Do We Overeat Because We Are Fat or Are We Fat Because We Overeat?

Overweight (2)In the Journal of the American Medical Association (JAMA) Drs. David S. Ludwig and Mark I. Friedman present their point of view that the more fat cells you have and the fatter they are the hungrier you get. They believe we all have a genetic set point for an ideal body weight and intake and use of calories or fuel to maintain that genetically set weight. They believe that in recent years the set point in many of us has been raised leading to the current obesity crisis. Their ideas are discussed in the NY Times Sunday Review Sunday May 18, 2014.

Drs. Ludwig and Friedman believe that when energy is stored as fat , there is less energy available to the other functioning body parts obtaining fuel through nutrients in the blood stream and this leads to increased hunger. They attribute the re-setting of the set point to the introduction of refined sugars or carbohydrates into processed and produced foods to replace fats that had previously done the filler job. This was done in the mistaken attempt to reduce heart disease and vascular disease.

They also believe caloric restriction diets do not work. If they are successful in very disciplined individuals the success is very short lived. They go on to say that in fat individuals who eat more to get more fuel to the cells they actually start to gain weight. If they cut back on calories their metabolism actually slows down aggravating the situation.

Drs. Ludwig and Friedman are great believers in low glycemic and low carbohydrate foods and diets. They cite a recent study published in JAMA in which 21 overweight and obese young adults were fed either a low carbohydrate or low fat diet. Their intake and activity level were similar. They found that those on the low carbohydrate program burned up about 325 more calories per day than those on a low fat diet. Dr. Ludwig published an animal study using rats in which those fat a rapidly digestible carbohydrate diet (high glycemic index) and far fewer calories gained far more weight than rats fed a low glycemic index diet with carbohydrates that took a long time to digest.

The low glycemic index foods are the heart and soul of the meal replacement Take Shape for Life program developed by Medifast. As we move towards the summer months and bathing suit weather the interest in healthy weight loss and sustained weight loss increases.

We are currently offering the Take Shape for Life program in the office and I am a certified TSFL coach. Call us and set up an appointment if you are interested.

Are Diet Sodas Unhealthy for Your Heart?

SodaI was eating lunch reading a report from the American College of Cardiology meetings stating that women who drank two or more diet sodas per day of 12 ounces or more were 29% more likely to have a cardiac event than those who consumed a lower quantity of no more than 3 diet drinks per month. The report was prepared by Ankur Vyas, MD, of the University of Iowa Hospitals and Clinics. The 5% of women with the highest consumption of diet beverages in the Women’s Health Initiative also had 26 % elevated all-cause mortality. Cardiac deaths were 52% more likely with two or more diet sodas or other diet drinks per day.

Jeffey Kuvin, MD, vice chair of the program committee for the ACC meeting, called the results “provocative” but not yet compelling. Clearly these results are convincing enough to plan another study with a larger group and stricter design to determine if it is the caffeine, the artificial sweetener or some other constituent causing this increased risk? Could it be that the individuals drinking two or more diet beverages are already practicing a relatively heart unhealthy lifestyle and are overweight, less active, diabetic, hypertensive and or smokers? This all needs to be determined before we condemn diet beverages. Dr. Kurvin pointed out that sugary non diet beverages are well known to cause weight gain, diabetes and eventually coronary artery disease.

What does one drink then? I chose to have an old fashioned unhealthy sugary soda with my heart healthy lunch. While I was sipping that sweet delicious beverage, but feeling extremely guilty about it, my computer sent me a medical alert, “Soda associated with increased heart attack and stroke risk.”. The soda came flying out of my mouth and nose instantly as if had coughed and it splattered everywhere moments before I read the full message closely and noted that they were referring to cocaine not soda.

This study will surely raise questions from my patients in my practice. I will advise them to avoid diet beverages if possible, just like I advise them to avoid sugary beverages in large quantities if possible. Drink water or drink diet beverages in extreme moderation until the data is clear. Moderation would mean no more than 36 ounces per week.

Supplement Toxicity on the Rise

VitaminsIn a report in MedPage Today, the medical newsletter of the University of Pennsylvania School of Medicine, researchers attending the meeting of the American Association of the Study of Liver Diseases reported a striking increase in the number of severe liver injuries reported in supplements between the years 2004 and 2012. They reported the number of cases increased from 7 – 20% and blamed the vast proportion of those cases on dietary and herbal supplements.  Particularly disturbing was the number of injuries in young people involved in bodybuilding.

Mary Rinella, MD of Northwestern Memorial Hospital in Chicago moderated a discussion group on the topic and mentioned what a large problem it is; “It’s made worse by the popular belief that such supplements are harmless, which leads patients to omit mentioning them when they are in a clinic or doctor’s office.”  She went on to say that, “We don’t know what’s in the products or even what’s in the bottle.” Rinella said.  “Dietary and herbal supplements are not considered drugs and so escape oversight by the FDA.”

Warren Kupin, MD, FACP of the University of Miami Miller School of Medicine division of nephrology delivered a similar message on the epidemic of kidney disease in young adults being caused by the contents of common herbs and supplements sold on our shelves with pleasant healthful sounding names. He raised the red flag on products produced in India and Asia or products containing materials from those areas which contain high levels of heavy metals such as mercury, cadmium, arsenic and others. The target market is young women of child bearing age and they expose their partners and children to these products.  He took a commonly sold supplement, opened the bottle and said that the aroma escaping contained so many heavy metals that if this was produced in a US factory OSHA would require the workers to be wearing respirators in that type of toxic environment.

Consumers need to read labels and ask questions of their doctors before they add an herb or supplement to their daily regimen.  Women of child bearing age need to be especially vigilant and discuss these supplements with their obstetricians and pediatricians before considering ingesting them. The National Institute of Health maintains a very objective website on alternative and complimentary medications at nccam.nih.gov/health/whatiscam that is a great resource and location of factual material.   

I always suggest that when you visit your doctor you bring all your medications, vitamins, minerals, herbs and supplements in a plastic bag with you so that the doctor can read the labels with you.  Accepting the advice you receive on the Internet or from the sales personnel at a vitamin and mineral store is not the most accurate way to learn the truth.  The public is injuring and maiming themselves by consuming too much of the wrong things and there is little or no government oversight and regulation of these products. Protect yourself and ask your doctor for assistance!

 

Walking Reduces Stroke Risk

Walking signBarbara Jefferis, PhD, of University College London UK presented data in the journal Stroke that indicated that older men who added a long walk to their daily routine significantly reduced their risk of having a stroke.  The association was independent of activity level or walking pace. Men who walked 8 – 14 hours per week had about a one third lower risk of stroke compared to men who walked no more than three hours per week or at all. The risk was about 2/3 lower for men who walked more than 22 hours per week.  Walking is recognized to be the predominant form of physical activity in older adults and its impact in reducing stroke risk is important to understand.

The study looked at 3,435 men followed over a ten year period.  The lead researcher said there is no reason to believe that the protective effect does not apply to women as well.

This is one of several studies published over the last few months that extol the benefits of modest age related exercise to preserve function and independence.  We have seen the benefits of an after dinner walk on blood sugar levels documented in recent studies. In a recent British Medical Journal article (BMJ 2013, 347:f5555) researchers reviewing 60 research trials conclude that exercise benefits patients with arthritis rather than being sedentary. We have seen other studies linking seniors with active leisure activity life style exhibiting improved cognitive function compared to seniors with a more sedentary leisure life style.

From a doctor’s perspective the advice is simple. Find something you enjoy doing that is active and aerobic such as walking, running, cycling, swimming, dancing, roller skating or roller blading and engage in this activity regularly to protect your health and independence.

 

Electrical Stimulation May Improve Sleep Apnea

Sleep Apnea v2Patrick Strollo Jr., MD of the University of Pittsburgh Medical Center presented preliminary data on the use of a surgically implanted neurostimulator to improve sleep apnea symptoms. The device was implanted to stimulate the hypoglossal nerve. The participants in the study were 124 patients who could not tolerate the CPAP mask treatment or who were never before treated. After implantation they were treated and followed for one year. The participants were mostly men (83%) in their mid-fifties (mean age 54.5 years old), Caucasian and overweight (mean BMI 28.4 kg/m2). Thirty eight percent of the participants had hypertension, 9% were diabetic, and 5% had COPD. Interestingly, 18% had undergone previous surgery on the uvula called uvulopalatopharyngoplasty which was felt to be an effective alternative to wearing a CPAP mask for sleep.

At 12 months all the parameters to assess the effects of sleep apnea had improved dramatically. Interestingly enough, some of the study participants were allowed to continue treatment while others were randomized to stop the neurostimulation. Those who stopped the treatment were followed and their scores regressed.

Like all treatments there were some adverse effects such as tongue pain and mild to moderate infection in 1%.

This is very preliminary data. The study must be presented to a peer review journal, evaluated and published before this treatment becomes acceptable. We recognize sleep apnea as a dangerous disease that leads to pulmonary hypertension and right heart failure if not treated. CPAP masks work well but are cumbersome, awkward and difficult to travel with. The epidemic of sleep apnea is being fueled by a worldwide epidemic of obesity. The current preliminary work at the University of Pittsburgh holds out hope for a future solution that may be easier to live with.

Prolotherapy for Osteoarthritis of the Knee

Knee X-rayThe National Institute of Health Division of Alternative and Complimentary Medicine has said that if a treatment works, and its results can be reproduced, then it is not alternative therapy.  Such a wise mantra is at the heart of a study published in the May/June issue of the Annals of Family Medicine and recently reviewed in MedPage.

David Rabago, MD, of the University of Wisconsin in Madison and his associates looked at whether prolotherapy is beneficial for those patients suffering from arthritis of the knee. Prolotherapy involves the injection of sugar water or dextrose into joints for the relief of pain. It has been used in different joints for over 75 years but most of the research studies available on its use suffer from poor scientific design and reproducibility.

This study involved 90 adults with knee arthritis in one or both knees for at least five years.  The mean age of the enrollees was 57 years with 2/3 of the enrollees being women and ¾ overweight or obese.  The enrollees were separated into groups. One group received dextrose injections, another received saline or salt water, and a non-injection exercise group. The injections were given at weeks 1, 5, 9, 13 and 17. 

Prolotherapy required them to make multiple punctures around the knee at various tendon and ligament sites. 22.5 mL of either concentrated dextrose or saline placebo were injected into the knees followed by an intra-articular injection of 6mL of additional fluid.   A third arm of the study included patients given no injections but instructed in a home exercise physical therapy program. 

In the dextrose group, 17 patients received injections in only one knee and 13 had treatment in both knees. In the placebo saline group, 15 had a single knee treated while 13 had both knees treated.   During the study, 14 patients in each group used oral non-steroidal inflammatory drugs to relieve pain and discomfort.  All patients receiving injections reported mild to moderate pain after the procedure and up to 2/3 used oral oxycodone before or after the procedure.

The patients used the Western Ontario McMaster University Osteoarthritis Index to score their pain, function and stiffness. There was a significant difference in the improvement of those receiving the dextrose injections as compared to those receiving saline injections. Ninety-one percent of those receiving the dextrose injections said they would recommend the treatment to others.

This was a preliminary study which showed the effectiveness of an alternative therapy in treating a common and chronic condition. It is clear that these findings necessitate a larger study which can look at the correct dosage to inject and to explore how the sugar injections actually work. It appears to be a relatively inexpensive way to relieve chronic pain and is worthy of further study!

Unique Stroke Symptoms in Women

Stroke - NIHIn a previous blog I have discussed the need to recognize stroke symptoms rapidly so that an individual can be transported to an approved stroke center quickly and receive treatment within 60 minutes of arrival and hopefully within 3 hours of the onset of the symptoms. The classical symptoms include:

  • Sudden numbness, weakness or paralysis of your face, arm or leg usually on one side of your body
  • Abrupt onset of difficulty speaking or understanding speech
  • Sudden vision change with blurring, double or decreased vision
  • Sudden dizziness, loss of balance or loss of coordination
  • The onset of a severe sudden headache which may be associated with a stiff neck, facial pain, vomiting or pain between your eyes
  • Sudden change in mental status or level of consciousness
  • Sudden confusion, loss of memory or orientation or perception.

New research shows that women often delay seeking help. It is believed this occurs because women often exhibit different warning signs in addition to the traditional ones. Women having a stroke may exhibit:

  •  Loss or consciousness or fainting
  • Shortness of Breath
  • Falls or Accidents
  • Seizures
  • Sudden pain in the face, chest, arms or legs

Benefits of Smoking Cessation Outweigh Negatives of Weight Gain

A196HJ Woman smoking a cigarette Exhaling tobacco smokeIf you wish to extend your life and stay healthy then giving up smoking tobacco is a major positive step. The benefits include an immediate drop in your cardiovascular disease risk profile, a drop in the possibility of developing numerous types of cancer and a decrease in the likelihood of developing chronic obstructive lung disease.

Smoking is an expensive, dirty habit that not only sickens you but exposes those around you to an increased chance of disease due to others breathing in your second hand smoke. Asthma in children is now believed to be related to the children’s exposure to their parents’ second hand smoke. One of the negatives of stopping smoking is that individuals tend to put on weight. Weight gain and obesity are known risk factors for the development of heart disease and vascular disease.

In the March 13th issue of the Journal of the American Medical Association (JAMA), Carole Clair, MD, of the University of Lausanne in Switzerland examined the question of whether the weight gain was detrimental to your heart health. She accessed data from the famed and long term Framingham Offspring Study looking at the years 1984 through 2011 for 3251 study participants who were free of cardiovascular disease at the start of the analysis. These participants underwent a checkup every four years and were placed into categories such as “recent quitter” (stopped smoking within 4 years),” long term quitter” (nonsmoker for > 4 years) and nonsmoker.

As anticipated, smoking cessation was associated with a weight gain of 5.9 lbs. in the recent quitters and 1.9 lbs. in the long term quitters. Smokers also gained weight during the study period while the country underwent and obesity epidemic. Smokers gained an average of 1.9 lbs. while nonsmokers gained about 3 lbs.

They followed these people for 25 years and defined 631 “cardiovascular events.” In reviewing the data they concluded that former smokers had about one half the risk of developing cardiovascular disease as smokers. When they factored in the weight gain associated with smoking cessation it had no effect on the reduction in cardiovascular disease.

They concluded that the findings support, “a net cardiovascular benefit of smoking cessation, despite subsequent weight gain.” The goal is clear. Stop smoking and then we will work on the weight gain.

ACE Inhibitors Linked to Hallucinations In The Elderly

????????????????John Doane, MD, and Barry Stults, MD, from the University of Utah Health Science Center in Salt Lake City reported in the Journal of Clinical Hypertension on four cases of visual hallucinations in elderly patients taking the drug lisinopril for blood pressure control. ACE inhibitors are a popular and relatively safe drug. They are used for blood pressure control especially in diabetics.

The patients’ adverse effect profile has been limited to a dry allergic cough, elevated potassium, rash, angioedema and renal insufficiency.   They ranged in age from 92-101 and were being treated for hypertension or heart failure. Two had mild cognitive impairment, one had Alzheimer’s disease and one had vascular dementia. The time from beginning the drugs until hallucinations appeared varied from two months to six years. In each case when the drug was stopped the hallucinations resolved. In one case the patient was re-challenged with lisinopril and the hallucinations returned.

The authors conducted a thorough literature search and found several other reports of ACE inhibitor related hallucinations. In each case the hallucinations resolved when the drug was discontinued. It is believed that ACE inhibitors raise the level of opioid peptides causing these hallucinations. While the side effect is rare, it is certainly worth knowing about as the population ages and clinicians are looking for safe drugs to treat high blood pressure and heart failure.

The Benefits of Exercise and Fitness

Woman with DumbbellsThe highly acclaimed Cooper Clinic has been following 20,000 patients’ fitness levels for the last 40 years. They recently published an article in the Annals of Internal Medicine proclaiming that fitness in the middle years of life lowers your risk of developing dementia in your senior years. The Cooper Clinic has been following these patients for evaluation of cardiovascular fitness and development of heart disease but decided to use the same data to review who, if any, developed dementia by their 70th, 75th, 80th and 85th birthdays. All participants initially were screened with exercise treadmill testing. They found that those who were the fittest were 36% less likely to be diagnosed with dementia after age 65 than the least fit.

David Geldmacher, MD, of the University of Alabama at Birmingham, told MedPage Today that the potential benefit of exercise to reduce dementia risk is worth bringing up with patients, even though recommendations for exercise are made routinely for cardiovascular health reasons. Many patients are willing to forego exercise with the belief that sudden death by a heart related illness isn’t such a bad way to expire. On the other hand the thought of living with a chronic debilitating disease like dementia is highly undesirable and exercise might be an acceptable lifestyle change to prevent that process. Knowing that fitness can reduce the Alzheimer risk may give them further motivation to follow through with an exercise and fitness plan.

In an unrelated but equally fascinating study, researchers at the Durham Veterans Affairs Medical Center in Durham, North Carolina found that Caucasian men who participated in regular exercise at a moderate level were less likely to have prostate cancer on biopsy of suspicious areas of the prostate. If the biopsy did reveal prostate cancer the grade of the cancer tended to be lower indicating a more favorable prognosis. This study of 164 Caucasian men and 143 black men did not show any fitness protection for black men who exercised regularly. The authors went on to point out the small size of the study and the fact that the level and frequency of exercise was self-reported not measured or monitored by the research team. Other factors such as heredity, diet and lifestyle issues may be factors as well. They recommended further study to determine the exact relationship between exercise and prostate health or disease.

Both these studies strongly support the concept that regular exercise of a moderate level probably has strongly favorable influences in multiple areas of health. I will continue to urge my patients to get some form of regular exercise that they enjoy on a daily basis while the researchers confirm the long term benefit of regular exercise and fitness.