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.

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Sunscreen Ingredients are Absorbed says FDA

For years public health officials, dermatologists and primary care physicians have been encouraging people to apply sunscreen before going out into the outdoors to reduce the risk of sunburn and skin cancers.  We are taught to apply it in advance of exposure by about 30 minutes and to reapply it every few hours especially if we are sweating and swimming.   Living in South Florida, sun exposure is a constant problem so we tend to wear long sleeve clothing with tight woven fabrics to reduce sun exposure.  My 15-month old grandson, visiting last weekend was smeared with sunscreen by his well-meaning parents before we went out to the children’s playground nearby.

These precautions seemed reasonable and sensible until an article appeared in JAMA Dermatology recently.  An article authored by M. Mata, PhD. evaluated the absorption of the chemical constituents of sunscreen after applying it as directed four times per day.  The article was accompanied by a supporting editorial from Robert M. Cliff M.D., a former commissioner in the FDA and now with Duke University School of Medicine and K. Shanika, M.D., PhD.

The study applied sunscreen four times a day to 24 subjects. Blood levels were drawn to assess absorption of the sunscreen products avobenzene, oxybenzone and octocrylene.  The results of the blood testing showed that the levels of these chemicals far exceeded the recommended dosages by multiples. The problem is that no one has evaluated these chemicals to see if at those doses it is safe or toxic causing illness?

The editorial accompanying the findings encourages the public to keep using sunscreen but cautions that the FDA and researchers must quickly find out if exposure to these levels is safe for us?  We do know that the chemical oxybenzone causes permanent bleaching and damage to coral reefs in the ocean from small amounts deposited by swimmers coated with sunscreen. The state of Hawaii has actually banned sunscreens containing oxybenzone to protect their coral reefs.

The fact that these chemicals have been approved and are strongly absorbed with no idea of the consequences is solely the result of elected officials wanting “small government” and reducing funding to the oversight organizations responsible for making sure what we use is not toxic.  It is a classic example of greed and profit over public safety.  The research on the safety of these chemicals must be funded and addressed soon. The American Academy of Pediatrics and Dermatology need to advise parents of youngsters whose minds and bodies are in the development and growth stages what is best to do for their children – sooner rather than later.

The Reality of Skilled Nursing Home Stays

The online journal Medscape published a Reuter’s article on Skilled Nursing Facilities and post hospital stays.  They discussed the often-lengthy time span between hospital discharge and the patient being seen by a physician or “an advanced care practitioner”.

Older, more infirm and cognitively impaired patients tend to be seen later than other patients. Apparently the later you are seen, the more likely it is that you will be sent back to the acute care hospital and be readmitted.  The study was conducted by Kira Ryskina of the Perlman School of Medicine at the University of Pennsylvania in Philadelphia. The researchers looked at Medicare claims from nearly 2.4 million patients discharged from acute care hospitals. Her data indicated that when patients were seen by doctors at the facility soon after discharge they tended to recover more often not requiring acute readmission to the hospital for the same problem.

The author went on to say that most families confronted with a family member requiring post hospital rehabilitation at a skilled nursing home do not know what to expect from a skilled nursing facility (SNF).  The truth is, most doctors who practice in the inpatient setting or in surgical and medical specialties have no idea what to expect. They have never gone into one, unless it is for their own recovering family member, and they have never cared for a patient on a daily basis in one.

My first month as a private physician in 1979, my employer took me to the local facilities to meet the administrators, charge nurses and social workers at the facilities. The medical director was a young internist who had no private outpatient office or practices just a nursing home practice at five institutions he called on.  I was told that the law required me to see new patients within 24 hours of arrival, examine them and write a note and review all orders and either approve or change them.  I was surprised that facilities were staffed with only one registered nurse per 40 patients. The RN was required to pass the medications each shift, with most patients being on multiple medications so that most RNs had little time per shift to do much else but pass the medications.

When a patient had a complication or problem the nursing staff called the family member and the doctor. The volume of calls was so immense that the young facility medical director could not find any physicians who would agree to cross-cover with him on the weekends so he could get some time off.  In most cases, even if I decided the phone call related medical problem could be dealt with at the facility, the family decided otherwise and wanted their loved one transported to the ER. Those of us who cared for patients at these SNF’s joked that the protocol for caring for a problem was to call 911 and copy the chart for transfer.

It used to disturb me that EMS services were being diverted to these facilities for non-critical issues taking them away from true emergencies, and delaying response times, but they seemed to like it.  The more trips they were called on, the more evidence they could present for a larger share of the city or county budget.

At some SNFs there was always an EMS bus or ambulance sitting in the parking lot outside.  The patients were insured by Medicare guaranteeing bill payment so the receiving Emergency Department and staff were happy as well.

We were required to see the patient monthly and write a note. I saw sicker and less stable patients more often than monthly.  Progress in rehabilitation was discussed at mid-day care planning conferences that the physicians were rarely made aware of.  My goal for discharge was when the patient could safely transfer from the bed to a walker or wheel chair, get to the bathroom and on and off the toilet safely and; get in and out of a car. If the family could convert their home into a “skilled nursing facility” the patient could go home as well.  Often the patient was sent home by the facility “magically cured” when their insurance benefits ran out.

Most of the work at the facilities is performed by lower paid aides. In my area of practice most of the aides are men and women of color from the Caribbean who have little in common with the mostly Caucasian elderly population they care for. The work is hard and the pay low with the employee turnover rate extraordinarily high annually at most institutions. The patients are elderly, chronically ill, often with impaired cognition, hearing, and vision. Their family’s vision of what should be done is vastly different from what can be accomplished.  I believe most of the staff are caring and well-meaning just under staffed and under trained.  Administrations concerns about liability from medical malpractice, elder abuse and other issues is well founded based on the plethora of ads on prime time TV, newspapers and the sides of travelling public buses touting law firms seeking elder care cases.

It is now harder and harder to actually see patients at these facilities even if you wish to.  While community- based physicians with local hospital privileges were once welcomed and encouraged to attend to their patients at the facility, now the facilities require doctors to go through a lengthy credentialing process – as if you were applying for hospital staff privileges.   When you actually show up and care for your patients you rarely see a physician colleague. Most of the care is assessed and provided by nurse practitioners and physician assistants working for physicians who rarely, if ever, venture into the facilities. They may supervise the care plan on paper but rarely lay eyes or hands on the patient.

These facilities serve a vital role in the post-acute hospital care of patients. According to this study and article, Medicare spent $60 billion dollars in 2015 on this care. When a hospitalized patient has a frail spouse or no spouse at home, with no local nuclear family able to provide home care, the SNF is the only real option.

I suggest families visit the potential choices first. Speak to patients and their families about the care and services.  Review online state inspection and violations records. Ask about the transition from the hospital to the SNF. Who will be responsible for caring for them at the facility?  Meet them and talk to them. Make sure you are on the same page. If you can find a facility that has an onsite physician team with a geriatrician as the chief medical provider.  It may be the best option.

For these transitions to work and save money by stopping the revolving door form hospital to SNF to emergency room for every medical question, the SNF’s need some form of sovereign immunity from frivolous lawsuits if their services and care meet the legally required standards. The recent post- hurricane heat-related tragedy at a Hollywood, Florida nursing home underscores the need for vigilant inspection and regulation of this industry. The good homes need to be identified and need to be given the support and latitude required to care for this ever increasing portion of our American society.

Keep Moving for Cardiovascular Benefits

We keep extolling the benefits and virtues of regular exercise and fitness. Some research studies have documented the intensity and duration of exercise programs with cardiovascular events and mortality. Those who do more and are fitter apparently do much better which surprises few of us.

It comes down to the “which came first the chicken or egg “question?  Are people genetically able to exercise at a high level living longer and healthier because they exercise at a high intensity and duration or vice versa?

It is quite comforting to read the recent study in JAMA by Andrea LaCroix, PhD, MPH and colleagues from the University of California, San Diego that shows the benefits of even modest movement and exercise.  The study was conducted under the umbrella of the Women’s Health Initiative and put pedometers and accelerometers on women to measure activity during waking hours.  Light physical activity was defined as less than 3 metabolic equivalents (Walking one mile in about 22 minutes expends about 3 Metabolic Equivalents of Activity).  They noted that for each hour per day increment in light activity there was a 14% lower risk of Coronary Heart Disease and 8% lower risk of cardiovascular disease.

The researchers evaluated 5,861 women with a mean age of 78.5 years. Average follow-up spanned 3.5 years with study members having 570 cardiovascular disease events and 143 coronary heart disease events. The study group was diverse with there being 48.8% Caucasian women, 33.5 % Black women and 17.6% Hispanic women.

The study’s results and message was clear. Keep moving. Even modest exercise is beneficial in reducing heart attack and stroke risk.

Free Choice of Physicians & Fee for Service Medicine Ending?

The Medicare Payment Advisory Commission is a panel of financial, economic and health policy advisors created by Congress to advise CMS (Center for Medicare Services) and Congress how to pay physicians, health care providers and facilities for services rendered. According to an online article on MedPage they are close to eliminating fee for service payments for health care. CMS has encouraged alternative delivery methods for years. For the most part this has resulted in hospital and health care systems buying up and employing doctors, mid-level providers being substituted for more highly trained doctors and these alternative systems covering care only with their panel of providers and diagnostic and treatment centers.

However, publicized figures have shown these Medicare alternative products actually cost more per patient per year than traditional Medicare. This particular article claimed a 1-2% savings.

We all see the ads for Medicare Advantage plans which, in addition to no co-pay and no deductible, provide for dental care, vision care, eye care and exercise and gym memberships. Apparently 50% of the Medicare population is now enrolled in such a program.

As a 69 year old individual paying into the Medicare system for the last 55 years I see the benefits and cost savings for seniors when they are healthy. What happens however, when you become ill? Clearly the Centers of Excellence for many of the ailments seniors contract are geographically and contractually outside the narrow networks and panels these private insurance companies run and the Accountable Care Organization run plans provide.

If I do not have coverage for the Mayo Clinic or MD Anderson Cancer Center or the Cleveland Clinic or Dana Farber Cancer Center or Johns Hopkins Medical Center then have I wasted 55 years of payments? Do I really want a nurse practitioner in south Florida directing my care off a protocol list of contracted providers or do I want a clinician who sees a dozen cases of this disease per week calling the shots?

I prefer the latter but may not have a choice but to pay out of pocket if MEDPACs recommendations are accepted by CMS and Congress and become law.

Eggs and Diabetes – New Information

Diabetes has been known as a risk factor for cardiovascular diseases for years. Egg consumption was discouraged by experts.   Our perception of eggs as they relate to diabetes and heart disease may have to be reconsidered based on a study published in the American Journal of Clinical Nutrition in May 2015

The Kuopio Ischemic Heart Disease Risk Factor Study enrolled 2,332 men, aged 42 -60 years old, and followed them for more than nineteen years.  Four hundred thirty-two participants developed Type 2 Diabetes.  Men who ate the most eggs demonstrated a 38% lower risk of developing Type 2 Diabetes in this study.  Higher egg intake was associated with lower levels of fasting plasma glucose and serum C – reactive protein.

The researchers published a follow up paper in the Journal of Molecular Nutrition and Food Research this year and came up with similar results stating that “moderate egg consumption of eggs can be part of a healthy dietary pattern for preventive action against Type 2 Diabetes Mellitus.” Their definition of moderate was an average of one egg or less per day.

This is preliminary data involving eggs will be discussed and battled over for years to come. What is important is that once again a modest intake of a protein in moderation is probably not deleterious as previously thought.

When dealing with diabetes, lifestyle issues such as weight control, smoking status, alcohol intake, regular exercise and simple carbohydrate intake are far more important issues to address than egg consumption in moderation.  This topic was reviewed in the latest online publication of Medscape Medical News. 

Artificial Sweeteners and Your Health

An article published in the online version of Primary Care brings up the issue of whether artificial sweeteners are a positive, helping people lose weight, or is there more to the story. Editor David Rakel MD, FAAFP discusses a recent article in the neurologic journal STROKE showing an association between the number of artificially sweetened beverages consumed per day and the onset of a stroke. This relationship was seen only with artificially sweetened beverages not with sugar sweetened beverages.

Dr Rakel goes on to discuss the ongoing public health concern of consuming nonnutritive sweeteners and its effects on weight gain and insulin resistance. Recent studies known as observational studies have linked high consumption of beverages with nonnutritive sweeteners with weight gain, increased visceral adiposity and a 22 % higher incidence of diabetes despite consuming less energy.

The reasons for consuming fewer calories but gaining weight are considered to be many. Sweet tasting compounds including NNS activate sweet “taste receptors” that were once thought to be only located in the mouth but are now known to be throughout the body. This activation results in release of insulin. The continued release of insulin by the pancreas, without energy producing calories present to be metabolized, may lead to insulin resistance. Insulin resistance involves insulin being released in response to food being consumed but is becoming ineffective in moving sugar into the cell where it can be metabolized into energy.

There is additional belief that supplying sweetness without calories may result in disturbances to appetite regulation and communication within the body about when we are full. Products such as aspartame, saccharin and sucralose have been found to have negative effect on the intestinal bacteria or microbiome potentially having an effect on glucose tolerance and metabolism.

We see artificial sweeteners on tables in every setting. Aspartame produces a sweetening effect 200x sugar. Saccharin produces a sweetening effect 500x sugar. Sucralose is 600x sugar sweetening and Advantame 20,000x sweeter.

A teaspoon of sugar only contains 16 calories. Portion control of products made with real sugar may be the safest and healthiest way to eat sweets as the holiday season approaches. A level teaspoon of sugar in your coffee or tea may be far healthier for you than that packet of artificial sweetener.