumors that are not deadly alone, or better yet, not find them in the first place. (The “C” word diagnosis, even for indolent tumors prokes anxiety and unnecessary worry). Have a treatment that can remove the potentially deadly tumor without sacrificing quality of life.

Well, maybe one exception, some tests like the MRI are expensive, and health insurances don’t always cover it despite evidence indicating that MRI testing reduces the risk of overdiagnosis.

Yep, that frustrates me too. HERE is what I found to work to get your prostate MRI covered.

The methods of the screening I highlight above are not perfect by themselves but better collectively in providing the best chance of accomplishing the goal of better screening practices to finding and treating deadly prostate cancer.

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[Not part of this series]

ADT, Apalutamide, Exercise in the treatment of prostate cancer

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Part Two: Benign, Non-Cancerous Reason’s why PSA rises

Part one: What is PSA and what it does

Part two: Benign reason’s why PSA goes up

Part three: PSA as a screening tool for prostate cancer

Part four: PSA after prostate cancer treatment

 

More often than not, PSA rises for reasons other than cancer. Still, this biomarker continues to stress men all over the world who get tested for it.

Here are non-cancer reasons why PSA goes up:

  • Ejaculating about 48 hours before the blood draw can cause a false increase in PSA by up to 1.3ng/ml.

 

  • PSA may be higher in smokers compared to non-smokers.

 

  • Inflammation of the prostate, or prostatitis, may cause an elevation in PSA. Symptoms of prostatitis include; pain or discomfort in the perineal area (between the scrotum and the anus), feeling of “sitting on a golf ball,” lower abdominal pain, lower back pain, burning, pain or discomfort after urination and/or ejaculation. Urinary frequency and urgency also appear in men with prostatitis. Treating prostatitis lowers PSA by close to 40%.

 

  • A digital rectal exam (DRE) before the PSA blood draw can increase PSA by 0.4ng/ml, which many physicians think it’s not a big deal. However, when a biomarker like PSA cause so much anxiety when elevated, anything you can do to keep the number low is a good idea, don’t you think? Also, the more vigorous the exam, PSA can go higher than 0.4 points.

 

  • Needle biopsy of the prostate raises the PSA level by seven times its normal value and stay elevated for up to 4 weeks.

 

  • Benign Prostatic Hyperplasia (BPH) or enlarged prostate cause an increase in PSA. One of the best methods to determine if PSA is high from BPH and less likely from prostate is by doing a PSA density. This is a simple calculation where the prostate size, best measured by an MRI, second best by ultrasound, is divided over PSA value. If the result of that calculation is higher than 0.15, the elevated PSA is likely from prostate cancer. If the PSA density is less than 0.15, it is likely from an enlarged prostate. PSA density should not be the only determining factor for prostate cancer diagnosis. Lastly, a group of pharmaceutical drugs called, 5-alpha reductase inhibitors (5-ARI), falsely reduces PSA by about 50%, meaning, that one can harbor prostate cancer and have a low PSA when being on these drugs. Finasteride and Dutasteride 5-ARI’s are the two main drugs used for BPH.

 

  • Riding a bicycle for long distance can increase PSA score by up to 10% by putting pressure on the perineum area close to where the prostate is located. Cycling for short distances may not make a difference. Similar to after ejaculating, it is best to abstain from riding for at least 48 hours before the blood draw.

 

  • Any form of vigorous exercise a day or two before a blood draw may result in a false increase in PSA.

Next week you will learn the use of PSA as a screening tool for prostate cancer and uncover the confusion associated with it.

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What Dietary Supplements Can and Can’t-Do

What’s a dietary supplement?

The Dietary Supplement Health and Education Act (DSHEA) defined a dietary supplement as either a vitamin, mineral, herbals and botanicals, amino acids, enzymes that people consume by mouth to supplement a diet in the effort to improve health. They come in the form of capsules, tablet, and powder.

1. Dietary supplements do not replace healthy eating. They complement it.

2. Dietary supplements are not expensive urine. The body uses what it needs then eliminates what it doesn’t through your urine, feces, and sweat. Should we stop drinking water because we pee it out?

3. Dietary supplements do not cure disease. And it’s illegal for unscrupulous companies to advertise their product cures disease. Several companies recently “got slapped on the wrist” by the FDA for making cancer claims.

4. Dietary supplements do support your body’s innate ability to keep you healthy or bring your body back to health after a diagnosis.

5. Dietary supplements can claim to support structure or function of the body, for example, “support joint function” or “improves anti-oxidant capacity.”

6. Some botanicals like curcumin and Boswellia have excellent anti-inflammatory benefits, study suggests.

How are Botanicals in Supplements different than Pharmaceutical Drugs?

Pharmaceutical drugs are much different than herbal substances. Herbs may have hundreds of natural chemicals in them while a pharmaceutical drug has one isolated chemical known as the active ingredient to enhance its effects.

Many medical drugs come from plants. For example, aspirin comes from the plant White willow bark. When making aspirin one component of the white willow bark, salicin, is taken out and concentrated.

Any time one ingredient from a plant is removed and concentrated for therapeutic purposes two things happen:

One, the drug may have a faster therapeutic effect.

Two, there is an increased chance of unwanted side effects

Is there any Scientific Evidence to support the use of dietary supplements?

I consume about 15 dietary supplements two times a day to support my health, reduce risk of disease and keep functioning optimally.

(That’s my afternoon dose on the picture up there).

I suspect the amounts of supplement pills will increase as I get older and my nutritional demands increase.

Despite what naysayers like Paul Offit, MD say about the lack of science behind the use of dietary supplements, there is ample evidence supporting its use.

A Few Studies Supporting the Use of Dietary Supplements

 

One randomized French study showed a 31% decrease in cancer incidence and 37% reduced the chance of dying from any cause (in men) when consuming supplement pills that have antioxidant activity, namely, vitamin C, zinc, selenium, and beta-carotene.

Another Swedish study showed the regular use of dietary supplements, 80% of which were multi-vitamin supplements, was associated with a significant 22% reduction in risk of MI in men and a significant 33% reduction in risk of MI in women compared with nonuse after controlling for consumption of fruit, vegetables, and fiber.

In the VITamins and Lifestyle (VITAL) study, which looked at over 35,000 subjects, the use of grapeseed supplements was associated with a 41% reduced risk of total prostate cancer which is the main reason grapeseed extract is found in ImmunoPCTN.

A meta-analysis of 13 prospective European and North American cohort studies reported a decrease in risk of colon cancer among Multi Vitamin (MV) supplement users compared with nonusers. MV supplement use for 15 years was associated with a 75% reduction in colon cancer risk in the prospective Nurses’ Health Study (NHS) based on questionnaires completed by 88,756 female nurses in the United States.

The Problem with Studying Dietary Supplements like Drugs

The scientific method is the approach used by the scientific community to assess if a pharmaceutical drug or a medical procedure has any effect on a particular disease. To control an experiment, you want to eliminate as many confounding factors an isolate the treatment as much as possible.

What do I mean?

If I want to know if drug A, a pill, can cure cancer, then I would set up a study where I recruit, say, one thousand people with cancer (any cancer, to keep it simple), randomly assign 500 subjects to the drug and the other 500 to an indolent pill that looks like pill A but only contains sugar ( placebo)
I would then follow both groups for as long as possible. The more subjects to study and the longer the study, the more valuable the data and the more clinical relevance it may have.

Of course, to run such a study, especially with something un-patentable is expensive.

That’s why studies like this are rare and should be executed with excellent methodology (the exact opposite of SELECT).

So, when scientists study nutrients in isolation, e.g., dl-alpha-tocopherol (not the natural form with other important components), selenomethionine (without other key forms of selenium), beta-carotene (excluding other carotenoids) – then, of course, the outcome is never good. These are high doses of a single chemical that usually comes in a complex package.

In other words, super concentrated nutrients without the synergism of other key components are similar to pharmaceutical drugs and carry the same risk. But physicians who are nutritionally oriented know that – and have known that for a long time.

And, only integrative, functional, and naturopathic doctors are the experts in the responsible use of nutritional supplements.

Manufacturing facilities of Dietary Supplements also matter

Top notch dietary supplement manufacturers self-police and go beyond the GMP by seeking 3rd party auditing of their facilities. NSF along with the American National Standards Institute (ANSI) came up with a national standard for the manufacturing of dietary supplements, which goes to the next step after the GMP’s and sets some specifications for levels of contaminants such as micro and heavy metals contamination undertake voluntary certification and quality control.

Supplements from XY Wellness or from sources prescribed by naturopathic or functional medicine  physicians work professional-grade manufacturing companies.

The Doggy Bag on Dietary Supplements

Nutritional supplements made from vitamins, mineral, and botanicals are effective to reduce the risk of disease, slow aging and enhance performance, only if it’s the right combination, in as much of its natural state as possible (no isolated ingredients)and from excellent manufacturing facilities. Lastly, supplements complement a superior dietary and exercise regimen. They don’t replace it.

My Dietary Supplement Protocol

I was hesitant to unveil what my dietary supplement regimen is because readers (not being monitored by a functional or naturopathic doctor) may think they should follow the same protocol.

But, I’ve been asked in emails and social media about my supplement intake. Before I share what that is, you should not assume the supplements I take you should consume as well. It may not be. Lastly, taking too much of any nutrient may have adverse reactions or interact negatively with certain prescription drugs. Just because dietary supplements are “natural” does not mean they do not have side effects.

Again, I am sharing my protocol for informational purposes only.

When taking dietary supplements, you need to have a goal in mind, not just because you read something interesting about a supplement formula. I have many patients who take things they read about or suggested by a friend, without knowing exactly why they are consuming all that they are.

My goal is to function mentally and physically optimally and reduce the risk of aging disease’s; cancer, brain problems, low immunity, heart problems, etc.

In other words, I’d like to live long and strong.

Here’s what I take (at least) two times a day:

(During flu season from October to May, I take 500mg every three to four hours)

  • XY Wellness, Omega Avail Ultra w K1, K2, and D3 – 3 pills *
  • XY Wellness, ImmunoPCTN – grape seed extract, curcumin, boswellia, reishi mushroom, green tea extract, pomegranate extract and modified citrus pectin. *
  • XY Wellness, GDtoxSel – Milk thistle, Selenium (from SelenoExcel), Vitamin C, zinc, Alpha Lipoic Acid, vitamin E (mixed tocopherols), Broccoli extract -3 pills a day *
  • New Chapter, Multivitamin for men over 40 – 2 pills a day
  • Thorne Catalyte – as needed when sweating excessively from athletic activity
  • Thorne Creatine – for better athletic performance ( I practice Krav Maga and some BJJ)

I like Thorne’s sports line of supplements and have my daughter who competes in soccer take them too.

During Flu season ( Like know) I additionally take

 

* Disclosure – I don’t get paid to promote any of the supplements listed except supplements from XY Wellness where I am co-founder and formulator of the company.

 

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The Truth on Dietary Fats & Prostate Cancer

 

The Truth on Dietary Fats and Prostate Cancer Risk

Recently the New York Times published an article titled: High-fat Diet May Fuel Spread of Prostate Cancer citing an animal study looking at the relationship of fats with this male disease.

The association between dietary fats and cancer is not new. Back in the early nineteen forties, a researcher, Dr. Tannenbaum postulated that fats indeed contribute to cancer.

But back then until roughly the 1990’s, dietary fats were considered the big evil monster – the primary culprit of all deadly health problems.

Today, popular diets like the ketogenic diet are all about eating fat in the attempt to make energy from the fat byproduct, ketones, not sugar.

Let’s take a closer look at the study questioned.

Study Details

• About ten mouse models were studied
• Some mice were fed a high, 60% fat diet and others a low, 17% fat diet
• Researchers observed two genes, PTEN and PML. (These genes normally protect us from cancer, and they are known as tumor suppressor genes.)
• When mice had little or no PTEN and PML genes, prostate cancer cells spread and produced fat molecules.
• When mice producing fats were given an obesity drug named “fatostatin” cancer regressed.
• This drug works by stopping the production of fat formation.
• A group of mice was then fed a high-fat diet compared to another group who at a low-fat diet and researchers noticed more tumor spread in the fat eating mice.

Does this Study Prove that Dietary Fats Fuel Prostate Cancer?

First, as you may guess, one cannot make strong conclusions from animal studies for  human application. If we would, we’d have the cure for every disease by now.

Second, what exactly was in the food in the group of mice eating a high-fat meal?

I was curious to know.

Here’s what I found

Among other things, the high-fat meal fed to mice contained non-fat components that are linked to prostate cancer; 265g Casein and Choline 3.0g

All these ingredients have been linked to prostate cancer and lard (pork fat) is probably the least culprit.

Casein, a protein found in dairy has been linked to the proliferation of prostate cancer.

Choline is a water-soluble vitamin also associated with advanced prostate cancer in studies.

To note: The low-fat feed contained no casein or choline.

Third, don’t be fooled, researchers in this study are interested in researching a drug interfering with fat metabolism and hopefully slowing down the spread of cancer, not the best diet for us to avoid or manage prostate malignancies.

Let’s Understand Fats Better

Without writing a scientific dissertation allow me to give you the skinny on fat.

Fat is one of three macronutrients in the body along with protein and carbohydrates. Notice the word “nutrient’ in macronutrient. That means dietary fat provides nutritious value and helps animals (especially humans)to grow and survive.

Simply put, without dietary fat we die.

Fats are an important component of every cell in your body giving them structure and making them semi-permeable – important in keeping water-soluble toxins outside of your cells.

Also, dietary fat helps you lose body fat. That’s right. Eating fat can likely help you lose unnecessary weight from fat.

Remember Snackwells by Nabisco back in the early 90’s? Nabisco decided to make all sorts of fat-free snacks loaded with sugar, and it did not only make people fatter, but Type 2 Diabetes also skyrocketed around that time. Now it seems like Snackwells are High Fructose Free – woohoo! Still very less optimal.

Very low carb diets higher in fat has shown to successfully lower body weight and stabilizes blood sugar levels – two things crucial in managing prostate cancer.

Lastly, eating fat makes you less hungry. So while you do eat more calories per serving when eating dietary fats, you end up eating less overall.

How does that oatmeal with banana for breakfast work you by mid-afternoon? You are starving.

Dietary fat is important for brain function because your brain is made up of mostly, you guessed it, fat.

And that’s just to name a few benefits this dietary nutrient.

Fats 101

In it’s strictest definition, fat is a series of carbons, single or double bonded, with a hydrogen molecule attached to each carbon molecule. On the first end of that chain you have a carboxylic acid, and on the other end, there’s a methyl group.

Depending on the length of the chain of carbons and the amounts of double bonds (or if there are no double bonds) will depend on the type of fat you are eating.

OK, maybe I geeked out a little here but here’s what you need to know; despite the conclusions of this recent mice study, it is critical for you to continue eating good quality dietary fats because it may not only protective against prostate cancer but imperative for wellness and optimal performance.

There are three main types of fat found in nature.

  • Polyunsaturated fat (poly =many, thus many carbon double bonds)
    broken down into omega 3 and omega 6-fatty acids
    o omega 3-fatty acids are further broken down to, ALA, EPA, and DHA (actual names of these abbreviations are not necessary)

    • ALA is found in plant oils like flaxseeds, walnuts, chia, hemp seeds
      • ALA (α-Linolenic acid) can be converted into DHA and EPA in the body, although the rate of conversion of α-linolenic acid into EPA is relatively inefficient, at 5–10% and is inhibited by linoleic acid (omega 6-fatty acid).
    • EPA and DHA are both found in marine oils. Examples, where found, include salmon, sardines, mackerel, and anchovies.
    • Omega 6-fatty acids are further categorized to linoleic acid, gamma-linolenic acid, arachidonic acid and a few others.
      • Oils high in Omega 6’s include, safflower oil, corn oil, soybean oil and canola oil.

 

  • Monounsaturated fat (mono= one, thus one carbon double bond) are found in olives, avocados, cashews and their respective oils. Numerous other foods contain monounsaturated too.

 

  • Saturated fat (no double bonds, every carbon is saturated with a hydrogen atom) found primarily in coconuts and coconut oil, butter, pork fat (lard) can be further broken down to lauric acid, butyric acid, palmitic acid, stearic acid, caprylic acid and mystiric acid.
    • Lauric acid is found in coconut oil and it’s excellent for human health with anti-viral, anti-fungal properties.
    • Butyric acid is found mostly in butter and essential for colon health.

So, unlike popular belief, there are benefits from eating some saturated fats as well.

Bad nutrition science and bad interpretation of nutrition science on media headlines are significant contributors to prostate cancer and premature deaths.

Is There a Connection Between Dietary Fats and the Spread of Prostate Cancer?

There is no conclusive association between eating fat, including saturated fat and prostate cancer.

With two possible exceptions: Too much Omega 6-fatty acids and trans – fatty acids.

Omega 6 fats are good for you but only when it is in the balance with omega 3-fats. The omega-6 to omega-3 ratio in the standard American (heart attack) diet is 20 or 30:1, omega 6 to omega 3. The healthier ratio is 2 or 1:1, respectively. Source.

Trans-fats or partially hydrogenated oils, as you may read ingredients lists, found in margarine and Crisco is an industrially created unsaturated fat that gets hydrogenated (synthetically adding hydrogen atoms) causing a trans molecular structure compared to the most natural cis form.

Since trans structured fats are unnatural, eating them causes havoc in the body including hardening of blood vessels (atherosclerosis) and increases systemic inflammation.

Trans fatty acids are found in virtually all processed foods, baked goods and deep fried foods.

Stay away from trans-fatty acids.

Overall, simple carbohydrates and trans-fats are public enemy number one and the two substances that most contributes to cancer, obesity, and disease-related deaths.

What do Human studies say about the connection between fats and Prostate Cancer?

The correlation between fat consumption and the risk of prostate cancer seems to depend on the specific types of fat and their constituent fatty acids.

This researcher studying close to 150 Jamaican men evaluated the relationship between the intake of dietary fatty acids and prostate cancer biopsy grade and volume and concluded that omega-6 fatty acids stimulated prostate cancer cell growth, whereas omega-3 fatty acids inhibited cancer cell growth.

This meta-analysis that studied close to 450,000 subjects showed a significant 63% reduction in prostate cancer–specific mortality, not prostate cancer diagnosis. Most fish is largely high in Omega 3-fats.

In the North Carolina-Louisiana PC Project, 322 cases out of 1800 were considered an aggressive disease. High total fat-adjusted and saturated fat intake was associated with increased prostate cancer aggressiveness, with a suggestion of a stronger effect in men not using statins.

Another study had the exact opposite results after prospectively following about 385 men for an average of five years. The saturated fat consumption was significantly associated with higher survival from prostate cancer (p = 0.008). Compared to men in the lower intake of saturated fat, those who ate more saturated fat had three times less risk of dying from prostate cancer.

The long European multicenter prospective study of 142 520 men in the European Prospective Investigation into Cancer and Nutrition (EPIC) study suggest that there is no association between dietary any type of dietary fat and prostate cancer risk.

Lastly, one study reported that consuming high amounts of fat from vegetable sources (e.g., olive oil, nuts) after diagnosis of non-metastatic prostate cancer was associated with lower risk of developing lethal disease.

Interestingly, in this same study, replacing 10% of calories from carbohydrates with vegetable fat was associated with a 29% lower risk of lethal prostate cancer. Perhaps even more interesting, Men who consumed more vegetable fat after diagnosis had a lower risk of all-cause mortality. Replacing 10% of calories from carbohydrates with vegetable fat was associated with a 26% lower risk of death from any cause.

Researchers also found a 5% increase in saturated fat was associated with a 30% higher risk of death and a 1% increase in trans fat was associated with a 25% higher risk of death.

What to make of the Studies on Dietary Fats and Prostate Cancer

Inconsistent and contradictory results from nutrition studies will continue to emerge in part because of the inherent variability of foods, as well as the uncontrolled variables in study populations and experimental designs.

In the North Carolina-Louisiana PC Project, for example, is the link between saturated fats and aggressive prostate cancer the result of eating too many cheeseburgers or pints of ice cream? I mean obesity in the South of the United States is rampant and fried chicken is a staple meal.

I do like my gumbo now and then though…

But really, we are not studying groups of people eating a tablespoon of butter (saturated fat) a day compared to another group eating a tablespoon of olive oil (monounsaturated fat) and the another taking an ounce of flaxseed oil (polyunsaturated) and then seeing what happens in ten years or so.

That would limit other variables found in fatty foods and provide clarity on what is truly causing what.

Such study, which will never happen for obvious reasons,  would show insight about the type of fat that may cause prostate cancer and overall deaths and which fats do not.

Just look at the recent animal study in question at the beginning of this post. The high-fat meal wasn’t only saturated fat, it consisted of other ingredients known to promote aggressive prostate cancer. So what caused cancer spread on these fat eating mice? Was it the saturated fat? Was it the casein? What it the choline? I don’t know.

And that’s why making oversimplified conclusion in nutrition science is so challenging.

How I provide solid guidelines for patients and my audience is by:

  1. Tirelessly reading most of the research papers on this type of topic, not just the last published study. There is more value in the preponderance of data than the latest journal article.
  2. Have a good understanding of nutrition and biological science. In other words, I teach my students to learn how the body functions normally so then identifying dysfunction becomes easier.
  3. I am my own experiment. I simply try different diets, different supplements, different exercises and then see how I feel and look at labs results. Yes, I am my number one guinea pig.
  4. In my busy practice, I get to see what works and what doesn’t with patients. And see for whom something works and doesn’t.

Here are my recommendations regarding fat consumption, prostate cancer, and longevity.

  • Overeating any macronutrient, protein, carbs or fat is a problem. The good thing with dietary fat is that you can’t eat too much of eat before becoming queezy. Carbs on the other hand, you can and want to keep eating for days.

 

  • IGF-1 is produced in the body when eating large amounts of protein. Dairy, for one, increases the levels of IGF-1. IGF-I is associated with increased risk of prostate cancer and a higher risk of prostate cancer-specific mortality in men with advanced cancer. Soy proteins also raises IGF-1 levels.

 

  • Carbohydrates, particularly those with a high glycaemic load consumed in excessive amounts result in increased fat stores due to influences on blood glucose and excess calories. This results in a state of relative hyperinsulinemia and obesity, which has been postulated to increase the risk of developing prostate cancer through higher bioavailability of circulating estrogen and IGF-1.

 

  • All dietary fats are important to eat, except hydrogenated, trans-fatty acids found mainly in fried and processed foods. Stay away from them.

 

  • Saturated fat is fine to eat, especially from better sources, coconut oil, Pastured butter even pastured lard. What! Lard!?

 

  • Animal fats are not all the same, and it depends on the environment and diet of the animal. grass-fed meat has more omega-3’s and CLA ( another healthy fat) than grain-fed beefPork fat (lard) is healthier and different when pigs are pasture grazing.

 

“ We are not only what we eat. We are what we eat eats too.” – Michael Pollan

 

  • The most harmful fats are polyunsaturated or monounsaturated fats exposed to heat, air or light for long periods of time. So that means frying your food in olive oil is not a good idea. Same with foods fried in canola, soy bean or vegetable oil. These oils become rancid and are cancer promoting.

 

  • Saturated fats, on the other hand, can be exposed to heat and do not oxidize. Again, coconut oil pastured butter and even pastured lard is ok, just not too much.

 

  • Plant-based oils and fats are  protective and promote longevity. Eat walnuts, almonds, flaxseeds, sunflower seed, etc.

 

  • Too much of any macronutrient has detrimental prostate cancer effects and interferes with longevity. That’s why I’ve become a fan of intermittent fasting as of late where you don’t eat any macronutrient for a longer period than usual, say twelve to sixteen hours a day or more.

 

And that’s it. For today.

 

Last 3 Blog Post

8 Years at XY Wellness

My Stint with Depression

Staying the Course

 

Knicks Joakim Noah suspension and SARMS

I am, painfully, a hardcore New York Knick basketball fan. They have been horrific all year so I have not tuned in much. As good as Phil Jackson was as a basketball head coach winning eleven championship rings, is as pathetic he is as a general manager of the Knicks. To culminate Jacksons distratrous performance, he gave Joakim Noah, a mediocre / poor player a four-year, $72 million contract. I feel like throwing up when I say that. Noah is injury prone recovering from knee surgery and recently on a 20 game suspension for using an illegal substance called LGD-4033.

LGD-4033 is a very powerful selective androgen receptor modulators (SARMS) which has found its way into illicit distribution. There are numerous websites selling SARM compounds but I would exercise caution with the use of the chemicals at this point. SARMS \ are prohibited by the World Anti-Doping Agency (WADA) and that’s way Noah has been penalized by suspension and $3 million fine.

What are SARMS?

SARMS are non-steroidal ligands ( molecules that bind to other molecules) that attach with selective androgen receptors (AR) and produce steroid-like results minus the steroids.

Who benefits from SARMS?

Patients with advanced cancer who are losing rapid weight may benefit the use of SARMS. Weight loss by muscle wasting (medically known as cachexia) in cancer is never a good thing as it increases the likelihood of premature death by up to 20%. There is currently a phase 3 randomized trial looking at the use of enobosarm (one of many SARMS in the market) for cachexia prevention in cancer patients. So far, smaller studies have shown promise in muscle wasting prevention in those with advanced malignancies.

Toxicity of chemotherapy is less prominent when a patient has more muscle mass. That is why I promote weight resistant exercises three to four times a week. Weight training is more important than just doing cardio exercises like running. They are both good, but if you have to choose one, let it be weight resistance training.

More muscle is a good thing, way beyond looking good. It helps with:

  • Improved insulin sensitivity requiring less insulin to metabolize sugars

(too much insulin is a problem for cancer and all health)

  • More sugar taken out from our blood by muscles and used for muscle

energy, resulting in less roaming sugar and insulin feeding cancer cells.

  • Weight resistance training increases IGFBP-3 (a good thing) , whichbinds to insulin-like growth factor (IGF), decreasing its ability to promote cancer (growth factors are normal within the human body, but too many can lead to excessive cellular growth, including cancer growth)7
  • Decreased inflammation (which by now you may know less is more)
  • Increased antioxidant defense, which protects your cells from DNA damage and oxidative stress
  • Strength and the stronger you are the longer you live.

Back to SARMS…

SARMS hold promise for promoting muscle gain for people with functional limitations associated with aging and chronic disease, frailty, cancer cachexia, and osteoporosis. What makes these chemicals different is that they are anabolic but not androgenic.

What do I mean by anabolic but not androgenic?

Anabolic by definition, builds up, in this case, muscle. (The opposite is catabolic, breaking down)

Androgenic is derived from the Greek words “andros” (man) and “genein” (to produce).and pertains to the development of male characteristics, including body hair, facial hair , prostate formation and growth and penis development.

Due to the enormous muscle and bone anabolic properties of SARMS have potential for misuse among professional athletes looking for a competitive edge ( or recovery from injury) which has led to the inclusion of SARMS into the World Anti-Doping Agency’s (WADA’s) Prohibited List in 2008. (Thevis & Shanzer, 2017)

LGD-4033

LGD-4033, also called Ligandrol or Anabolicum, has been through multiple human trials (most SARMS have been studied on animals), with interesting results:

One is a placebo-controlled study of 76 healthy men (21-50 years),  randomized to placebo or 0.1, 0.3, or 1.0 mg LGD-4033 daily for 21 days. LGD-4033 was safe, and increased lean body mass even during this short period without change in prostate-specific antigen (PSA).

LGD-4033 is not the only SARMS being studied. This blog site from my friends at bulletproof lists others being looked at scientifically.

My Take on SARMS and LGD-4033

I am biased on putting the work in to improve Testosterone (T) levels, gain musculature and strength with dedicated strength training exercises, good eating, key nutrients and botanicals. However, I know some people are starting at zero and need a pharmacological boost sometimes.

I am an agnostic doctor. I care for what works best for patients.

For example, some obese patients I have seen have extremely low T levels ( visceral fat makes estrogen do to the enzyme aromatase found heavily in fat) where exogenous testosterone cypionate helped with, not only building muscle and losing fat but with quality of life.

The problem is, of course, patients taking exogenous T need to be closely monitored by a physician who knows what they are doing as side effects from too much hormone include: too much red blood cell production, stimulate prostate growth by too much conversion to Dihydrotestosterone (DHT) and may be too androgenic – not a good thing if you are a women.

SARMS , however, just seem to build muscle and bone strength without side effects from exogenous T. I am specifically excited for the potential use of SARMS in patients whose muscles are wasting from cancer. The frail elderly population can also benefit from the use of these substances since muscle wasting (sarcopenia) is a major cause of death among those up there in calendar years.

I am keeping a close eye on the benefits of SARMS so stay tuned.

Meanwhile, I hope the Knicks tank the rest of the season and get a good draft pick for 2018. That would give me and Spike Lee some optimism.