Glucosamine – Heart Disease and Osteoarthritis

Glucosamine associated with chondroitin Sulfate is a supplement taken for joint health and to relieve joint pain. Several studies have shown unclear results regarding its efficacy in arthritis, but it has been shown to be safe.

A study in the Annals of Rheumatologic Disease suggested it reduced the symptoms of knee pain from osteoarthritis by modifying the inflammatory response not suppressing the symptoms as non-steroidal anti-inflammatory drugs do.  In the MOVES trial, glucosamine was compared with Celebrex (celecoxib) for relief of knee pain in osteoarthritis. At six months the two were noted to be equivalent in reducing pain. Glucosamine did not produce the gastrointestinal side effects that Celebrex and other NSAIDs can while reducing pain.

In an editorial, written in the online journal Primary Care, Dr. David Rakel looked at 466,000 patients entered into the United Kingdom Biobank database who took glucosamine products for arthritis. They were followed for seven years.  Over that period, the glucosamine users had a 15% lower incidence of cardiac events than non-users. Smokers showed a higher reduction in cardiac events – almost 37%.  They attribute this to a reduction in systemic inflammation as evidenced by a decrease in the inflammatory marker levels of C Reactive Protein in glucosamine users.

In general, glucosamine is usually taken at a dose of 750 mg twice a day.  It is combined with chondroitin which increases the viscosity of the synovial (joint) fluid. Glucosamine helps retain fluid in the joint. It usually takes about six to eight weeks to see a positive effect.   For reasons that are not entirely clear, it works best in lean individuals rather than obese ones.

Glucosamine is made from Crustacean shells so those people with a shellfish allergy should avoid it.

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Is TMAO the New LDL CHOLESTEROL?

Prevention of heart disease has centered on smoking cessation, controlling blood pressure, achieving an appropriate weight, regular exercise, control of blood sugar and control of your cholesterol.  Despite addressing and controlling these items individuals still have heart attacks and strokes and vascular events. Researchers are now directing their attention to a dietary metabolite of red meat called trimethlamine N-oxide or TMAO.

Recent peer reviewed and published studies have shown an association between high blood levels of TMAO and increased risk of all-cause mortality and cardiovascular disease.  A 2017 study published in the Journal of the American Heart Association found a 60% increased risk of a major cardiovascular event and death from all causes in individuals with elevated TMAO.  Other research has linked high TMAO levels to heart failure and chronic kidney disease.

Our bodies make TMAO when choline and L-carnitine are metabolized by our gut bacteria in the microbiome. Red meat is particularly high in L-carnitine.  A study group at the Cleveland Clinic found that red meat raised the TMAO levels more than white meats or non-meat protein. They also discovered that red meat allowed more bacteria in the gut microbiome to be switched to producing TMAO. Of interest was the fact that the amount of fat in the food, particularly saturated fat, made no difference on the TMAO levels obtained.   Stanley Hazen, M.D. PhD, section head of preventive cardiology at the Cleveland Clinic, feels the TMAO pathway is “independent of the saturated fat story.”  The important issue to Dr Hazen is the presence of the gut bacteria to produce the TMAO from foods eaten.

Not all scientists buy into the TMAO theory of cardiovascular disease because of the relatively high level of TMAO found in many fish.  Some experts believe the beneficial effects of omega 3 fatty acids in fish offset the negative effects of TMAO. The leading researcher on TMAO says it is an evolving study and he is supported by experts who believe TMAO is “atherogenic, prothrombotic and inflammatory” per Kim Williams, M.D., chief of cardiology at Rush University Medical Center in Chicago.

There is even a blood test to measure TMAO levels developed by the Cleveland Clinic and available through Quest Labs.  Do not get too excited about asking your physician to order it on your blood because it requires eliminating meat, poultry and fish plus other food items for several days in advance of the test.

For many years researchers at the Cleveland Clinic and Emory University recognized that 50% or more of heart attacks occurred in men who followed all the risk reduction guidelines including stopping smoking, controlling blood pressure and lipids, losing weight and getting active. Perhaps the answer as to why will be in the TMAO research and the solution will be changing the gut bacteria or their ability to convert L-carnitine to TMAO.

Tick-Borne Powassan Virus Infections Are Increasing

As we begin the summer months, and people spend more time outside, we experience more tick-borne illnesses. Mention tick-borne illnesses and you immediately think of Lyme Disease which is the most common tick-borne disease in the United States.

A new tick-borne illness is emerging in the same geographic area that Lyme Disease is seen.   Powassan Virus (POWV) has increased from two cases reported in 2008 to well over 30 reported in 2017.  Two cases have been reported recently in New Jersey, including one fatality.

In Lyme Disease the tick attaches to the human body for 36-48 hours prior to the bacterium being transmitted to humans. In Powassan Virus this occurs within the first 15 minutes that the tick latches on. The incubation period can range from one week to one month with patients experiencing fever, vomiting, headache, weakness, loss of coordination, confusion, difficulty speaking and or seizures. The virus affects the central nervous system and can cause encephalitis and meningitis. One in 10 cases is fatal.  Recovery with permanent neurological damage can occur.

There are no medications or vaccines available to prevent or treat POWV infections. Treatment is supportive. Scientists believe the increase in ticks and POWV is a direct result of climate change.

Prevention is the key especially if you are going to be in an area known to have ticks. Experts suggest:

1. Wear long sleeves and pants with socks pulled up over the bottom of the leg pants.
2. Wear light colored clothes so ticks can be spotted on your clothing
3. Use insect repellant with at least 20% DEET. Spray it on the exterior of your clothing and apparel
4. Upon returning inside perform a thorough tick check.

This is an infection and virus most practicing physicians know very little about. There are no telltale warning rashes as in Lyme Disease.  Until more is known, prevention is the best option.

Tidbits on Dementia and Alzheimer’s Disease

A few years back I attended a lecture given by the director of geriatrics and memory / wellness program at the Massachusetts General Hospital. She began the program by asking the audience for a show of hands as to how many doctors and health care providers were suggesting that their older patients try brain teasers and brain games and puzzles to keep their geriatric patients mentally sharp and stave off dementia.  Everyone’s hand shot up indicating that we all were trying this method to stave off memory loss. She responded with, “Your patient’s will all be great problem solvers when we diagnose their dementia.”   She delivered a message of the importance of older patients maintaining a social network of friends and family that provided the stimulation rather than relying on computer games and brain teasers.  Like everything else in medicine, time and research modify your approach as to what works.

Two studies published in the Journal of Geriatric Psychiatry promoted the use of regular puzzle attempts by seniors. The first by Helen Brooker, Ph.D. from Exeter in the United Kingdom showing that older adults who regularly use word and number puzzles have higher cognitive functioning than those who do not.  She looked at 19,000 plus cognitively healthy individuals aged 50-93 years.  Participants self-reported their frequency of playing word puzzles.  Their frequency of performing word puzzles correlated positively with 14 measures of cognitive function.  They then compared individuals who used number puzzles against those who did not and found similar positive results for the puzzle participants.

Clearly being able to enjoy solving puzzles is correlated with beneficial cognitive performance. It is probably one piece of a larger puzzle including socialization, healthy lifestyle choices, genetics and human interaction that contributes to overall health.

Fever Blisters or Herpes Simplex Labialis Treatment with Honey versus Acyclovir

Herpes Simplex lesions cause mouth and gum ulcers and fever blisters. In order for the virus to be activated it requires exposure to sunlight. As these ulcerations appear they are painful, unsightly and the virus can be transmitted person to person.  Modern day treatment has consisted of taking an antiviral medicine such as Acyclovir in topical form applied four to six times per day for seven days. The medication reduces the healing time and pain in this infection.

Researchers in New Zealand decided to test their home grown Kanuka Honey versus Acyclovir in the treatment of herpes labialis. They randomized 952 adults who presented to community pharmacies with herpes labialis over a two year period to two groups.  One group received a traditional acyclovir 5% cream, the other kanuka honey (90%), and glycerin cream (10%). They applied their medication five times daily.

They then observed how long it took for the infected and involved skin to return to normal and pain resolution.  It took 8-9 days for the acyclovir to work and 8-9 days for the kanuka honey to return skin to normal appearance. There were no differences in pain observations or time for the open wound to close.

A large jar of Kanuka honey costs $60 by ordering online. A 15-gram tube of 5% acyclovir topical ointment sells for $379.99 locally.

Summer Insects, Ticks & Insect Repellant

As our climate warms, and we enter the summer season, the pathogens we face taking a walk outside have changed as well.  Recently in the northeastern US an individual walking through a well-manicured lawn in the mid-day sun was bitten by a type of disease spreading tick called the worrying long-horned tick never before seen in that region. Ticks primarily attacked in shaded areas with long uncut grass and shrubs. This is a new distribution of tick locations and behavior.

Mosquito borne diseases such as Zika (no reported cases in Broward, Dade or Palm Beach Counties in 2019), Chickengunya fever and even Yellow Fever are common in the Caribbean and parts of Central and South America. For this reason, the release of Consumer Reports’ recommended insect repellants prior to us spending more time outside in the summer weather is always of interest.

Consumer Reports emphasized that its top-rated products all contained either DEET, Picardin or Oil of Lemon Eucalyptus. DEET should have a concentration of 25-30% to be most effective and is considered safe at that strength.  Picardin is a synthetic relative of the black pepper plant and is suggested in the 20% range.  Oil of Lemon Eucalyptus should be in the 30% range.

Interestingly, Oil of Lemon Eucalyptus, a natural occurring product, is the only chemical not yet tested for safety in young children.  It consequently should not be used in children three years of age or younger. Sprays were felt to be more effective than creams or lotions.  In all cases they recommend spraying it on exposed skin and the outside of clothing – never on the skin under areas covered by clothing.  Don’t use the product near food and wash your hands after applying.

Their top two rated products were Total Home (CVS) Woodland Scent Insect Repellent, an aerosol spray containing 30% DEET and selling for $6.50 and Off Deep Woods Insect Repellent VIII Dry for $8.50 containing 25% DEET.   Rated right below these two was Repel and Oil of Lemon Eucalyptus pump spray for $7 a bottle.

Consumer Reports has stopped testing products for Tick effectiveness because in the past they found that DEET and Picardin products which protected against mosquitoes also protected against tick bites. They emphasized wearing shoes and socks, long pants and sleeves and spraying insecticide externally on the clothing helped protect against tick bites.  They advised seeing a physician quickly if you contract a tick bite. They additionally discussed the fact that many of these recommended insect products stained the very clothing you applied it to as protection.  These warnings are listed in their product ratings.

Consumer Reports Releases Sunscreen Ratings

Periodically, Consumer Reports aggressively reviews and tests sunscreens for effectiveness. Last month they posted their 2019 ratings.

The report was divided into creams and lotions versus sprays.   To test each sunscreen, they applied it to human skin then soaked the skin in water to duplicate the effects of swimming and sweat. They then exposed the volunteers to sunlight.  To cover the skin adequately they used about a shot glass worth of sunscreen on bodies wearing a bathing suit. They said this approximated using one teaspoon per body part area such as one teaspoon for your face, one teaspoon for your head and neck, one teaspoon for each arm and leg etc.

Their top-rated lotion was La Roche-Posay Anthelios 60 Melt In Sunscreen giving it a rating of 100.  A tube costs $36.  The next highest rated was BullFrog Land Sort Quik Gel SPF 50.  It was given a rating of 95 and only costs $13 for a bottle.

Consumer Reports also rated spray sunscreens. To properly apply the spray they suggested holding the nozzle close to the skin and then spraying until the skin glistens. At that point they advise rubbing it in even if the product is advertised as a “no rub“ product.  Once this is done, they suggest repeating the process. They emphasize to never spray directly into the face or eyes. They suggest trying to refrain from inhaling the spray which is why spray sunscreen is not recommended for children.  Their favorite spray choice is Trader Joe’s Spray SPF 50+.  It gets a rating of 100 and sells for $6.  They describe it as having a beach aroma in a combination of floral and citrus scents.   Banana Boat SunComfort Clear UltraMIst Spray SPF 50+ received a score of 96 and is priced at $13.

This past year research has shown that several sunscreen ingredients including oxybenzone are absorbed and achieve blood serum levels at much higher numbers than anticipated.  Oxybenzone is now forbidden in sunscreens used in the state of Hawaii because small amounts of bleach which can kill their coral reefs. There are now sunscreens without Oxybenzone.  Walgreens Hydrating Lotion SPF 50 achieved a score of 74 and has none of the offending ingredient.  It sells for $3. Hawaiian Tropic Sheer Touch Ultra Radiance Lotion SPF 50 achieved a score of 70 and cost only $8.

Mineral or barrier sunscreens composed of titanium dioxide and zinc oxide are known to be safe in major studies.  Consumer Reports believes these products do not provide as much protection as the products containing oxybenzone and similar active absorbable chemical.  “Some provide adequate SPF protection but not enough UVA protection and vice versa.”  The mineral sunscreens that performed admirably in their tests include California Kids # Supersensitive Lotion SPF 30+ for $20 and BadgerActive Natural Mineral Cream SPF 30 for $16.