Heavy drinking in middle age linked to memory loss in men

Cigarettes, cigars, and the like are the most deadly product that consumers can legally buy. Why they are sold in pharmacies, which are meant to dispense medications and other things designed to heal or promote health, has always been a mystery to me. I’m not alone. The American Pharmacists Association, the American Medical Association, and other groups have urged pharmacies to stop selling cigarettes.

Several major pharmacy chains have been mulling over whether they should take this advice. Today, one of them has acted. The CVS chain has decided to stop selling tobacco products, and will phase out their sales over the next year. The news came in a press release from CVS and an opinion piece published today in JAMA, the journal of the American Medical Association.

The authors of the article are Dr. Troyen Brennan, executive vice president and chief medical officer of CVS Caremark, and Dr. Steven A. Schroeder, director of the Smoking Cessation Leadership Center at the University of California San Francisco. (Full disclosure: both have been close colleagues of mine for many years.)
A shrinking circle

Fifty years ago, when the Surgeon General issued his famous document summarizing the health risks of smoking, more than 40% of American adults smoked. It was okay to smoke anywhere and everywhere—in restaurants, grocery stores, airplanes, and even in hospitals. It wasn’t until the mid-1980s that Brigham and Women’s Hospital, where I work, became one of the first hospitals to ban smoking inside its buildings.

Efforts to limit where people can smoke and buy cigarettes and other tobacco products has helped reduce the number of smokers to about 18% of adults in the United States. Increasing the cost through taxes has also put a dent in the number of smokers.

But we need to do more. There’s abundant evidence that making tobacco products hard to get reduces their rate of use. So I applaud CVS’s decision to stop selling tobacco products in its stores. With this public announcement from its chief medical officer, CVS is claiming the high ground. The company estimates that it takes in $1.5 billion a year from selling tobacco products, but “the financial gain is outweighed by the paradox in promoting health while contributing to tobacco-related deaths.”

Pharmacists will likely cheer the decision. According to Brennan and Schroeder, one survey of pharmacists showed that only 2% of them favor the sale of tobacco products in their stores.

It also makes sense as large chains begin to make themselves over as health care outlets, with in-store retail clinics. It has always been sadly ironic to see someone come to a drug store to get his or her medicines for high blood pressure, high cholesterol, diabetes, or pain from metastatic cancer—and then stop at checkout and get a pack of the substance that caused and continues to perpetuate those illnesses. Mass marketing of testosterone therapy may have men eager to try this seemingly simple fix. But the latest science should have them scratching their heads and putting away the credit card—at least for now.

A new study published in the online journal PLOS One shows an increase in the risk of having a heart attack in the months after starting testosterone therapy. The potential for danger was highest in older men. A report in the November 6, 2013, issue of JAMA showed that men who used testosterone therapy didn’t fare as well after artery-opening angioplasty as men who didn’t take testosterone.

A word of warning about these reports: neither was the type of study that can prove cause and effect. They can only show associations, or links. That means there’s no smoking gun here that testosterone therapy is harmful. But the studies do suggest caution.

On Friday, the FDA announced it would look into possible links between testosterone therapy and heart attack, stroke, or death in men taking FDA-approved testosterone products. In an announcement, it urged health care professionals to “consider whether the benefits of FDA-approved testosterone treatment is likely to exceed the potential risks of treatment.”
Potential risks as well as benefits

Millions of American men use a gel, patch, or injection to boost their testosterone levels. Getting extra testosterone can help those with truly low testosterone that is causing problems such as loss of bone and muscle or a low sex drive. What it can do for men with borderline low testosterone, or those without symptoms, is up in the air. As the February 2014 Harvard Men’s Health Watch reports, “The ongoing pharmaceutical marketing blitz promises that treating ‘low T’ this way can make men feel more alert, energetic, mentally sharp, and sexually functional.” What it doesn’t point out are the possible risks, according to Daniel Pendick, the newsletter’s executive editor.

Testosterone doesn’t immediately agree with a small number of men. They quickly develop acne, enlarged or tender breasts, or swelling in the ankles. In some men, testosterone causes an overproduction of red blood cells, which can increase the risk of developing blood clots inside arteries or veins.

The long-term risks aren’t really known. As the articles described above suggest, taking extra testosterone could pose problems for the heart. There are also worries that testosterone therapy could stimulate the growth of prostate cancer. But the evidence is mixed. Some studies, in fact, have shown that men taking testosterone have fewer heart problems. The link between testosterone therapy and prostate cancer is also murky.

What’s needed is a randomized, placebo-controlled trial, in which some men get testosterone and others get an inert substitute. In such a trial no one except some record keepers know who is getting what—not the volunteers or their doctors. If such a trial is done and it is large enough and lasts long enough, we should get clear answers on the benefits and risks of testosterone therapy. This wouldn’t come fast, or cheap. The Women’s Health Initiative, which tested in this way the benefits and risks of hormone therapy for women, took years and cost millions of dollars.
What to do today

Until such a trial is done, what’s a man to do in the face of such uncertainty? Take a cautious approach, advises the Harvard Men’s Health Watch:

    Take stock of your health first. There may be other reasons than your testosterone level for fatigue, a low sex drive, erectile dysfunction, and other symptoms attributable to low testosterone.
    Get an accurate assessment. If you or your doctor think you might have low testosterone, have it measured between 7 am and 10 am, when testosterone is at its daily peak. Then confirm the result with a second test on a different day.
    Be mindful of unknown risks. Ask your doctor to explain the various side effects for the different formulations of testosterone, such as gels, patches, and injections. Know what to look for if something goes wrong. And approach testosterone therapy with caution if you are at high risk for prostate cancer; have severe urinary symptoms from prostate enlargement; or have diagnosed heart disease, a previous heart attack, or multiple risk factors for heart problems.

Finally, “testosterone therapy is not a fountain of youth,” cautions the Men’s Health Watch. Don’t try it in hopes of channeling your more youthful physical or sexual self, of living longer or healthier, or of improving your memory or mental sharpness. Exercising more would be a safer—and probably more effective—approach for achieving those goals. You’ve heard it a thousand times: The key to a healthy heart and brain is a healthy diet. For a growing number of people, a Mediterranean-style diet has been the stand-in for “healthy diet.” A landmark clinical trial done in Spain, known by the acronym PREDIMED, has been putting the Mediterranean eating plan on a more solid scientific foundation.

Last year, PREDIMED researchers reported that Mediterranean-style eating—rich in fruits, vegetables, and healthy plant oils—prevents heart attacks, strokes, and death from heart disease. This week in The Journal of the American Medical Association, they report that a healthy Mediterranean-style diet can also help prevent peripheral artery disease (PAD), a form of “hardening of the arteries.” PAD happens when fatty deposits obstruct the arteries that supply blood to parts of the body beyond the heart and brain, like the legs, arms, and abdomen.

“To our knowledge, this is the first randomized primary prevention trial to suggest an association between a dietary intervention and [reduced risk of] PAD,” the study authors wrote.

It’s an important finding. As many as 12 million Americans, most of them older, have PAD. It can cause leg pain when walking that goes away with rest (called intermittent claudication); a weakening of the aorta, the main pipeline that delivers blood to the body; pain after eating; erectile dysfunction; and other problems.

Though the findings were solid, keep in mind that they are preliminary. For one thing, PREDIMED was not designed to detect an effect of diet on the risk of developing PAD—although it’s not hard to imagine it being able to do so, given the diet’s effect on heart and artery health. To be scrupulously scientific, such incidental findings need to be confirmed with a study specifically targeted at PAD.
Better evidence

But taken as a whole, the PREDIMED trial has gone a long way to place healthy eating on par with medication as a way to prevent heart disease and stroke. Many previous studies observed that people who ate the Mediterranean way seemed to be healthier than others, but only a randomized clinical trial can pinpoint cause and effect.

“PREDIMED is a randomized trial and, as such, it provides higher quality evidence in comparison to evidence from observational studies on the health benefits of the Mediterranean diet,” says Dr. Dimitrios Trichopoulos, an epidemiologist with the Harvard School of Public Health who has conducted some of those studies.

In Spanish, PREDIMED stands for Prevención con Dieta Mediterránea, or “prevention with Mediterranean diet.” The Mediterranean diet is not a specific eating prescription, but rather a general style of eating that emphasizes certain healthy foods and minimizes other not-so-healthy ones. The basic mix is a variety of fruits, vegetables, nuts, and seeds, along with moderate consumption of fish, poultry, dairy, eggs, and olive oil, and minimal red and processed meat. Some cultures that favor Mediterranean-style diets may include a glass of red wine with their meals, but it isn’t required.

In PREDIMED, nearly 7,500 men and women were randomly assigned to adopt one of three diets: a reduced-fat diet or a Mediterranean diet supplemented with generous amounts of either nuts or extra virgin olive oil. Participants were 55 to 80 years old and at high risk of cardiovascular disease, but were still healthy at the time they entered the study.

As reported earlier in The New England Journal of Medicine, the trial found that a Mediterranean diet reduced the risk of cardiovascular problems by around 30%. In a more recent report from PREDIMED, the olive oil-supplemented version of the Mediterranean diet reduced the risk of developing diabetes by 40%.
How to go Mediterranean

It’s not hard to get started on a Mediterranean style of eating. Here are some general cooking and meal-planning tips from the Harvard Health Letter to help you make the transition:

    Sauté food in olive oil, not butter. Make your own salad dressings with extra-virgin olive oil, which is pressed mechanically from ripe olives and processed without high heat or chemical solvents. This protects healthy substances in the oil.
    Eat more vegetables by having them as a snack, or adding them to other recipes. Include a portion of fruit with breakfast and desserts.
    Choose whole grains instead of refined breads and pastas.
    Incorporate kidney beans, lentils, and other legumes in salads and side dishes.
    Substitute fish for red meat at least twice per week. If you don’t like fish, use beans or poultry to get your protein.
    Limit high-fat dairy by switching to skim or 1% milk from 2% or whole milk.
    Add a modest portion of nuts to cooked grain and side dishes, and sprinkle nuts and seeds on salads.
For some people, like those with an addiction, any amount of alcohol is too much. For others, drinking alcohol is something of a balancing act — a little may be healthful, while more than a little may be harmful.

In people who can physically, mentally, and emotionally tolerate alcohol, moderate drinking has been linked to lower risks of heart disease and type 2 diabetes. Moderate drinking means no more than two drinks a day for men; no more than one a day for women. Heavier drinking increases the risk of developing some cancers, heart disease, high blood pressure, cirrhosis, and alcohol dependence.

A new report in the journal Neurology highlights the dual effects of alcohol in men. As part of the Whitehall II study in Britain, researchers assessed the drinking habits of middle-aged men and women three times over a 10-year period. The study participants also took a mental skills test three times over the next 10 years. Compared with men who didn’t drink or who drank moderately, mental decline began to appear one to six years earlier in men who averaged more than 2.5 drinks a day. (There weren’t enough heavy drinkers among women to show any clear differences.)

What’s “a drink”?
Researchers and public health experts define a drink like this:
12 ounces of beer that is 5% alcohol
5 ounces of wine that is about 12% alcohol
1.5 ounces (a standard shot glass) of 80-proof spirits (about 40% alcohol).

You can see more definitions at Rethinking Drinking, a website from the , or try one of its cocktail calculators.
Aiming for healthy drinking

There seems to be a fine line between the amount of alcohol consumed and health benefits or harms. For example, even light to moderate alcohol use is associated with a higher risk of some cancers, such as breast cancer in women. According to the Neurology study, a similar pattern may be emerging between drinking and thinking skills.

How do you know if you are drinking too much? Several simple tests have been developed to help people gauge their drinking habits. One is the 4-question CAGE test, so called because of the first letters of the key word in each question. Another is the 10-question Alcohol Use Disorders Identification Test (AUDIT), developed by the World Health Organization. You can see both of these tests at www.health.harvard.edu/173.
If you’re concerned

A little advice and encouragement may help you figure out if your drinking follows a risky pattern and what to do about it. The source of advice could be your primary care doctor. Or the doctor might refer you to an alcoholism counselor.

This is not long-term therapy. It’s perhaps two or three discussions. The helper can ask you how much you are drinking and let you know how it compares with the norm. He or she might.

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