Wisdom Wednesday: Food Sensitivity Series

There appears to be a lot of confusion and misconception about food sensitivities. For the next several weeks the Wisdom Wednesday blogs will cover the most common reactive foods. In order they are wheat, dairy, soy, corn and the nightshades.

In general, any food sensitivity is the result of a trigger mechanism in the GALT (gut associated lymphoid tissue) that lines the digestive tract.

The GALT is a component of the mucosa associated lymphoid tissue (MALT). It lays throughout the intestine and is about 300 square meters in size. This large surface area is achieved by finger-like projections (villi) creating folds in the lining. A single layer of epithelial cells covers the GALT separating it from the lumen of the intestine and its contents. The epithelial cells are covered in mucus to protect them from the harsh environment of the digestive tract.

The epithelial cells are constantly being replaced with a complete turnover every 24-36 hours. That’s by far the fastest cell turnover of any tissue in the human body. Inflammation, disease, and even nutritional deficiencies can reduce the replication rate resulting in gaps in the epithelial cell layer. This is the origin of “leaky gut” in which partially digested foods, bacteria, viral particles or other irritants can enter the blood stream to trigger an immune response.

The GALT is constantly analyzing the contents of the gut. Dendrites (a crane-like immune cell) can actually reach into the lumen to test a potential foreign object. On occasion, they will actually carry the foreign object back into the GALT for further evaluation.

The information gleaned by the GALT then stimulates the thymus. The thymus in turn produces either a Th1 cell or a Th2 cell. If the immune system identifies the foreign body as “living”, then Th1 cells are produced. This is the normal response to a virus or bacteria. However, if the foreign body is deemed “non-living”, like gluten or lactose, then Th2 cells are produced. The total number of Th cells doesn’t really fluctuate much, just the ratio of Th1:Th2. So patients will have a high ratio of Th1 with infection and a high ratio of Th2 with allergy or food sensitivity.

Forget Steroid Shots for Long-Term Relief of Arthritic Knees

Steroid shots are a common treatment for arthritic knees. But, a new study says their long-term use is ineffective and may even reduce cartilage.

Knee osteoarthritis patients who got steroid injections every three months for two years had no less pain than those taking a placebo treatment. And they had greater loss of cartilage, the rubbery tissue that acts as a cushion between the bones of the joints, researchers found.

“This research will change how I talk to patients,” said Dr. Seth Leopold, a professor of orthopedics and sports medicine at the University of Washington School of Medicine. “I will tell patients that the best information we now have suggests that these injections may not help, and extended use may thin your cartilage,” said Leopold, who wasn’t involved in the study.

Osteoarthritis is the wear-and-tear form of the joint disease, characterized by pain, swelling and stiffness. Knee arthritis is a major cause of disability, affecting more than 9 million Americans, according to the background notes with the study.

Steroid shots in the knee joint are commonly given as a short-term treatment for pain flare-ups, and they can be useful for that purpose, said study lead author Dr. Timothy McAlindon. He’s chief of rheumatology at Tufts Medical Center in Boston.

For the new study, researchers tracked 140 patients, age 45 and older, who had arthritis knees with inflammation of the synovial membrane – a thin membrane lining the joint. The patients were randomly assigned to receive injections with either a steroid (intra-articular triamcinolone) or saline.

Wisdom Wednesday: Hormone Therapy Not Advised for Preventing Disease After Menopause

Using hormone therapy to prevent chronic health issues, such as heart disease and bone loss, in postmenopausal women may do more harm than good, the U.S. Preventive Services Task Force (USPSTF) says.

After reviewing current evidence, the task force has issued an updated draft recommendation, reaffirming its final statement issued in 2012. The expert panel advises against the use of hormones – including estrogen and progestin – to prevent chronic conditions among postmenopausal women, including those who’ve had their uterus removed.

Hormone therapy in postmenopausal women first came under scrutiny in 2002, when a large U.S. trial known as the Women’s Health Initiative abruptly halted a look at the benefits and harms of hormone therapy because it appeared to raise the risks of breast cancer, heart attack, stroke and blood clots.

Women typically enter menopause around the age of 50. Following menopause, women’s hormone levels change. These changes may increase a woman’s risk for long-term health issues, such as heart disease and fractures due to bone loss.

“The benefits of using menopausal hormone therapy to prevent chronic conditions like heart disease and diabetes do not outweigh the harms in women who have gone through menopause,” said panel member Dr. Maureen Phipps in a task force news release.

“It’s important to note that this draft recommendation applies only to women who have gone through menopause and are considering hormone therapy to prevent chronic conditions,” said panel member Ann Kurth. “It does not apply to women who are considering hormone therapy to manage menopausal symptoms, such as hot flashes or night sweats,” she said.

Timing of Menopause May Affect Heart Failure Risk

Women who entered menopause early or who never gave birth might have an increased risk of heart failure, a new study suggests.

Researchers analyzed data from more than 28,000 postmenopausal women who did not have heart disease at the start of the study. During an average follow-up of about 13 years, just over 5% of the women were hospitalized for heart failure.
The study was published May 15 in the Journal of the American College of Cardiology.

“Our finding that a shorter total reproductive duration was associated with a modestly increased risk of heart failure might be due to the increased coronary heart disease risk that accompanies early menopause,” senior author Dr. Nisha Parikh said in a journal news release. Parikh is an assistant professor at the University of California, San Francisco School of Medicine.

“These findings warrant ongoing evaluation of the potential cardioprotective mechanisms of sex hormone exposure in women,” Parikh added.

Previous studies found that sex hormones present during a woman’s childbearing years may affect heart disease risk.

My Take:
Last fall I attended a seminar on “Hormones & Cardiometabolic Function” presented by Jack Monaco, MD. He cited extensive research that indicates that sex hormones serve as cardioprotective.

The sex hormones appear to reduce vascular inflammation in the intima of the vessel walls. This is how atherosclerosis begins. It is only after the intima becomes inflamed that LDL cholesterol binds to homocysteine and plaque forms against the inflamed intima.

This research has created a boon for hormone replacement therapy (HRT). However, the introduction of exogenous sex hormones has significant side effects. Even bioidentical hormones down regulate cell hormone receptor sites after just two months of treatment. This requires more and more hormone to obtain the same response.

The Bottom Line:
Despite the cardiovascular protection afforded by endogenous hormones, exogenous hormone therapy has severe side effects and should be limited to short term therapy up to two months. The key is to stimulate endogenous hormone production from the adrenal glands in menopause and andropause. More on this topic in my next blog.

Source: May 15, 2017 National Institutes of Health

New Guidelines Say NO to Most ‘Keyhole’ Knee Surgeries

Clinical trials have shown that keyhole surgery doesn’t help people suffering from arthritis of the knees any more than mild painkillers, physical therapy or weight loss, said lead author Dr. Reed Siemieniuk. He is a health researcher with McMaster University in Toronto, Canada.

“You can make a pretty strong statement saying that from a long-term perspective, it really doesn’t help at all,” Siemieniuk said. “If they knew all the evidence, almost nobody would choose to have this surgery.”
Keyhole surgery is one of the most common surgical procedures in the world, with more than 2 million performed each year, Siemieniuk said. The United States alone spends about $3 billion a year on the procedure.

The new guidelines – published online May 10 in the BMJ – were issued as part of the journal’s initiative to provide up-to-date recommendations based on the latest evidence. The guidelines make a strong recommendation against arthroscopy for nearly all cases of degenerative knee disease.

This includes osteoarthritis as well as tears of the meniscus, the padding between the two leg bones in the knee, Siemieniuk said. “With age and use, the grinding of the two bones together can break down that padding,” he said. “It’s very common to see little rips and tears in that padding in patients with arthritis.” Siemieniuk and his colleagues noted that a trial published in 2016 showed that surgery was no better than exercise therapy in patients with a meniscus tear.

Despite this and other medical evidence, most guidelines still recommend keyhole surgery for people with meniscus tears, sudden onset symptoms like pain or swelling, or mild to moderate difficulties with knee movement.

Wisdom Wednesday: Common Painkillers Tied to Slight Rise in Heart Attack Risk

Commonly used painkillers such as Motrin, Advil and Aleve might increase your risk for heart attack, even in the first week of use, a new study suggests.

Overall, these drugs and others known as nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of a heart attack by 20-50%, compared with not using them, researchers found. For most people, however, this represents only a small increased risk – about 1% a year, the researchers said.

Still, “from the viewpoint of public health, even small increases in risk of heart attack are important because use of NSAIDs is so widespread,” said lead researcher Michele Bally. She’s an epidemiologist at the University of Montreal Hospital Research Center.

The increased risk of heart attack associated with NSAIDs was seen at any dose taken for one week, one month or more than one month. And the risk rose with higher doses, the study found.

To lower your odds for heart harm, she suggested considering all available treatment alternatives before deciding to treat occasional pain, fever or inflammation. Read the label of NSAID medications and use the lowest possible effective dose, added Bally, who was a doctoral student at McGill University in Montreal at the time of the study.

The NSAIDs the researchers studied were ibuprofen (Motrin, Advil); naproxen (Aleve); diclofenac (Voltaren); celecoxib (Celebrex); and rofecoxib (Vioxx). Vioxx was pulled from the U.S. market in 2004 because it increased the risk of heart attack and stroke.

The risk of heart attack linked to NSAIDs was greatest with higher doses during the first month of use, Bally said. The researchers found that daily doses of more than 1,200 mg of ibuprofen and over 750 mg of naproxen were particularly harmful within those first 30 days.

Nearly a Third of Drugs Hit by Safety Issues After FDA Approval

Researchers examined data on drugs approved by the FDA between 2001 and 2010, with follow-up through 2017. The investigators found that 32% of the drugs had safety issues after approval.

“That is very rarely a drug withdrawal, but more commonly a black-box warning or drug safety communication issued by the FDA to let physicians and patients know that new safety information has been determined,” said study leader Dr. Joseph Ross. He is an associated professor of medicine and public health at Yale University.

Of 222 drugs approved by the agency during the study period, three were withdrawn, 61 received boxed warnings and 59 prompted safety communications, the findings showed.

Drugs most likely to have post-approval safety concerns included biologics, psychiatric drugs and medicines approved through the FDA’s accelerated approval process. The report is timely because the FDA is under pressure to accelerate drug approvals, the study authors noted.

“It shows that there is the potential for compromising patient safety when drug evaluation is persistently sped up.” Ross said in a university news release.

To assess experimental drugs for safety and effectiveness, the FDA relies on pre-market drug testing and clinical trials. Most of the trials involve fewer than 1,000 patients studied over a period of six months or less. This makes it hard to detect safety issues that might surface once more patients use the drug over a longer time period, the researchers explained.

Walking vs. Running – Which is Better?

Running and walking are both popular ways to get a great cardio workout. But is a brisk walk really as good an exercise as a sweaty, heart-pounding run?

Research reported by the American Heart Association finds that walking is just as good as running when it comes to lowering your risk for heart disease.

Researchers analyzed the health of some 48,000 runners and walkers mainly in [their] 40s and 50s. They found that, mile for mile brisk walking lowers the risk for diabetes, high cholesterol and high blood pressure as much as running does.

The difference? You’ll have to spend more time walking than you do running to get the same health benefits simply because it takes longer to walk than to run the same distance. For instance, a 15-minute jog burns about the same number of calories as a half-hour brisk walk.

Keep in mind that the chance of being injured is greater in runners because running puts more stress on the body – on the joints in particular.

But if you’re still thinking of stepping up the pace to running, first check with your doctor, especially if you have arthritis or other health conditions, like heart disease.

Wisdom Wednesday: Could Fasting Every Other Day Help You Lose More Weight?

After one year, researchers found that weight loss was about the same – 6% for those on the alternate-day fasting diet and a little over 5% for those on the daily restricted-calorie diet.

“We thought that alternate-day fasting group would do better. It allows people to have a break from dieting every other day, so we thought their adherence would be better,” explained lead author Krista Varady.

“But it turns out people in both diets lost the same amount of weight,” said Varady. She’s an associate professor of kinesiology and nutrition at the University of Illinois at Chicago.

“People in the alternate-day fasting group were eating more than the 500 calories prescribed on the fast day, but a lot less than the calories prescribed on the feast day. That’s why they lost the same amount of weight,” she explained. However, “people who stuck to the [alternate-day fasting] diet lost 20 to 50 pounds in a year,” Varady added. “It does work for some people.”

In the study, Varady’s team randomly assigned 100 obese people to an alternate-day fasting diet, a conventional diet (25% reduction in calories every day), or no diet at all (the “control” group).

People on the conventional diet were able to stick to their calorie goals better than the alternate-day fasting group, the researchers found. The dropout rates were 38% or the alternate-day fasting group and 29% for the conventional group.

The fasting diet appeared to be safe, Varady noted. On fasting days, people were encouraged to eat a lot of protein because protein makes you feel full, she said.

Eating Gluten-Free Without a Medical Reason?

Gluten-free diets have soared in popularity in recent years. But, shunning gluten has no heart benefits for people without celiac disease, and it may mean consuming a diet lacking heart-healthy whole grains, according to the quarter-century study.

“For the vast majority of people who can tolerate it, restricting gluten to improve your overall health is likely not to be a beneficial strategy,” said study leader Dr. Andrew Chan.

Gluten is a protein found in wheat, rye and barley. People with celiac disease – less than 1% of the U.S. population – have an immune system reaction when they eat gluten, triggering inflammation and intestinal damage. They also have an increased risk of heart disease, but that declines after they begin eating a gluten-free diet.

Recently, researchers have reported that some people may have what’s known as non-celiac gluten sensitivity, a condition that’s not totally understood. “I don’t what to dismiss the fact that there are people who have the sensitivity,” said Chan, an associate professor of medicine at Harvard Medical School. But, the rest of the population should not think that going gluten-free will help their health – at least not their heart health, he said.

For the study, Chan and his colleagues analyzed data on nearly 65,000 women and more than 45,000 men, all U.S health professionals without a history of heart disease when the study started. The study participants completed a detailed food questionnaire beginning in 1986 and updated it every four years until 2010.

The researchers looked at gluten intake, dividing participants into five groups from low to high, then calculated how likely they were to develop heart disease over roughly 26 years. When the researchers compared the highest-intake gluten group with the lowest, the rates of heart disease were not very different.

New Bowel Disorder Treatments Needed, FDA Says

There’s no known cause or cure for irritable bowel syndrome (IBS), which affects more than 15 million Americans, according to the U.S. Food and Drug Administration.

The disorder involves the large intestine (colon). It causes symptoms such as abdominal pain, bloating, cramping, excessive gas, mucus in the stool, and changes in bowel habits (constipation and/or diarrhea).

No single treatment is effective in all IBS patients, so there’s a need to develop new therapies for the condition, said Dr. Tara Altepeter. Altepeter, an FDA gastroenterologist, noted that the agency is working to make more treatments available to patients. “There’s a lot of new research about the role of carbohydrates, and specifically a nutrient called polyols, in triggering the irritable bowel syndrome in some patients,” Altepeter said in an FDA news release.

Current treatments for IBS include changes in diet and nutrition, and exercise. Some patients take medications to manage their symptoms, but there are no medications to cure IBS.

“IBS is not like other chronic conditions, such as hypertension, which is constant. IBS is a variable condition. Even without treatment, the problem might go away in some patients. But the symptoms might return after a few months,” Altepeter said.

IBS symptoms can be triggered by certain foods, including those high in carbohydrates, spicy or fatty foods, milk products, coffee, alcohol and caffeine.

Wisdom Wednesday: Is it Wise to Take a Steroid for a Sore Throat?

Researchers seeking new sore throat treatments reportedly modest success with a single dose of a steroid medication.

Concerns about growing bacterial resistance to antibiotics have lead scientists to look for alternative therapies for sore throat, a common reason for doctor visits.

In this new British study, a steroid medication led to improvement in about one-third of patients with sore throat. But two U.S. physicians said they aren’t rushing to prescribe the drugs on the basis of these results.

The new study looks at a steroid – a drug designed to dampen immune system responses. Researchers led by Gail Nicola Hayward, of the University of Oxford, analyzed the effects of a single dose of dexamethasone. Similar steroids include prednisone and methylprednisolone.

The researchers randomly assigned 565 adults in England with a sore throat that didn’t require an antibiotic to take a large dose of dexamethasone (10 mg) or a placebo. Half the patients were younger than 34.

At 24 hours, the 288 patients who took the medication fared about the same as the 277 who didn’t. But at 48 hours, more than one-third of those who took the drug – 102 – had recovered.

According to Dr. Robert Centor, a professor of internal medicine at the University of Alabama at Birmingham, U.S. physicians don’t often prescribe steroids for sore throats. However, some emergency rooms and urgent care centers appear to do so. “It’s not standard treatment or in any guideline, but these people [physicians] say, ‘Well we can make them feel better. How could a couple days of steroids even hurt?’”

But there’s a risk that the drugs could hide symptoms that something serious is going on, Centor said.

Side effects from steroids are also possible but rare, according to Dr. Jeffrey Linder of Northwestern University School of Medicine in Chicago. “They include increased blood pressure, increased blood sugar, fluid retention,” he said. “They could be significant for people at risk for diabetes complications and at risk for cardiovascular disease,” said Linder.

New Bowel Disorder Treatments Needed, FDA Says

There’s no known cause or cure for irritable bowel syndrome (IBS), which affects more than 15 million Americans, according to the U.S. Food and Drug Administration.

The disorder involves the large intestine (colon). It causes symptoms such as abdominal pain, bloating, cramping, excessive gas, mucus in the stool, and changes in bowel habits (constipation and/or diarrhea).

No single treatment is effective in all IBS patients, so there’s a need to develop new therapies for the condition, said Dr. Tara Altepeter. Altepeter, an FDA gastroenterologist, noted that the agency is working to make more treatments available to patients. “There’s a lot of new research about the role of carbohydrates, and specifically a nutrient called polyols, in triggering the irritable bowel syndrome in some patients,” Altepeter said in an FDA news release.

Current treatments for IBS include changes in diet and nutrition, and exercise. Some patients take medications to manage their symptoms, but there are no medications to cure IBS.

“IBS is not like other chronic conditions, such as hypertension, which is constant. IBS is a variable condition. Even without treatment, the problem might go away in some patients. But the symptoms might return after a few months,” Altepeter said.

IBS symptoms can be triggered by certain foods, including those high in carbohydrates, spicy or fatty foods, milk products, coffee, alcohol and caffeine.

“Drugs are a last option. Patients should try dietary modifications, relaxation techniques, and other lifestyle changes, such as exercise, before resorting to medication,” Altepeter said.