With winter’s icy conditions around the corner, our risk for falls is about to go up. When we were younger, falls usually did not result in significant consequences. However, when we reach middle age and chronic diseases become more prevalent, falls become more substantial. And, unfortunately, falls are a serious concern for older patients, where consequences can be devastating. They can include brain injuries, hip fractures, a decrease in functional ability, and a decline in physical and social activities (1). Ultimately, falls can lead to loss of independence (2).

Of those over the age of 65, between 30 and 40 percent will fall annually (3). Most of the injuries that involve emergency room visits are due to falls in this older demographic (4).

What can increase the

risk of falls?

A multitude of factors contribute to fall risk. A personal history of falling in the recent past is the most prevalent. But there are many other significant factors, such as age; female gender; drugs like antihypertensive medications used to treat high blood pressure; and psychotropic medications used to treat anxiety, depression, and insomnia. Chronic diseases, including arthritis, as an umbrella term; history of stroke; cognitive impairment and Parkinson’s disease can also contribute. Circumstances that predispose us to falls also involve weakness in upper and lower body strength, decreased vision, hearing disorders and psychological issues, such as anxiety and depression (5).

How do we prevent falls?

Fortunately, there are ways to modify many risk factors and ultimately reduce the risk of falls. Of the utmost importance is exercise. But what do we mean by “exercise?” Exercises involving balance, strength, movement, flexibility and endurance, whether home-based or in groups, all play significant roles in fall prevention (6). We will go into more detail below.

Many of us in the northeast suffer from low vitamin D, which strengthens muscle and bone. This is an easy fix with supplementation. Obviously, footwear needs to be addressed. Non-slip shoes, if last year is any indication, are of the utmost concern because of ice, especially black ice. Inexpensive changes in the home can also make a big difference.

Medications that exacerbate fall risk

There are a number of medications that may heighten fall risk. As I mentioned earlier, psychotropic drugs top the list. Ironically, they also top the list of the best-selling drugs. But what other drugs might have an impact?

High blood pressure medications have recently been investigated. A recent propensity-matched sample study (a notch below an RCT in terms of quality) showed an increase in fall risk in those who were taking high blood pressure medication (7). Surprisingly, those who were on moderate doses of blood pressure medication had the greatest risk of serious injuries from falls, a 40 percent increase. One would have expected those on the highest levels of BP medication to have the greatest increase in risk, but this was not the case.

While blood pressure medications may contribute to fall risk, they have significant benefits in reducing the risks of cardiovascular disease and events. Thus, we need to tread lightly before considering stopping a medication; we need to weigh the risk-benefit ratio, specifically in older patients. When it comes to treating high blood pressure, lifestyle modifications may also play a significant role in treating this disease (8).

Where does arthritis fit into this paradigm?

In those with arthritis, compared to those without, there is an approximately two-times increased risk of two or more falls and, additionally, a two-times increased risk of injury resulting from falls, according to the CDC (1). This survey encompassed a significantly large demographic; arthritis was an umbrella term including those with osteoarthritis, rheumatoid arthritis, gout, lupus, and fibromyalgia. Therefore, the amount of participants with arthritis was 40 percent. Of these, about 13 percent had one fall and, interestingly, 13 percent experienced two or more falls in the previous year. Unfortunately, almost 10 percent of the participants sustained an injury from a fall. Patients 45 and older were as likely to fall as those 65 and older.

Why is exercise critical?

All exercise has value. A meta-analysis of a group of 17 trials showed that exercise significantly reduced the risk of a fall (9). If their categories are broken down, exercise had a 37 percent reduction in falls that resulted in injury and a 30 percent reduction in those falls requiring medical attention. But even more impressive was a 61 percent reduction in fracture risk. Remember, the lower the fracture risk, the more likely you are to remain physically independent. Thus, the author summarized that exercise not only helps to prevent falls, but also fall injuries. The weakness of this study was that there was no consistency in design of the trials included in the meta-analysis. Nonetheless, the results were impressive.

What specific types of exercise are useful?

Many times exercise is presented as a word that defines itself. In other words: just do any exercise and you will get results. But some exercises may be more valuable or have more research behind them. Tai chi, yoga and aquatic exercise have been shown to have benefits in preventing falls and injuries from falls.

A randomized controlled trial (RCT), the gold standard of studies, showed that those who did an aquatic exercise program (HydrOS) had a significant improvement in the risk of falls (10). Results showed a reduction in the number of falls from a mean of 2.00 to a fraction of this level — a mean of 0.29. There was no change in the control group.

Both groups were given equal amounts of vitamin D and calcium supplements. The aim of the aquatic exercise was to improve balance, strength and mobility. Also, there was a 44 percent decline in the number of patients who fell. This study’s duration was six months and involved 108 post-menopausal women with an average age of 58. This is a group that is more susceptible to bone and muscle weakness. The good news is that many patients really like aquatic exercise.

Thus, our best line of defense against fall risk is prevention. Does this mean stopping medications? Not necessarily. But for those 65 and older, or for those who have “arthritis” and are at least 45 years old, it may mean reviewing your medication list with your doctor. Before considering changing your BP medications, review the risk-to-benefit ratio with your physician. The most productive and least dangerous way to prevent falls is through lifestyle modifications.

References

(1) MMWR. 2014;63(17):379-83. (2) J Gerontol A Biol Sci Med Sci. 1998;53(2):M112. (3) J Gerontol. 1991;46(5):M16. (4) MMWR Morb Mortal Wkly Rep. 2003;52(42):1019. (5) JAMA. 1995;273(17):1348. (6) Cochrane Database Syst Rev. 2012;9:CD007146. (7) JAMA Intern Med. 2014 Apr;174(4):588-95. (8) JAMA Intern Med. 2014;174(4):577-87. (9) BMJ. 2013;347:f6234. (10) Menopause. 2013;20(10):1012-1019.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

I recently watched “The Caine Mutiny,” a wonderful 1954 film starring Humphrey Bogart. I encourage those who have not seen the movie to watch it, but this is not a film review. Sadly, Humphrey Bogart died at 57 from esophageal cancer. It got me thinking: what might prevent this cancer? I thought of proton pump inhibitors. This class of medication includes Nexium (omeprazole), Prilosec (pantoprazole), and Prevacid (lansoprazole). As I am sure you know, PPIs can be found in both prescription and over-the-counter forms.

What are PPIs?

PPIs are acid-reducing medications that work by blocking the gastric proton pump (H+/K+ ATPase) of parietal cells in the lining of the stomach. They are used to treat GERD reflux; Barrett’s esophagus, a potential consequence of reflux; esophagitis (inflammation of the esophagus); and ulcers in the stomach and small intestines (1). Barrett’s can potentially lead to esophageal cancer.

Are PPIs effective?

The prevailing thought is that, by treating reflux disease with PPIs, you reduce the risk of esophageal cancer in those who have Barrett’s esophagus. However, the effectiveness has been called into question by a Danish study, which I will explain in more detail below.

How common are PPIs?

According to the FDA, there were 21 million prescriptions filled in 2009 for this class of medication (2). PPIs were the fifth most common drugs prescribed in the U.S. in 2011 (3). The median length of use is six months.

Do PPIs have significant

side effects?

Unfortunately, PPIs have side effects, and with chronic use, we seem to be seeing more side effects. The FDA warns of infections, both community-acquired pneumonia and Clostridium difficile, a bacterial infection that causes watery diarrhea and substantial discomfort; potential absorption issues with vitamins and minerals such as magnesium, calcium and B12; drug interactions with Plavix (clopidegril); increased bone fracture risk; and negative effects in older patients in general (2). Note that none of these side effects has been definitively tied to this class of drugs, but it should make you think twice.

Let’s look at the evidence.

Do PPIs prevent esophageal cancer?

The answer is probably not, and they may even increase risk. In a newly published Danish study, the surprising results showed that PPIs did not decrease the risk of esophageal cancer or high-grade dysplasia (abnormal growth of tissue) in patients who had Barrett’s esophagus (4). One precursor of cancer of the esophagus is Barrett’s esophagus, which can develop from chronic reflux disease. The risk of esophageal cancer in long-term users was greater in those who were more adherent than in those who had lower adherence with PPI use, but both had significantly increased risk of cancer development, 3.4 times and 2.2 times, respectively. This study involved 9,883 patients over a 10-year duration.

This study was observational, so the results are suggestive and require further studies to confirm these results. The authors surmise that the reason for this increased risk is that reflux disease involves other factors besides stomach acid production, and PPIs may increase the proportion of bile acids that are prone to cause cancer. Another reason may be that gastrin (which initiates secretion of stomach juices) production increases with the use of PPIs and may be responsible for the increased risk.

Do PPIs really increase
the risk of infection?

There are two scary diseases that are a potential result of PPIs: pneumonia and Clostridium difficile.

Pneumonia risk

PPIs may increase our risk of the most common type of bacterial pneumonia, Streptococcus pneumoniae. In an observational prospective (forward-looking) study, those who used PPIs were at two times the increased risk of developing this type of pneumonia compared to those not using these drugs (5). There were 463 patients involved in this study.

Fortunately, the severity of pneumonia was the same whether it was potentially caused by PPIs or not. In other words, PPIs did not make the pneumonia worse. The researchers surmise that PPIs may increase the risk of pneumonia because of potential bacterial overgrowth in esophagus due to a decrease in gut acid production and from modulation of the immune system.

In a meta-analysis (a group of nine studies), results showed that PPIs increased the risk of developing pneumonia (6). The most interesting part of this study was that those at higher risk were patients who used PPIs for less than 30 days. These patients had a 65 percent increased risk. Those who used high doses of the therapies were at a 50 percent increased risk. Interestingly, patients who had been using the PPIs for over six months did not show an increased risk of pneumonia. So it may not always relate to just long-term or chronic use.

Clostridium difficile risk

The infection by a bacterium Clostridium difficile may cause mild to severe watery diarrhea and abdominal pain. It is typically precipitated by antibiotic use. However, PPIs might also be implicated. In a meta-analysis (a group of 42 observational studies), results showed that PPIs increased the risk of Clostridium difficile infection by 74 percent compared to those who did not use these medications (7). And those who used both PPIs and antibiotics were at an even greater risk of 96 percent. There were 313,000 patients involved in this meta-analysis. No definitive conclusions can be made, though, since these results were based on observational trials; however, it makes you ponder the use of these drugs.

Aspirin and PPIs

Many people take daily low-dose (75 to 325 mg) aspirin to prevent a heart attack, stroke or even potentially cancer. Well, when it comes to taking two of the most common drugs together, aspirin and PPIs, this may not be a good combination. In a recent observational study, the results showed that PPI use in those patients who take low-dose aspirin prompted a more than twofold greater risk of causing a break in the mucosa, or lining of the small bowel (8). This study involved 198 patients. The researchers used video capsule endoscopy to confirm the rupture of the mucosa.

Bone Fracture and PPIs

While the results with bone fracture are mixed, it seems that the longer the use and the higher the dose, the greater the risk (9).

Does the lack of efficacy with preventing serious consequences of esophageal cancer mean that the drugs are ineffective? The answer is no. This class of drugs is still valuable for treating heartburn symptoms. In addition, there needs to be randomized controlled trials before we can even consider making a definitive statement about the risks. The problem is that most of the trials are post-marketing studies and there is a lower probability of funding for side effect trials that will be large enough to be useful.

Therefore, be cautious with the use of PPIs. Just because they are over the counter does not mean they are harmless. GI doctors have the most experience with the drugs. Do not change your use of the medications without talking to your doctor.

References

(1) uptodate.com. (2) FDA.gov. (3) imshealth.com. (4) Aliment Pharmacol Ther. 2014 May;39(9):984-91. (5) Aliment Pharmacol Ther. 2012;36(10):941-49. (6) Expert Rev Clin Pharmacol. 2012 May;5(3):337-44. (7) Am J Gastroenterol. 2012;107(7):1011. (8) Gastrointest Endosc online May 13, 2014. (9) JAMA. 2006;296(24):2947.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

Last week, I wrote about factors that increase the risk of gallstones, an all-too-common GI problem. Many of these are modifiable. A logical extension of this discussion is complications and prevention techniques. Let’s look at the evidence.

What are the complications?

Complications include cardiovascular disease, psoriasis and pancreatitis. I wrote about how gallstones are the major risk factor for acute pancreatitis in my Oct. 16, 2014 article, entitled “How much do you know about pancreatitis?” Here, we will touch on some of these additional complications.

Cardiovascular complications

Cardiovascular disease, comprised of heart disease and stroke, is responsible for about 45 percent of deaths in the United States. In a recent observational, prospective (forward-looking) study, the results show an overall 32 percent increased risk of cardiovascular disease in patients with gallstones (1). When these results are further broken out, there was a 42 percent increased risk of heart disease, 15 percent increased risk of stroke, and a 31 percent increased risk of heart failure. These results are scary, and it is not even Halloween yet.

Interestingly, those who were younger, 18 to 40 years old, were at the highest risk of developing cardiovascular disease. And those who had mild gallstone disease were at higher risk, as well. This study was six years in duration and involved more than 34,000 patients. The authors hypothesized that the possible reason for this association, between gallstones and cardiovascular disease, may have to do with an abundance of cholesterol, inflammation and oxidative stress.

Psoriasis & Psoriatic Arthritis

In the Nurses’ Health Study II, a prospective observational trial, results show that there is a 70 percent increased risk of developing psoriasis and an 196 percent increased risk of developing psoriatic arthritis in women who have a personal history of gallstone disease (2). These results were segregated from obesity. In fact, this association between gallstones and psoriasis was greatest in those who were <30 BMI — a threefold increased risk.

This is not an excuse to be obese, however, because there was still a significantly increased risk, 1.71-fold, in this group. There were 89,234 women involved in this study over a 14-year follow-up period. As with cardiovascular disease’s association with gallstones, inflammation also may play a role with gallstones and psoriasis and psoriatic arthritis. Therefore, it may be important to reduce inflammation in the body to prevent gallstones and their complications.

prevention 

Fortunately, there are several ways to reduce the occurrence of gallstones, including lifestyle changes with exercise and diet, such as coffee, more fiber, statins and unsaturated non-trans fats (3).

physical activity

In last week’s article on risk factors for gallstones, low physical activity increased the risk of this disease. It turns out that the opposite is also true. In the Physicians’ Health Study, results showed a significant reduction in the risk of gallstones in those in the highest quintile of activity compared to those in the lowest quintile (4). In fact, men who were in the highest quintile and under 64 years old saw the greatest reduction — 42 percent — in the risk of gallstones. However, those over the age of 65 and in the highest quintile of activity also had substantial reductions in risk — 25 percent. There were 45,813 men involved in this study over an eight-year duration. The authors concluded that, overall, 34 percent of symptomatic gallstones could be avoided if men did aerobic training for an average of 30 minutes per day, five days a week.

Fruits and vegetables

If you ever needed another reason to consume more fruits and vegetables, reducing the risk of gallstones may motivate you.

In the Nurses’ Health Study, the results showed that those in the highest quintile of fruit and vegetable intake had a 21 percent reduction in the need for a cholecystectomy (surgery to remove the gallbladder, usually due to symptomatic gallstones) compared to those in the lowest quintile (5). Interestingly, fruits and vegetables looked at separately had the same significant reduction as fruits and vegetables taken together. There were 77,090 women involved in the study with a duration of 16 years.

The fruits and vegetables consumed in the study were common; they included citrus fruits, green leafy vegetables, cruciferous vegetables, and other vitamin C-rich fruits and vegetables. The authors surmise that the effect may be due to antioxidants, vitamin C, dietary fiber, and minerals like magnesium – and to the interactions among these different components.

This was not just a reduction in gallstones, but a reduction in the actual number of surgical procedures. This makes it a very powerful study. To give perspective, there are around 800,000 cholecystectomies done each year in the U.S. (6).

rapid weight-loss diets

I mentioned in last week’s article that rapid weight loss increases the risk of gallstone formation. However, if you were going to attempt a rapid weight-loss diet, which is better: high-fiber or high-animal-protein? Well, in a small, randomized controlled study, the gold standard of studies, results show that a high-fiber, very low-calorie diet had one-third the number of patients with gallstone formation compared to a high-protein, very low-calorie diet (7).

Although it is better not to lose weight rapidly, as far as gallstones are concerned, there may be lower risk with a high-fiber diet rather than with an animal-protein-dominant diet. It is important to note that this study considered rapid weight loss to be more than 20 pounds. in a month. Both groups lost about the same amount of weight. However, the high-fiber diet resulted in less biliary sludge. The study included 68 patients with a mean BMI of 35 kg/m2, severely obese, at the start of the trial.

Coffee effect

Coffee must be one of the more controversial beverages. Using the Swedish Mammography Cohort and the Cohort of Swedish Men studies, a meta-analysis of two studies, the results show that only women, not men, had a significantly reduced risk of undergoing cholecystectomies in those who drank at least six cups of coffee a day, versus those who drank fewer than two cups (8). And this effect was not seen in all women, but only in those women who were premenopausal or on hormone replacement therapy. A cup was considered eight ounces. Does this mean these specific women should drink more coffee? Not necessarily, for it seems as if every good result is balanced out with a bad result when it comes to coffee and gallstones.

In conclusion, it is important to prevent gallstones, since this disorder can lead to significant complications, including cardiovascular disease and death. Lifestyle modifications and even some medications may reduce the risk of gallstones, which in turn could have a beneficial impact on reducing heart disease and strokes, as well as autoimmune diseases, such as psoriasis and psoriatic arthritis. Inflammation seems to be the common denominator when it comes to gallstones, their complications and the ways to prevent them.

References

(1) PLoS One. 2013 Oct 3;8(10):e76448. (2) Br J Dermatol. online Oct 11, 2014. (3) uptodate.com. (4) Ann Intern Med. 1998;128(6):417. (5) Am J Med. 2006;119(9):760. (6) AdvData. 2002;(329):1-19. (7) Georgian Med News. 2014;(231):95-9. (8) Clin Gastroenterol Hepatol. online Sep 19, 2014.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

A good follow-up to last week’s acute pancreatitis article is one on gallstones. As I wrote, gallstones are the most significant contributing factor to the development of acute pancreatitis. Like pancreatitis, gallstones are a very common gastrointestinal disease; they affect up to 20 million Americans between the ages 20 of and 74, with a more than two-times increased occurrence in women than in men, according to the NHANES III survey (1). There are two types of gallstones, the majority of which are cholesterol stones — 80 percent occurrence — with pigment stones — 20 percent occurrence — making up the remainder.

Common symptoms

Gallstones may be asymptomatic; however, when gallstones block either the cystic or common bile ducts, symptoms occur. Symptoms include abdominal pain, exacerbated by meals, that is dull or crampy and lasts one to five hours; jaundice, which includes yellowing of skin and eyes; nausea and vomiting; rapid heart rate; hypotension — low blood pressure — and fever (2).

Tests used for diagnosis

Blood tests include complete blood count where there may be a rise in white blood cells; liver enzymes; and pancreatic enzymes — lipase and amylase. In general, diagnostic tests that have more accuracy are the endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). However, these are invasive tests. Less accurate but non-invasive tests include abdominal x-ray, ultrasound and CAT Scan (CT). The tests used also depend on where the stone may be located. Hepatobiliary (HIDA) scans are accurate if the stone is located in the cystic duct. And magnetic resonance retrograde cholangiopancreatography (MRCP) is used if the stone is thought to be located in the common bile duct (2).

What are the risk factors?

There are a multitude of risk factors. Some of these are modifiable, whereas others are not. The modifiable ones include obesity, measured by body mass index (BMI); rapid weight loss; fat consumption; hormone replacement therapy (HRT); oral contraceptives; decreased physical activity; Crohn’s disease and certain drugs. One non-modifiable risk factor is age; the older we get, the higher the risk, with 40 years of age being the demarcation line (3). Other risk factors are gender — females are more predisposed — pregnancy; and family history (4).

Let’s look at the evidence.

Obesity

Again, as with acute pancreatitis, obesity may play an important role. Obesity is not age-discriminant; it can impact both adults and children. The reason obesity is implicated is potentially due to bile becoming supersaturated (5). Bile is a substance produced in the liver and stored in the gallbladder. Bile aids in the digestion or breakdown of fats in the small intestines. Crystals may form, creating cholesterol gallstones from the bile.

Body Mass Index

A body mass index of greater than 30 kg/m2 is considered obese. In a meta-analysis of two prospective, forward-looking observational trials — Copenhagen General Population Study and the Copenhagen City Heart Study — those in the highest quintile of BMI were almost three times as likely to experience symptomatic gallstones compared to those who were in the lowest quintile (6). The highest quintile was those who had a mean BMI of 32.5 kg/m2 and thus were obese, whereas those in the lowest quintile had a mean BMI of 20.9 kg/m2. This is a comparison of ideal to obese BMI. Not surprisingly, since women in general have a higher risk of gallstones, they also have a higher risk when their BMI is in the obese range compared to men, a 3.36-fold increase and 1.51-fold increase, respectively.

Also, the research showed that for every 1 kg/m2 increase in BMI, there was a 7 percent increase in the risk of gallstones. Those who had genetic variants that increased their likelihood of an elevated BMI had an even greater increase in gallstone risk —17 percent —  per 1 kg/m2. In the study population of approximately 77,000, more than 4,000 participants became symptomatic for gallstones.

Gallstones in children

Sadly, obese children are not immune to gallstones, even though they are young. In a prospective observational study based on Kaiser Permanente data from Southern California, children who were overweight had a twofold increased risk of gallstones (7). But if that is not enough, girls who were extremely obese had a higher propensity for gallstones, similar to women in the previous study, with a  greater than sevenfold increase compared to a still very substantial greater-than-threefold increase for obese boys. Hispanic children were affected the most. The age range in this study was between 10 and 19 years old. Obesity is a disease that is blind to age.

Physical activity

We know physical activity is very important to stave off many diseases, but in this case, the lack of physical activity can be detrimental. In the Physicians’ Health Study, a prospective observational trial, those in the lowest quintile of activity between the ages of 40 and 64 had a 72 percent increased risk of gallstone formation, and those 65 and older had a 33 percent increased risk. (8). Also, men who were 65 and older and watched television more than six hours a week were at least three times as likely to have gallstones as those who watched fewer hours. There was a substantial increased risk for those under 65, as well, though to a slightly lesser degree.

Diabetes rears its ugly head

Just like with obesity, diabetes is almost always a culprit for complications. In a prospective observational study, those with diabetes were at a significant 2.55-times greater risk of developing gallstones than those without (9). Again, women had a higher propensity than men, but both had significant increases in the risk of gallstone formation, 3.85-times and 2.03-times, respectively. There were almost 700 participants in this study. The researchers believe that an alteration in glucose — sugar — metabolism may create this disease risk.

Hormone Replacement Therapy

If you needed another reason to be leery of hormone replacement therapy (HRT), then gallstones might be it. In a prospective observational trial, women who used HRT, compared to those who did not, had a 10 percent increased risk in cholecystectomy — removal of the gallbladder — to treat gallstones (10). Though this may not sound like a large increase, oral HRT increased the risk 16 percent, and oral estrogen-only therapy without progestogens increased the risk the most — 38 percent. Transdermal HRT did not have a significantly increased risk.

It is never too early or too late to treat obesity before it causes, in this case, gallstones. With a lack of exercise, obesity is exacerbated and, not surprisingly, so is symptomatic gallstone formation. Diabetes needs to be controlled to prevent complications. HRT, unless menopausal symptoms are unbearable, continues to show why it may not be a good choice. Next week, we will look at the complications of gallstones and how to prevent them.

References:

(1) Gastroenterology. 1999;117:632. (2) emedicine.medscape.com. (3) J Hepatol. 1993;18 Suppl 1:S43. (4) uptodate.com. (5) Best Pract Res Clin Gastroenterol. 2014 Aug;28:623-635. (6) Hepatology. 2013 Dec;58:2133-41. (7) J Pediatr Gastroenterol Nutr. 2012;55:328-333. (8) Ann Intern Med. 1998;128:417. (9) Hepatology. 1997;2:787. (10) CMAJ. 2013;16;185:549-50.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

Everyone has heard of pancreatic cancer, but pancreatitis is a significantly more common disease in gastroenterology and seems to be on an upward projection. Ironically, this disease gets almost no coverage in the general press. In the United States, it is among the top reasons for patients to be admitted to the hospital (1).

Now that I have your attention, let’s define pancreatitis. A rudimentary definition is an inflammation of the pancreas. There are both acute and chronic forms. We are going to address the acute – abrupt and of short duration – form. There are three acute types: mild, moderate and severe. Those with the mild type don’t have organ failure, whereas those with moderate acute pancreatitis experience short-term or transient (less than 48 hours) organ failure. Those with the severe type have persistent organ failure. One in five patients present with moderate or severe levels (2).

What are the symptoms?

In order to diagnosis this disease, the American College of Gastroenterology guidelines suggests that two of three symptoms be present. The three symptoms include severe abdominal pain; increased enzymes, amylase or lipase, that are at least three times greater than normal; and radiologic imaging (ultrasound, CT, MRI, abdominal and chest X-rays) that shows characteristic findings for this disease (3). Most of the time, the abdominal pain is epigastric, and it may also present with pain in the right upper quadrant of the abdomen (4). Approximately 90 percent of patients may also experience nausea and vomiting (5). In half of patients, there may also be pain that radiates to the back.

What are the risk factors?

There is a multitude of risk factors for acute pancreatitis. These include gallstones, alcohol, obesity and, to much lesser degree, drugs. Gallstones and alcohol may cause up to 75 percent of the cases (2). Many of the other cases of acute pancreatitis are considered idiopathic (of unknown causes). Although medications are potentially responsible for between 1.4 percent and 5.3 percent of cases, making it rare, the number of medications implicated is diverse (6) (7). These include certain classes of diabetes therapies, some antibiotics – Flagyl (metronidazole) and tetracycline – and immunosuppressive drugs used to treat ailments like autoimmune diseases. Even calcium may potentially increase the risk.

Obesity effects

When given a multiple-choice question for risk factors that includes obesity as one of the answers, it’s a safe bet to choose that answer. Pancreatitis is no exception. However, in a recent study, using the Swedish Mammography Cohort and the Cohort of Swedish Men, results showed that central obesity is an important risk factor, not body mass index or obesity overall (8). In other words, it is fat in the belly that is very important, since this may increase risk more than twofold for the occurrence of a first-time acute pancreatitis episode.

Those who had a waist circumference of greater than 105 cm (41 inches) experienced this significantly increased risk compared to those who had a waist circumference of 75 to 85 cm (29.5 to 33.5 inches). The association between central obesity and acute pancreatitis occurred in both gallbladder-induced and nongallbladder-induced disease. There were 68,158 patients involved in the study with a median duration of 12 years. Remember that waistline is measured not from the hips, but rather from the navel. This may be surprising wake-up call for some.

Mortality risks

What makes acute pancreatitis so noteworthy and potentially dangerous is that the rate of organ failure and mortality is surprisingly high. One study found that the risk of mortality was 5 percent overall. This statistic broke out into a smaller percentage for mild acute pancreatitis and a greater percentage for severe acute pancreatitis, 1.5 percent and 17 percent respectively (9). This was a prospective (forward-looking) observational trial involving 1,005 patients.

However, in another study, when patients were hospitalized for this disease, the mortality rate was even higher at 10 percent overall (10).

Diabetes risks

The pancreas is a critical organ for balancing glucose (sugar) in the body. In a recent meta-analysis (involving 24 observational trials), the results showed that more than one-third of patients diagnosed with acute pancreatitis went on to develop pre-diabetes or diabetes (11). Within the first year, 15 percent of patients were newly diagnosed with diabetes. After five years, it was even worse; the risk of diabetes increased by 2.7-fold. This is scary, considering that diabetes has become a pandemic. If we can reduce the risk of pancreatitis, we may also help to reduce the risk of diabetes.

Surgical treatments

Gallstones and gallbladder sludge are major risk factors, accounting for 35 to 40 percent of acute pancreatitis incidence (12). Gallstones are thought to cause pancreatitis by temporarily blocking the duct shared by the pancreas and gallbladder that leads into the small intestine. When the liver enzyme ALT is elevated threefold (measured through a simple blood test), it has a positive predictive value of 95 percent that it is indeed gallstone-induced pancreatitis (13).

If it is gallstone-induced, surgery plays an important role in helping to resolve pancreatitis and prevent recurrence of acute pancreatitis. In a recent study, results showed that surgery to remove the gallbladder was better than medical treatment when comparing hospitalized patients with this disease (14). Surgery trumped medical treatment in terms of outcomes, complication rates, length of stay in the hospital and overall cost for patients with mild acute pancreatitis. This was a retrospective (backward-looking) study with 102 patients.

Can diet have an impact?

The short answer is: yes. What foods specifically? In a large, prospective observational study, results showed that there was a direct linear relationship between those who consumed vegetables and a decreased risk of nongallstone acute pancreatitis (15). For every two serving of vegetables, there was 17 percent drop in the risk of pancreatitis. Those who consumed the most vegetables – the highest quintile (4.6 servings per day) – had a 44 percent reduction in disease risk, compared to those who were in the lowest quintile (0.8 servings per day). There were 80,000 participants involved in the study with an 11-year follow-up. The authors surmise that the reason for this effect with vegetables may have to do with their antioxidant properties, since acute pancreatitis increases oxidative stress on the pancreas.

References:

(1) Gastroenterology. 2012;143:1179-1187. (2) www.uptodate.com. (3) Am J Gastroenterol. 2013;108:1400-1415. (4) JAMA. 2004;291:2865-2868. (5) Am J Gastroenterol. 2006;101:2379-2400. (6) Gut. 1995;37:565-567. (7) Dig Dis Sci. 2010;55:2977-2981. (8) Am J Gastroenterol. 2013;108:133-139. (9) Dig Liver Dis. 2004;36:205-211. (10) Dig Dis Sci. 1985;30:573-574. (11) Gut. 2014;63:818-831. (12) Gastroenterology. 2007;132:2022-2044. (13) Am J Gastroenterol. 1994;89:1863-1866. (14) Am J Surg online. 2014 Sept. 20. (15) Gut. 2013;62:1187-1192.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

NFL players are wearing pink shoes and other sportswear this month, making a fashion statement to highlight Breast Cancer Awareness Month. This awareness is critical, since annual breast cancer incidence in the U.S. is 230,000 cases, with approximately 40,000 patients, or 17 percent, dying from this disease each year (1). The good news is that from 1997 to 2008 there was a trend toward decreased incidence by 1.8 percent (2).

We can all agree that screening has merit. The commercials during NFL games tout that women in their 30s and early 40s have discovered breast cancer with a mammogram, usually after a lump was detected. Does this mean we should be screening earlier?

Screening guidelines are based on the general population that is considered “healthy,” meaning no lumps were found, nor is there a personal or family history of breast cancer. All guidelines hinge on the belief that mammograms are important, but at what age? Here is where divergence occurs; experts can’t agree on age and frequency. The U.S. Preventive Services Task Force recommends mammograms starting at 50 years old, after which time they should be done every other year (3). The  American College of Obstetricians and Gynecologists recommends mammograms start at 40 years old and be done annually (4). Your decision should be based on a discussion with your physician.

The best way to treat breast cancer – and just as important as screening – is prevention, whether it is primary, preventing the disease from occurring, or secondary, preventing recurrence. We are always looking for ways to minimize risk. What are some potential ways of doing this? These may include lifestyle modifications, such as diet, exercise, obesity treatment and normalizing cholesterol levels. Additionally, although results are mixed, it seems that bisphosphonates do not reduce the risk of breast cancer or its recurrence.

Let’s look at the evidence.

Bisphosphonates

Bisphosphonates include Fosamax (alendronate), Zometa (zoledronic acid) and Boniva (ibandronate) used to treat osteoporosis. Do they have a role in breast cancer prevention? It depends on the population, and it depends on study quality.

In a meta-analysis involving two randomized controlled trials, results showed there was no benefit from the use of bisphosphonates in reducing breast cancer risk (5). The population used in this study involved postmenopausal women who had osteoporosis, but who did not have a personal history of breast cancer. In other words, the bisphosphonates were being used for primary prevention. The study was prompted by previous studies that have shown antitumor effects with this class of drugs. This analysis involved over 14,000 women ranging in age from 55 to 89. The two trials were FIT and HORIZON-PFT, with durations of 3.8 and 2.8 years, respectively. The FIT study involved alendronate and the HORIZON-PFT study involved zoledronic acid, with these drugs compared to placebo. The researchers concluded that the data were not evident for the use of bisphosphonates in primary prevention of invasive breast cancer.

In a previous meta-analysis of two observational studies from the Women’s Health Initiative, results showed that bisphosphonates did indeed reduce the risk of invasive breast cancer in patients by as much as 32 percent (6). These results were statistically significant. However, there was an increase in risk of ductal carcinoma in situ (precancer cases) that was not explainable. These studies included over 150,000 patients with no breast cancer history. The patient type was similar to that used in the more current trial mentioned above. According to the authors, this suggested that bisphosphonates may have an antitumor effect. But not so fast!

The disparity in the above two bisphosphonate studies has to do with trial type. Randomized controlled trials are better designed than observational trials. Therefore, it is more likely that bisphosphonates do not work in reducing breast cancer risk in patients without a history of breast cancer or, in other words, in primary prevention.

In a third study, a meta-analysis (group of 36 post-hoc analyses – after trials were previously concluded) using bisphosphonates, results showed that zoledronic acid significantly reduced mortality risk, by as much as 17 percent, in those patients with early breast cancer (7). This benefit was seen in postmenopausal women, but not in premenopausal women. The difference between this study and the previous study was the population. This was a trial for secondary prevention, where patients had a personal history of cancer.

However, in a RCT, the results showed that those with early breast cancer did not benefit overall from zoledronic acid in conjunction with standard treatments for this disease (8). The moral of the story: RCTs are needed to confirm results, and they don’t always coincide with other studies.

Exercise

We know exercise is important in diseases and breast cancer is no exception. In a recent observational trial, exercise reduced breast cancer risk in postmenopausal women significantly (9). These women exercised moderately; they walked four hours a week. The researchers stressed that it is never too late to exercise, since the effect was seen over four years. If they exercised previously, but not recently, for instance, 5 to 9 years ago, no benefit was seen.

To make matters worse, only about one-third of women get the recommended level of exercise every week: 30 minutes for five days a week. Once diagnosed with breast cancer, women tend to exercise less, not more. The NFL, which does an admirable job of highlighting Breast Cancer Awareness Month, should go a step further and focus on the importance of exercise to prevent breast cancer or its recurrence, much as it has done to help motivate kids to exercise with its “Play 60” campaign.

Soy intake

Contrary to popular belief, soy may be beneficial in reducing breast cancer risk. In a recent meta-analysis (a group of eight observational studies), those who consumed more soy saw a significant reduction in breast cancer compared to those who consumed less (10). There was a dose-response curve among three groups: high intake of >20 mg per day, moderate intake of 10 mg and low intake of <5 mg. Those in the highest group had a 29 percent reduced risk, and those in the moderate group had a 12 percent reduced risk, when compared to those who consumed the least. Why have we not seen this in U.S. trials? The level of soy used in U.S. trials is a fraction of what is used in Asian trials. The benefit from soy is thought to come from isoflavones, plant-rich nutrients.

Western versus Mediterranean diets

In an observational study, results showed that, while the Western diet increases breast cancer risk by 46 percent, the Spanish Mediterranean diet has the inverse effect, decreasing risk by 44 percent (11). The effect of the Mediterranean diet was even more powerful in triple-negative tumors, which tend to be difficult to treat. The authors concluded that diets rich in fruits, vegetables, beans, nuts and oily fish were potentially beneficial.

Hooray for Breast Cancer Awareness Month stressing the importance of mammographies and self-breast exams. However, we need to give significantly more attention to prevention of breast cancer and its recurrence. Through potentially more soy intake, as well as a Mediterranean diet and modest exercise, we may be able to accelerate the trend toward a lower breast cancer incidence.

References:

(1) CA Cancer J Clin. 2013;63:11-30. (2) J Natl Cancer Inst. 2011;103:714-736. (3) Ann Intern Med. 2009;151:716-726. (4) Obstet Gynecol. 2011;118:372-382. (5) JAMA Inter Med online. 2014 Aug. 11. (6) J Clin Oncol. 2010;28:3582-3590. (7) 2013 SABCS: Abstract S4-07. (8) Lancet Oncol. 2014;15:997-1006. (9) Cancer Epidemiol Biomarkers Prev online. 2014 Aug. 11. (10) Br J Cancer. 2008;98:9-14. (11) Br J Cancer. 2014;111:1454-1462.

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 and/or consult your personal physician.

This is the second article in a two-part series on salt.

Last week, we discussed the potential negative effects of high sodium levels and low sodium levels, or the extremes. As I mentioned in last week’s article, the “extremes” of greater than 6,000 mg and less than 3,000 mg per day may increase the risk of cardiovascular events and all-cause mortality. However, the Prospective Urban Rural Epidemiology study on which these conclusions are drawn was significantly flawed. So don’t start using the salt shaker just yet without impunity. The bigger picture is that high sodium levels are dangerous and the low sodium levels used in this study likely are not.

Ironically, the sodium guidelines from a variety of health organizations range from recommendations of less than 1,500 mg per day to recommendations of less than 2,300 mg per day. Still, the average American takes in over 3,300 mg per day, with potentially disastrous health consequences. Theoretically, very low sodium levels – there’s no consensus on what those levels would be and the previous study does not help to shed light on that level – could potentially be harmful, but less than 1 percent of 100,000 people reached even the strictest of sodium levels (<1,500 mg per day). What we do know is the potential impact of higher levels. This week, we will continue to examine the latest research on sodium intake, in light of recent headlines that highlight disparities in medical opinions on sodium intake.

Blood pressure effect

Last week, we introduced the PURE study, which examined sodium intake by analyzing estimates of daily urinary sodium excretion extrapolated from once-a-day morning excretions. In another analysis involving the PURE study, results showed that those who excreted higher levels of sodium, greater than 5,000 mg a day in this case, had a substantially greater risk of high blood pressure (1).

Meanwhile, those who excreted 3 to 5 grams had a modest risk increase, and those who excreted the lowest amount, less than 3,000 mg, had no increased risk. This also involved over 100,000 participants. Potassium showed a positive impact; the greater amount of excretion, the lower the systolic (top number) blood pressure. The researchers concluded that those who were older, those who consumed more sodium and those with hypertension (high blood pressure) were more likely to experience a rise in their blood pressure.

Cardiovascular impact

However, in the NUTRICODE study, a meta-analysis (a group of 103 studies), results showed that there were over 1.5 million cardiovascular deaths in 2010 that were associated with higher sodium consumption (2). In this study, higher consumption meant greater than 2,000 mg of sodium per day. This number of deaths is based on a global scale involving 66 countries. The reason the cutoff for high sodium was lower than the other studies was that the researchers used the World Health Organization criteria. They calculated that nearly 1-in-10 cardiovascular deaths could be attributed to sodium intake. This is a sobering study that follows others showing similar results with sodium intake and cardiovascular disease.

Effects of reducing sodium

What happens when we reduce salt? Do we have Armageddon? Not quite. In fact, in a recent British analysis of the Health Survey for England, the results showed that reducing sodium by 1,400 mg per day significantly reduced the risk of cardiovascular events (3). The number of deaths from stroke decreased by 42 percent. There were also significant reductions in blood pressure and ischemic heart disease. The term ischemic heart disease is an umbrella term that means reduced blood supply to the heart, usually caused by atherosclerosis, or plaque in the arteries. It is the most common form of heart disease.

This study used 24-hour urinary excretion rates, the gold standard for estimated sodium consumption. Unlike studies mentioned previously, these rates were not estimated. However, there were issues with confounding factors (uncontrolled variables) not being taken into account. This was not a study without flaws, either. Having said this, decreasing sodium intake by a significant amount in the diet might actually have positive benefits. We need a randomized controlled trial to confirm this.

Sodium impact on children

Sodium may have deleterious effects in children. In a recent report from the Centers for Disease Control, 90 percent of kids take in too much salt. These children are between the ages of 6 and 18. Almost 17 percent, or 1 in 6 kids ages 8 to 17, have high blood pressure. This does not mean sodium is directly correlated, since it is not a study. However, it is likely to be a contributor. A handful of foods including chicken nuggets, chips, breads, cold cuts, sauces and soups. contribute 40 percent of our sodium intake. The good news is that the government is going implement sodium reduction in school food 50 percent by the year 2022. However, much of the problem also occurs at home.

Sodium-potassium ratio

You may not be able to look at sodium alone without considering the sodium-potassium ratio. In an observational study, results showed that those with a high sodium-to-potassium ratio had an almost 1.5 times greater probability of all-cause mortality and cardiovascular disease-related death than those with a much lower sodium-to-potassium ratio (5). The group that had higher sodium-to-potassium ratios also had a two-times increased risk of having ischemic heart disease. The duration was a strong point of this study, with almost 15 years of follow-up data. There were over 12,000 patients. It is believed that potassium gets its beneficial effects by activating nitric oxide, which causes vasodilation of arteries and, thus, may lower blood pressure.

While it is possible to get too little salt, it is rather unlikely and rare, especially with a plant-based diet. A diet rich in leafy green vegetables provides about 600-700 mg of sodium by itself, as well as high amounts of potassium. Low sodium is less than 140 mg per serving. But caveat emptor (buyer beware): serving sizes on labels can be deceiving, especially when you might eat more than one serving.

Reducing sodium is an easy way of helping to reduce acute (short-term) symptoms, such as dehydration, bloating and weight gain, while decreasing the risk of many diseases in the long term. Focus on decreasing the sodium, as the British study showed the positive impact on cardiovascular disease. And, if you have adolescents, preteens and teens, try to help reduce their sodium intake as well. Concentrate on increasing potassium intake and decreasing the sodium intake to optimize your sodium-to-potassium ratio.

References:

(1) N Engl J Med. 2014;371:601-611. (2) N Engl J Med. 2014;371:624-634. (3) BMJ Open. 2014;4:e004549. (4) www.cdc.gov. (5) Arch Intern Med. 2011;171:1183-1191.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

This is the first of a two-part series on salt. Salt, or sodium, is one of the most pervasive essential nutrients in our diet. While we need exogenous (external) salt, the debate on the amount we need continues. Are we getting too much or too little? A recently published study would indicate that the extremes – too much and too little – are dangerous. The newspaper headlines from this study suggest that reducing sodium may be harmful.

Is this true or is it hyperbolized? We will investigate this study in much more detail. However, I will say this: Many Americans get far more than the recommended amount of sodium intake, regardless of which guidelines you are using. Very few individuals suffer from dietary sodium deficiency.

So what are the guidelines, and how much are Americans consuming on average? According to the Centers for Disease Control, the U.S. government recommends no more than 2,300 mg of sodium per day (1). But for those who are over 50 years old, are African American or who have high blood pressure, diabetes or chronic kidney disease, then sodium should be restricted to less than 1,500 mg per day. One teaspoon of salt is the equivalent of 2,300 mg of sodium. The World Health Organization recommends less than 2,000 mg per day (2) and the American Heart Association recommends less than 1,500 mg for everyone (3). This is approximately two-thirds of a teaspoon of salt. The average amount Americans consume is 3,300 mg per day.

This is not about the salt shaker, though. Most people protest that they don’t use salt or processed foods, which are notoriously high in sodium. Sodium lurks in many places, though.

What are the potential obscure sources of sodium? Participants in a recent study were able to identify that processed foods were a major source of sodium and its excess; however, less than one-third knew that bread, pasta, cereal and cheese were major sources (4). Other sources include soups (yes, even many “healthy” soups); many frozen foods; condiments, including salad dressings; and sauces, especially spaghetti sauces, regardless of whether or not they are organic. So, if we include bread, sauces and cheese, that makes pizza one of the worst offenders! Also remember that eating out significantly contributes to increased sodium intake.

I had an interesting situation occur recently with a patient. After one month, he came back for a visit. During that month he went on vacation for a couple of weeks. We looked at his body composition. While he gained 5 pounds, what was surprising was that he actually lost 12 pounds of body fat, but gained 17 pounds of water weight. He had said he was eating really well. Unfortunately, he was unable to control for salt intake while eating out. Thus, as a consequence, he had significantly swollen ankles and significantly increased blood pressure that was uncontrolled. Even over a short period of time, salt can have a large impact on the body.

What are the potential short-term symptoms of too much salt? They can include headaches, dizziness, dehydration, edema (swelling), arrhythmias and weight gain.

Too much salt can increase our risk of disease or exacerbate pre-existing diseases. For instance, salt can raise blood pressure and contribute to kidney stones, osteoporosis, diabetes and chronic kidney disease. It can also exacerbate autoimmune disease, such as rheumatoid arthritis and Sjögren’s, and increase the risk of cardiovascular disease and mortality from CVD and all-causes (5). There are several studies that emphasize the impact of sodium on cardiovascular disease globally.

Also, don’t fall for the idea that when we exercise most of us need sodium replenishment. If we exercise strenuously – on the level of football players or marathon runners – then, yes, we need more sodium (6). However, for the rest of us who exercise no more than 90 minutes every day at a vigorous pace, it is unlikely that we require additional sodium.

One of the most frequent questions I am asked is whether there are any benefits from using Himalayan salt, kosher salt or sea salt instead of regular table salt. When we talk about symptoms or disease consequences from excessive salt consumption, it doesn’t matter whether the source is a more sophisticated form of salt. The effects are the same. Salt is salt! Let’s look at the evidence.

Impact of salt extremes

In the Prospective Urban Rural Epidemiology study, an observational study, results showed that participants who were at the “extremes,” those who had high amounts of sodium and those who had low amounts of sodium, all experienced higher risk of cardiovascular events and all-cause death (7). When blood pressure was factored in, those in the higher sodium group did not have significantly increased cardiovascular events.

There were three groups in the study: those who excreted high amounts of sodium, defined as greater than 6,000 mg or the upper “extreme”; moderate amounts, defined as 3,000 mg to 6,000 mg; and low amounts, defined as less than 3,000 mg or the lower “extreme.” There were over 100,000 participants from 17 countries. The duration of the study was approximate 3.5 years. The amounts of urinary sodium excreted were based on an estimated 24-hour urine output, which is a way of measuring sodium intake. The results also showed that increasing potassium levels greater than 1,500 mg had the opposite effect of sodium, decreasing the risk of cardiovascular events and death. The potassium levels were a 24-hour estimate, as well.

A weakness of this study was that data were based on one urinary sodium excretion in the morning and then extrapolated out to 24-hour urine output, which is considered a better biomarker. Nonetheless, there was only one reading per participant and this was not a 24-hour reading. Thus, this is not a very accurate way to measure sodium, since it was a single snapshot view.

Even if one did suffer from not enough sodium, causing hyponatremia (low sodium in the blood), eating more from the diet might perpetuate increased thirst and, thus, potential fluid overload. This could lead to edema and even lower sodium.

Therefore, from this study, we don’t know if sodium of less than 3,000 mg per day is dangerous. There were two times more participants who had high sodium excretion compared to low sodium excretion, and there were seven times as many participants with sodium levels greater than 4,000 mg than those with levels less than 3,000 mg. Granted, low sodium may be an issue, but what is really too low? We don’t know, and it does not happen often.

We as a society consume much more than any of the guidelines suggest. It would be a disservice to believe that adding more salt to your diet would not be harmful or that not reducing your intake is okay. So don’t reach for the salt shaker and read labels carefully. Rather reach for foods that have high levels of potassium and naturally occurring sodium such as green leafy vegetables.

References:

(1) www.cdc.gov. (2) www.who.int. (3) www.heart.org. (4) Appetite. 2014;83C:97-103. (5) www.uptodate.com. (6) Evid Based Nurs. 2014;17:92. (7) N Engl J Med. 2014;371:612-623.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

Weight loss should be a rather simple concept. It should be solely dependent on energy balance: the energy (kilocalories) we take in minus the energy (kilocalories) we burn should result in weight loss if we burn more calories than we consume. However, it is much more complicated. Frankly, there are numerous factors that contribute to whether people who want or need to lose weight can.

The factors that contribute to weight loss may depend on stress levels, as I noted in my previous article, “Ways to counter chronic stress.” High stress levels can contribute to metabolic risk factors such as central obesity with the release of cortisol, the stress hormone (1). Therefore, hormones contribute.

Another factor in losing weight may have to do with our motivators. We will investigate this further.

And we need successful weight management, especially when approximately 70 percent of the American population is overweight or obese and more than one-third is obese (2).

Recently, obesity in and of itself was proclaimed a disease by the American Medical Association. Even if you don’t agree with this statement, excess weight has consequences, including chronic diseases such as cardiovascular disease, diabetes, osteoarthritis and a host of others, including autoimmune diseases. Weight has an impact on all-cause mortality and longevity.

It is hotly debated as to which approach is best for weight loss. Is it lifestyle change with diet and exercise, medical management with weight loss drugs, surgical procedures or even supplements? The data show that, while medication and surgery may have their places, they are not replacements for lifestyle modifications; these modifications are needed no matter what route is followed.

But the debate continues as to which diet is best. We would hope patients would not only achieve weight loss, but also overall health.

Let’s look at the evidence.

Low-carbohydrate diets versus low-fat diets

Is a low-carbohydrate, high-fat diet a fad? It may depend on diet composition. In a newly published study of a randomized controlled trial, the gold standard of studies, results showed that a low-carbohydrate diet was significantly better at reducing weight than low-fat diet, by a mean difference of 3.5 kg lost (7.7 pounds), even though calories were similar and exercise did not change (3).

The authors also note that the low-carbohydrate diet reduced cardiovascular disease risk factors in the lipid (cholesterol) profile, such as decreasing triglycerides (mean difference 14.1 mg/dl) and increasing HDL (good cholesterol). Patients lost 1.5 percent more body fat on the low-carbohydrate diet, and there was a significant reduction in inflammation biomarker, C-reactive protein. There was also a reduction in the 10-year Framingham risk score. However, there was no change in LDL (bad cholesterol) levels or in truncal obesity in either group. This study was 12 months in duration with 148 participants, predominantly women, with a mean age of 47, none of whom had cardiovascular disease or diabetes, but all of whom were obese or morbidly obese (BMI 30-45 kg/m2).

Although there were changes in biomarkers, there was a dearth of cardiovascular disease clinical endpoints. This begs the question: Does a low-carbohydrate diet really reduce the risk of developing cardiovascular disease or its subsequent complications? The authors indicated this was a weakness since it was not investigated.

Digging deeper into the diets used, it’s interesting to note that the low-fat diet was remarkably similar to the standard American diet; it allowed 30 percent fat, only 5 percent less than the 35 percent baseline for the same group. In addition, it replaced the fat with mostly refined carbohydrates, including only 15 to 16 g/day of fiber.

The low-carbohydrate diet participants took in an average of 100 fewer calories per day than participants on the low-fat diet, so it’s no surprise that they lost a few more pounds over a year’s time.

Patients in both groups were encouraged to eat mostly unsaturated fats, such as fish, nuts, avocado and olive oil.

As David Katz, M.D., founding director of Yale University’s Prevention Research Center noted, this study was more of a comparison of low-carbohydrate diet to a high-carbohydrate diet than a comparison of a low-carbohydrate diet to a low-fat diet (4).

Another study actually showed that a Mediterranean diet, higher in fats with nuts or olive oil, compared to a low-fat diet showed a significant reduction in cardiovascular events — clinical endpoints not just biomarkers (5). However, both of these studies suffer from the same deficiency: comparing a low-carbohydrate diet to a low-fat diet that’s not really low in fat.

Diet comparisons

Interestingly, in a meta-analysis (a group of 48 RCTs), the results showed that whether a low-carbohydrate diet (including the Atkins diet) or a low-fat diet (including the Ornish plant-based diet), the results showed similar amount of weight loss compared to no intervention at all (6). Both diet types resulted in about 8 kgs (17.6 pounds) of weight loss at six months versus no change in diet. However, this meta-analysis did not make it clear whether results included body composition changes or weight loss alone.

In an accompanying editorial discussing the above meta-analysis, the author points out that it is unclear whether a low-carbohydrate/high animal protein diet might result in adverse effects on the kidneys, loss of calcium from the bones or other potential deleterious health risks. The author goes on to say that for overall health and longevity and not just weight loss, micronutrients may be the most important factor, which are in nutrient-dense foods.

A recent Seventh-day Adventist trial would attest to this emphasis on a micronutrient-rich, plant-based diet with limited animal protein. It resulted in significantly greater longevity compared to a macronutrient-rich animal protein diet (7).

Psyche

Finally, the type of motivator is important in whatever our endeavors. Weight loss goals are no exception. Let me elaborate. A recently published study followed West Point cadets from school to many years after graduation and noted who reached their goals (8). The researchers found that internal motivators and instrumental (external) motivators were very important.

The soldiers who had an internal motivator, such as wanting to be a good soldier, were more successful than those who focused on instrumental motivators, such as wanting to become a general. Those who had both internal and instrumental motivators were not as successful as those with internal motivators alone. In other words, having internal motivators led to an instrumental consequence of advancing their careers.

When it comes to health, an instrumental motivator, such weight loss, may be far less effective than focusing on an internal motivator, such as increasing energy or decreasing pain, which ultimately could lead to an instrumental consequence of weight loss.

There is no question that dietary changes are most important to achieving sustained weight loss. However, we need to get our psyches in line for change. Hopefully, when we choose to improve our health, we don’t just focus on weight as a measure of success. Weight loss goals by themselves tend to lead us astray and to disappoint, for they are external motivators. Focus on improving your health by making lifestyle modifications. This tends to result in a successful instrumental consequence.

References:

(1) Psychoneuroendocrinol Online. 2014 April 12. (2) JAMA 2012;307:491–497. (3) Ann Intern Med. 2014;161:309-318. (4) Huffington Post. 2014 Sept. 2. (5) N Engl J Med. 2014;370:886. (6) JAMA. 2014;312:923-933. (7) JAMA Intern Med. 2013;173:1230-1238. (8) Proc Natl Acad Sci U S A. 2014;111:10990-10995.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.

The end of the Labor Day holiday represents the unofficial end of summer, the beginning of the academic calendar and noticeably shorter daylight hours. The pace of life tends become more hectic. Although some stress is valuable to help motivate us and keep our minds sharp, high levels of constant stress can have detrimental effects on the body.

It is very likely that there is a mind-body connection when it comes to stress. In other words, it may start in the mind, but it can lead to acute or chronic disease promotion. Stress can also play a role with your emotions, causing irritability and outbursts of anger, and possibly leading to depression and anxiety. Stress symptoms are hard to distinguish from other disorders but can include stiff neck, headaches, stomach upset and difficulty sleeping. Stress may also be associated with cardiovascular disease, with an increased susceptibility to infection from viruses causing the common cold and with cognitive decline and Alzheimer’s (1).

A stress steroid hormone called cortisol is released from the adrenal glands and can have beneficial effects in small bursts. We need cortisol in order to survive. Some of cortisol’s functions include raising the glucose (sugar) levels when they are low and helping reduce inflammation and stress levels (2). However, when cortisol gets out of hand, higher chronic levels may cause inflammation, leading to disorders such as cardiovascular disease, as recent research suggests. Let’s look at the evidence.

Inflammation may be a significant contributor to more than 80 percent of chronic diseases, so it should be no surprise that inflammation is an important factor with stress. In a recent meta-analysis (a group of two observational studies), high levels of C-reactive protein, a biomarker for inflammation, were associated with increased psychological stress (3).

What is the importance of CRP? It may be related to heart disease and heart attacks. This study involved over 73,000 adults who had their CRP levels tested. The research went further to suggest that increased levels of CRP may result in more stress and also depression. With CRP higher than 3.0 there was a greater than twofold increase depression risk. The researchers suggest that CRP may heighten stress and depression risk by increasing levels of different proinflammatory cytokines, inflammatory communicators among cells (4).

In one recent study, results suggested that stress may influence and increase the number of hematopoietic stem cells (those that develop of all forms of blood cells), resulting in specifically an increase in inflammatory white blood cells (5). The researchers suggest that this may lead to these white blood cells accumulating in atherosclerotic plaques in the arteries, which ultimately could potentially increase the risk of heart attacks and strokes. Chronic stress overactivates the sympathetic nervous system — our “fight or flight” response — which may alter the bone marrow where the stem cells are found. This research is preliminary and needs well-controlled trials to confirm these results.

Stress may increase the risk of colds and infection. Cortisol over the short term is important to help suppress the symptoms of colds, such as sneezing, cough and fever. These are visible signs of the immune system’s infection-fighting response. However, the body may become resistant to the effects of cortisol, similar to how a type 2 diabetes patient becomes resistant to insulin. In one study of 296 healthy individuals, participants who had stressful events and were then exposed to viruses had a higher probability of catching a cold. It turns out that these individuals also had resistance to the effects of cortisol. This is important because those who were resistant to cortisol had more cold symptoms and more proinflammatory cytokines (6).

When we measure cortisol levels, we tend to test the saliva or the blood. However, these laboratory findings only give one point in time. Thus, when trying to determine if raised cortisol may increase cardiovascular risk, the results are mixed. However, in a recent study, measuring cortisol levels from scalp hair was far more effective (7). The reason for this is that scalp hair grows slowly, and therefore it may contain three months’ worth of cortisol levels. The study showed that those in the highest quartile of cortisol levels were at a three-times increased risk of developing diabetes and/or heart disease compared to those in the lowest quartile. This study involved older patients between the ages of 65 and 85.

Lifestyle plays an important role in stress at the cellular level, specifically at the level of the telomere, which determines cell survival. The telomeres are to cells as the plastic tips are to shoelaces; they prevent them from falling apart. The longer the telomere, the slower the cell ages and the longer it survives. In a recent study, those women who followed a healthy lifestyle — one standard deviation over the average lifestyle — were able to withstand life stressors better since they had longer telomeres (8).

This healthy lifestyle included regular exercise, a healthy diet and a sufficient amount of sleep. On the other hand, the researchers indicated that those who had poor lifestyle habits lost substantially more telomere length than the healthy lifestyle group. The study followed women 50 to 65 years old over a one-year period.

In another study, chronic stress and poor diet (high sugar and high fat) together increased metabolic risks, such as insulin resistance, oxidative stress and central obesity, more than a low-stress group eating a similar diet (9). The high-stress group was caregivers, specifically those caring for a spouse or parent with dementia. Thus, it is especially important to eat a healthy diet when under stress.

Interestingly, in terms of sleep, the Evolution of Pathways to Insomnia Cohort study shows that those who deal with stressful events directly are more likely to have good sleep quality. Using medication, alcohol or, most surprisingly, distractors to address stress all resulted in insomnia after being followed for one year (10). Cognitive intrusions or repeat thoughts about the stressor also resulted in insomnia.

Psychologists and other health care providers sometimes suggest distraction from a stressful event, such as television watching or other activities, according to the researchers. However, this study suggests that this may not help avert chronic insomnia induced by a stressful event. The most important message from this study is that how a person reacts and deals with a stressors may determine whether they suffer from insomnia.

Constant stress is something that needs to be recognized. If not addressed, it can lead to suppressed immune response or increased levels of inflammation. CRP is an example of an inflammatory biomarker that may actually increase stress. In order to address chronic stress and lower CRP, it is important to adopt a healthy lifestyle that includes sleep, exercise and diet modifications. A good lifestyle may be protective against cell aging when exposed to stressors.

References:

(1) Curr Top Behav Neurosci. 2014 Aug. 29. (2) Am J Physiol. 1991;260(6 Part 1):E927-E932. (3) JAMA Psychiatry. 2013;70:176-184. (4) Chest. 2000;118:503-508. (5) Nat Med. 2014;20:754-758. (6) Proc Natl Acad Sci U S A. 2012;109:5995-5999. (7) J Clin Endocrinol Metab. 2013;98:2078-2083. (8) Mol Psychiatry Online. 2014 July 29. (9) Psychoneuroendocrinol Online. 2014 April 12. (10) Sleep. 2014;37:1199-1208.

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, go to the website www.medicalcompassmd.com and/or consult your personal physician.