A New Debate on Milk?

While I generally enjoy Mark Bittman, his most recent article on the necessity of milk, or lack thereof, is controversial at best. His premise that it's "a pretty good sign that we’ve evolved to drink human milk when we’re babies but have no need for the milk of any animals" makes no sense.







Being of Asian descent, I can certainly attest to the fact that there are many, many people who are lactose intolerant, but well done, double blind, randomized trials (NEJM), show that even individuals who are truly lactose intolerant can easily tolerate a cup (250 ml) without significant clinical effects.


Mr Bittman quotes Neal Barnard, who states,“Sugar — in the form of lactose — contributes about 55 percent of skim milk’s calories, giving it ounce for ounce the same calorie load as soda.” Not sure where this data comes from but 1 cup of skim milk contains 86 calories, 12 g of which are from carbohydrates. This equates to 48 calories or, yes 56% calories from sugar.
The logic falls apart when you do the calculations for soda. 1 cup of Coca-cola (from their website) contains 100 calories, of which 27 g are carbs, equating to 108 calories, which is actually >100% calories from sugars! I'm not sure where Neal Barnard calculated his data from, but this sort of misinformation is not helpful, and potentially harmful. There really is NO comparison between the value of milk and soda in any sense.

I completely agree that other dairy sources such as hard cheeses and yogurt are better tolerated and digested than milk, but don't think milk should be discarded for soda!

I am happy that Mr Bittman has solved his own personal health problems, but to make an argument that we should stop drinking milk is based on misinformation at best, and possibly harmful at worst.

Let me know what you think!

PSA Testing: Yea or Nay?

In the town I live in, we have an annual "Fathers' Day Prostate Cancer Walk". This year will be the 14th annual, and the disease is continuing to increase in numbers, despite ongoing research and funding. We often see advertisements to "get checked", but recently, medical studies have questioned whether PSA testing is helpful.(NEJM, March 2012). This study concluded, that although PSA screening decreased the mortality from Prostate Cancer by 21%, it did NOT reduce the overall mortality rate. In fact, to prevent ONE death from prostate cancer, you would need to screen over 900 men.

So, is this a good screening tool?



What is a Good Screening Tool?

We tend to like answers to questions to be black or white. For example, I want the answer to my prostate test to be "No, you do NOT have cancer."
I don't want to hear, "Well, you probably don't, but I'm not 100% sure." Unfortunately, NO screening test can give you a one-hundred percent guarantee.
Screening tests should do the following, in the best cases.

• It tests for an important disease
• There is treatment available, when given early has more benefit than if giving later in disease
• The prevalence of the disease is relatively high
• The test is relatively inexpensive
• The test is consistent
• The test is VALID (ie. can distinguish between real disease and normal state)
• The test is easy to administer and causes little discomfort

Looking at these features, a test like measuring Blood Pressure is a good screening tool. It's easy to do, and if you treat it early, you can prevent a lot of complications.

Doing a PSA Test is a little more tricky. 

Why the Controversy?

The controversy as to whether PSA testing is a good screen is for a few reasons. Unfortunately, the lab result is NOT an absolute answer. It doesn't give that clean black/white answer we crave. You simply get back a number, and are left to interpret what it might mean. Obviously, a sky high value is worrisome for cancer, but, where should the cut-off be? We can't have it be too high, or we'll miss some cases, but if we set the cut-off too low, we start biopsying patients who don't have cancer. This causes undo stress and anxiety in patients, for no good reasons.

The other problem (although a better problem to have) is that prostate cancer tends to be a slow growing cancer. In other words, it's not uncommon that if a man was never screened, he likely would die of some other cause than the prostate cancer itself. In other other words, NOT ever knowing might have been fine.

Finally, the treatment, be it surgery, radiation, or other, is NOT without it's own complications. Infections, incontinence, impotence are possible, for a disease which might not have killed you in the first place.

All that being said, I have also seen many cases of prostate cancer with awful endings, as well.

So What Should I Tell My DAD to do?

I think the best advice, is for every man over 40, to at a minimum see their physician for an annual check up. As a family doctor, I don't see nearly enough middle aged men on any regular basis. A discussion about the pros and cons of the nowhere near perfect PSA test should take place, and irregardless, a digital rectal exam should be done. 

If after discussion, knowing the risk/benefit of the PSA lab test, I offer it to all my middle-aged men.

Definitely a complicated topic with no right answer in my opinion.

Let me know what you think, and don't forget to wish your dad a HAPPY FATHER'S DAY!