Wellness in urology: Consider non-drug measures up front

Mark A. Moyad, MD, MPHPoor lifestyle choices and obesity are prevalent among the U.S. population, but objective education on dietary supplements and lifestyle changes is equally poor, says Mark A. Moyad, MD, MPH. In this interview, Dr. Moyad discusses non-drug interventions for urologic conditions, the difference between prescription drugs and nutraceuticals, and why a heart-healthy diet is a prostate-healthy diet. Dr. Moyad is the Jenkins/Pokempner Director of Complementary and Alternative Medicine in the department of urology at the University of Michigan, Ann Arbor (an endowed position funded by patients). Dr. Moyad is on the speaker’s bureau for Abbvie and is a consultant for Farr Labs. Dr. Moyad was interviewed by Urology Times Editorial Consultant Philip M. Hanno, MD, MPH, emeritus professor of urology at the University of Pennsylvania, Philadelphia.

Interest in patient empowerment has increased tremendously, and a large part of this is the popularity of nutraceuticals, the explosion of direct-to-consumer advertising of prescription drugs, and the move to bring more prescription drugs over the counter. How do you see these current trends?

It’s a train on a track that’s going faster and faster. I don’t see any of these trends slowing down. I think a couple of things are happening in my generation that are going to increase patient education exponentially, not just in my field but other fields as well. Part of this comes from pressure on physicians to maintain patient volume. It’s different from when I used to watch my dad, who is also a physician, at the hospital. Today, it seems very much like a volume-based system. You have to see more and more patients, which means you have less time.

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When I last checked, there are some 20,000 new medical papers coming out per month. Physicians have an exponential amount of education to digest and are supposed to see more people, so how can they possibly become more efficient? Doctors should not have to solve this issue by going to school even longer. Patients have to become smarter to make the visit more efficient. If I looked at current trends from Obamacare or elsewhere, it all leads to patients having to know more about their health than ever before; otherwise, the visit will not be its very best.

I always tell people they should be reading relevant books and pamphlets before they visit the doctor so they can streamline their questions, because the visit is going to be very short. Efficiency is everything.

“Nutraceutical” has no legal definition. One definition I’ve seen is “pharmaceutical products containing a concentrated form of a presumed bioactive phytochemical or zoochemical agent from a food and used with the purpose of enhancing health in dosages that exceed those that could be obtained from normal foods.” How do you see the difference between a nutraceutical, a functional food, and a drug?

I don’t see a difference. We are playing a funny game, and the game is any active nutraceutical that has evidence, to me, is a drug and there’s no difference. It’s all perception versus reality. Some of our best-selling supplements are actually drugs from other countries. We just don’t know it.

We’re playing a game and nobody’s winning. If a company sells a product over the counter, they cannot make a disease claim even though physicians will recommend the product for diseases. Even if a nutraceutical shows a benefit against a disease, the manufacturer cannot say that because that would be breaking the rules. The problem with that rule is not only is it a dumb rule, but nobody wins.

I see no difference between a nutraceutical and a drug except a nutraceutical that’s effective can’t make a drug claim. I would argue that in conventional medicine, if we accepted that definition, it would bring more respect to nutraceuticals, and if the nutraceutical industry accepted that definition, they would do more to get exemptions whenever there were data.

People frequently ask me whether nutraceuticals work. That’s like asking if prescription drugs work; it depends specifically on the situation and on the data and evidence. But we handle nutraceuticals differently. I get asked whether vitamin E works. Well, it’s really bad in some cases, and there are other diseases where it might help, so I treat it no differently than a drug.

Next: "I think companies have to be rewarded for doing research."

Scientific evidence supports the biologic activity of many bioactive compounds when ingested as foods, including the Mediterranean diet and fish consumption for preventing cardiovascular disease. But health claims attributable to most biologically active ingredients when ingested in the form of isolated compounds as nutraceuticals are quite sketchy from a scientific standpoint. How should nutraceuticals and nutraceutical claims be regulated?

I think companies have to be rewarded for doing research. Companies should be allowed to make a disease claim if they do the research, but the opposite is also true: that if something is found to be extremely harmful or worthless, you shouldn’t even allow a hint at a claim.

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Two very large phase III trials, both very well done, showed no benefit with saw palmetto over placebo in men with BPH. I think that has to be reported on the label. Why are the manufacturers still allowed to say their product is “prostate healthy” when there were two negative phase III trials that would have been considered failures if they were drug trials? If you can advertise the benefit, why can’t you also expose the negative? Selenium can also state it is “prostate healthy” when it is arguably the first supplement proven to increase the risk and/or progression of prostate cancer when taken in large isolated dosages. I even see a popular brand advertise that it “may reduce the risk of certain forms of cancer.”

The game is now becoming dangerous. That’s why we’ve seen so many articles on side effects in the past 12 months. One out of five serious hepatotoxic events in the United States is due to supplements.

What do you think of people on television shopping networks who promote supplements? They’re very convincing.

They are very good at convincing people they need to take something when they’re completely healthy because they’re deficient in it. I find that comical because we no longer live in the year 1825. We still teach in medical schools and still write chapters on deficiencies as if we live in the year 1825: “If you don’t get enough vitamin C, you’ll get scurvy.” How much scurvy have you seen in the past 10 years?

We’ve reached a new point in medicine in which we’re getting plenty of what we need, and we’re finding that taking more of something when you’re healthy is not better. For example, vitamin E and selenium increase the risk of prostate cancer and in the case of selenium perhaps increase the risk of other cancers such as skin cancer recurrence. I often give the example to patients and the public that if you fertilize your healthy lawn, it can become healthier, but if you use too much fertilizer it can damage or destroy the lawn. More has not been proven to be better.

The deficiencies that I see today, interestingly enough, are either lifestyle related or people taking too many pills, which itself is creating a deficiency. It’s not because we’re not being exposed enough to the mineral or nutrient. For example, chronic use of acid reflux drugs can significantly lower magnesium and B12 levels, and some patients and even some doctors I know have had some devastating consequences. Weight gain drops not just testosterone but lowers iron, vitamin D, and other nutrient blood levels.

What’s missed in the nutraceutical argument is that there are actually two players in this field: the pill companies and the food companies. Food companies are allowed to add large amounts of nutritional material to give their product pizazz or an advertising edge. Calcium is the worst offender I’m seeing lately. So much calcium is added to food that what we’re seeing almost an overdose without people realizing it. If you drink 8 ounces of almond milk, that’s 455 mg per 8 ounces for many of the products. If you drink two 8-ounce bottles of almond milk, you’re done for the day, and then we have countless patients on top of that taking individual calcium supplements and multivitamins with large amounts of calcium in them. We are just adding more risk or cases to an ongoing kidney stone epidemic.

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So we’re not seeing deficiency anymore, we’re seeing overexposure. That’s what really scares me about the trend. Every couple of years, we have a new du jour deficiency and then we wake up years later and we realize we have been overexposed to these nutrients and that it comes with serious risk. Right now, vitamin D is the du jour deficiency.

Next: "When there is a deficiency of anything, someone is going to capitalize on it quickly."

Another example involving vitamin D is a study showing that people who avoid the sun to prevent skin cancers have a negative effect on their life expectancy, presumably due to effects of vitamin D deficiency and cardiac complications (J Intern Med, March 16, 2016 [Epub ahead of print]). It was explainable if you thought about it, but it seemed so counterintuitive.

You have to remember that when there is a deficiency of anything, someone is going to capitalize on it quickly. Then that deficiency is going to be, in very little time, wiped out.

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That’s what sabotaged the largest supplement trial ever done in urology’s history, the Selenium and Vitamin E Cancer Prevention Trial (SELECT). The thought process going into it, which was that there is a lot of selenium deficiency, was OK. But as selenium was garnering evidence before the trial launched, everybody started adding selenium back into the food supply and into pills. So before the trial starts to test this deficiency, almost everybody in the trial is clearly sufficient or overexposed before they even get the pill. It completely confounded the results.

Vitamin D is going to play out this way as well. It already is. There’s a belief that you need mega quantities, and no one mentions the fact that essentially many of the randomized trials have all failed in most areas of medicine.

Also, the vitamin D deficiency is really tied to the obesity epidemic. Vitamin D levels go down substantially with adipose tissue and a lack of physical activity. I’m sorry vitamin D deficiency has become more of a pill issue than a lifestyle issue.

To get around being treated like a medicine, nutraceuticals are careful not to make any claim that purports to diagnose, mitigate, treat, cure, or prevent a specific disease. Rather, they promote a specific health, like prostate health or sexual health. Do you think this is fair to pharmaceuticals?

These are the rules that were established by the government. It was decided to just make the “structure/function” claim. Companies are taught to use three words, and if you use those three words, then the government might not come after you. The words are: “promotes,” “supports,” and “maintains.”

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These rules have become so confusing that it’s not only not benefiting the patient, it’s not benefiting the health care professional. They’re not becoming objectively educated.

Next: "We should encourage the fact that someone’s not on pills"

You’ve given an AUA course on “Strategies for Managing Lifelong Wellness” for many years. Please discuss your overall philosophy on wellness and health.

My philosophy is that whenever anyone offers you a nutraceutical or pharmaceutical product, there should be a three-step barrier to taking it. First, there should an objective assessment. How do you know that if you take this pill, it actually does anything? What can your physician measure? You have to have an objective measurement that can make you feel like there was a reason to take it.

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Second, there should be a subjective measurement. How do you feel when you take that pill? Do you feel better, worse, or the same? If you feel worse, that’s a bad thing. I don’t care what the pill is.

Third, which is very important, is there a lifestyle change you can make in moderation that would get you off this pill or reduce the dosage of this pill to the lowest possible?

If patients applied that third step every time we addressed a pill, it would be a very different world. We only really apply that step in one situation, which is when diet and exercise doesn’t work, there’s cholesterol-lowering medication, which makes sense to most patients. What they don’t realize is that’s true for almost every aspect of preventive medicine, including urology. When diet and exercise doesn’t work, there’s Viagra. When diet and exercise doesn’t work, there’s Flomax. But people don’t think of it along those parameters.

In addition, people take pride in higher dosages. There’s a good chance patients could lower their medication dosage if they would just incorporate some moderate lifestyle changes. Then we wouldn’t have all this worry about side effects. Most of the side effects that scare us in urology and elsewhere are with the higher dosage. But if you go to the lower dosages on some of the most effective drugs, many of them have side effects similar to a placebo.

Physicians and patients should get a failing grade by either encouraging the highest dose or taking honor in taking the higher dose. We should encourage the fact that someone’s not on pills, not celebrate the fact that they’re on pills, especially at higher dosages. That is my mantra.

As part of promoting wellness, I wrote “The Supplement Handbook,” which shows that when a supplement works well, it works like a drug and it’s great. When it works poorly, don’t take it. People tell me that if I recommend products, I must have a conflict of interest, but I don’t work for any of these companies. I only recommend the dietary supplements that have been used in the largest or most methodologically rigorous clinical trials for a specific medical condition, which is exactly what physicians generally do for pharmaceutical drugs.

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Let’s be consistent here, and everyone wins: the health care professional, the patients, patient trust in physicians, and evidence-based medicine. It is also interesting that many of those same supplements are some of the lowest priced in the industry with the highest quality control.

Next: Dr. Moyad's criteria for a diet

Is alternative medicine becoming a standard part of the medical curriculum?

I think it is because when I educate health care professionals, I show them a single slide showing that alternative medicine of some sort, including dietary supplements, is part of or going to be a part of clinical guidelines. If there’s evidence, we’ve already put it in there. It’s a part of teaching now. My classes are always full. When I began teaching and working in urology almost 25 years ago, I felt like I was on an island where I and a few others were an interesting exception, but today, whether it is residency, guidelines, the AUA annual meeting, AUA section meetings, grand rounds, or most medical centers, all have some teaching or research going on with alternative medicine and urology. In other words, today you are the exception if you are not doing something with alternative medicine.

Should the AUA have guidelines for supplements?

They should have supplement guidelines across the board for all different urologic disease states. They’re missing out on an incredible opportunity to educate patients and health care professional. And they should mention the exact products that went through negative or positive trials.

What are your recommendations regarding diet and weight loss?

I use five criteria for a diet or even fad diets. I call them the five “B’s.” The first “B” stands for “BMI and/or belly.” Are you actually losing weight on the diet? Is it changing your BMI or your waist? The next three are all related to heart health: blood cholesterol, blood pressure, and blood sugar. Working with a physician that you trust, are these getting better on this diet? If those four are changing, that means you’re going in the right direction.

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The fifth “B” is brain health. In other words, how’s your mood, stress, and anxiety levels on this diet? Are you miserable and making people miserable around you, or are you content and happy? I’ve talked to patients who fulfill those five “B’s” who are on ketogenic, vegan, alkaline, gluten-free, or paleo diets, to name a few. For the patients who weren’t successful on those diets, one of those five “Bs” changed in the wrong direction, so we ask them to get off the diet.

Next: Why "a heart-healthy diet is a prostate-healthy diet" is still true

I frequently share your quote, “A heart-healthy diet is a prostate-healthy diet” with patients. Is that still true?

I put that line in a medical journal article in 2003 and have continued using it ever since, and it is more relevant today after all this research in lifestyle medicine than at any other time in urology. If you think about everything that we’re dealing with in terms of heart health, if urologists just said, “Become more heart healthy,” they’d literally be saying the smartest thing patients can do to reduce their risk of BPH, prostate cancer, ED, testosterone deficiency, kidney stones, and bladder cancer. These are all tied to some heart-healthy factor and lifestyle changes.

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So, we’ve now accepted in urology that heart healthy is just not prostate healthy; heart healthy also applies to bladder, kidney, and sexual health. The whole ED movement is based on heart-healthy guidelines.

Many patients ask what they can do to lower their PSA and risk of prostate cancer. What do you tell them?

I tell them that heart healthy is prostate healthy. One of the biggest reasons we’ve run into a PSA screening controversy is that we have over-diagnosed some men. Part of the dilemma arises in the fact that a man has a rising PSA and we’re not sure why. That would be eliminated, in part, if men went on a heart-healthy program, lost weight, and made heart-healthy changes, because what you see with some of these men is that if their rising PSA is due to BPH or LUTS and they lose weight, their PSA starts to go down.

What I love about lifestyle change is it’s the truth serum of your health in terms of what you require now and in the future. As long as you fulfill your lifestyle change obligation, you are handled better as a patient in 2016 because we know better what’s going on with you. A classic example is testosterone replacement. For a lot of men, if they just lost weight, their testosterone would go up. They should be given the option that if they lost 5 or 10 pounds and their testosterone goes up 100 points, then maybe they don’t need testosterone.

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But then you have men who lose 30-40 pounds and the testosterone doesn’t go up at all; maybe those are the patients who need testosterone. If we require that lifestyle change up front, then you understand better what you’re dealing with now and in the future or whether or not you need any or more medicinal intervention. This is what happens with blood cholesterol, blood pressure, blood sugar… so why not urology? It is just an educational issue.

Next: "I try to take a Centrum Silver when I remember to, which is a couple of days a week."

Part of the problem is the pharmaceutical industry doesn’t say patients should try and lose weight first; that’s not the message they’re getting on TV.

In public talks I give to men, I tell them that in 40 studies I evaluated that had any correlation to weight loss and testosterone, 38 of them showed a clear correlation. Thirty-eight out of 40 in medicine is a grand slam; there’s a clear association. We know that from bariatric surgery. When people lose weight, their testosterone goes way up.

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We’re not talking about huge amounts of weight loss. If you lost a little bit of weight or a little bit around your waist, you might get that testosterone boost and never need the medication. We need to do a better job of telling patients about this wonderful option before they move to the next option and explaining how much data there is. The AUA and the American Medical Association could do a better job of that, and in turn it will further enhance the trust that patients put into the AUA or even educational material from the AUA because it would help to break part of the pervasive myth that large medical organizations are just another advertising voice or avenue for the pharmaceutical industry.

What vitamins and supplements do you take, and what do you recommend to your patients?

I try to take a Centrum Silver when I remember to, which is a couple of days a week. The only reason I do that is because Centrum Silver was the subject of the only large, randomized, long-duration trial ever done in U.S. history on a multivitamin. Think of the irony here. The multivitamin is the best-selling over-the-counter pill in the United States, not only to patients but also to clinicians. Yet, we didn’t have a single large randomized study on any multivitamin until 2011-2012, with Physicians Health Study II.

Comparing Centrum Silver versus placebo, they showed a slight reduction in risk of cancer (JAMA 2012; 308:1871-80). They used dosages from the 1990s all the way through the recent past. I find it amazing that one of the cheapest multivitamins available in the United States with some of the fewest ingredients is the only one that actually has any clinical evidence in healthy people. I will go kicking and screaming into the night before I take any other pill. In other words, I celebrate with my wife that we do not take any pills unless we need them. Currently, we are on no other pills but when I need them one day, I will use them for a medical condition that cannot be solved with moderate lifestyle changes. I try and practice what I preach.

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When I passed the age of 50, my blood pressure and cholesterol starting increasing and before accepting a pill or pills from my primary care physician, I lost a few more pounds, slightly reduced my caloric intake, and increased my exercise time, and now my numbers are back to normal. I try and honor medicine and pills by accepting the fact that when realistic lifestyle changes cannot solve my health issues, then I will welcome the pills I qualify for or need with an open hand and mouth.

Next: "Patients want the information from you, the health care professional first and foremost"

What are you planning to do in the future?

My goal is to continue to bring the message to a diverse audience, to always be thankful for my urology roots and thankful for my ongoing almost 25-year relationship with the University of Michigan urology department, and to retire from there one day in the distant future. I want to continue to stay with urology but to keep educating people outside of urology to help make a difference in medicine. Urology is an incredible stepping stone, but we’re dealing with the same issue in other fields-namely, very poor objective education on dietary supplements and/or lifestyle changes.

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I’m trying to continue the delicate dance of educating health professionals but then jumping quickly to educate the public and jumping back to health care professionals. I volunteer for most major prostate cancer advocacy groups from Us TOO to Prostate Advocates Aiding Choices in Treatments, and moderate and help run the largest patient meetings in the world on prostate cancer; for example, the Prostate Cancer Research Institute annual fall conference. It is also why I try to do one book a year for health care professionals with Springer, and then I do something with Rodale for the public. I work with pharma only when I can make an objective durable impact. I have done the Promoting Wellness for Prostate Cancer series with the help of Abbvie now for 15-plus years, which is arguably the longest running lecture or educational source on diet, lifestyle, and supplement changes in the entire field of medicine.

In addition, I co-wrote “The Supplement Handbook,” a 512-page guide on over 100-plus medical conditions released in 2014. It is still a best seller, which is further proof the public is very hungry for evidence-based medicine when it comes to dietary supplements, contrary to what some might argue. Patients want the information from you, the health care professional first and foremost, but if you disregard it or fail to learn it or dishonor their needs in this area, they turn to the Internet or the person at the health food store, who is always more than willing to educate them.

With everything I do, I try my very best to keep the people’s trust. I didn’t realize this at first, but over time, I’ve gained a trust with colleagues, patients, and the public. It’s a very delicate trust and you have to respect it and be careful not to abuse it. So another goal of mine is to make sure patients and health care professionals know I’m really trying to do the right thing even though there are times that I don’t want to do the right thing. There’s a lot of temptation out there.

In the movie “The Natural,” there is a line that goes, “I believe we have two lives, the life we learn with and the life we live after that.” That line now echoes in my head when I think of the past 25-plus years and whenever I see a cancer patient ask a question or a group of health care professionals looking at me ready to hear a lecture. So, I just want to try and keep moving in the right direction and setting a new standard in my discipline, because we seem to really need an objective voice now more than ever before.

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