Type 2 diabetes mellitus is associated with an increased risk of liver, pancreas, breast and colon cancers. Whether cancer risk is associated with elevated blood sugar levels among non-diabetic subjects is less well known.

A recent study from Umea University Medical Centre in Sweden reported its findings on 31,304 men and 33,293 women who were non-diabetic (Diabetes Care 2007; 30: 561 – 567). In women, the total cancer risk was highest in women with the highest fasting blood sugar level. Comparing the groups with the highest and  the lowest blood sugar levels, women in the highest blood sugar level group had a 26% higher total cancer risk than the lowest group. This association was not seen in men. However, for men and women, high blood sugar level was shown to be associated with increased risk of certain cancers, namely pancreas, malignant melanoma (a form of skin cancer), urinary tract and endometrium (womb).

Individuals with abnormally elevated blood sugar levels do progress to having type 2 diabetes. In developed countries, diabetes is the most common cause of end-stage kidney failure, one of the leading causes of blindness and it also plays an important role in causing peripheral vascular diseases. The direct health-care costs of treating diabetes range from 2.5% to 15% of national health budgets. According to the 2006 WHO report, the number of diabetics worldwide increased from 30 million to 171 million during the period 1985 to 2000. It is estimated that 4.6% of adults aged 20 years or older are affected. The increase in diabetes has been attributed mainly to a rise in new type 2 diabetes cases, which in turn is driven by increasing obesity rates and ageing of the population. Most people in the East mistakenly think that diabetes and obesity are ‘Western’ health problems. It is true that diabetes prevalence rates are higher in developed countries (normally seen as Western countries, 6.3%) than in developing ones (normally seen as Eastern countries, 4.1%). Surprisingly, since 1995, the developing nations have seen the greatest rise, approximately a 25% increase, in diabetes rates!

Obesity is not a ‘Western’ problem. It is a global problem! A recent study looked at the prevalence of overweight and obesity in pre-school children, aged 4 -6 years, in Ho Chi Minh City (HCMC) in Vietnam (Int J Pediat Obesity 2007; 2: 40 – 50). A sample of 670 children attending kindergartens in HCMC was studied. The prevalence of overweight and obesity among these children was 20.5% and 16.3% respectively. Interestingly, whether the children came from a wealthy or less wealthy urban area of HCMC made no difference to the level of overweight / obesity among the children. Children born to parents who were overweight were 87% more likely to be overweight / obese than those whose parents had normal weight. Birth weight of > 4 kg was significantly associated with overweight and obesity in these children as compared to those with a birth weight between 2.5 to 3.0 kg. Another surprising fact from the study is that the risk of obesity in breast – fed children was reduced by 5 % for each additional month of breast-feeding. Children who had longer duration of sleeping each day had a significant 13% decrease in their odds of being overweight / obese for each additional hour of sleep. Indeed, evidence has shown that the incidence of overweight / obesity among kindergarten children in HCMC has increased rapidly in the new millennium. The most likely cause of which is over nutrition!

Recently, researchers from University of Leicester performed a meta-analysis of all the published randomized controlled trial results on lifestyle and pharmacological interventions to delay or prevent type 2 diabetes in individuals with impaired glucose tolerance (BMJ 2007; 334: 299 - 302). The analysis showed that lifestyle interventions do reduce the rate of progression to type 2 diabetes in people with impaired glucose tolerance. The difficulty is to maintain the long term beneficial effect of lifestyle interventions. Hence, there is a definite need to reinforce the advice on diet and exercise on a regular basis.

In Asia, the idea that skinny children are considered less healthy while chubby children are adored and considered as a symbol of good health has been etched into most Asians’ memory. The ability to eat an inordinate amount of food at the dinner table is lauded and admired. For a man, having a pot belly in your middle age is considered ‘a sign of prosperity’. Perhaps, such attributes are not so ‘healthy’ after all. So, next meal time, when you have the urge to offer a second or even a third helping to your loved ones, you might just want to think again.

Cancer screening is an important public health care exercise because early detection of the underlying cancer will usually lead to a better outcome and longer survival. Despite the fact that we have the technology to probe the universe with unmanned craft, our achievement in curing lung cancer has been left wanting. Throughout the world, lung cancer is the number one cancer killer in man. In United States of America, cancer of the lung and bronchus are the leading causes of cancer death. Thirty two percent of cancer deaths in men and 25% in women are due to lung cancers. At present, the 5 year survival for patients diagnosed with lung cancer is low, a mere 14%. Thus, any technology which can be used routinely to detect lung cancer at an early stage must be a real welcome.

In October 2006, a report from Cornell University, New York, reported their findings on annual lung CT scanning in detecting early lung cancer in at risk asymptomatic people (N Engl J Med 2006; 355: 1763 – 1771). Researchers of the International Early Lung Cancer Action Program screened 31,567 asymptomatic people, at risk for lung cancer, with low dose CT from 1993 to 2005. From 1994 to 2005, 27,456 repeat CTs were performed 7 – 18 months after the previous screening. These investigators detected lung cancer in 484 people. Of these 412 (85%) had stage I lung cancer and the study estimated the 10 year survival rate for this group of individuals to be 88%. In the 302 stage I cancer patients who underwent surgery within 1 month, the survival rate was an estimated 92%. The publication of this research paper led to calls from advocacy groups to implement widespread CT scanning for all smokers and others at risk for lung cancers.

Five months later, a study from Memorial Sloane Kettering Cancer Centre in New York reported their study on CT screening of asymptomatic current or former smokers (JAMA 2007; 297: 953 – 961). This involved 3246 participants attending academic medical centres in United States and Italy. This group of individuals was followed up for a median of 3.9 years. Researchers diagnosed 144 cases of lung cancer compared to 44.5 expected cases if there were no CT screening. One hundred and nine individuals had an operation versus an expectation of 10.9 cases of operable cases only. However, despite the fact that more lung cancer cases were diagnosed and more cases were operated upon, the researchers found no evidence of a decline in the number of advanced lung cancers being detected (42 individuals compared to 33.4 expected cases) or deaths from lung cancer (38 deaths observed versus 38.8 expected deaths). Since this study did not show CT screening to lead to a meaningful reduction of the risk of being diagnosed with advanced lung cancer or dying from lung cancer, the investigators suggested further research studies to further clarify the potential benefits and risks of CT screening. This research finding certainly has put the cat among the pigeons! Drawing comments such as “I do not agree with waiting for randomized trials … We have proven CT screening to be effective … It is unethical to continue with a randomized trial now that the benefits of CT screening are proven” from the researchers from Cornell University.

So, is the evidence so clear cut that CT screening for lung cancer is the standard of care? A group of researchers at the University of Aberdeen performed a review of the published data on CT screening for lung cancer (Thorax 2007; 62: 131 – 138). They searched the databases from 1994 until January 2005 and found that there were a total of 12 studies done on CT screening for lung cancer. At the end of the review, these researchers concluded that “Currently, there is insufficient evidence that computed tomography screening is effective in reducing mortality (death) from lung cancer”.

CT screening can lead to false positive cases (i.e. the diagnosis of a lung cancer by CT which after further investigations turned out to be not lung cancer). These false positive patients will have to endure a period of great anxiety and potentially invasive procedures before they are found to be clear of lung cancer. A study from Madrid studied 482 individuals over 50 years of age who were active smokers (Lung Cancer 2007 Feb 19; epub). In the study the false positive rate was 28%.

The controversy surrounding CT screening for lung cancer will continue to rage until 2009 when the results from the National Lung Screening trial sponsored by the National Cancer Institute will be available. This may or may not settle the argument!

While the argument rages in the medical community on “To CT or not to CT”, should the society at large not be better off asking “How can we prevent lung cancer?” instead of “How can we detect lung cancer earlier?”.  For decades, we have known that smoking is the greatest culprit in causing lung cancer. We also know that smoking causes other major ailments such as heart disease, chronic lung diseases and peripheral artery disease. Yet, we are preoccupied with ‘how to detect early’ rather than ‘how to prevent’. The mind boggles!

High cholesterol levels (hypercholesterolaemia) lead to an increase risk of heart diseases and stokes. Medical treatment for hypercholesterolaemia is available and effective. One of the most commonly used drugs to reduce cholesterol levels is the statin family of drugs. A few examples of the statin family of drugs include atorvastatin (Lipitor), pravastatin (Lipostat), fluvastatin (Lescol), rosuvastatin (Crestor) and simvastatin (Zocor). The global market for statin drugs is estimated at $30 billion per year and growing. In USA alone, statins earned $16 billion. In 2006, the best selling statin drug in USA was Lipitor. Zocor, made by Merck, was second in sales to Lipitor and earned nearly $ 4.5 billion for Merck in 2005. On 23rd June 2006, the patent on Zocor expired. To Merck it spells significant revenue loss as cheaper generic versions of Zocor/simvastatin can be made available to the market at a substantially lower price. Thus, to any drug company the expiry of a drug patent or the presence of a new entrant to the cholesterol lowering medication market would not be good news.

Recently, I was asked about the potential role of red yeast rice (RYR) as a health supplement for reducing cholesterol levels. Professing ignorance I looked it up and found that I actually grew up with RYR being a part of my diet without realizing it!

The use of red yeast rice in China was first documented in the Tang Dynasty in 800 AD. RYR is the fermented product of rice mixed with red yeast (Monascus purpureus) to make rice wine and is used as a food preservative for maintaining the colour and taste of fish and meat. (In my family, my mother would either use the fermented rice to stir fry it with Chinese lettuce or simmer it with pork.) The ancient Chinese pharmacopeoia Ben Cao Gang Mu-Dan Shi Bu Yi, published during the Ming Dynasty (1368-1644), contained a complete description on how to make RYR. In it, RYR is characterized as mild and useful for improving blood circulation. RYR was and still is a dietary staple in Asian communities. How RYR works was not known then but now we know.

In 1979, a Japanese researcher found that a strain of Monascus yeast naturally produced a substance that inhibits cholesterol synthesis. He named the substance monacolin K (also known as mevinolin and lovastatin). He also found a family of 8 monacolin-related substances which can inhibit 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase. HMG-CoA reductase is the first enzyme in the metabolic pathway for the production of cholesterol which takes place in the liver. Simplistically, when you consume RYR, you block HMG-CoA reductase. As a result, you inhibit cholesterol synthesis. But, what is the evidence for RYR as a cholesterol-lowering preparation?

In 1995 and 1996, Chinese researchers reported the positive effects of RYR in lowering cholesterol levels in people with hypercholesterolaemia. In 1999, researchers at UCLA conducted a randomized double blind study involving 83 healthy individuals with hypercholesterolaemia (Am J Clin Nutr 1999; 69: 231 – 236). All participants consumed a diet similar to the American Heart Association Step I diet for controlling cholesterol. In addition, one group of participants was given RYR while the other group was given a placebo (i.e. no RYR). At the end of an 8 week period, the group which was taking RYR had significantly lower total cholesterol and LDL-cholesterol (‘bad’ cholesterol) levels compared to the placebo treated group. (To read this article, click on the link and go to page 4) Since then there have been other studies showing the efficacy of RYR or its extract in reducing cholesterol levels both in humans (Eur J Endocrinol 2005; 153: 679 – 686 ) and in broiler chickens (Appl Microbiol Biotechnol 2006; 71: 812 – 818)! A recent meta-analysis, performed at the University of Tromso, Norway, of all published studies on RYR concluded that short term RYR use is effective in lowering cholesterol level. The long-term effect and safety of RYR usage needs further studies (Chin Med 2006 Nov 23; 1 – 4).

Like all health supplements there are, no doubt, many different commercially available preparations of RYR. Do they all perform as efficaciously in reducing cholesterol? That is likely to depend on the content of the active ingredient, monacolins. A study from UCLA looked at the monacolin content of 9 RYR preparations available in the market (J Altern Complement Med 2001; 7: 133 – 139). Total monacolin content varied from 0% to 0.58% w / w and only one of the 9 preparations had the full complement of 10 monacolin compounds! Citrinin, a toxic fermentation byproduct, was found at measurable concentrations in 7 of the 9 preparations. .

Indeed there is scientific basis to why RYR works. The issue lies with which preparation works better and which does not. This will require standardized manufacturing practices to ensure equivalence of the content of active ingredients in the preparation and to limit the presence of unwanted byproducts of fermentation.

One more thing, if you are taking RYR as a supplement, you need to know that statins can cause liver and muscle toxicity. Individuals who have been started on statins are advised to have their liver function monitored on a regular basis and to report to their doctors if they experience muscle aches and weakness. Perhaps you should be aware too.