Month: March 2017

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Health

Type 2 diabetes – can it be reversed?

For years, studies have looked at ways to prevent Type 2 (adult onset) diabetes, and have identified a healthy diet and exercise can prevent it…but what about those who already have it? A new study suggests that it may be possible to reverse this destructive disease in the early stages, at least temporarily. This is important, given that treatments for diabetes lose their effectiveness over time, creating an ongoing struggle with gradually increasing medication to keep blood sugar levels under control.

People with type 2 diabetes were signed up to either an 8-week or 16-week intensive treatment program, or to usual care. The treatment included intensive lifestyle counselling (targeting weight loss) with frequent nurse and dietician contact, and treatment with insulin, metformin (a drug that increases sensitivity to insulin) and acarbose (a medicine that slows the breakdown of carbohydrates into sugar in the digestive system). The goal was to have blood glucose of less than 5.4mmol/l before meals and an average after meal glucose of less than 6.8mmol/ after 8 or 16 weeks.

Half of people in the 8-week group achieved these goals compared to only 3.6% of the control group, and 70% of the 16-week group reached the targets. The drugs were then discontinued in the treatment groups and their blood sugar was monitored.

What was really interesting, was that some people in the treatment groups continued to maintain blood glucose control even after the drugs and insulin were discontinued. Twelve weeks after the completion of the intervention, 21.4% of the 8-week group and 40.7% of the 16-week group met criteria for complete or partial diabetes remission, compared to only 10.7% of “controls” who had received only the usual care.

These results suggest that an intensive diabetes treatment strategy delivered over 2 to 4 months may induce remission of type 2 diabetes. Of course, further research needs to be done in the area to confirm the results, especially as this was only a short-term study, but it’s encouraging to see that the effects of 8 to 16 weeks of treatment can continue for several months, at least in some people with diabetes.

Since the intervention also intensively targeted lifestyle and weight loss, the remission of diabetes could be due at least in part to these factors; I would like to have seen a comparison of drug intervention with an intensive lifestyle and weight loss group rather than only with usual care. However, any study into possible ways to reverse diabetes is valuable, given the increasing rates of diabetes that are occurring now.

This study was published in the Journal of Clinical Endocrinology and Metabolism on March 15, 2017 (N.McInnes, et al; Piloting a Remission Strategy in Type 2 Diabetes: Results of a Randomized Controlled Trial).

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Health

Is it OK to be over weight? The “Weight debate”…

The BMI (Body Mass Index) is a widely-used system that classes body weight into 4 categories: underweight, normal, over weight and obese. But if you assumed that being “normal” weight was best for your health, you would be wrong!

Here is an online BMI calculator to check what category you are in: http://www.mayocllinic.org .

Now, let me tell you about a study published in the Journal of the American Medical Association (JAMA) back in 2005… It was entitled “Excess deaths associated with underweight, overweight, and obesity”. But in the results section, it states: “Overweight was not associated with excess mortality” (emphasis added!).

However, the study actually found that being overweight was associated with a significantly reduced mortality…in other words, an increased life expectancy. Yes, that’s what it said…Those who were “overweight” lived the longest!

But, most medical information sites (including the one I link to above) continue to state that being overweight is harmful to health…similar to obesity, but not as bad – a sort of “obesity lite”, as one author described it.

Another Canadian study, entitled “BMI and Mortality: Results From a National Longitudinal Study of Canadian Adults” published in Obesity journal in 2010 found that even the “obesity” class (but not the heavier “obesity II” class had lower mortality than the “normal” class of BMI.

So, with this evidence, why do many medical professionals and online websites continue pressure us to reduce body weight lower than is necessary to reduce risk to health? It is well established that many people, especially women, have issues with body image, with thinness being widely promoted as the ideal we should struggle to achieve. But these studies strongly suggest that we are reducing our life expectancy in the process.

Physician and author, Malcolm Kendrick, suggests this may be due to an unspoken rule of sorts in medicine: not to question those in authority, not to “buck the system”. Family doctors defer to the opinions of specialists and organizations, and success (and hospital privileges!) sometimes bypass those who ask uncomfortable questions.

I’ve noticed this. When asked for an opinion on the cholesterol controversy (see previous blog), my husband’s family physician simply said that they follow recommendations from the specialists. And when we asked my husband’s specialist what he thought about the controversy, he said he hadn’t read it and invited us to submit the article I’d read. We dropped off 3 articles to him, with our email clearly written on the front, but received no reply at all! I was surprised – I expected to at least receive some sort of rebuttal…

Perhaps something similar is happening to the “weight debate” … the BMI calculation is too well established for mere front-line doctors to challenge. However, a friend told me that her family doctor advises adding an extra 10 pounds as one ages, as he has observed himself that this additional weight enabled his patients to cope with disease more easily with greater chance of survival.

So, is it dangerous to your health to be moderately overweight? Studies suggest that it’s not only OK, but it’s beneficial to your health to carry a little extra weight as you age! It’s time to update BMI charts…

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Article reprint Health

The homeopathy debate…

What is it about homeopathy that has enabled it to survive over 200 years of usage in spite of having what some current studies insist is no greater effect than placebo? Is it simply that the placebo, or essentially our own immune system, is that effective when given a little encouragement?

My overall experience in using these medications with clients has been surprisingly positive. I was first introduced to the medication system in the mid-nineties when we had just opened a new pharmacy. My husband, who is also my business partner (and a non-pharmacist), had noticed the rising interest in natural remedies and, in spite of my hesitation, insisted that we should stock homeopathy as well as herbal medicines.

As a pharmacist, I had a hard time getting my head around the way homeopathy was prepared, and the Latin names and different preparations were confusing to me, but I agreed to give it a try. Of course, we didn’t have the “meta-analysis” studies that we have today, which would likely have convinced me to do otherwise.

Initially, my role was simply to provide specific medications that clients came in looking for, or I would consult homeopathy texts to help clients determine which medication would specifically be recommended for them when someone asked. Although I didn’t have an overwhelmingly large number of clients and didn’t specifically track their responses, it seemed that I received far more positive feedback than negative.

Very early on, I had a chat about homeopathy with a pharmacy student who was with me for the summer. “I think it’s a crock,” she said. Then a client came in, looking for more Rhus Toxicodedron to take along with his standard rheumatoid arthritis medications. He felt that he was sleeping better with the homeopathy added.

My pharmacy student decided to take some home for her mom to try for her arthritis. Within a week or two, she marvelled that several spots of eczema that she had had for several years had disappeared! We consulted a text and discovered that Rhus Toxicodendron was also useful for the crusted-over stage of eczema! Our little “N=1” study had produced results, although not what we expected. We certainly couldn’t credit the placebo response in this case, since none of us knew this agent was recommended for eczema. I suppose one could say it was just chance, and it was going to disappear anyway on its own, but it seemed more than that.

One type of situation where I found homeopathy particularly useful was in cases where it was not safe to recommend standard medication. An example of this would be a client with high blood pressure or diabetes who was looking for something for a low-level sinus problem (where my questioning had determined that it was unlikely they had a sinus infection). I would cautiously suggest a combination sinus product with several homeopathic ingredients, since I did not have the time or expertise to do a full homeopathic assessment to determine the single most recommended ingredient. After a few such recommendations, this product quickly became one of my best-selling sinus medications. It was obvious that people were being referred by others who had tried it. “My friend/neighbour/relative told me I should get some of the sinus medication they bought here, called ‘Sinus-something’ (Sinusalia),” they would often say.

Comparing to other accepted products…
To be fair to homeopathy, I should mention that there are a large number of other questionable medications being carried in pharmacies. Pharmacists happily recommended children’s DM and decongestant products for years, only to find out that they were ineffective and did more harm than good. I even gave them to my own children, believing that they would help. And perhaps they did, given that the care and attention that I administered them with probably helped to stimulate a good placebo response.

And what about all the vitamins that are stocked in pharmacies? There has been plenty of educated commentary advising that we should be able to get all the nutrients we need from our food, making multivitamins unnecessary for most people.

To be in compliance with Natural and Nonprescription Health Directorate guidelines for obtaining a Natural Product Number (NPN), most herbal products no longer make any claims at all on their labels, presumably leaving other sources (such as websites, and advertising) to promote claims that are not acceptable to Health Canada. This leaves the consumer to search out whatever information they might find, often on the Internet or through word of mouth. That’s not always an ideal situation, depending on the source!

As a pharmacist, I subscribed to reputable sites and bought approved texts on herbal medicines so I could give evidence-based replies to questions about herbal medicines. I tried to do the same with homeopathic medicines, and purchased several standard and newly printed texts on homeopathy.

Knowing how highly diluted homeopathic medications are prepared, I had difficulty understanding how they possibly could work. There is a parallel with vaccines, where the agent that causes the problem is basically destroyed and then made into a solution that then stimulates the immune system to do the action we desire. This seemed to be a plausible explanation for how homeopathy could work, but why would a more dilute solution give a stronger effect rather than a weaker one?

Confounding my understanding was the existence (although rare) of the “exacerbation reaction,” which is reported in the literature and was experienced by one of my clients who tried an allergy product. How could a substance that is diluted beyond Avogadro’s number (leaving it unlikely to contain even a single molecule of the original substance) cause her allergic symptoms to strongly intensify only minutes after taking a homeopathic medicine?

Could it be that standard testing methods cannot be used for homeopathy due to its individualization?

Homeopathic medications are used around the world far more commonly than they are in North America. England even has homeopathic hospitals, described to me by a pharmacy student who had done a rotation in such a hospital. Another student from India told me that homeopathic medicines were routinely used at home.

One of my best clients was a veterinarian who regularly used homeopathic medications with his animal patients—if the action of homeopathy relies only the placebo response, how could they work in an animal?

Are we missing something? Could it be that standard testing methods cannot be used for homeopathy due to its individualization? Do we need to, perhaps, include the ability of the immune system to respond in our attempts to prove or disprove this system? More questions than answers…

The bottom line…

So, while other pharmacists may make a different decision, I found a way to use these medications safely and productively in my pharmacy practice. When someone asks for advice on a homeopathic product, I make sure they are using it for a self-limiting condition or at least as an adjunct to a standard treatment.

And I find homeopathic remedies are useful to have available when a client is determined that they want to take a medication, but it is unsafe for them to take the standard non-prescription medication because of an existing condition or another medication they are taking.

I also make sure that they know what non-drug measures are helpful for their condition. In this way, I can try to ensure that they benefit from having visited the pharmacy and that their treatment doesn’t do more harm than good.

An important part of the decision to use homeopathy, is making sure that the condition is self-limiting. In other words, only use homeopathy for conditions that the immune system can overcome. At the very least, given the power of the placebo, the fact that they are taking something may well mean that they will get better sooner!

Previously published in Pharmacy Practice Plus journal for pharmacists

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Health

Stressed? Try the Relaxation Response

The Relaxation Response essentially functions as the opposite of the Stress Response. Stress increases heart rate, and blood pressure – which increase risk of heart disease and stroke – as well as breathing rate and rate of body metabolism. The Relaxation Response does the opposite, and has been proposed as a method of reducing the physical effects of stress and decreasing anxiety.

These are the 4 steps to induce the Relaxation Response:

  1. Find a quiet environment – decrease outside distractions

  2. Focus on something – repeat a word or sound aloud or in your head, look at a symbol or just down at the ground, or concentrate on a particular feeling (love, happiness) to help eliminate outside thoughts

  3. Keep a passive attitude – empty thoughts from your mind; do not be concerned about how you are doing

  4. Sit in a comfortable position – you need to remain still for 10 – 20 minutes. You do not want to fall asleep. Note that these 4 elements will also aid in falling asleep if you are lying down.

It is recommended to practice this relaxation exercise for 10 to 20 minutes, twice a day. Some find the timing in relation to their day’s events can make a difference in their results – for example, inducing a relaxation response before bedtime can make it easier to fall asleep.

Many cultures and religious practices, even back in ancient times, include forms of exercise similar to this as a way to enlightenment, improvement in mood and happiness. The focus can be reciting a prayer for those who practice religion – the result is the same: slowed breathing, heart rate, and metabolism; reduced blood pressure; and improved mood. Yoga and transcendental meditation are two examples that are still widely practiced today.

In the distant past, the ability to respond to physical dangers was life saving…the “fight or flight” response that increased blood flow to limbs, increased heart rate and breathing, and increased blood pressure, set man up to fight off a wild animal or escape from it.

But modern life exposes us to many, much different sources of stress, few of which require a physical strength response. Changes in work, family or environment – especially rapid changes – require us to constantly adjust, triggering the same release of stress hormones. Loss of a loved one, especially a spouse, creates high levels of stress and even happy events, like a promotion, marriage or a new baby, induce a stress response. Simply living in the city versus a rural area is associated with higher stress, and uncertainty (think of world politics!) adds to stress too.

Studies have demonstrated that repeated transient surges of stress hormones eventually lead to a permanent increase in blood pressure, also known as “hypertension”. This provides a plausible explanation for the 90-95% of hypertension of unexplained cause, termed “essential hypertension”. Since increased blood pressure, is associated with increased risk of heart disease and stroke, practicing the Relaxation Response at least during times of increased stress may be a means to reduce the risk these diseases. While relaxation exercises are not a substitute for medication in moderate to severe hypertension, studies suggest they could add to the effect of medication, allowing lowered doses for control. Studies also suggest practicing the Relaxation Response could avoid development of the condition and be beneficial in controlling mild forms, along with other lifestyle changes.

However, few doctors ask about your levels of stress at a check up. Stress hormones naturally fluctuate widely during the day, generally being higher in the morning, peaking at each meal, and dropping lower at night – a good thing, as the effects of stress hormones keep you alert and awake, and ready for “fight or flight” – not what you want at bedtime! It seems likely that middle of the night awakening, where you’re tired but your mind is racing (described as “tired but wired”) may be caused by an inappropriate surge in production of stress hormones in the middle of the night.

Stress is most often treated within the realm of psychology and mental illness, with tranquilizers and antidepressants being prescribed when stress-induced anxiety becomes unbearable. However, learning to trigger the Relaxation Response to reduce the negative effects of stress is side effect-free and costs nothing to practice.

While family physicians receive little formal training in these techniques, many alternative medicine practitioners use meditation and relaxation techniques as part of their therapy. Integration of standard medical treatment and alternative medicine practices like these could result in better treatment for patients and minimization of medications, while reducing cost and decreasing the risk of negative side effects.

This relaxation technique is easy to learn – just follow the 4 steps above. Entering a full relaxation response with lowered blood pressure will become easier and more complete with practice, and can make a significant improvement in your health!

Reference: The Relaxation Response, by Herbert Benson MD

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Health

What is Endometriosis?

Endometriosis is a condition in which the endometrium, the tissue that normally the lines the uterus, grows outside the uterus. Like the endometrium, this tissue grows in response to monthly cycling hormones and sheds during menstruation. Since the shed fluid cannot easily exit the body, it can cause swelling and pain.

Growths can expand over time, forming scar tissue, causing adhesions (binding organs to each other), causing inflammation, and/or causing infertility by blocking fallopian tubes or growing over ovaries.

Most often endometriosis is found on the ovaries, but these growths can also be located on or in the Fallopian tubes, on the outside of the uterus, on ligaments that support the uterus, on the pelvic wall, intestines, bladder and ureters (tubes joining kidneys and bladder). Some women will experience pain with bowel movements or when urinating. Very rarely it can occur in the lungs, diaphragm, brain, or even the skin.

Up to 11% of women have endometriosis but, as about 25% of affected women have no symptoms, more may have the condition but remain undiagnosed. Almost half of sufferers have chronic pelvic or back pain, and up to half may experience infertility. Pain during sex is common, described as a “deep pain”. Seventy percent of women with endometriosis have pain during menstruation. The degree of pain does not necessarily correspond to the extent of endometriosis.

The cause or causes of endometriosis are not clear:

  • Family history increases risk, so researchers suspect an inherited component. Women who have a close family member with the condition may have six times greater risk of developing it.

  • Researchers also suspect a connection to environmental toxins with estrogen-like activity, and perhaps also a connection to decreased progesterone production (the natural hormone that balances or “opposes” estrogen reducing its effect).

  • “Retrograde menstruation”, where menstrual fluid flows in reverse out of the fallopian tubes and attaches to the outside of organs in the abdominal cavity, is the most accepted theory for the cause of this disease. However, this factor alone does not explain the cause, as many women can have retrograde menstruation but will not develop endometriosis.

  • Additional factors, such as genetic or immune differences need to be included to account for the fact that many women with retrograde menstruation do not have endometriosis.

Diagnosis

A health history and physical examination can lead to the suspicion of endometriosis, and ultrasound may identify the condition if large areas are present with associated cyst. However, laparoscopy (small incision surgery using cameras) is needed unless lesions are visible externally (for example in the vagina). A biopsy (removal of a small area of tissue for microscopic examination) confirms the disease.

Treatment

Pain medications

Non-prescription pain relievers in the NSAID family (non-steroidal anti-inflammatory drugs), such as ibuprofen and naproxen can help ease painful menstrual cramps. Naproxen sodium (rather than plain naproxen) is often preferred as it is absorbed more quickly, giving faster relief. NSAIDs also block prostaglandins, substances produced by the body that cause inflammation and promote cramping of the uterus, so they relieve cramps as well as pain. These medications should always be taken with food or milk to prevent stomach irritation.

Hormonal medications

  • Progesterone or synthetic progestins. Progesterone counteracts the actions of estrogen, and blocks the growth of both the endometrium and endometriosis tissue. Oral contraceptives and other forms of hormonal birth control, such as patches, vaginal rings and injections, contain progestin often along with estrogen and can have a favourable effect. Continuous cycle hormonal contraceptives are often preferred to decrease the frequency of menstruation with its accompanying pain.

  • Progestin-only birth control pills, IUDs (Mirena intrauterine device), implants or injections (Depo-Provera) can stop menstrual periods and reduce growth of areas of endometriosis. Usually, after a few cycles, periods will cease.

  • Regular estrogen/progestin birth control pills are also used, but add more estrogen to the woman’s system which theoretically could oppose the beneficial blocking effect of the progestin on the endometriosis.

  • Gonadotropin-releasing hormone agonists (blockers), such as Lupron, block the menstrual cycle by preventing production of the hormones FSH and LH that stimulate the ovaries, resulting in stopping of periods altogether. They work well to shrink areas of endometriosis, but they effectively induce a chemical menopause with associated symptoms of hot flashes, vaginal dryness and bone loss. Periods return when the medication is stopped.

  • Danazol is another drug that blocks production of the hormones that stimulate the ovaries, preventing menstruation and symptoms of endometriosis. However, danazol is less preferred due to its side effects (male hormone-like effects: facial hair growth and voice changes) and potential to harm the baby, should a pregnancy occur.

  • Avoiding xenoestrogens (estrogen-like chemicals in the environment). Because these have a similar effect to our own estrogen, they can stimulate growth of endometriosis. Xenoestrogens are found in some pesticides, herbicides and plastics.

  • Aromatase inhibitors (drugs used to block formation of estrogen in women with estrogen related cancers) are being investigated for treating endometriosis.

Surgery

  • Areas of endometriosis are surgically removed as much as possible. Laparoscopy can be used for this surgery, allowing a faster recovery from surgery. Recurrence of endometriosis after surgery is up to 50% within 5 years, however, and adhesions (where pelvic organs become attached to each other) during healing are quite common.

  • A total hysterectomy (removal of the uterus, cervix and ovaries) is sometimes performed in women who do not wish to conceive, but areas of endometriosis also need to be removed to ensure pain does not persist. A partial hysterectomy (uterus only) is much less effective, as the ovaries continue to produce estrogen that would stimulate any remaining endometriosis causing pain. A hysterectomy is usually considered as a last resort treatment.