Why Live to 100!*

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

2. Why Live to 100!* • Enjoy a full live • Not just years, but quality years • Be a productive member of society • Impart wisdom to your offspring • Many issues I discuss are controversial, discuss with your doctor! • *In memory of John Wooden 1910-2010

3. Why Live to 100! • Slightly based on the book “The Long Life Equation” by Trisha McNair and Dr. Olga Calof

4. Why is it realistic to live to 100 in 2010? • Better screening • Better treatment • More knowledge on diseases

5. What can you do? • Informed consumer • Days of blindly following your doc are long gone • Be your own advocate-docs are busy/overwhelmed-you need to lobby/push • Keep your own records • Be organized • Get a good doctor that will listen to and work with you • Make it easy for your doc • Go to good docs-if something seems illogical, get a 2nd opinion.

6. How to Live to 100-my approach • Identify and screen for major causes of death (heart disease, cancer, diabetes) • Know when to screen • Learn to do the right test • Improve modifiable risk factors • Can’t pick your parents (but know your family history) • Healthy lifestyle • Medications as needed • Risk/benefit ratio for each person-I do not believe that each test has to be “cost-effective” for population • Start now, set a time to get everything done by (next birthday)

7. How to Live to 100-my approach • Screening has risks (identifies an abnormality that is not a clinically important problem) • Interventions have risks. • Always think about risk/benefit ratios. • Medicines have side effects and interact, only take what you need.

8. What diseases can you prevent? • 90% • Exceptions: • Some cancers • Some types of heart disease • Heart failure • Rare incidents of heart attacks strokes

9. Leading Causes of Death (all ages)

10. Leading Causes of Death by Age

11. Heart disease • Also called atherosclerosis or coronary artery disease. • Cholesterol plaques build up in the blood vessels in the heart supplying blood to the heart muscle. • Plaques become calcified • As plaques get larger, not enough blood goes through the arteries to the heart muscle-angina-chest pain (pressure) • Angina almost always starts at exertion as heart needs more blood to keep up with demand

12. Plaques

13. Heart disease • As plaques increase in size, angina gets worse-may occur at rest. • If artery is blocked-heart attack (myocardial infarction)-crushing chest pain • Leads to damage of heart muscle-heart failure • Associated with arrhythmias • Want to avoid heart attacks and its damage • If having a heart attack-call 911 and take an aspirin • In emergency rooms, can dissolve clot or open up clot with angioplasty

14. Heart disease-detection • EKG-can detect angina (impaired blood flow to muscles), current or prior heart attack, or arrhythmias can not detect early blockage • Stress test-can detect angina on exertion-major blockage of heart vessels • Echocardiogram-can detect heart failure, structural problems and prior damage to the heart • Angiography-can accurately detect varies degrees of blockage in heart vessels, but very invasive • High-resolution CT scans and MRIs- new, somewhat experimental, but likely to have a role

15. EBCT-Priceless • Electron beam CAT scan- (EBCT) • This is often part of what is called a “body scan,” which also looks for lung cancer and other types of cancer. • The electron beam CT scan of the heart detects early calcification in the heart vessels. • Radiation exposure is very low. • Early calcification is a sign of atherosclerosis. • The electron beam CT scan of the heart is done at most major medical centers and costs between $350 and $500 (may or may not be covered with insurance).

16. EBCT-Priceless (2) • Patients get a calcium score, which indicates how much calcium plaque the patient has in their heart’s vessels. • It tells you the number of plaques and how big they are, to come up with a calcium score, and also usually tells which coronary artery contains the plaque. • In some circumstances, if the calcium plaques are in a dangerous region, such as in the main coronary artery called the left anterior descending, it may be more dangerous than having them in a more minor heart vessel. • A person can get a zero score, which is ideal; and the lower the score, the better. • Generally, a score above 300 is considered dangerous

17. Who should get a EBCT • Men > 40 years, women > 45 years • Patients that are being considered for treatment of elevated cholesterol. • Cholesterol is only a marker for heart disease, and it is much better to look for actual heart disease. • If you have no calcifications in your heart vessels, it does not really matter what your cholesterol is, as you are not going to die from or develop atherosclerosis.* • If you do have significant coronary calcification, you should be on drugs designed to lower your cholesterol, such as statin drugs, take an aspirin and undergo other dietary and exercise modification to decrease your chances of having heart disease. • *A low percentage on patients have light, fluffy LDL particles that do not give calcification, yet can lead to heart disease. • ** Patients can also have a good cholesterol profile and still get heart disease.

18. EBCT Sample results

19. EBCT Sample results

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

21. Medical treatment to prevent/treat heart disease-Aspirin • Aspirin (baby aspirin-81 mg/day) • It used to be said that taking an aspirin was the most important prevention for cardiovascular disease that you could do • Evidence is shifting and aspirin is less strongly recommended • Aspirin leads to increase gastro-intestinal bleeds and maybe more cerebro-vascular hemorrhages • Aspirin is effective in men in preventing heart disease and in women in preventing strokes • Likely to benefit more those that have risk factors for heart disease: elevated cholesterol, high blood pressure, diabetes • Most beneficial study at reducing heart attacks was the Physicians Health Study which studied men and gave them aspirin at a dose of 325 mg every other day. Other studies using smaller doses were less effective.

22. Aspirin (2) • US preventive service task force recommendations • Encourage men age 45 to 79 years to use aspirin when the potential benefit of a reduction in myocardial infarctions outweighs the potential harm of an increase in gastrointestinal hemorrhage. • Encourage women age 55 to 79 years to use aspirin when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. • Do not encourage aspirin use for cardiovascular disease prevention in women younger than 55 years and in men younger than 45 years. • Evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older.

23. Aspirin (my recommendations) • Anyone with a positive score on heart scan. • Anyone with history of heart disease • Men greater than 45 with elevated cholesterol or diabetes • Men greater than 45 and women greater than 55 with high blood pressure

24. Medical treatment to prevent/treat heart disease • Blood pressure control • Target blood pressure should be 130/80. • Diet first-exercise, low salt, less stress. • Make sure BP monitor is accurate and no white coat syndrome. • Most drugs work well, combinations often have to be given. • Diuretics (HCTZ) are cheap and effective, but raise cholesterol slightly. • ACE inhibitors (Benzapril, Lisinopril) and ARBs (Cozaar, Diovan) are good choices. • Beta blockers (Metoprolol, Atenolol, Propanalol) may give fatigue, hair loss, and erectile dysfunction and are less recommended.

25. Cholesterol Lowering Agents • LDL Cholesterol-bad cholesterol- high levels strongly linked to heart disease • HDL Cholesterol-good cholesterol- low levels linked to heart disease • Triglycerides- fat in blood, very high levels related to pancreatitis, slight relation to heart disease • Non-HDL cholesterol= total cholesterol -HDL cholesterol-also linked to heart disease. • Apolipoproteins- Proteins that bind to cholesterol-related to heart disease. • CRP-marker of inflammation-linked to heart disease.

26. Statins • Blocks cholesterol synthesis • Lipitor, Zocor (generic, simvastatin), Crestor, Prevachol (any that work is ok) • Lowers LDL cholesterol • Reduces inflammation (CRP) • Most widely prescribed class of medications • Heavily pushed by industry • Definitely reduces heart disease and deaths • Side effects include muscle pain, cramps, elevated liver tests

27. Who should get a statin? • Anyone with plaques on EBCT! • LDL Cholesterol > 160 mg/dL • One risk factor (age > 50, family history, smoker): LDL Cholesterol > 130 mg/dL • Diabetes, kidney disease: LDL Cholesterol > 100 mg/dL • Known heart disease, history of MI : LDL Cholesterol > 70 mg/dL

28. Zetia/Vytorin • Zetia-prevents cholesterol absorption-lowers cholesterol, less side effects • Not shown to reduce heart disease • Vytorin-combination of simvastatin (Zocor; statin) and Zetia • Recent study says it was no better than simvastatin alone at reducing a marker of plaques at 100 times the cost.

29. Niacin • Vitamin B3 (deficiency is called pellagra) • One of the oldest cholesterol-reducing agents around with a long-standing track record of effectiveness and safety • Available as a prescription drug as well as a variety of "nutritional supplements” • Niacin lowers the amount of small low density particles, the most damaging variety. • It can cause rashes and aggravate gout, diabetes, or peptic ulcers. Early in therapy, it can cause facial flushing for several minutes soon after a dose, although this response often stops after about two weeks of therapy and can be reduced by taking aspirin or ibuprofen half an hour before taking the niacin. A sustained-release preparation of niacin (Niaspan) appears to have fewer side effects. • Increase high-density lipoprotein (HDL), the "good" cholesterol. • Brand names include niaspan and niacor. • Niacin is found in many foods, including:Dairy products, Lean meats, Poultry, Fish, Nuts, Eggs, Enriched breads and cereals

30. Fish oils • Ratio of linoleic acid (omega-6 fat) and linolenic acid (omega-3 fat) important • Too much omega-6 fat = inflammation and damage to organs • Omega-6 fat in fried foods, snacks and other foods with corn oil • Omega-3 fat in fish (ocean caught, not farmed), walnuts, fruits and vegetables • Can supplement Omega-3 fat • Omega-3 fat fortified ice cream and margarine have lots of fat and calories • Better to eat foods high in Omega-3 fat

31. Cancers • Genetic and environmental causes • Avoid toxic chemicals (oil refinery in Los Angeles) • Solvents and other chemicals • Obesity/poor diet is related to cancers • Do not smoke! • Both males/females

32. Cancers-Males • Colon cancer • Prostate cancer • Lung cancer

33. Cancers-Females • Breast cancer • Colon cancer • Ovarian cancer • Uterine/Cervical cancer • Lung cancer

34. Other Cancers • Brain cancer • Lymphoma/Leukemia • Pancreas cancer • Kidney cancer • Stomach cancer

35. Colon Cancer • Colonoscopy! • Starts as polyps • Prep is not pleasant, but otherwise easy and very recommended. • Males > 40, females >45 (earlier than often recommended). • If negative, every 5 to 10 years • All males with anemia, old females with anemia should get it • Do not recommend sigmoidoscopy or stool occult blood. • Virtual colonoscopy in the future, but not as good as colonoscopy

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

37. Prostate Cancer (men) • Prostate specific antigen (PSA; blood test) every 5 years starting at age 50. • Digital rectal exam -not sure its worthwhile. • If either are suspicious-ultrasound or MRI • Problem is many men have slow growing prostate cancer that doesn’t effect their life and is better if its not known. • Basic tests can not tell the difference between slow growing and aggressive cancers (will change in the near future). • Intervention may be worse than the disease (erectile dysfunction, osteoporosis). • Rate of increase of PSA may be more accurate than the actual levels

38. Breast Cancer (women) • Mammograms yearly starting at age 40 • Problem is picking up benign lesions that lead to unnecessary surgery • Ultrasounds or MRIs can be done as well, if strong family history or on suspicious lesions. • BRCA screening (common in Ashkenazi Jews) if family history of early breast or ovarian cancers • Self exam doesn’t hurt, but does not substitute for mammogram

39. Ovarian Cancer (women) • Pelvic ultrasounds every 3 years starting at age 40 • BRCA screening if family history of early breast or ovarian cancers • CA125-blood test that picks up ovarian cancer every 3 years starting at age 40 • Pelvic exam-yearly at age 40

40. Cervical Cancer (women) • Liquid based PAP test-every 2 years • Beginning at age 30, women who have had 3 normal Pap test results in a row may get screened every 2 to 3 years. • Get vaccinated against human papilloma virus

41. Endometrial Cancer (women) • See if a gynecologist if you have post-menopausal vaginal bleeding

42. Other Cancers • Whole body scan every 5 years starting at the age 50. • CBC (blood counts) to look for leukemias yearly starting at age 50. • New onset depression should be a possible flag for cancers (brain, pancreas, colon) • Unexplained weight loss is also a flag for cancer

43. Stroke • Same risk factors and markers as heart disease • Good blood pressure control < 130/80 • EBCT-shows calcification in aorta-similar to that of carotid (neck) arteries. • Daily baby aspirin • Carotid ultrasound-(plaques in the neck arteries)-every 5 years starting at age 45

44. Diabetes • Very linked to being overweight/inactivity • Fasting glucose should be < 100 mg/dL (get screened yearly) • Diabetes is fasting glucose is > 126 mg/dL • Prediabetes is fasting glucose is 101-125 mg/dL • Best way to prevent progression form pre-diabetes to diabetes is exercise and weight loss • Fasting insulin level > 15 iU/mL -insulin resistance • Prediabetes or insulin resistance-can take the medicine metformin (glucophage)

45. Diabetes (2) • HgbA1C-measures average blood glucose levels • Includes glucose after meals • Does not require fasting. • Diabetes >7.0% • Prediabetes 5.8% to 7.0% • Test yearly • Avoid getting diabetes and if you get it, get it under control. • See a specialist • HgbA1C < 7.0%, LDL cholesterol < 100, BP < 130/80

46. Osteoporosis • Thin bones • Predisposes to fractures, especially hip fractures • Hip fractures are a major cause of mortality • Bone density (DXA scan) in women starting at age 50, men starting at age 65. • Mostly a disease of thin women • Treat if osteoporosis, watch with repeat DXA scans if osteopenia • Look for underlying cause-vitamin D deficiency or high parathyroid hormone

47. Accidents • Car accidents-safest car possible-electronic stability control, air bags • Avoid cell phone (may also lead to cancers) • Avoid texting • New tires, keep car maintained • Wear seat belts • Drive defensively, don’t take risks • Avoid road rage/inciting road rage • Avoid bad neighborhoods • Do not confront thieves rogues • Avoid firearms • Avoid risky sports (skydiving, scuba diving, diving, rapid river rafting, hiking alone, motor sports, skiing)

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

49. Infections • Wash hands! • Avoid antibiotics for viruses as that will lead to drug resistance when you get bacterial infections • Avoid non-domesticated animals (turtles and reptiles-salmonella, wild birds) • Get vaccinated-influenza, H1N1, pneumovax • Get early treatment for pneumonia-high fever chills, pain on breathing

50. Dental Hygiene • Poor dental hygiene linked to heart disease, respiratory disease and diabetes. • Gingivitis allows bacteria to enter blood stream-leads to inflammation • See your dentist regularly • Brush and floss regularly