The Artificial Sweetener Conundrum

Years ago I attended a Weight Watchers meeting in Brooklyn, NY with the lecturer being their public founder Jean Nidetch. She joked about her sugar free gum, sugar free soda and sugar free snacks contributing to “artificial diabetes.” She drew a big laugh but little did she know her comedy may have a ring of the truth to it.

Researchers have now published reputable data that drinking a diet soda daily greatly increases your chances of having a stroke or developing dementia. In an observational study, researchers using data from the Framingham Heart Study Offspring cohort noticed that individuals who drank diet soda and used artificial sweeteners were at an increased risk of ischemic stroke and all cause dementia when compared to individuals of similar age and risk factor stratification that did not use artificial sweeteners. Their data was published in the neurology journal Stroke. This is an observational study which cannot show cause and effect but uses the analogy and theory “where you see smoke there is fire”.

In an unrelated study, researchers looking at how we metabolize sugars noted that consuming artificial sweeteners may lead to larger food and beverage intake and ultimate weight gain. The data was not much better when they looked at individuals who consumed real sugar in sugary drinks. They noted that sugary drinks accelerated the process of aging in cells. This was somewhat in conflict with the original study referenced in which consumption of sugary beverages did not appear to have an association with stroke or dementia.

Clearly the data is confusing as to what to do. Once again moderation with diets with controlled portion size, limited chemical and antibiotic exposure and; rich in vegetables as well as fruits and nuts with a high quality protein seems to be the direction to go. No matter who studies the Mediterranean type diet the results are favorable.

Once again I lobby for nutritional training in the elementary, middle and high schools with healthy cooking and preparation classes as a sound investment for a healthier population in the future. The classes should go as far as teaching students how to create their own gardens and grow some fruits and vegetables on their own for home consumption. We may not be able to impact the adult population in mass but at least let’s give the children a chance.

Water versus Diet Drinks for Dieting and Weight Loss

Water and many diet beverages quench your thirst and are listed as providing no energy or calories to your daily intake. With this in mind, researchers at the University of Nottingham in the United Kingdom set up a definitive study to assess the effect of water on weight loss after a meal versus a diet beverage’s effect on weight loss.

Ameneh Madjid, PharmD and associates looked at 81 overweight and obese women with Type II Diabetes Mellitus. Members of the group were either asked to continue drinking diet beverages five times per week after lunch or substitute water for the diet beverages. The researchers found that over a 24 week period, the water group had greater decreases in weight, body mass index, fasting plasma glucose, fasting insulin homeostasis and two hour post-meal glucose readings compared with the diet beverage group.

A similar study published in the American Journal of Clinical Nutrition looking at 89 obese women found that after six months the water group had lost an extra three pounds compared to the diet beverage group.

As a clinician, the idea of putting water into your body as opposed to diet drink chemicals makes great sense. There have been some researchers who felt that diet beverages eliminated calories in soft drinks but that users consumed more dietary food and calories when drinking diet beverages as opposed to water.

I will suggest to my patients that they try water instead of diet beverages but remind them that an occasional diet beverage probably will not hurt their long term goals.

Weight Loss May Prevent Recurrent Atrial Fibrillation

Heart - CopyAtrial fibrillation is a chaotic heart rhythm seen generally in patients with an enlarged left atrium chamber of the heart and or disease of the heart valves. The heart beats irregularly in many cases decreasing the effective pumping ability of the heart muscle. Patients with atrial fibrillation tend to form blood clots in the left heart chambers which are at risk to break off and travel downstream especially to the brain causing embolic strokes. Newly diagnosed patients are placed on anticoagulant medications such as warfarin, dabigatrin, rivaroxaban, or apixaban to prevent these clots from forming in addition to medicines to slow down the heart rate and hopefully shift you back to your normal heart sinus rhythm in time. Other patients are forced to undergo electrical shock cardioversion to re-establish their normal sinus rhythm while others require ablation therapy to do the same. Once these procedures and chemical maneuvers have been successful, and many times they are not, patients are placed on medications to maintain the correct rhythm.

At a meeting of the American College of Cardiology, Rajeev K. Pathak, MBBS, of Australia’s Royal Adelaide Hospital, presented data showing patients who went on a diet and lost 10% of their body weight were six times more likely to be free from the arrhythmia without having to use antiarrythmic medication at five years (rate 46% versus 13% with less than a 3% weight loss.) The results were presented at the ACC meeting and published in the Journal of the American College of Cardiology.

The study looked at 355 patients who had atrial fibrillation and a body mass index of 27kg/m2 or greater. They were offered a low fat, low carbohydrate weight loss program plus an exercise program at a weight loss clinic. They determined freedom from recurrent atrial fibrillation by using a seven day Holter monitor recording. The evaluations showed that those patients who kept the weight off with less than a 2% fluctuation in weight were 85% more likely to not have recurrent atrial fibrillation or require medication use to control their rhythm.

Lifestyle modification in the form of weight loss is always preferable to the use of medication and procedures. Bernard Gersh, J. MBChB, DPhil, of the Mayo Clinic in Rochester, Minnesota was adamant in saying, “Bottom line is this is a very simple strategy for people with atrial fibrillation. They must lose weight.” He went on to say that weight loss should be considered and tried before a patient is sent for an ablation procedure.

It is important to note that this study is an observational study and did not actually prove that losing weight caused atrial fibrillation to disappear. A further study is underway to prove this point. The article additionally did not specify if the researchers discontinued anticoagulants in the weight loss group no longer exhibiting atrial fibrillation.

Benefits of Exercise on Blood Pressure and Prevention of Atrial Fibrillation

Senior Citizens, exercise v2Junxiu Liu, MD, of the University of South Carolina published an article in the September 15 , 2014 edition of the Journal of the American College of Cardiology showing that exercise and improving fitness levels prevented an age related expected rise in patient systolic blood pressure. His study followed 14,000 men for 35 years. Sedentary men started to see their systolic blood pressure rise at about age 46. Men who were fit delayed this rise in blood pressure until they were 54 years of age. The effect on the diastolic blood pressure was even more pronounced when looking at fitness levels. Men with low fitness ratings elevated their diastolic blood pressure to above 80 by age 42. Those men with a high fitness level did not see the rise in diastolic BP until they were beyond age 90. His research suggests that “highly fit men are likely to reach abnormal BP readings a decade later or more than sedentary men.

In an unrelated study published in the same issue, researchers in Texas found that regular aerobic exercise prevented the hearts left ventricle or main pumping chamber from developing stiffness. The stiff ness of the ventricle contributes too many common cardiovascular conditions effecting older patients. They found that low levels of casual lifelong exercise such as four (4) sessions of 30 minutes per week throughout adult hood was sufficient to keep the ventricle from stiffening.

Marco Perez, MD of Stanford University looked at exercise levels in women and the development of the heart arrhythmia atrial fibrillation. He found that sedentary women were much more likely to develop this pathologic arrhythmia than women who exercised regularly. Obesity and being overweight is a risk factor that increases your chances of atrial fibrillation. Regular exercise by obese women reduced this risk by about nine percent (9%).

The message is very clear that keeping moving and being active improves your blood pressure control and reduces your risk of developing many cardiovascular related problems. My advice is find some activity you enjoy doing and make sure you try it several times per week to gain the natural benefits the exercise provides.

Are Older Women Receiving Too Much Calcium?

CalciumThe June issue of Menopause, a peer reviewed medical journal, carried an original research article by Margery Gass, MD and colleagues which indicated that older women are taking too much Vitamin D and Calcium. She conducted a randomized and placebo controlled trial of 163 women with low Vitamin D levels. The age range of the study group was 57 to 90. They were given Vitamin D and Calcium citrate tablets to reach the recommended daily amount of 400 to 4800 IU per day of Vitamin D and 1200 mg of calcium per day. Follow-up lab studies revealed that almost 10% of the women developed elevated blood calcium levels. More disturbing was the fact that 31% developed elevated levels of calcium in their urine predisposing them to kidney stones.

The lead author suggested that every patient calculate how much calcium they are getting daily in their normal diet before supplementing it with extra calcium. Her group pointed out the benefits of clinicians periodically measuring patients 24 hour urine calcium level. Those with a level > 132 mg were at much higher risk of developing hypercalcemia and its complications and need to reduce their supplemental calcium intake. We will begin suggesting 24 hour urine collection in our patients in the near future.

The Importance of the Physical Examination

Physical ExamMedical Schools and residency training programs are beginning to realize that they must devote more attention to training young physicians in the skills of physical examination. In recent years the tendency has been to concentrate on the technology rather than taking a thorough history and performing a comprehensive examination. Abraham Verghese M.D., a chairperson at Stanford’s medical program has been instrumental in creating the Stanford Medicine 25 program which emphasizes 25 physical exam skills that all students must learn, demonstrate and then teach. Prior to the program Verghese felt that ,” If you come to our hospital missing a finger, no one will believe you until we get a CT scan, an MRI and an orthopedic consult.” Steven McGee M.D., of the University Of Washington School Of Medicine is author of a book on evidence based diagnosis based on physical examination. He believes a physical exam can be as accurate as technology citing instances where evaluating patients’ eye movements are as accurate as an MRI scan in differentiating vertigo due to an inner ear problem as compared to dizziness from a stroke. W. Reid Thompson M.D. of the John Hopkins Pediatric Cardiology Division launched Murmurlab, a website containing the heart sounds of 1300 people to train his students how to distinguish which cardiac findings require further evaluation and an echocardiogram and which do not.

These physicians believe tests lead to tests and more tests and may obscure the diagnosis when a simple physical exam might provide the answer. They cite examples such as the 40 year old woman in a Northern California hospital who was being evaluated for a blood clot to her lungs with a CT scan because she had extremely high blood pressure and was confused. A simple examination of her breasts which had not previously been performed revealed bilateral hard non moveable malignant masses which were in fact the source of her problems.

Not all leaders in medical education feel the need to teach physical examination more effectively. Robert Wachter MD, the father of hospitalist medicine and former head of the American Board of Internal Medicine disagrees and feels more time should be spent on developing critical thinking skills than on physical diagnosis. Dr Wachter is part of a movement to shorten medical school education and shorten residency training. He believes in educating new physicians in a much narrower specialty oriented manner. Under his influence and leadership the Internal Medicine Board Examination is now a separate exam for doctors practicing in hospitals and those practicing outside hospitals.

I have been a faculty member teaching medical history taking and physical diagnosis to medical students for over a decade at the University Of Miami Miller School Of Medicine and the Charles E Schmidt College of Medicine at Florida Atlantic University. These two institutions have managed to teach both critical thinking skills and excellence in physical diagnosis without shortchanging either skill. There is no reason to narrowly train doctors when the fund of knowledge and technology is dramatically increasing. The goal to shorten medical school and residency seems to be an economic goal designed to reduce the costs of education and training a doctor and produce a class of physicians who can be compensated at a lower level. If anything today our future physicians need a broader more comprehensive training to improve understanding and communication regarding the increasingly complex and aging patient population they care for.

Extreme Intensity Exercise Good for the Ego But Maybe Not for the Heart

ExerciseHealth experts have encouraged regular moderate level exercise for adults 5-7 days a week lasting 30 – 60 minutes per session to stay heart healthy.  We talk about walking 15 – 20 minute miles while being able to comfortably carry on a conversation as your suggested goal. We all see other adults appearing far more fit and aggressive working out daily at a much quicker and much more strenuous pace. Experts have always wondered if they are healthier and if they fare better?

Two articles addressing this issue appear in the journal Heart. Researcher Ute Mons, MA, of the German Cancer Research Institute found that men with known stable coronary artery disease who exercised strenuously daily had more than a two fold increase in cardiovascular mortality compared to men with CAD who exercised 2 -4 times per week at a moderate level. The study was the first of its kind to look at different levels of exercise and frequencies of exercise. Certainly more research is now required to verify these findings in studies which do not rely on patient self reporting of how often, how hard and how long you work out. It is also critical to remember that this study was conducted on individuals known to have heart disease.  The message to them should be clear to exercise moderately for the most benefit and least risk. The study says nothing about the benefits or risks of individuals without cardiovascular disease who exercise moderately versus strenuously.

In another related article men at age 30 who reported exercising 5 or more hours a week had an increased risk of developing the arrhythmia atrial fibrillation as compared to those who exercised more modestly. While these were both excellent preliminary works requiring further study, they both point toward moderation once again as the healthiest and best lifestyle path.