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From the Townsend Letter
December 2010

Literature Review & Commentary
by Alan R. Gaby, MD

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Diet and Exercise Improve Erectile Dysfunction
One hundred ten obese nondiabetic men with erectile dysfunction (defined as a score of 21 or less on the International Index of Erectile Function [IIEF]) were randomly assigned, in single-blind fashion, to one of two groups. The intervention group received detailed advice about how to lose 10% or more of total body weight by reducing caloric intake and increasing physical activity. The control group was given general information about healthy food choices and exercise. Compared with the control group, the intervention group had a significantly greater increase in physical activity and a significantly greater decrease in body mass index. The mean IIEF score improved in the intervention group (from 13.9 to 17; p < 0.001), but did not change in the control group. After two years, 30.9% of the men in the intervention group and 5.5% of those in the control group (p = 0.001) had an IIEF score of 22 or higher, a score that indicates a very high likelihood of normal erectile function.

Comment: In our zeal to find the magic pill for the magical erection, we tend to forget that all of our bodily functions depend on a healthy body. That includes maintaining a proper body weight, good muscle tone, and aerobic fitness. It is noteworthy that nearly one-third of the men in the study described above achieved normal erectile function simply by getting in better shape.

Esposito K et al. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial.
JAMA. 2004;291:2978–2984.

DHEA, Erectile Function, and the Prostate
Forty men (mean age, 56.5 years) with erectile dysfunction were studied. None of the men had well-known causes of erectile dysfunction, such as hypertension, diabetes, or ischemic heart disease. All men achieved a full erection after an erection test with intracavernosal administration of prostaglandin E1. Other inclusion criteria were normal serum levels of testosterone, dihydrotestosterone, and prostate-specific antigen (PSA), and a serum DHEA-sulfate level below 1.5 µmol/L. The men were randomly assigned to receive, in double-blind fashion, 50 mg per day of DHEA or placebo for six months. The International Index of Erectile Function (IIEF), a 15-item questionnaire, was used to assess the results. In the DHEA group, significant increases (improvements) were seen compared with baseline for all five domains of the IIEF (erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction; p < 0.01 to p < 0.001). These values were unchanged or became slightly worse in the placebo group. DHEA treatment had no effect on mean serum values for PSA or testosterone, or on the mean postvoid residual urine volume. Mean prostate volume decreased slightly in the DHEA group and increased slightly in the placebo group.

Comment: The results of this study suggest that DHEA may be an effective treatment for erectile dysfunction in some cases. Moreover, although androgenic hormones have the theoretical potential to promote or exacerbate benign prostatic hyperplasia (BPH), there was no evidence that DHEA treatment had an adverse effect on the prostate. To the contrary, there was a trend toward better prostate health in the DHEA group compared with the placebo group. In my experience, the physiological dosage range for DHEA is usually 10 to 20 mg per day for men, and I rarely use larger doses, except to treat autoimmune diseases. It is my practice to consider the use of DHEA for patients whose serum DHEA-sulfate concentration is below or in the bottom 10% to 20% of the normal range for young adults of the same gender.

Reiter WJ et al. Dehydroepiandrosterone in the treatment of erectile dysfunction: a prospective, double-blind, randomized, placebo-controlled study. Urology. 1999;53:590–595.

Essential Fatty Acids for Benign Prostatic Hyperplasia
Nineteen men with benign prostatic hyperplasia (BPH) received 1.95 g per day of an essential fatty acid (EFA) preparation (source not specified) that contained linoleic acid, alpha-linolenic acid, and other fatty acids. After three days, the dose was reduced to 1.3 g per day for several weeks, then to 0.65 g per day. After an unspecified period of time, all patients had a decrease in postvoid residual urine volume, and in 12 of the 19 patients this parameter became normal. The prostate size, as determined by palpation, decreased in all 19 patients.

Comment: EFAs are precursors to prostaglandins, a group of hormonelike compounds that were so named because of their presence in high concentrations in prostatic secretions. Prostaglandins are believed to modulate the effect of testosterone (or dihydrotestosterone) on prostate cell growth. It has been hypothesized that prostaglandin synthesis by the prostate becomes less efficient with advancing age, resulting in an exaggerated effect of testosterone (or dihydrotestosterone) on prostate cell growth. The distribution of prostaglandins in prostate tissue has been found to differ between men with and without BPH. Prostaglandins A1, A2, B1, F2a, and Y (an unidentified prostaglandin) were present in hyperplastic prostates but absent in normal prostates. In contrast, prostaglandins E2 and X (another unidentified prostaglandin) were present in normal prostates but absent in BPH samples. While the significance of these findings is not clear, they raise the possibility that altering prostaglandin levels by supplementing with EFAs could be beneficial for men with BPH.

The study described above is not well known, because it was written in 1941 and never published in a medical journal. However, in my experience and in the experience of other practitioners, EFA supplementation often improves symptoms in men with BPH. My usual recommendation is 1 tablespoon of oil per day, alternating flaxseed oil with sunflower or safflower oil. Because increasing intake of polyunsaturated fatty acids (as are found in these oils) increases the requirement for vitamin E, patients taking EFA supplements should take 50 to 100 IU per day of additional vitamin E.

Hart JP, Cooper WL. Vitamin F in the treatment of prostatic hypertrophy. Report #1, Lee Foundation for Nutritional Research. November 1941.

Probiotic Prevents Infections in Children
Six hundred thirty-eight children (aged 3–6 years) attending day care or schools in the Washington, DC, area were randomly assigned to receive, in double-blind fashion, a fermented dairy drink containing Lactobacillus casei DN-114 001 or a placebo drink with no live cultures for 90 days. The incidence of common infectious diseases (i.e., respiratory tract and gastrointestinal infections) was 19% lower in the active-treatment group than in the placebo group (p < 0.05).

Comment: Probiotics are bacteria or yeast organisms that may have beneficial effects on human physiology and health. Probiotic organisms are believed to work in part by enhancing digestion and immune function, by competing with pathogenic microorganisms for binding sites on mucosal surfaces, and by producing chemicals that inactivate or kill pathogens. The results of the present study indicate that administration of a specific probiotic organism prevented infections in young children.

Merenstein D et al. Use of a fermented dairy probiotic drink containing Lactobacillus casei (DN-114 001) to decrease the rate of illness in kids: the DRINK study. A patient-oriented, double-blind, cluster-randomized, placebo-controlled, clinical trial. Eur J Clin Nutr. 2010;64:669–677.

Vitamin D May Prevent Relapses of Crohn's Disease
One hundred eight patients with Crohn's disease in remission were randomly assigned to receive, in double-blind fashion, 1200 IU per day of vitamin D3 or placebo for 12 months. All patients received 1200 mg per day of supplemental calcium. At baseline, the mean serum 25-hydroxyvitamin D concentration was 69 nmol/L, which indicated adequate vitamin D status. After 12 months, the relapse was lower in the vitamin D group than in the placebo group (13% vs. 29%; p = 0.06).

Comment: In this study, vitamin D supplementation reduced the relapse rate by 55% in patients with Crohn's disease in remission. Although the results were only of borderline statistical significance, the effect size was large. Since 1200 IU per day of vitamin D appears to be safe, vitamin D supplementation should be considered for all patients with Crohn's disease. The beneficial effect of vitamin D was probably not due to the correction of a deficiency, since the patients in the study generally had adequate vitamin D nutritional status at baseline. Vitamin D may work by exerting anti-inflammatory and immunomodulating effects.

Jorgensen SP et al. Clinical trial: vitamin D3 treatment in Crohn's disease - a randomized double-blind placebo-controlled study. Aliment Pharmacol Ther. 2010;32:377–383.

Glucosamine Sulfate Not Effective for Low Back Pain
Two hundred fifty patients with chronic low back pain associated with degenerative lumbar osteoarthritis were randomly assigned to receive, in double-blind fashion, 1500 mg per day of glucosamine sulfate or placebo for six months. Compared with placebo, glucosamine sulfate had no effect on pain-related disability at the end of the treatment period or at six months after the treatment had ended.

Comment: Most, but not all, studies have found that glucosamine sulfate is an effective treatment for osteoarthritis of the knee and for osteoarthritis affecting certain other areas of the body. However, the results of the present study show that glucosamine sulfate is of no value as a treatment for low back pain associated with lumbar osteoarthritis. That finding should not be surprising, considering that low back pain is one of the most frustrating and treatment-refractory conditions, for which few (if any) treatments have been consistently found to be effective. The lack of effectiveness of glucosamine sulfate as a treatment for low back pain should not deter its use for other forms of osteoarthritis.

Wilkens P et al. Effect of glucosamine on pain-related disability in patients with chronic low back pain and degenerative lumbar osteoarthritis: a randomized controlled trial. JAMA. 2010;304:45–52.

Tai Chi for Fibromyalgia
Sixty-six patients (mean age, 29 years) with fibromyalgia were randomly assigned to participate in classic Yang-style tai chi or to a control group that received wellness education and underwent stretching exercises. Participants in both groups attended 60-minute sessions twice a week for 12 weeks. In the tai chi group, the mean score on the Fibromyalgia Impact Questionnaire improved by 44%, as compared with a mean improvement of 14% in the control group (p = 0.001 for the difference in the change between groups). Significantly greater improvements were also seen in the tai chi group relative to the placebo group in both the physical and mental components of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). The improvements were maintained at 24 weeks (12 weeks after the program had been discontinued).

Comment: Tai chi is a mind-body practice that combines meditation with slow, gentle movements, deep breathing, and relaxation. It is believed to have a positive influence on physical, psychosocial, emotional, and spiritual components of health. Fibromyalgia is a common, chronic condition that is frequently refractory to conventional therapy. The results of the present study indicate that practicing tai chi is beneficial for patients with fibromyalgia.

Wang C et al. A randomized trial of tai chi for fibromyalgia. N Engl J Med. 2010;363:743–754.

Antibacterial and Healing Properties of Honey
The authors of this report identified a unique protein in medical-grade honey, bee defensin-1, which was found to be responsible in large part for the antibacterial effect of the honey. In vitro studies demonstrated that honey was bactericidal against a wide range of organisms, including Bacillus subtilis, methicillin-resistant Staphylococcus aureus, extended-spectrum beta-lactamase producing Escherichia coli, ciprofloxacin-resistant Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus faecium.

Comment: Topical application of honey has been used for more than 2000 years and is widely accepted in folk medicine as a treatment for wounds. In addition to its antibacterial effect, topically applied honey creates a moist environment and is said to debride wounds, promote healing by stimulating tissue regeneration, and inhibit scar formation. In clinical trials, application of honey promoted healing of infected surgical wounds, poorly healing wounds, and disrupted or broken-down wounds. In many cases, honey appeared to be considerably more effective than conventional methods of wound care.  A disadvantage of honey is that it becomes more fluid at higher temperatures, and may liquefy at wound temperatures. Treatment with honey also causes some patients to experience a drawing or stinging sensation in the wound. In addition, there is a small risk of contracting botulism or other infections from nonsterilized honey. Irradiation renders honey sterile without affecting its antibacterial activity. It has been suggested that honey for medicinal use should be sterilized; however, additional research is needed to determine whether sterilized honey is as effective as nonsterilized honey.

With the increasing prevalence of antibiotic-resistant bacteria (particularly methicillin-resistant S. aureus [MRSA]), honey deserves greater attention as a treatment for infected wounds and skin ulcers.

Kwakman PH et al. How honey kills bacteria. FASEB J. 2010;24:2576–2582.

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