One of the certainties of life is that, unless one departs first, sooner or later each of us will have to deal with the death of a loved one.
Among his many duties as a spiritual leader, Stephen Karol, now Rabbi Emeritus at Temple Isaiah in Stony Brook, has ministered to the bereaved. He has officiated at funerals, counseled families and helped people navigate the mourning period that begins upon a death and continues through memorial services throughout the ensuing years.
Rabbi Karol has gathered a series of memorial sermons into a book titled, “Finding Hope and Faith in the Face of Death” and subtitled, “Insights of a Rabbi and Mourner.”
Author Stephen Karol
What motivated you to write this book?
I decided to do it for a couple of reasons. First, I’ve gotten really good feedback on my Yizkor (memorial) sermons. People have asked for copies and that sort of thing. And, throughout my career officiating at funerals, I just think people need comforting, hopeful messages to help them cope with death. That’s what this book provides.
Is this a ‘Jewish’ book, or do you feel it has broader appeal?
The book is written primarily for Jews, but not exclusively. While I speak from a Jewish context, a lot of what I have to say in these messages can be applied to people who are Jewish or not, religious or not, whatever they may be.
Why publish it now?
As a congregational rabbi I was devoted to my congregants — and happily so — and didn’t have the time to write a book. Now, in retirement, I decided to share my words of comfort. And when I submitted my proposal to the publisher (Wipf and Stock), they loved my idea and enthusiastically agreed to publish it under their Cascade Books imprint.
What was the most challenging part of compiling the manuscript?
In creating the introduction to the book, I wanted to be honest. I had to confess that, despite my faith in life after death, I am afraid to die. So, I describe my fear and explain how it materialized at a particularly happy time in my life, shortly after my daughter’s birth. I tell about the ways I’ve learned to cope with it and describe how a combination of hope and faith have helped me not only as an individual but also as a rabbi. That’s why I think my words can be universal, because you don’t have to be a rabbi to believe what I believe, and to feel and think what I feel and think.
How did you choose the sermon that became Chapter 1?
The first chapter in the book was chosen because it dealt with a personal loss. I titled it, “Accompanying the Dead” and it begins: “My uncle Harry died last month.” I talk about the experience of being in my uncle’s hospital room with him when he died, and officiating — along with my brother who is also a rabbi — at his funeral. A good number of the chapters involve personal experiences.
The cover of Karol’s book.
Aside from your own personal losses over the years, did other experiences contribute to your understanding of life and death?
I suffered a heart attack in 1995 that gave me a greater sense of perspective. One of the messages in the book is that we need to value life and make every day count. We need to tell people that we love them whenever we can.
How long was this book in the making?
The book consists of 16 sermons that I have given both at Temple Isaiah and at Congregation Sha’aray Shalom in Hingham, Massachusetts, over the course of my tenures at both synagogues. So, when people ask me how long it took to write the book, tongue in cheek I say: 35 years.
“Finding Hope and Faith in the Face of Death” is currently available for purchase on Amazon, Kindle and Ingram. Meet Rabbi Karol at a book talk and signing on June 24 at Temple Isaiah, 1404 Stony Brook Road, Stony Brook from 5 to 7 p.m.; or at a book signing on June 28 at Barnes & Noble at the Smith Haven Mall in Lake Grove from 7 to 9 p.m.
‘You don’t take a photograph. You make it’— Ansel Adams
By Heidi Sutton
Gurwin Jewish Nursing & Rehabilitation Center in Commack hosted an award ceremony for its annual Photo Contest last Thursday evening. The event, which was held in the center’s Simon Rainbow Room, celebrated 25 years of bringing beautiful photos to their residents and featured a slide show of the winning selections from this and previous years.
‘Indigo’ by Stan Mehlman
Generously sponsored by the Tiffen Company for the 12th year in a row, this year’s competition drew over 700 entries from amateur photographers across the country. Of those submissions, 47 photos were chosen to be enlarged, framed and hung on permanent display for the enjoyment of the residents, staff, visitors and volunteers.
“It’s hard to believe we’ve been doing this for a quarter of a century,” said Dennine W. Cook, public relations director at Gurwin, who came up with the initial idea in 1993 as a way of “making [Gurwin’s] bare walls worthy of a smile.” According to Cook, in its infancy, the contest had two categories — color and black and white — with less than 100 entries. The annual event has since expanded to offer 12 categories including Nature, Long Island/New York, Travel, Still Life and the ever popular Pets, Children and Nature. “Needless to say, we’ve come a long way,” she said.
Addressing the photographers in the audience, Cook said, “[At Gurwin] our mission … is to provide the highest quality of care to our residents while also providing them the very best quality of life. And that’s where all of you come in.”
She continued, “This contest … is different from any other contest you might enter. Sure there are winners … and there are prizes, but that’s where the similarities end.” Cook went on to explain that each year’s winners are displayed permanently for the enjoyment of the residents, first in the center’s Helen and Nat Tiffen Gallery and then up to the resident units to make space for the current year’s winners.
‘Popping Bubbles’ by Donna Crinnian
The public relations director went on to speak of the profound impact these beautiful images have made on residents of the 460-bed facility. She spoke of Faith who loves to look at photos of babies. “The babies, it seems, make her smile the most and so we move the [baby pictures] to Faith’s unit.” She spoke of Len, who is visited each day by his wife. “Together they stroll the halls, stopping to admire a photo that catches their eye. They may go the same way each day but they find something new to discuss every time.”
While the original 8- by 10-inch submissions will not be returned, Cook assured guests that all of them will be put to good use. “Each photo … is given to our recreation departments in our nursing homes, assisted living and day care programs to be used for all kinds of projects all year long.” Whether they become inspiration for a painting, part of a collage or even placed at the doorway of a resident’s room, “they have a much higher purpose.
This year’s judges, James Dooley (former Director of Photography for Newsday and Administrator of the Alexia Foundation), Susan Dooley (Emeritus Chair of the Art Department at Nassau Community College and member of fotofoto gallery of Huntington) and Tony Lopez (Tony Lopez Photography), were tasked with choosing a grand prize winner along with honorable mentions for each category as well as Best in Show, which this year was awarded to Kathleen Hinkaty ofHuntington for her playful piece, “Diaper Races.”
‘Diaper Races’ by Kathleen Hinkaty
In addition, Gurwin’s resident judges Nancy and Trudy selected five of their favorites to be honored. According to Cook, “They poured over the photos … considering not only their own preferences but also what they thought others would appreciate.”
“Although this contest is a great achievement for you as a photographer, it’s really about the people who get to see your work once it is chosen,” explained Cook.
President and CEO of Gurwin Family of Healthcare Services Stuart B. Almer agreed, stating, “We always enjoy this particular event,” sharing that when he gives tours of the facility, “everyone always stops to admire the photos. This is not just a once-a-year event — this is a 365-day-a-year event,” he stressed, thanking the photographers for their contribution.
“All of the selections will be judged, discussed and enjoyed by so many appreciative eyes for years to come and to me that is the real honor — that your photos will hang for decades in our resident’s home,” said Cook. “These photos make all the difference in the world.”
Entries for next year’s Photo Contest will be accepted between Feb. 15 and April 15, 2019. Visitwww.gurwin.org/about/photo-contest to see more of this year’s winners.
When June finally busts out all over, local strawberries will be at their peak. Despite their slow start because of the rain, they will be their usual juicy ruby red selves ready to be picked or purchased at local farms or those out east. There will be plenty for dropping into baskets and just as many for popping into our mouths as we move between the rows. When fresh strawberries are so naturally delicious without any adornment except maybe a little sugar and cream, anything further seems like sacrilege.
On the other hand, when they’re that good, any recipe that features them is always that much better because those little gems themselves are so good. So when you get home from your strawberry picking with your baskets of ruby treasures, consider an old-fashioned strawberry shortcake, a strawberry-arugula-radish salad with balsamic dressing or a strawberry sorbet.
Aunt Edith’s Strawberry Shortcake
Aunt Edith’s Strawberry Shortcake
YIELD:Makes 10 servings
INGREDIENTS:
1 quart fresh strawberries, washed and crushed
¼ cup sugar
2½ cups flour
1/3 cup sugar
1 tablespoon baking powder
¼ teaspoon salt
1/3 cup cold butter, cut into small pieces
1 cup milk
1 egg yolk, slightly beaten
2 tablespoons sugar
1 cup heavy whipping cream
1 tablespoon sugar
1 teaspoon vanilla extract
DIRECTIONS:
Heat oven to 400 F. In a large bowl combine the berries with the quarter cup sugar and set aside. In a medium bowl combine the flour, one-third cup of sugar, baking powder and salt. Using a pastry blender or two knives, cut the butter into the flour mixture until it resembles coarse crumbs; stir in milk. Knead until dough forms, then, on a lightly floured surfaced, pat into a half-inch thickness.
Using a 2½-inch cutter or the same-size upside-down glass, cut into 10 circles and place on ungreased cookie sheet. Brush egg yolks over tops, then sprinkle with two tablespoons sugar. Bake 10 to 15 minutes, until golden brown on top. Remove from oven and let cool 10 to 15 minutes. Meanwhile, whip cream with remaining tablespoon sugar and vanilla. Split shortcakes in half horizontally, place on plates, then spoon whipped cream and strawberries in any order you wish and replace tops. Serve immediately with hot or iced coffee or tea.
Strawberry-Arugula-Radish Salad with Balsamic Dressing
YIELD:Makes 8 servings
INGREDIENTS:
10 ounces fresh arugula, washed and dried
1 quart fresh strawberries, washed, hulled and sliced
8 radishes, washed, trimmed and very thinly sliced
½ cup olive oil
3 tablespoons balsamic vinegar
1 teaspoon raspberry vinegar
1 tablespoon orange juice
1 teaspoon Dijon mustard
1 teaspoon honey
1 whole garlic clove, peeled
Salt and freshly ground pepper, to taste
DIRECTIONS:
Have all ingredients at room temperature. Place arugula, strawberries and radishes in a large bowl. Combine remaining ingredients in a small bowl and let sit for one hour. Remove and discard garlic. With a fork or small wire whisk, emulsify the oil, vinegars, juice, mustard, honey, salt and pepper. Pour over greens and toss thoroughly. Serve immediately as a first course or with meat, poultry or fish.
Strawberry Sorbet
Strawberry Sorbet
YIELD:Makes 1 quart
INGREDIENTS:
2 quarts strawberries, washed and hulled
1 cup sugar
1 ounce freshly squeezed lemon juice
½ ounce vodka
Pinch coarse salt
DIRECTIONS:
Place all ingredients in a food processor and puree until there are no lumps left.Transfer to another container, cover and refrigerate 6 hours. Place in an ice cream maker and churn according to manufacturer’s directions until mixture resembles soft ice cream.Transfer one more time to airtight container and freeze at least 4 hours. Serve with crisp cookies, biscotti or pound cake.
From left, Sharks Jay Norman, George Chakiris and Eddie Verso in a scene from ‘West Side Story’
“Something’s coming, something good …”
Fifty-seven years after its world premiere screening at the Rivoli Theatre in New York City, the award-winning musical “West Side Story” will return to over 600 select cinemas nationwide on June 24 and 27, courtesy of Turner Classic Movies and Fathom Events.
Richard Beymer and Natalie Wood sing ‘Tonight’ in a scene from ‘West Side Story’
Starring Natalie Wood, Rita Moreno, Russ Tamblyn, Richard Beymer and George Chakiris the film takes inspiration from Shakespeare’s “Romeo and Juliet” and turns the Montague-Capulet battle into a feud between two New York City street gangs — the Jets and the Sharks. When a member of the Jets falls in love with the sister of the Sharks’ leader, things look hopeful at first, but rapidly go downhill. Illustrating the events are many memorable song and dance numbers such as “America,” “Tonight,” “A Boy Like That,” “One Hand, One Heart,” “Somewhere” and “I Feel Pretty.”
With book by Arthur Laurents, music by Leonard Bernstein and lyrics from Stephen Sondheim, the film went on to win 10 Oscars at the 34th Academy Awards, including Best Picture and both supporting acting awards, for Chakiris and Moreno, becoming the record holder for the most wins for a movie musical. Deemed “culturally significant” by the United States Library of Congress, it was selected for the National Film Registry in 1997.
The film will be presented in its original wide-screen aspect ratio and include a mid-film intermission, as was featured in the original theatrical release. It will also include pre- and postshow commentary from TCM host Ben Mankiewicz.
There’s no better way to prepare yourself for Steven Spielberg’s reboot, so mark your calendars!
Participating movie theaters in our neck of the woods include AMC Loews Stony Brook 17, 2196 Nesconset Highway, Stony Brook (at 2 and 7 p.m. on both days); Farmingdale Multiplex Cinemas, 1001 Broadhollow Road, Farmingdale (on June 24 at 2 p.m. and June 27 at 7 p.m.); and Island 16 Cinema de Lux, 185 Morris Ave., Holtsville (on June 24 at 2 p.m. and June 27 at 7 p.m.) To purchase your ticket in advance, visit www.fathomevents.com.
STROLLING ON THE SHORE: Tom Caruso of Smithtown snapped this adorable piping plover at Short Beach in Nissequogue. The tiny shorebirds build nests on the beaches of Long Island and much of the Atlantic coast this time of year
After a 14-year hiatus, Pixar’s beloved superhero family, the Incredibles, has returned and immediately picks up where the original left off. “Incredibles 2” follows the Parr family — parents Bob/Mr. Incredible (Craig T. Nelson) and Helen/Elastigirl (Holly Hunter) along with kids Violet (Sarah Vowell), Dash (Huck Milner) and Jack-Jack (Eli Fucile) — as they strive to find their place in a society that has criminalized their superpowers.
The Parr family is back to save the day.
The story opens when the city is under attack by the Underminer who appeared in the final moments of the original movie. The fallout from this epic and highly destructive confrontation causes all Superhero activity to be banned in the city, and the Parr family is forced to go underground, taking up residence in a dingy motel.
The outlook is bleak for the superfamily until they are approached by the wealthy and eccentric siblings Evelyn (Catherine Keener) and Winston Deavor (Bob Odenkirk) who offer them a chance to restore the reputation of all Supers to the glory of a bygone era.
Elastigirl is chosen to take on the mission independently due to her proven track record of causing minimal collateral damage; leaving Mr. Incredible to deal with the equally daunting task of staying home with the kids. In the new role of Mr. Mom, he struggles to manage Violet’s teenage angst, Dash’s math homework, and the highly unpredictable Jack-Jack, who is beginning to show an impressive range of superabilities including self-replication, morphing into demon form and laser vision.
Jack-Jack’s superpowers come out in full force in new Incredibles sequel.
Meanwhile, Elastigirl is faced with her first assignment — to save the passengers on a newly unveiled high-speed train that has been set on a collision course by the mysterious supervillain, Screen Slaver. She accomplishes her mission with flawless style and is applauded for reminding society of the Supers’ value as protectors of the innocent. Mr. Incredible watches his wife’s success on the news and is forced to reconsider the effectiveness of his macho, alpha-male persona.
The plot remains fast-paced and unpredictable up until the conclusion. Pixar’s brilliant character design and highly creative action sequences will keep your attention from start to finish.
“Incredibles 2” is a breath of fresh air in the superhero genre, which has become saturated with sequels based on unoriginal, formulaic story lines. The superhero film has been brought back to a focus on strong character development, dazzling creativity and a continuous thread of humor and levity woven throughout the story line. While the film maintains a light-hearted tone it also touches on relevant social issues such as gender stereotypes and the public’s obsessive consumption of digital media and entertainment.
Elastigirl in a scene from the movie.
“Incredibles 2” is a worthy sequel that doesn’t disappoint. Pixar has again succeeded in creating a film that will appeal to audiences of all ages by avoiding the typical limitations of a children’s film. The film’s primary strength is in the creativity and beauty of its visual execution and character design. Although the plot is certainly original and engaging, what will keep your attention is the incredible depth of expression that is achieved through character development, world building and visual design.
The film is a must see for Incredibles fans and is bound to be a major hit this summer for all audiences. Running time is 1 hour and 58 minutes.
Rated PG (for action sequences and some brief mild language) “Incredibles 2” is now playing in local theaters.
This sweet girl is a 5-year-old Shiba Inu mix who recently arrived at Kent Animal Shelter from Thailand. Rescued from the meat trade industry, she had a rough start in life but that is all behind her now. Alta takes a little time to warm up to new people because she is a little shy, but her gentle nature will capture your heart if you give her a chance. Stop by and meet her today! Alta comes spayed, microchipped and up to date on all her vaccinations.
Kent Animal Shelter is located at 2259 River Road in Calverton. The adoption center is open from 10 a.m. to 4 p.m. every day. For more information on Alta and other adoptable pets at Kent, visit www.kentanimalshelter.com or call 631-727-5731.
The Smithtown Historical Society (SHS) teamed up with Ranger Eric Powers last Friday night to give our local bats a much needed helping hand. The North Shore community was invited to the historic Frank Brush Barn to learn about our mosquito-eating friends, build a bat house to take home and then stroll the grounds in hopes of catching a glimpse of these fascinating mammals.
David and Susan Henderson with their bat house
And the turnout was impressive as residents of all ages embraced the batty subject and enjoyed a wonderful educational evening. Participants were able to ask questions, had the opportunity to see a bat specimen up close and learned about the different styles of bat houses before assembling one of their own using plywood, screws and wood stain.
Powers was invited to present this program by Melissa Clements, the director of education at the SHS, who attended a bat workshop led by Powers a few months ago at Sands Point Preserve in Port Washington. “I had such a great time and enjoyed it so much,” she said, and couldn’t wait to bring Powers to Smithtown.
An ardent nature lover, Powers moved from Greeley, Colorado, to Long Island 20 years ago partially because “we live in this cool sweet spot where we have northern species and our own species and also southern species that come up — so there is this awesome convergence right here.”
Accompanied by his trusty sidekick, Gangsta, a 100-pound mush of a therapy dog, the wildlife biologist passionately spoke about one of his favorite animals, bats, and his mission to help them. “I’m focusing on bringing back nature, helping to restore the balance of nature, and a lot of that means supporting our natural ecosystem,” he said. And what better way to do that than with bats?
According to Powers, bats are important in so many ways. The only mammals that can fly, bats eat tons of flying insects including beetles, flies, moths, hatching termites and, most importantly, mosquitoes. “They’re out there eating bugs that are bugging us,” he laughed. They also play an important role as pollinators and seed dispersers.
Children stain their bat houses under the watchful eye of mom.
Aside from cats that are allowed to roam free, humans are the bat’s biggest threat. On top of dealing with habitat loss, “Everyone is spraying their property. There is such a chemical soup happening right now, all for killing bugs, killing beneficial insects,” he said sadly, continuing, “The bat’s food, flying bugs, is way down. The vast numbers of bugs are just not there anymore. And now, because we’re so out of balance with our ecosystem, the one thing that is surviving very well are mosquitoes.”
Before they got their hands dirty, Powers showed participants how to assemble a bat house, stressing that, when completed, it should be positioned at least 15 feet high on a tree or post and should be placed where the yard gets full sun from around noon to sunset. “Bats need a safe, warm place to hang out all day long.” Each bat house can accommodate up to 50 bats.
Dominick Domino of St. James decided to bring his daughter Hannah to the event. “It’s an activity we can do together,” he said. Hannah, who will attending summer camp at the historical society this summer, “is always interested about bats. She loves them.” The Dominos will be putting their new bat house in their garden.
Dominick and Hannah Domino show off their completed bat house.
David and Susan Henderson of Kings Park learned of the program on Instagram and decided to attend. “We love bats, they are just cute” said Susan, who received a bat house for Christmas. “We put it in our yard but we haven’t had bats yet so we were hoping to learn what we need to fix [to attract them].”
“We are looking forward to getting bats,” said David optimistically, as the couple finished assembling their second bat house.
For SHS Office Manager Victoria DelVento, the program was a great way to dispel any stigmas people have about bats and she was pleased with the wonderful and enthusiastic turnout. “Bats aren’t just for Halloween and they don’t suck your blood,” she laughed. “That was the point of this event.”
Above, a battle scene shot at Benner’s Farm in East Setauket last summer.
Film showcased at SBU’s Staller Center for the Arts
By Talia Amorosano
The wait is over. On Sunday, June 24, an integral piece of U.S. and Long Island history will be revisited in the geographic location where much of it actually took place. At 7 p.m., the Stony Brook University’s Staller Center for the Arts, 100 Nicolls Road, Stony Brook, will host the first major public screening of “One Life to Give,” a film about the friendship and lives of young American heroes Benjamin Tallmadge and Nathan Hale, whose actions would lead to the creation of a Revolutionary spy ring based on the North Shore of Long Island.
Presented in the Main Theater, doors will open at 6:45 p.m. After a message from publisher Leah Dunaief, a short behind-the-scenes documentary will be shown followed by the main film screening. After a message from the creators, the evening will conclude with a Q&A with the cast and crew. Admission to the event is free, courtesy of TBR News Media. No reservations are necessary.
Cast and crew gather around a camera to view playback last summer.
The film’s co-producer and writer, Michael Tessler, describes the film as an exploration of historical events with a human focus. “After spending several years researching Benjamin Tallmadge and the other heroes featured in our film, I began to look at them not as detached names in a textbook, but more so as real people, with real stories that deserve to be told,” he said.
Dave Morrissey, the actor who portrays Tallmadge in the film, describes his character as a “22-year-old kid,” who, despite his relative youth, is “focused” and “grounded,” propelled into action by the death of his brother at the hands of the British. “When something like that happens to you, you turn into a machine … into something else,” said Morrissey. “If you channel the energy and do what’s right, the possibilities are endless.”
By focusing a metaphorical macro lens on the multidimensional characters of Tallmadge and Hale, the film traverses consequential moments of American history: the Battle of Long Island, the anointing of America’s first spy and the events that would lead to the creation of the Culper Spy Ring, a group of men and women who risked their lives and status to gather British intelligence for the Revolutionary cause.
Though Tessler notes that the film is, at its heart, a drama, he and the film’s director and co-producer Benji Dunaief stress the cast and crew’s commitment to accuracy in their interpretation of historical events.
“The history comes second to the narrative in most [other film adaptations of historical events],” says Dunaief. “Our approach with this film was the exact opposite. We wanted to see where we could find narrative within [pre-existing] history.”
“Many of the lines from the film were plucked directly from the diaries of the heroes themselves,” stated Tessler. “We worked closely with historians and Revolutionary War experts to achieve a level of accuracy usually unseen in such a local production.”
The fact that many scenes from the film were shot in the locations where the events of the real-life narrative took place helped give the visuals a sense of truthfulness and the actors a sense of purpose.
“The location took production to the next level. It’s really crazy how closely related the sets we used were to the actual history,” said Dunaief, who specifically recalls filming at a house that contained wood from Tallmadge’s actual home. “It helped to inspire people in the cast to get into character.”
Morrissey recalls spending a particularly inspiring Fourth of July on Benner’s Farm in East Setauket. “We were filming the war scenes with all the reenactors … in the cabin that we built for the set … in the town where the battles and espionage had really happened. There were fireworks going on in the background while we sang shanty songs. It was amazing.”
The Continental Army shoots off a cannon at Benner’s Farm.
Though locational and historical accuracy played a large role in making filming a success, ultimately, Dunaief and Tessler credit the resonance of “One Life to Give” to an engaged and participatory community. “This was a community effort on all accounts,” says Dunaief, noting the roles that the Benners, Preservation Long Island, The Ward Melville Heritage Organization, the Three Village Historical Society and others played to bring “One Life to Give” to fruition.
The fact that the screening will take place at the Staller Center, in the heart of the community that helped bring the film about, represents a full-circle moment for the cast and crew. “We’re calling it a screening but it is so much more,” said Dunaief. “It is a fantastic example of how the community has stood by this film, from beginning to end.”
“We’re beyond honored and humbled to use a screen that has seen some of the greatest independent films in history,” said Tessler. “Stony Brook University has been a wonderful partner and extremely accommodating as we work to bring our local history to life.”
Tessler projects confidence that viewers will leave the screening with a similar sense of gratitude. “This story shows a part of our history that I think will make the audience very proud of the place they call home.”
The future of ‘One Life to Give’:
Michael Tessler and Benji Dunaief plan to show the film at festivals around the country, to conduct a series of screenings on Long Island, and to partner with local historical societies that can use it as an educational tool. Additionally, a sequel to “One Life to Give,” titled “Traitor,” is already in the works. Filming will begin this summer.
Reflux (GERD) disease, sometimes referred to as heartburn, though this is more of a symptom, is one of the most commonly treated diseases. Continuing with that theme, proton pump inhibitors (PPIs), which have become household names, are one of the top-10 drug classes prescribed or taken in the United States. In fact, Centers for Disease Control and Prevention data shows that use has grown precipitously in the 10 years ending in 2010 for those ages 55 to 64, from 9 percent of the population to 16 percent (1). This is a 78 percent increase in the number of prescriptions for these drugs.
In 2010, there were 147 million prescriptions filled for PPIs (2). The class of drugs includes Prevacid (lansoprazole), Prilosec (omeprazole), Nexium (esomeprazole), Protonix (pantoprazole) and Aciphex (rabeprazole). This growth may not capture the fact that several of these medications are now available over the counter.
I remember when PPIs were touted as having one of the cleanest side effect profiles. This may still be true, if we are using them correctly for reflux disease. They are supposed to be used for the short term. This can range from 7 to 14 days for over-the-counter PPIs to 4 to 8 weeks for prescription PPIs.
Why did we not know that this class of drugs might be associated with chronic kidney disease, dementia, bone fractures and Clostridium difficile (a bacterial infection of the gastrointestinal tract) before they were approved? Well, if you look at the manufacturers’ package inserts for these drugs, the trials, such as for Protonix, were no longer than a year (3), yet we are putting patients on these medications for decades. And the longer people are on them, the more complications arise.
Typical symptoms of reflux are heartburn and/or regurgitation. Atypical symptoms include coughing and throat clearing. But these atypical symptoms may not be as common as you might think. In fact, in one study, coughing and throat clearing taken together only resulted in a very small portion of patients having reflux disease (4). Having one of these two symptoms showed a slightly higher risk of reflux, but very modest.
Let’s look at some of the research.
Though PPIs may increase the risk of a number of complications, keep in mind that none of the data are from randomized controlled trials (RCTs), which are the gold standard of studies, but mostly observational studies that suggest an association, but not a link. Long-term RCTs to determine side effects are prohibitively expensive.
PPI and kidney disease
Recent research has tied proton pump inhibitors to a host of alarming health problems. Stock photo
In two separate studies, results showed that there was an increase in chronic kidney disease with prolonged PPI use (5). All of the patients started the study with normal kidney function based on glomerular filtration rate (GFR). In the Atherosclerosis Risk in Communities (ARIC) study, there was a 50 percent increased risk of chronic kidney disease, while the Geisinger Health System cohort study found there was a modest 17 percent increased risk. The first study had a 13-year duration, and the second had about a six-year duration. Both demonstrated a modest, but statistically significant, increased risk of chronic kidney disease.
But as you can see, the medications were used on a chronic basis for years. In an accompanying editorial to these published studies, the author suggests that there is overuse of the medications or that they are used beyond the resolution of symptoms and suggests starting with diet and lifestyle modifications as well as a milder drug class, H2 blockers (6).
PPI and bone fractures
In a meta-analysis (a group of 18 observational studies), results showed that PPIs can increase the risk of hip fractures, spine fractures and any-site fractures (8). Interestingly, when it came to bone fractures, it did not make a difference whether patients were taking PPIs for more or less than a year. How much less than a year was not delineated. They found increased fracture risks of 58, 26 and 33 percent for spine, hip and any site, respectively. It is not clear what may potentially increase the risk; however, it has been proposed that it may have to do with calcium absorption through the gut.
PPIs reduce the amount of acid, which may be needed to absorb insoluble calcium salts. In another study, seven days of PPIs were shown to lower the absorption of calcium carbonate supplements when taken without food (9).
PPI and dementia
Stock photo
A German study looked at health records from a large public insurer and found there was a 44 percent increased risk of dementia in the elderly who were using PPIs, compared to those who were not (7). These patients were at least age 75. The authors surmise that PPIs may cross the coveted blood-brain barrier and have effects by potentially increasing beta-amyloid levels, markers for dementia. With occasional use, meaning once every 18 months for a few weeks to a few months, there was a much lower increased risk of 16 percent.
The researchers also suggested that PPIs may be significantly overprescribed in the elderly. Unfortunately, there were confounding factors that may have conflated the risk, such as multiple drug use, having diabetes, or patient also having depression or a stroke history. Researchers also did not take into account family history of dementia, high blood pressure or excessive alcohol use, all of which have effects on dementia occurrence.
Need for magnesium
PPIs may have lower absorption effects on several electrolytes including magnesium, calcium and B12. In one observational study, PPIs combined with diuretics caused a 73 percent increased risk of hospitalization due to low magnesium (10). Diuretics are water pills that are commonly used in disorders such as high blood pressure, heart failure and swelling.
Another study confirmed these results. In this second study, which was a meta-analysis (a group of nine studies), PPIs increased the risk of low magnesium in patients by 43 percent, and when researchers looked only at higher quality studies, the risk increased to 63 percent (11). The authors note that a significant reduction in magnesium could lead to cardiovascular events.
The bottom line is even though some PPIs are over-the-counter and some are prescription medications, it is best if you confer with your doctor before starting them. You may not need PPIs, but rather a milder medication referred to as H2 blockers (Zantac, Pepcid). Even better, start with lifestyle modifications including diet, not eating later at night, raising the head of the bed, losing weight and stopping smoking, if needed, and then consider medications (12). If you do need medications, know that PPIs don’t give immediate relief and should only be taken for a short duration: 7 to 14 days, according to the FDA (13), without a doctor’s consult, and 4 to 8 weeks with one. Most of the problems occur with long-term use.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.
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