Three years ago, the American Heart Association and the American College of Cardiology released highly controversial guidelines for treating elevated cholesterol. Many people, myself included, were very cautious and skeptical of them when they first were released. They represented a pretty radical shift in how we think about prescribing medications called statins. These medications, including atorvastatin (Lipitor), simvastatin (Zocor), and rosuvastatin (Crestor), have been around for decades and despite their share of controversy have been shown to substantially lower the risk of heart attacks and strokes when given to the right people.

With the passing of time, additional reading on the subject, and some reflection, I have come to embrace these new recommendations. Here are some things that I would like you to consider:

Statins have been shown to reduce a person’s risk of a heart attack or stroke by 30-50% over a 10-year period. This seems to apply pretty much across the board regardless of one’s baseline risk. To illustrate, a 40 year old, otherwise healthy woman has about a 2% chance of having a heart attack or stroke over the next 10 years – remember that these can happen unexpectedly in people of all ages but are quite rare in young and the healthy people. Taking a statin would reduce her absolute risk by 30%, bringing her chances down slightly but not very much (50% of almost 0 is still almost 0). But on the other hand, a 60 year old man who smokes and has high blood pressure might have a 30% chance of having a heart attack or stroke over the next decade and taking a statin would reduce his risk to about 15%. He still has a pretty large risk of having an event, but it has been reduced quite a bit.

The current guidelines recommend starting a statin when a person’s 10 year risk of a heart attack or stroke is >7.5%. Another group, the US Preventive Services Task Force earlier this year recommended that treatment begin when the baseline risk is 10%. I think that the difference between 7.5% and 10% for a treatment starting point is not much different from one another. Even before the latest recommendations came out, I didn’t strongly encourage starting statins unless someone was in the 10% or higher risk group. In part it is because of some of the limitations of how the calculator works (a few points up and down in blood pressure or cholesterol can have a real change in the risk estimate) and also because there is fairly modest benefit in treating the lower risk individuals. For example, for someone to reduce their 7.5% chance of having a heart attack or stroke down 4.5% meant that 33 people would need to be treated with a statin for 10 years for one of them to see a benefit. But in the earlier example, reducing a risk from 30% down to 15% will mean that only 7 people will need to be treated for one to see a benefit.

On the topic of risk estimation, the calculator used by the guidelines is rather imprecise and does not take into account family history. I think family history is a major risk factor for a lot of people – both in over- and under-estimating the need for treatment. Because of this, I use risk-calculating tool as a starting point to think about whether or not to start a statin and not as a definitive answer. Although I don’t usually recommend statins for otherwise low risk individuals with a strong family history of heart attacks or strokes (unless they have a bad cholesterol (LDL) >190 which is a separate indication for treatment), I will occasionally deviate from the guidelines if they have a very strong family history. Alternatively, a person with a lot of longevity in their family without early cardiovascular disease might do well to remain off of a statin. If their estimated risk is over 7.5% I will still recommend that they start treatment, but if they decline it I am less likely to ask them to reconsider.

Here are some facts that I would like you to know about the prostate, prostate cancer, and prostate cancer screening.

What is the prostate?

It is a gland that men have deep in their lower pelvis, between their bladder and rectum. It is usually about the size of a plum and makes a lot of the liquid that becomes part of their semen. A rectal examination can feel the outside portion of about a third of the gland.

Prostate cancer is common. And deadly.

According to the American Cancer Society, prostate cancer is the most common cancer in men (other than skin cancer). About 181,000 Americans expected to be diagnosed with it this year. This means that over the course of a man’s lifetime, he has about a 1 in 7 chance of being told that he has prostate cancer. And it tends to be an older man’s disease with about 60% of prostate cancers diagnosed in men 65 or older.

And about 26,000 men will die from prostate cancer this year. That means that more men will die from prostate cancer than any other cancer except for lung cancer. Overall, about 1 in 39 men will eventually die from prostate cancer.

But most men with prostate cancer do not die from it. They die with it.

Currently, there are about 2 million prostate cancer survivors in the US. And the survival rates for prostate cancers (combining all stages of the disease together) are almost 100% after 5 years, 98% after 10 years and 95% after 15 years.

Prostate cancer screening is not very accurate.

The only screening test we have available is a blood test called the prostate specific antigen (PSA). This is a protein that the prostate makes to help keep semen stay as a liquid. This protein is released into the blood when the prostate is irritated for any reason. This includes cancer but can also be from infections or inflammation from other things like having a lot of sex or riding a bicycle. And for reasons that are not clear, a lot of prostate cancers do not release a lot of PSA into the bloodstream. As a result the PSA is often normal in men with cancer and high in men without it.

Prostate cancer screening rarely saves lives.

It is estimated that only about 1 in 200 men who are screened for, and ultimately diagnosed with prostate cancer, actually has their life saved from screening. The other 199 would never have died from the disease but would have died from something else even though they had prostate cancer. But aggressive screening and treatment leads to a lot of worry, harm related to treatment (erectile dysfunction, urinary incontinence, rectal pain and irritation), and additional financial costs.

Prostate cancer treatment is often quite good at prolonging life – even in very advanced disease.

With some of the newer approaches to prostate cancer, including hormonal therapies and advances in chemotherapy and radiation, many men with disease that has spread throughout their body are able to go into rapid and longstanding cancer remission.

So, taken as a whole, many experts are now recommending that we do not routinely screen men for prostate cancer. I think this makes a lot of sense and I personally do not want to be screened for it until a better test is available.

Lots of people have made money selling diet and nutrition books, often with completely contradictory information. And now there is a new TV show adding even more confusion to the topic. ABC just started showing My Diet is Better Than Yours which “features celebrity trainers coaching average Americans to lose weight and get in shape. Each trainer brings his/her own individually designed and wildly diverse diet and exercise plan to their contestant, and works with them to change their lives.” I haven’t seen the show yet, more to come on that. For this post, I’m going to focus on my recommendations for healthy eating – not weight loss per se.

Medical researchers really don’t really know with certainty what we should eat, but they have some good ideas based upon decades of research. The challenge researchers face is that the long-term effects of our diet on our health are really hard to measure. It’s one thing to feed mice a low carb diet or a high fat diet and see what happens to them over the course of their short lives. It’s quite another to do the same to people. And as has been seen time and time again, the information we glean from studying animals doesn’t often apply to humans.

I suspect that another issue limiting our ability to study diet and health is that there are likely metabolic differences between people. Although researchers tend to conduct research under the assumption that our bodies all pretty much work the same when it comes to nutrition, I think this is a mistake. In many circumstances it is true that our bodies work the same. We all have very similar anatomy and can have blood and parts interchanged with others, for example. But it is quite likely there are some fundamental differences in how individuals break down and use nutrients from our diet. It’s probably not as simple as eating for our blood type as a famous book has suggested, but I think there is some truth to the overall concept that different people likely benefit more from diets rich in certain compounds.

Maybe some of this variation is genetic; maybe some is environmental. We know that people metabolize alcohol differently (depending on our genetics and whether we consume alcohol regularly or not) and that our livers metabolize certain medications differently.

And we also know that bacteria in our intestinal tracts vary a lot from person to person and that these microbes (called the microbiome) play a very large role in why two people might respond very differently to the same diet. Not only is it that the food one eats might be broken down more easily by certain bacteria, but also eating certain types of foods over a long period of time can lead to the growth of either healthy or unhealthy bacteria which have their own independent influences on our health. Researchers are just starting to understand this better, but I predict that this will be a huge shift in how we look at nutrition in the coming years.

But let’s get back to what we do know. First of all, pretty much all research indicates that eating lots of fruits, vegetables, nuts, seeds and legumes is healthy for our bodies. These should all be the cornerstone of what all of us eat. Not only do these foods provide us with lots of essential nutrients, including vitamins and minerals, they also provide us with lots of fiber and other nutritional compounds that researchers continue to uncover and report: exotic sounding things like lycopenes, biotin, and retinoids. These substances, both known and currently unknown, are thought to play a very substantial role in reducing our risk of developing cardiovascular disease, cancer, dementia and many other conditions. The very things that make an apple red or a blueberry blue are the things that help keep us healthy.

Also, experts are generally in agreement that one should limit simple carbohydrates in our diet – things made with white flour and sugar, white rice and pasta. Although both cheap and relatively filling, these do not provide fiber or other nutrients and they are quickly broken down into simple sugars. These sugars cause spikes in insulin, which can cause us to feel hungry not long after eating and can lead to increases in body fat.

And what about fat? Should you use oils? Well, yes. Particularly plant-based oils like olive, canola, and coconut. These have a lot of nutritional value, particularly in providing essential fatty acids like omega-3 and omega-6.

I think that all of the above are reasonable guidelines that most people should follow. In all of these things, moderation is the most important consideration. I don’t like to tell people that they can never eat white bread, or cake or drink a soda. But these processed should be occasional treats rather than the cornerstone of one’s diet. And limiting calories is also important both for weight control and also for longevity.

The real controversial issue is animal protein, including eggs and low fat dairy. The data here is really mixed and I think that this is a truly unresolved issue. Certainly people who do not want to eat meat for ethical or religious reasons can have a very healthy and complete diet (with the exception of getting enough vitamin B12 which is found almost exclusively in animal products). But I think that the real question that remains is whether most people should or should not follow a vegan diet. On the one hand, lean animal protein is a filling and balanced source of amino acids and is rich in vitamin B12. On the other hand, some data shows that when our bodies break down animal proteins from any source, the byproducts create some cancer causing compounds.

So in summary, my recommendations (until we can create a truly personalized diet) are as follows:

• Eat mostly plant-based foods.
• Limit simple carbohydrates.
• Stay away from processed foods.
• Think about limiting animal protein.
• And don’t eat too much.

So you are scheduled for an appointment to see a clinician. Maybe it is a doctor or nurse practitioner; your primary care provider or a specialist; a visit to someone new or someone you have seen countless times before. Regardless of the circumstances, here are some tips to make the most of your visit:

1. Make a list of your concerns. Even if you coming in for a “physical” or other type of wellness visit, make a list of any additional concerns. Maybe you have something on your skin you want checked. Or some fleeting chest pain that you want to make sure is nothing serious. Or there is something worrisome going on that you want to discuss. Write it down beforehand so you don’t forget. Paper and pencil are ok, but putting it on your smartphone is a better idea to make sure that you bring it in with you at the visit.
2. Share your list early in the visit. Don’t wait until the doctor is about to leave to bring up issues. Even if they are embarrassing things to talk about. Set an agenda at the start. But keep it short – no more than 3 things is a good rule of thumb given that clinicians are seeing patients every 15 minutes or so and you want to make sure that they have enough time to properly address your concerns. And let the clinician know whether each item is something that you want evaluated and treated or just for informational purposes.
3. Bring in a list of your medications, including supplements and over the counter products. If you take anything on a regular basis you should let us know. You might think that the herbal supplement you started taking to improve your memory is nothing to worry about – but it might interact with something you are prescribed, or even causing the symptoms that are on your list. Don’t assume that your clinician will specifically ask about supplements and over the counter remedies. Although I mean to do so, often I forget.
4. Discover about your family history. This is particularly important when you come in for a preventive care focused visit, but the information may be helpful in other circumstances as well. Try to know the specifics as much as possible (e.g. “a heart problem” vs. “coronary artery bypass surgery at age 55”) without sweating the finer details. It doesn’t matter much (to the person taking the family history, at least) whether your grandfather had 3 or 4 arteries bypassed during his surgery. Try to provide information on your parents, siblings, grandparents and children. And if there was anything unusual in extended family members, including a lot of cancers, please bring these up as well.

Show up early. This might seem obvious, but take extra care to show up on time. There’s a perception that doctors are always running late, and while that is true some of the time for just about everyone (including myself) I am often running right on time, meaning if you have a 10:00 booked that I am planning to see you right at 10:00. So it’s best to show up 20-30 minutes early to make sure you get to the waiting room on time. My patients who are late often either only have the remaining time left in their scheduled visit (so that I am on time for the next person), will have to wait until I have a chance to see them (often at the end of my sessio