Aging Gracefully – Part 2 Slowing The Aging Process

Can we slow the aging process?  The answer is a definite yes and it all has to do with our lifestyles and behaviors.  Here is a quiz.  What percent of Americans can answer yes to all five of the following statements?

 

Here’s a clue.  We know that about 20% of Americans smoke so the highest answer you can give to this question is that 80% could answer yes to all five.  The actual answer may surprise you.  It did me.  Only 3% of Americans can answer yes to all five! 

Let’s return to bone mineral density.  The way to slow BMD decline is to exercise and to eat a nutritious diet.  (Vitamin D supplements may also be necessary for those in temperate climates who get little sunshine on their skin.) So instead of a 1% decline per year it can be more of a ½% decline per year.  On the other hand for couch potatoe that decline won’t be 1% but it may be more like 1½ to 2% per year.  The same goes for cognition.  There are certain adverse factors such as vascular conditions and the metabolic syndrome (a precursor to diabetes) and also the chemicals released through chronic stress that speed up cognitive decline.  But there are also protective factors which we can control ourselves.  These include being physically active, intellectually challenged, and socially engaged.  It may be a surprise that physical activity is important for cognition but it has been clearly demonstrated to be critical.  Intellectual challenge is different than reading a book, even a complex book.  That’s not a challenge.  But if you belong to a book club and have to actively defend your perspective and point of view that then becomes a challenge.  Socially engaged means being involved as a human being with other human beings.  This is something that is frequently lost during older years if isolation develops due to limited mobility, inability to drive, etc. 

So the essential steps of slowing the aging process are: Avoid tobacco and remember it’s never too late to quit.  Reduce chronic stress because the chemicals released from stress have a very adverse effect on many physiologic systems such as immune function.  Eat a nutritious diet.  Do cognitive exercises which challenge your intellect.  Remain socially well connected. Physical exercise should include aerobic activity of about thirty minutes five days per week (just simple walking is adequate); resistance or weight training 2-3 times per week and balance exercises 2-3 times per week. 

 

To summarize, there is a steady slow loss of physiologic function in most of our organs over time. It is possible to slow this 1% decline and with it the ultimate functional impairments. It is also possible to avoid or certainly delay age-prevalent diseases.  But in both cases it’s up to us.  It’s up to us to adjust our lifestyles and we preferably need to do so beginning at a young age. That said, it is never too late to begin a preventive program.  We can slow physical decline with exercise, diet and reducing stress.  We can avoid many diseases by not smoking. We can slow cognitive decline with physical activity, intellectual challenges and social engagement.  It’s worth it.

Next post – The importance of comprehensive primary care in managing the aging process.

Aging Gracefully – Part 1 The Normal Aging Process

It is possible to slow the aging process.  No there is no Fountain of Youth and no, there is no pill that’s been discovered.  It’s all about lifestyle and this means starting at an early age and sticking with it through the years. 

I was recently invited to give a talk to a group of about 100 individuals contemplating moving to a continuing care retirement community.  The topic - is it possible to slow the aging process?  I titled it “Aging Gracefully.”  Here are my thoughts divided into three major categories:  the normal aging process, slowing the aging process, and (in a post to follow) obtaining the very best comprehensive health care.  The talk was picked up by the Howard Times of the Baltimore Sun; the reporter’s article is available at this link:  http://bsun.md/1AtQW7E

 “Old parts wear out.”  That’s normal aging.  It’s universal, it’s progressive and, at least as we know it today, it is irreversible.  Most organ functions decline by about 1% per year.  Fortunately our organs have a huge redundancy and so we can afford the declines without illness.  But eventually if we live long enough and the process continues at the usual rate a point is reached at which functional impairment or actual disease presents. 

Let’s use bone mineral density and cognitive function as examples.  During our childhood and teenage years our bone mineral density increases and with it our bone strength.  It reaches a peak at about age 20 and plateaus and then by age 35 starts a slow but inexorable decline of about 1% per year.  Should we live long enough we will reach a point which we can call the “fracture threshold” meaning that if we fall it’s possible to break a leg or a bone in our back.  Of course that 1% decline per year is an average.  Some people decline faster and some people decline more slowly.  We’ll come back to that point.  The same goes for cognitive function.  We’re at a peak at about age 20 and then there is a long plateau with a slow decline such that by the time we’re in our 80’s or 90’s most people have some noticeable decline in cognition. 

There are certain impairments that come with aging such as reduced vision, reduced hearing and reduced mobility.  We might not consider these as true diseases.  However there is also an increased prevalence of chronic illnesses such as heart failure, cancer, chronic lung and kidney disease and diabetes.  They often manifest in older ages but they actually originated many years ago.  For example coronary artery plaque buildup begins in childhood but may not manifest itself as a heart attack until the late 60’s.  Similarly lung cancer is on average diagnosed at age 72 but the cause began way back as a teenager when the person first went back behind the garage for a smoke. (BTW, not all lung cancers are due to smoking but for those that are, it was a long slow process over time.) 

These chronic illnesses are largely due to our adverse behaviors, our lifestyles.  The four big behaviors that need to be addressed are nutrition, exercise, chronic stress and tobacco.  We could add other factors but especially inadequate dental hygiene and excessive alcohol. All too many of us have poor nutrition (e.g. packaged and processed foods, lack of fresh fruits and vegetables, etc.) and at the same time we eat too much of it.  Most Americans don’t get an adequate amount of exercise.  It seems that everyone has some level of chronic stress and 20% of Americans smoke. 

To summarize, there is a normal aging process wherein organs reduce their function by about 1% per year. This rate of decline is related, in part, to our lifestyles beginning when we are quite young. There are also age-prevalent chronic diseases that are also life style driven. Our personal agendas need to include attention to healthy living so that we can preserve wellness.

Next time – Slowing the Aging Process

 

 

Lung Cancer Overview - Part 1 of 5

There has been some remarkable progress in recent years in the diagnosis and treatment of lung cancer. 160,000 Americans die annually from lung cancer making it second only to heart disease as a cause of death and slightly more than the next four cancers combined – breast, colon, pancreas and prostate.  This is largely because lung cancer is usually discovered only after it has spread. Now CT scanning has been shown to detect lung cancer when it is still small and localized. Further there have been major advances in treatment with radiation, with combination drug therapy and with new compounds targeted at “driver mutations”. Although cures are rare still they are growing in number. For those with extensive disease, there are useful responses to newer therapies that prolong survival and improve the quality of life. As a result, there now appears to be some light at the end of this very long tunnel. 

Facts and Figures - About 225,000 individuals will develop lung cancer in 2013. The incidence among men is higher than among women (76 and 53 per 100,000 respectively, age adjusted.) This is presumably due to the greater past use of tobacco by men over the years. The lifetime risk for men and women combined is about seven percent. That translates to one of every 14 individuals will develop lung cancer sometime during life. The incidence rises substantially with age. About one third of cases develop below the age of 65, one third between 65 and 75 and one third above age 75. The median age of onset is 70 years.  

It is certainly no surprise that smoking is the leading cause of lung cancer; about 80 percent of individuals are current (20 percent) or former (60 percent) smokers. Smoking increases a person’s lifetime risk by a factor of 20 times. Other causes are radon, second hand smoke, asbestos (especially when combined with smoking) and a variety of other environmental factors including arsenic, nickel and chromium. But there are those, especially younger women, who are developing lung cancer despite no known exposures. Lung cancer among both men and women who have never smoked is the sixth leading cause of cancer deaths with about 28,000 dying annually, about the same as prostate cancer caused deaths. 

The incidence of lung cancer has plateaued or even dropped slightly for men but is continuing to rise for women. This reflects the fact that a leveling off of smoking occurred sooner for men than women.

Most lung cancers are diagnosed after it has already spread past the lungs. As a result, surgery alone uncommonly leads to cure and unfortunately most patients are not even candidates for surgery due to local, regional or distant spread at diagnosis. Only about 15 percent of lung cancers are diagnosed when still localized to its pulmonary site of origin; the rest have already spread regionally (22 percent) or distantly (56 percent) with the remainder uncertain as to stage. Compare this to breast cancer or prostate cancer where about 60 percent and 80 percent respectively are localized at diagnosis. This makes for a huge difference in the ability to treat successfully. For women, it means that 73,000 die of lung cancer compared to 40,000 for breast cancer each year despite the fact the age adjusted incidence of the two diseases are 53 per 100,000 and 124 per 100,000, respectively.  

Lung cancer, with its 160,000 annual deaths, accounts for nearly 30 percent of all cancer deaths and is somewhat more than the combined mortality of the next four leading causes of cancer deaths - colon (about 56,000 deaths per year), breast (40,000), pancreas (37,000) and prostate (28,000).  

Survival is generally short with only about 15 percent five-year survivors (5 year survival rates are commonly used measures of successful therapy for cancer). Compare this to the rates of cure for breast cancer (about 90 percent), prostate cancer (nearly 100 percent), and colon cancer (65 percent). Given that the long phase of initiation of smoking to cancer diagnosis is many decades and given that 20 percent of Americans smoke regularly today it is reasonable to forecast that by 2030 the number of cases will increase by about 50 percent for both men and women.  

Categories and Early Detection - Lung cancers are categorized as either small cell or non-small cell lung cancer (SCLC, NSCLC) and the NSCLC are further defined by both their appearance under the microscope as squamous, adeno or large cell and increasingly by genomic analysis. Lung cancer can now be detected early with low dose CT scanning. This means that more individuals are potentially amenable to having their cancer cured. The demonstration that adjuvant chemotherapy for those with possible distant microscopic disease increases the rate of cure for resected NSCLC is a major advance.  But for each cancer lesion detected early by CT scans, 19 benign lesions are also detected which are usually not easily distinguishable from cancerous ones. This results in a dilemma for the patient and the physician – to have an invasive procedure to get a definitive answer or to have regular CT follow-up to see if the lesion progresses, stays stable or regresses. Clearly, new rapid, effective yet less invasive approaches to resolving this dilemma are critical.

Treatment - The opportunity to detect the cancer early means more individuals can be cured with surgical excision or with radiation therapy. Either can be followed by adjuvant chemotherapy for those with a high likelihood of microscopic disease spread. The combination of chemotherapy with radiation therapy has curative potential in locally advanced NSCLC and in limited stage SCLC. New approaches to radiation therapy allow for much higher doses of radiation to the tumor with much less damage to surrounding normal tissues. Current chemotherapy drugs, usually used in combination with one another, have clearly improved the quality of life for patients with more advanced disease, slowed progression of the tumor and created definite a, albeit relatively short, survival advantage.

Of interest in drug therapy today is the advent of “targeted drugs,” ones that inhibit a specific abnormal protein in the tumor cell that is a “driver” of the cancer. These are the products of DNA mutations or DNA rearrangements and are uncovered by genomic analysis. Because the new drugs are quite specific, they affect the tumor but cause proportionally less side effects. Responses among patients with the DNA mutations in their cancers tend to occur rapidly and often with marked regression of the tumor. Unfortunately, relapses eventually occur as resistance develops and the drugs are quite expensive. There is an important proof of principle here that has been accomplished and improvements in targeted treatment are coming fast and furiously.

There is good evidence that the best results with early diagnosis and with effective treatment lies in organizations that have high levels of expertise and utilize a multi-disciplinary approach to care wherein the patients is seen concurrently by surgeon, radiation therapist and medical oncologist to devise the most appropriate approach to care. Added to this, palliative care begun at the time of diagnosis adds to patient comfort, lessens anxiety, and reduces overall costs while improving satisfaction with caregivers and therapies.

With the advent of early diagnosis with CT screening, more effective yet less damaging approaches to radiation therapy, effective chemotherapy, targeted drug therapy for those with driver mutations, all initiated in experienced hands with a multi-disciplinary approach and early institution of palliative care, perhaps the light is now actually beginning to glow at the end of the tunnel for lung cancer patients and their families.

Four follow-on articles will discuss in more depth early diagnosis, treatment options of surgery, radiation and drugs, the use of multi-disciplinary team care and the value of palliative care teams. This five part series first appeared in Medical News Today at http://bit.ly/12bCUqD   

Smoking Is The Single Most Dangerous Adverse Health Behavior

No other cause of illness or death is more important than smoking. This is the clear message of two new studies of large numbers of Americans conducted by Jha etal and by Thun etal and published by the New England Journal of Medicine on January 24, 2013.

About 19% of Americans smoke regularly today, down from about 40% a few decades ago. Good progress. But for those who do smoke, diseases leading to death are common. Smokers mortality is about 3 times that of nonsmokers and essentially equal between men and women. Certain diseases have been clearly linked to smoking and these caused about 60% of the smokers’ deaths – ischemic heart disease (heart attacks and related), stroke, chronic lung disease and lung cancer being the most common.

The Thun study compared data from three time periods reaching back 50 years. Overall mortality declined by 50% over those 50 years in large part as a result of progress against heart disease. But this was a benefit largely enjoyed only by the nonsmokers since smoking exacerbates coronary artery disease.

Thun made some key observations. First, smoking deaths continue to increase among women because women who smoke smoke as much as do men. Second, death from all causes is at least 3X higher for smokers than for nonsmokers with at least two thirds of all deaths in smokers directly related to smoking. Third, the rate of death from chronic lung disease (COPD) is rising among both men and women.  They hypothesize that this rise in incidence is related to the changes in cigarettes over the years that encourage deeper inhalation with more toxins reaching the periphery of the air sacs. Using the same reasoning, they suggest that deeper inhalation than in the past may be causing the increased incidence of peripheral lung cancers especially adenocarcinomas rather the more centrally located mostly squamous cell cancers that were more common in the past. Fourth quitting smoking lowers death rates very substantially and quitting before the age of 40 can eliminate the relative risk of early death.

 

In the Jha study, the increased risk for ischemic heart disease among smokers compared to nonsmokers was about 3.5 i.e., smokers had 3.5 times as many deaths from heart disease as did the nonsmokers. Since heart disease is more frequent than lung cancer or chronic lung disease, this represented a large and common cause of death for smokers. Considering just women for example, among the 23,839 women who smoked in the study, 251 died of heart disease compared to 382 of the 67,574 women who never smoked. Lung cancer caused fewer total deaths but the relative risk for smokers was very high – 18 – based upon 289 women who smoked and died of lung cancer compared to 83 lung cancer deaths for the larger number of women who never smoked.

These two studies are a stark reminder that smoking is not simply a health hazard. It directly leads to very substantially increased risks of death from heart disease, stroke, chronic lung disease and lung cancer, among others. In the Jha study, 62% of the smokers’ deaths were attributable to smoking.

Attempts to curtail the initiation of smoking and to assist with smoking cessation are important – perhaps the single most important - health promotion and disease prevention goals for America.