Why does sodium matter? Too much of it can increase blood pressure and make the kidneys work harder. High blood pressure is a leading cause of stroke, heart attack, heart failure, kidney disease, and more. Current recommendations urge us to consume less than 2,300 milligrams (mg) of sodium a day, equivalent to about a teaspoon of table salt. The bar is set lower—1,500 mg a day—for those with cardiovascular disease or high blood pressure. Yet the average American takes in about 3,400 mg a day.

Harvard researchers recently conducted a study that assessed the cumulative health effects of excess sodium. They estimated that excess sodium accounts for the 2.3 million deaths each year around the world. The U.S. ranked 19th out of the 30 largest countries, with 429 deaths per million adults due to taking in too much sodium. That represents one in 10 U.S. deaths due to heart attack, stroke, and other cardiovascular diseases.

Counting the milligrams

For the JAMA Internal Medicine study, researchers with the Center for Science in the Public Interest (CSPI) in Washington, DC, evaluated the sodium in 78 foods served at fast food and chain restaurants between 2005 and 2011, collecting nutritional information from the company websites. They did the same for foods plucked from shelves at stores in Washington, DC, and at one Walmart in Elverston, Pennsylvania.

The average sodium in chain restaurant items increased 2.6% between 2005 and 2011. In packaged foods, it fell on average 3.5%. The sodium in some products fell as much as 30%, although a greater number increased by more than 30%.

Food manufacturers have developed lower-sodium foods—none of which were included in the JAMA Internal Medicine study—and have reduced sodium in other products. So far these efforts, plus continuing public education campaigns, have failed to change this sobering fact: the average American still takes in far more sodium that their bodies need.

CSPI, which sponsored the study, has called for tighter government regulation on the sodium content in processed and restaurant foods, including phasing in ever-stricter limits on how much sodium foods may contain.

“Stronger action…is needed to lower sodium levels and reduce the prevalence of hypertension and cardiovascular diseases,” wrote Michael F. Jacobson, Ph.D., and colleagues, the authors of the JAMA Internal Medicine study.

When applied to millions of people, even small changes in sodium consumption can save lives. “The evidence is convincing that substantially reducing sodium intakes from current levels will have significant population benefits,” says Dr. Dariush Mozaffarian, associate professor of medicine at Harvard-affiliated Brigham and Women’s Hospital. “The data justify government intervention to reduce sodium levels in all processed, pre-prepared, restaurant, and other commercial foods.”

How to reduce your sodium

You don’t need to wait for more government regulations to keep the sodium in your diet in check. There is the obvious solution, says Dr. Helen Delichatsios, an assistant professor of medicine at Harvard Medical School. “Eat out less and cook at home more. There is much less sodium in home cooking than in prepared or restaurant foods.” Here are some other options:

• When shopping, check nutrition labels and limit foods that deliver a lot of sodium. The five top processed food sources of sodium are bread and rolls, cold cuts and cured meats, pizza, poultry, and soups. “Better yet, avoid foods with labels, and instead eat real food like fruits, vegetables, legumes, and whole grains,” says Dr. Delichatsios.
• When dining out, ask for information on calories, fat, and sodium. Chain restaurants commonly post the nutritional profile of their products online.
• Cook more. Base your meals on fresh and whole foods that you cook yourself, not processed warm-and-serve products, since they tend to be loaded with sodium.

There’s long been a perception—not necessarily backed by strong evidence—that eating steak, hamburger, lamb, and other red meat ups the risk of heart disease. The saturated fat and cholesterol they deliver have been cited as key culprits. A team from a half dozen U.S. medical centers says the offending ingredient is L-carnitine, a compound that is abundant in red meat.

According to this work, published online in the journal Nature Medicine, eating red meat delivers L-carnitine to bacteria that live in the human gut. These bacteria digest L-carnitine and turn it into a compound called trimethylamine-N-oxide (TMAO). In studies in mice, TMAO has been shown to cause atherosclerosis, the disease process that leads to cholesterol-clogged arteries. We know that clogged coronary arteries can lead to heart attacks.

So, case closed—don’t eat red meat? Sorry, nutritional science isn’t that simple.

“The studies of red meat and heart disease in humans are conflicting,” says Dr. Dariush Mozaffarian, associate professor of medicine at Harvard-affiliated Brigham and Women’s Hospital. “This new research was well-done and compelling, but it’s too early to decide that this molecule, TMAO, causes atherosclerosis in humans or that this is responsible for some of the associations of meat intake and risk.”

Dr. Mozaffarian, a cardiologist and epidemiologist, studies the health effects of dietary habits and other lifestyle factors in large populations. His team has previously pooled the findings of the best studies available on red meat and health and found that people who eat unprocessed red meat regularly have, at worst, only a slightly higher risk of developing heart disease. Unprocessed red meat includes virtually all fresh cuts of beef, pork, lamb, and the like.

“If you look at people who eat unprocessed red meat, there is a relatively weak association with heart disease,” Dr. Mozaffarian says. “It’s not protective—and healthier dietary choices exist—but major harms are also not seen.”

In the bigger picture, we do have pretty damning evidence about the harms of eating a particular type of meat. “Processed red meats—bacon, sausage, salami, deli meats—are associated with much higher risk of heart disease,” Dr. Mozaffarian says.

Research at the Harvard School of Public Health has shown that people who eat the most processed meats have a higher overall risk of death. The ultimate reason for this is not yet clear, says Dr. Mozaffarian, but it may be the huge doses of sodium delivered by all those low-fat deli sandwiches and salami-festooned platters.

And here comes other spoilers against the L-carnitine study: Processed meats generally contain less L-carnitine than does fresh red meat. Heart-healthy fish and chicken also contain L-carnitine, Dr. Mozaffarian points out—although five to 10 times less of it than red meat. “TMAO needs to be studied more in humans to understand the implications for public health,” Dr. Mozaffarian says. “This new research is very interesting but is not yet the final word.”

To further complicate matters, a study published online today in the Mayo Clinic Proceedings suggests that supplements of L-carnitine may help heart attack survivors reduce the chances of dying prematurely or reduce symptoms of angina (chest pain with exertion or stress).

L-carnitine supplements: “Think three times before taking”

There’s still a long way to go before we know the full story about L-carnitine and heart disease. Even so, the Nature Medicine report is very important, Mozaffarian says. It suggests that regularly eating red meat boosts the number of L-carnitine-loving bacteria in your gut. “It’s the best demonstration so far of two-way communication between ourselves and the bacteria in out gut: what we eat affects the bacteria, and what they do with what we eat can influence health.”

“Based on the Nature Medicine study, I’d be concerned about taking L-carnitine supplements,” Dr. Mozaffarian says. “There was no strong reason to take such supplements before the study, and now this well-done study suggests there may be harm. I would definitely think three times before taking an L-carnitine supplement.” The studies in the Mayo report were mostly small with short follow-up, and included only heart attack survivors.

Of course, there are reasons to avoid eating red meat that aren’t directly related to individual health. Cattle farming has devastating environmental effects, including production of greenhouse gases, water pollution, and deforestation. “Health effects in humans aside, red meat consumption is clearly bad for the health of our planet,” says Mozaffarian.

Over the years there has been substantial debate about whether acupuncture really works for chronic pain. Research from an international team of experts adds to the evidence that it does provide real relief from common forms of pain. The team pooled the results of 29 studies involving nearly 18,000 participants. Some had acupuncture, some had “sham” acupuncture, and some didn’t have acupuncture at all. Overall, acupuncture relieved pain by about 50%. The results were published in Archives of Internal Medicine.

The study isn’t the last word on the issue, but it is one of the best quality studies to date and has made an impression.

“I think the benefit of acupuncture is clear, and the complications and potential adverse effects of acupuncture are low compared with medication,” says Dr. Lucy Chen, a board-certified anesthesiologist, specialist in pain medicine, and practicing acupuncturist at Harvard-affiliated Massachusetts General Hospital.

How does it work?

Acupuncturists insert hair-thin needles into the skin at specific points around the body. It is virtually painless when done by an experienced practitioner. Inserting the needles is thought to correct imbalances in the flow of energy in the body, called qi (pronounced “chee”). As I write in the April issue of the Harvard Men’s Health Watch, in Western scientific terms acupuncture is thought to ease pain by affecting neurotransmitters, hormone levels, or the immune system.

For new pain, an acupuncturist should not always be your first stop. Dr. Chen recommends that individuals have clear diagnoses of what is causing their pain to rule out serious medical conditions that should be treated right away—and then seek out acupuncture if appropriate.

• How often is acupuncture needed? Plan on weekly treatments until you start to see a benefit, then gradually lengthen the time until the next visit.
• What does it cost? Acupuncture treatments range from $65 to $125 per session. Private insurers usually don’t pay for it, nor do Medicare or Medicaid. Some plans may cover the cost of a physician-acupuncturist.
• Who administers it? Ideally a trusted, certified provider. You can search for a trained acupuncturist at the National Certification Commission for Acupuncture and Oriental Medicine or by calling the organization at 904-598-1005.

The original latex came from the sap of the rubber tree (Hevea brasiliensis), earning it the designation of “natural rubber latex.” It is used to make a host of stretchy products, including adhesive bandages, condoms, gloves used in health care and dishwashing, balloons, rubber band, elastic used in waistbands and socks, baby bottle nipples, pillows, and more. Natural rubber latex contains proteins that set off some people’s immune systems, leading to an allergic reaction. An alternative, synthetic latex, doesn’t contain these proteins and so doesn’t provoke allergies.

Although anyone can develop a latex allergy, it usually occurs in people with repeated exposure to the rubber proteins. Allergies to latex skyrocketed in the 1990s as a more and more people (mostly in healthcare and associated professions) were required to use gloves to avoid getting and spreading infections. Although the use of alternatives has decreased latex allergies, up to 12% of healthcare workers and up to 6% of the general population may have a latex allergy or sensitivity. “The most common patient is a healthcare worker or frequent surgical patient,” says Dr. Peter Schalock, assistant professor of dermatology at Harvard-affiliated Massachusetts General Hospital.

According to the American Latex Allergy Association, the signs of a latex allergy, which is really a system-wide immune reaction, include

• hives or welts
• swelling of the affected area
• a runny nose
• sneezing
• reddened, itchy, or teary eyes
• headache
• sore throat, hoarse voice
• abdominal cramps
• chest tightness, wheezing, or shortness of breath (asthma)

Sometimes the reaction is so powerful it can put a person into anaphylactic shock, which can be deadly.

There’s no cure for a latex allergy. That makes avoiding latex a must.

Inflames on contact

Not everyone who is latex sensitive has a full-blown allergy. Some people get contact dermatitis—a skin rash and itching that start one to several days after contact with a latex product. With repeated exposure, it can get pretty nasty, with dry and crusted scabs on the skin. “Most of what we see in the allergic contact dermatitis clinic is hand rashes from the rubber accelerators in latex and some non-latex gloves,” Dr. Schalock says.

Accelerators are a type of chemical used to manufacture latex products. The person’s skin reacts to the chemical, not the latex proteins. For these people, Dr. Schalock says, the remedy is antihistamines, like diphenhydramine (Benadryl) or cetirizine (Zyrtec) and “complete avoidance in the future.”

Shopping to avoid latex

Since latex is found in so many products, latex-sensitive consumers have to trust labels. But the FDA’s warning highlights that products advertised as “latex-free” may not always live up to the claim. That’s because products that are made without latex can be contaminated with latex proteins during the manufacturing or packaging process.

Instead of “latex free” and “does not contain latex,” the FDA wants labels to say “not made with natural rubber latex.” That still leaves the latex-sensitive crowd at risk, because it’s not possible to certify that a product is truly “latex-free.”

For anyone with latex sensitivity, it’s best to approach potential triggering products with caution.

Lack of sleep. Not getting enough sleep is perhaps the greatest unappreciated cause of memory slips. Too little restful sleep can also lead to mood changes and anxiety, which in turn contribute to problems with memory.

Medications. Tranquilizers, antidepressants, some blood pressure drugs, and other medications can affect memory, usually by causing sedation or confusion. That can make it difficult to pay close attention to new things. Talk to your doctor or pharmacist if you suspect that a new medication is taking the edge off your memory. As shown in the table below, alternatives are usually available.

(Adapted from Improving Memory: Understanding age-related memory loss, a Harvard Medical School Special Health Report)

Underactive thyroid. A faltering thyroid can affect memory (as well as disturb sleep and cause depression, both of which contribute to memory slips). A simple blood test can tell if your thyroid is doing its job properly.

Alcohol. Drinking too much alcohol can interfere with short-term memory, even after the effects of alcohol have worn off. Although “too much” varies from person to person, it’s best to stick with the recommendation of no more than two drinks per day for men and no more than one a day for women. One drink is generally defined as 1.5 ounces (1 shot glass) of 80-proof spirits, 5 ounces of wine, or 12 ounces of beer.

Stress and anxiety. Anything that makes it harder to concentrate and lock in new information and skills can lead to memory problems. Stress and anxiety fill the bill. Both can interfere with attention and block the formation of new memories or the retrieval of old ones.

Depression. Common signs of depression include a stifling sadness, lack of drive, and lessening of pleasure in things you ordinarily enjoy. Forgetfulness can also be a sign of depression—or a consequence of it.

If memory lapses are bugging you, it’s worth a conversation with your doctor to see if any reversible causes are at the root of the problem. Something like getting more sleep, switching a medication, or a stress reduction program could get your memory back on track.

The new evidence comes from the NIH-AARP Diet and Health Study, which has followed the health of nearly 400,000 men and women since 1995. At the study’s start, the participants were asked how much supplemental calcium they took. From diet surveys, the researchers also assessed the likely amounts the participants were getting from food. Over 12 years of follow-up, men who took more than 1,000 milligrams (mg) of daily supplemental calcium were 20% more likely to succumb to heart disease than those who didn’t take calcium supplements. There was no connection between calcium supplements and heart disease in women (which has been seen in earlier studies), and no connection with calcium from food. The results were published yesterday in JAMA Internal Medicine.

This one study isn’t enough to find calcium guilty of heart disease in the first degree. It wasn’t a randomized trial, the gold standard of medical research, so it’s possible that other unmeasured factors could account for, or at least contribute to, the link between calcium supplements and heart disease.

But it’s not the only research to point the accusing finger. “This is another study looking at high calcium supplements and their effect on heart disease, and it’s starting to get concerning,” says Dr. David Slovik, an osteoporosis expert, endocrinologist, and associate professor of medicine at Harvard Medical School.

Calcium for health

Everyone needs calcium to keep bones strong. It’s especially important for older folks, in whom the mineral can leach from bones. Losing calcium weakens bones and leaves them more prone to breaking. Vitamin D is the helpmate to calcium, allowing the body to absorb more of the mineral during digestion.

Many people don’t obtain enough calcium or vitamin D from natural sources—food in the case of calcium and sunlight in the case of vitamin D. They make up shortfalls by taking daily supplements.

Until the calcium–heart disease issue is worked out, it’s best to get as much calcium as possible from food. The menu options go beyond milk and cheese. “There are a lot of common foods that people don’t realize have calcium,” says Dr. Michelle Hauser, a clinical fellow in medicine at Harvard Medical School and a certified chef and nutrition educator.

The go-to foods for calcium have traditionally been milk (an 8-ounce glass contains 300 mg of calcium) and other dairy foods. But dairy foods often come with saturated fat and plenty of calories, which limits their use for delivering calcium.

Dr. Hauser points out that a number of common foods besides milk, cheese, and dairy foods can deliver comparable amounts of calcium.

• An 8-ounce portion of off-the-shelf orange juice contains about 300 mg of calcium. The calcium in fortified soy milk also compares favorably to whole milk.
• Breakfast cereals (which are also fortified) contain substantial amounts of calcium, especially when combined with low-fat milk.
• A portion of oatmeal on its own contains just 100 mg of calcium. “But if you cut up some dried figs and add it to a bowl of oatmeal with milk, you easily get about half of what you need without having any supplements,” Dr. Hauser says.
• Lunch and dinner afford opportunities to boost calcium. Start with salads with leafy greens like kale, turnip greens, and Swiss chard. “A large salad would contain about as much calcium as a glass of milk,” Dr. Hauser says. But go easy on the spinach—it is high in iron, which tends to block absorption of calcium.
• If you enjoy sardines and other canned fish with bones included, you are in luck: they are unusually high in calcium. One 3-ounce serving of sardines provides about 325 mg of calcium.

An extensive list of the calcium content of hundreds of foods is available for free from the U.S. Department of Agriculture’s website.

Take time for calcium

Since the NIH-AARP participants were surveyed in 1995-1996, efforts have intensified to prevent osteoporosis not just with calcium supplements but also with a nutritious diet and, perhaps most important, regular weight-bearing exercise. “I think we should be a little more cautious about calcium from supplements,” Dr. Slovik says. “I tell my patients they should get as much as possible of the recommended amount from food.” Drs. Slovik and Hauser also emphasize the importance of getting enough vitamin D.

It might seem that popping a calcium supplement is an easy answer to maintaining bone health. But it comes with an uncertain risk of heart problems, and denies you the nutrients that hitchhike along with calcium in whole foods.

As I write in this month’s Harvard Men’s Health Watch, these so-called topical analgesics work best for more superficial joints like the knees, ankles, feet, elbows, and hands. “In those areas, the medication can penetrate closer to the joint,” says Dr. Rosalyn Nguyen, a clinical instructor in physical medicine and rehabilitation at Harvard Medical School.

The active ingredient in most topical analgesics is a nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen, naproxen, aspirin, or diclofenac. These medications target inflammation, which contributes to pain, swelling, and stiffness.

We know that oral NSAIDs can quell arthritis pain. Do they work as well when applied to the skin? A scientific review by the Cochrane Collaboration, an international body of health experts, found that some prescription topical NSAIDs can offer the same pain relief as oral medications with fewer gastrointestinal concerns.

The advantage of using a topical analgesic is that the medication works locally. Targeting pain more precisely using a medication applied to the skin can help skirt the side effects of oral drugs. This can be a boon for people whose stomachs are sensitive to NSAIDs. (Keep in mind that a small amount of the medicine still enters the bloodstream and ends up in the stomach and elsewhere, so a topical analgesic isn’t a guarantee against NSAID-related stomach irritation.)

Other people seek topical NSAIDs because they want to avoid adding another pill to their daily regimen, or have trouble taking pills.

Using a topical analgesic

Topical analgesics can be applied two to four times a day to control mild to moderate pain. Make sure to wash your hands thoroughly after use so you don’t smear the drug into your eyes, nose, mouth, or other mucous membranes.

Side effects from topical medications include redness, itching, and other skin irritation. They are generally mild—and uncommon. The cause of skin irritation is often the material used to make the cream or gel, not the NSAID, says Dr. Joanne Borg-Stein, medical director of the Harvard-affiliated Spaulding-Wellesley Rehabilitation Center in Massachusetts. When that happens, it’s possible for a pharmacist to create a preparation with ingredients that are less irritating to your skin.

A topical analgesic may not be the best choice when pain affects an extended area, like the lower back, or affects more than one part of the body.

A key warning about using topical analgesics: don’t use them if you are also taking an oral NSAID—either prescription or over-the-counter—without telling your doctor. Taking too much of an NSAID can land you in the hospital with stomach bleeding or an ulcer flare-up. In fact, up to 100,000 Americans are hospitalized every year for NSAID-related gastrointestinal problems.

Availability and cost may limit the use of topical NSAIDs. In the United States, the only prescription topical NSAID widely available in pharmacies is diclofenac gel. Other types, such as ibuprofen, ketoprofen (Orudis), indomethacin (Indocin), and piroxicam (Feldene) may require a special order from a compounding pharmacy.

The FDA lowered the starting dose for women from 10 milligrams (mg) to 5 mg; for men it is now 5 to 10 mg. The drug should be taken right before going to bed.

The dosage change highlights what doctors prescribing sleep drugs are already acutely aware of: Taking too much can give you a “hangover” of daytime drowsiness the next morning that could raise the risk of accidents or falls.

“This just reiterates that zolpidem is a potent sleeping pill and very effective at getting people to sleep, but that lower doses may be all that you need,” says Dr. John Winkelman, medical director of the Sleep Health Center of Brigham and Women’s Hospital and associate professor of psychiatry at Harvard Medical School.

Sedating effects

Sleepiness is great when you are lying cozily in your bed. It’s a hazard if you are walking, driving, or working. Because people respond to medications in their own ways, it’s safest to start taking a sleep drug on a weekend, says Dr. Winkelman. He also has his patients begin taking a dose lower than the maximum recommended starting dose. If they feel drowsy the next day, the dose can be reduced; if it didn’t work, the dose can be increased.

Doctors are especially cautious in prescribing sleep aids for people over 65 because of the potential for harmful falls. Although this topic is controversial, and it remains unclear how often sleep drugs themselves can be blamed for falls, the starting doses for older adults are lower. Some geriatricians are wary of prescribing sleep drugs at all.

The right tool

Like any drug, prescription sleep aids should be tailored to the nature of the problem. “Some medications can help you fall asleep but not stay asleep; others are better for staying but not falling asleep; some can do both,” Dr. Winkelman says.

Zolpidem and other drugs developed to help with sleep are known as hypnotics. They vary in their ability to help you nod off and keep you asleep through the night. Zolpidem (Ambien, Edluar, and Zolpimist), eszopiclone (Lunesta), and zaleplon (Sonata) all help you fall asleep faster, usually acting within 20 minutes or so.

Of these, only Ambien and Lunesta have been shown in clinical studies to lengthen total sleep time. Sonata wears off fastest. That means it can help you fall asleep but not necessarily stay asleep.

A low-dose version of zolpidem that goes by the brand name Intermezzo is intended for people who wake up during the night and want help getting back to sleep. The recommended dose is only 1.75 mg for women and 3.5 mg for men. Intermezzo should be taken only once per night, and only if there are more than four hours left before needing to get out of bed.

A variety of other drugs for are available to combat sleeplessness; many were not developed for that purpose. They include benzodiazepines like triazolam (Halcion), lorazepam (Ativan), and temazepam (Restoril). The antidepressant trazodone (Desyrel), at a low dose, is frequently used as a sleep aid. A new type of drug, rozerem (Ramelteon), acts on the brain circuits that regulate the body’s day-night rhythm.

Use as directed

Taking sleep drugs at the right time (at the beginning of your sleep period) and at the right dose, helps prevent what doctors call carryover—the drug is still in your system and acting on your brain even after you wake up. The FDA recommendation underscores the fact that all sleep aids—not just zolpidem—should be used at the lowest effective dose. “It is better to undershoot than overshoot,” Dr. Winkelman says.

But sleep drugs aren’t right or necessary for everyone. Changing sleep habits and behavior can be helpful for people with occasional or short-term insomnia. This includes adopting a regular sleep schedule, creating a comfortable sleeping environment, avoiding alcohol and caffeine close to bedtime, and other steps known as “sleep hygiene.” (See Dr. Winkelman’s 10 tips for a good night’s sleep.)

If you do need an over-the-counter or prescription sleep aid, take it as directed and at the lowest dose that helps you sleep in order to prevent daytime drowsiness.

In the study, aspirin’s effect on vision was small—far smaller than the lifesaving benefit it offers people with heart. “The benefits of cardioprotection are well established,” says Dr. William Christen, an epidemiologist and associate professor of medicine at Harvard Medical School. “There are too many unanswered questions in this study for it to impact the use of aspirin for cardiovascular disease.”

The study’s lead scientist, Dr. Barbara Klein, agrees. “Coronary heart disease is a killer,” emphasizes Dr. Klein, a professor of ophthalmology at the University of Wisconsin School of Medicine and Public Health. “If you are convinced that people need to be protected from heart disease with aspirin, you wouldn’t stop it because of this potential risk.”

A thief of vision

Macular degeneration occurs when something goes wrong with the macula, a small part of the eye’s light-sensing retina. The macula is responsible for sharp central vision. There are two forms. “Dry” macular degeneration is the most common. It is caused by thinning of the retina. Some people with it have no symptoms and are unaware they have the condition, others have vision loss.

In some people, dry macular degeneration progresses to “wet” macular degeneration. The name reflects the fact that abnormal blood vessels growing in the layers of cells beneath the retina leak fluid and blood, which can injure and scar the retina, causing loss of vision.

For dry macular degeneration, a cocktail of certain vitamins and nutrients can slow or even stop progression to an advanced, vision-robbing form. For the wet form, new drugs can stop or slow the growth of and leakage from abnormal blood vessels.

All eyes on Beaver Dam

As part of the ongoing Beaver Dam Eye Study, Dr. Klein and other researchers have been following nearly 5,000 adults living in the city and township of Beaver Dam, Wisconsin since 1987 to see how their eyesight changes as they age. Participants in the study were checked for signs of macular degeneration every five years. Among other questions, they were asked if they had regularly taken aspirin at least twice a week for at least three months.

In today’s Journal of the American Medical Association, the Wisconsin researchers reported that people in the Beaver Dam study were at slightly greater risk of developing late-stage AMD if they had had been regularly taking aspirin 10 years previously.

“Late stage” means the disease is far enough along to affect vision in one or both eyes. It could mean impaired vision or, eventually, blindness. The study links aspirin particularly to the wet form of AMD.

The added risk associated with aspirin use was small. After adjusting for factors that significantly affect risk for AMD, like smoking and age, 14 in 1,000 aspirin users developed late-stage wet AMD compared to 6 in 1,000 non-users.

Seeing the big picture

Keep in mind that the risk for developing macular degeneration balloons with aging. Should older adults shy away from aspirin?

The answer is no, especially for people who take a low-dose aspirin daily to prevent heart attacks. The small (and still unconfirmed) added risk of AMD is far outweighed by the rock-solid benefits of cardioprotective aspirin. But this study does raise the issue that even a simple, safe medication like aspirin isn’t something you want to be taking unless it will clearly do you some good.

The Beaver Dam study can’t really say for certain if aspirin actually causes late-life vision loss. As in all “observational” studies, researchers can only observe trends and try to link them statistically to plausible explanations—a bit like searching for suspicious-looking characters at the scene of a crime. Scientists try to control for factors that could affect the risk, like smoking and race, it’s hard to be sure what is causing what in the Beaver Dam study.

“They might be at higher risk for developing AMD for precisely the same reasons they are taking aspirin, like cardiovascular disease or an underlying inflammatory condition,” Dr. Christen says. “It’s difficult to disentangle whether this is due to aspirin or underlying risk factors that lead people to use aspirin.”

The American Academy of Ophthalmology recommends that everyone have a baseline comprehensive eye exam at age 40 to check vision, and look for early warning signs of macular degeneration and other eye problems, with follow-up exams as needed. For people 65 and older, the Academy recommends comprehensive exams at least every other year, though people with existing eye conditions might need more frequent follow up. Whether the latest Beaver Dam study will alter the Academy’s recommendations for people who take aspirin remain to be seen.

Testosterone first?

Before Viagra appeared on the scene in 1998 and transformed the treatment of erectile dysfunction, testosterone was an important medical therapy for it. Testosterone is central in the male sexual response, including the desire for sex and the mechanics of triggering an erection.

To be sure, getting more of this hormone isn’t a universal solution for ED. Some men with erectile problems have perfectly normal amounts of testosterone. Many doctors won’t consider prescribing testosterone unless certain other symptoms are also present, such as decreased desire for sex (libido) and fatigue. And boosting testosterone doesn’t always improve erections. But it is an option on the table for men with low testosterone.

“It’s well established that testosterone by itself, for men with sexual dysfunction that includes erectile dysfunction, can improve erections in the majority of men who take it,” says Dr. Abraham Morgentaler, an associate clinical professor of urology at Harvard-affiliated Beth Israel Deaconess Medical Center.

Dr. Morgentaler is also the founder and director of Men’s Health Boston, which treats many men with low testosterone. At the clinic, “our first choice for men who have low testosterone and erection problems is to give them testosterone and not sildenafil,” says Dr. Morgentaler, the author of Testosterone for Life. “Improved doesn’t always mean adequate, though, so, it is not unusual to add sildenafil or a similar medication if a man still is not satisfied with quality of his erection with testosterone therapy alone.”

One potential advantage to the “testosterone first” approach is that could make it unnecessary to take a pill in the anticipation of a sexual encounter. Also, men with low testosterone and symptoms may experience extra benefits of testosterone replacement, such as more “pep” and more desire for sex in the first place.

Call in the cavalry?

The current ED medications belong to a class of drugs known as PDE-5 inhibitors. They enhance blood flow to the spongy tissues in the penis, which creates an erection. Several competitors have since leapt into this lucrative market: tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra).

Today, one of these drugs is usually the first treatment a primary care doctor recommends for erectile complaints—not testosterone. That’s because they tend to work more reliably than testosterone, and the response is usually quicker. But like testosterone, they don’t work for about 30% of men who try one.

Questionable combination

Men with ED who also test low for testosterone may be offered a hormone boost, frequently in the form of a rub-on gel applied daily, in addition to an ED drug. Does this make a difference? To find out, a team of researchers based at Boston University Medical School conducted a study involving 140 men with low testosterone. Half took Viagra and used a daily testosterone gel, while the other half took Viagra and used a placebo gel.

Adding testosterone to Viagra didn’t make a difference. Erections, desire for sex (libido), and sexual activity were the same in both groups.

“One of the central findings of the study is that sildenafil works extremely well,” says Dr. Matthew Spitzer, the lead author of the study, which was published in the Annals of Internal Medicine.

The researchers speculate that Viagra may supercharge the process that creates erections beyond the point at which testosterone could add anything more. In other words, for these men the Viagra worked so well that there was little room for improvement. “Once a guy has a good erection,” Dr. Morgentaler says, “how are you going to make him do better on testosterone?”

A logical approach

More and more, erectile dysfunction is being viewed as a systemic medical problem. In some studies, ED is like the canary in a coal mine for a future heart attack. That’s because ED is often due to atherosclerosis—the same artery-clogging process that usually precedes heart attacks and strokes. So it should be approached more systematically than just starting with an ED drug.

If a man notices he is having trouble getting or sustaining an erection, and other things in his life are relatively stable, then a conversation with a doctor is in order. A blood test for testosterone is a good next step. If the testosterone level is low, then trying testosterone replacement makes sense. If that doesn’t improve erections, then it’s time to try an ED drug.